Date of Biopsy __________
Enter the date of biopsy. Enter the date in the DD/MMM/YYYY format.
Renal biopsy reason
Indicate the reason a biopsy was performed.
- Protocol surveillance biopsy
- For-cause biopsy
If reason is protocol surveillance, select status option for biopsy
- Implant
- Just prior to discontinuation of mycophenolate mofetil
- Just prior to discontinuation of tacrolimus
- One year after discontinuation of tacrolimus
- One year after discontinuation of MMF if tacrolimus not discontinued
Banff Scoring (per 2015 Report)
Category 1
Normal or nonspecific changes ☐
Indicate if the renal biopsy was normal or exhibited nonspecific changes. If normal, mark the check box.
Category 2
Antibody-mediated changes
Indicate if there were any antibody-mediated changes.
- Suspicious for acute/active antibody-mediated rejection
- Acute/active antibody-mediated rejection
- Chronic active antibody-mediated rejection
- C4d staining without evidence of rejection
Category 3
Borderline changes, suspicious for acute T cell-mediated rejection ☐
Indicate if the renal biopsy exhibited borderline changes, suspicious for acute T cell-mediated rejection. If so, mark the check box.
Category 4
*Acute T cell-mediated rejection
T cell-mediated rejection type
If T cell-mediate rejection is exhibited, indicate type of rejection.
- Chronic active T-cell mediated rejection
If acute, select grade
- IA
- IB
- IIA
- IIB
- II
Category 5
Interstitial fibrosis and tubular atrophy grade
Indicate grade of interstitial fibrosis and tubular atrophy. If biopsy did not exhibit this leave blank.
- I
- II
- III
Category 6
Specify other changes not considered to be caused by acute or chronic rejection __________
Indicate any other changes that may not have been caused by acute or chronic rejection. If there are not other changes to be considered, leave field blank.
CCG v.1 | CRF v.1
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