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Our approach to a renal transplant biopsy
  1. R John,
  2. A M Herzenberg
  1. Department of Pathology, University Health Network, and University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Andrew Herzenberg, Department of Pathology, University Health Network, 11 Eaton, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4; andrew.herzenberg{at}


Kidney transplantation has become increasingly common in major health centres, making renal allograft evaluation through biopsy a common procedure. Early allograft dysfunction occurs in 30–50% of all transplants, while chronic graft failure is almost uniform at a rate of 2–4% a year. Allograft biopsy remains the gold standard for the diagnosis of graft dysfunction. Rejection, albeit the most important, is only one of many causes of allograft dysfunction. The widely accepted Banff classification has set criteria for the diagnosis of acute and chronic rejection. The major differential diagnoses are acute ischaemic injury, calcineurin inhibitor toxicity (acute and chronic), infections, including pyelonephritis and polyomavirus nephropathy, chronic obstruction/reflux, hypertension, and recurrent and de novo disease. In this review, there is an outline of the Banff criteria and their implications, the various causes of graft dysfunction, and a discussion on morphological guidelines towards the various diagnoses.

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  • Competing interests None.

  • Provenance and Peer review Commissioned; not externally peer reviewed.