ISHLT System for Grading Rejection

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The Internationational Society for Heart and Lung Transplantation (ISHLT) System for Grading Rejection:

Old term	Grades	Notes	Proposed simplification (1994)
No rejection	0	Biopsies with very sparse lymphoid infiltrates should be included in this grade.
Mild rejection	1A	Focal perivascular or interstitial infiltrates. The mild intensity and lack of myocyte damage distinguish this from higher grades.	Grade 1
Mild rejection	1B	Diffuse but sparse infiltrate. As with 1A, there must be no myocyte damage.	Grade 1
‘Focal’ moderate rejection	2	One focus only with aggressive infiltration and/or focal myocyte damage. The choice of a single focus as the cut-off from higher grades is arbitrary in practice, with the amount of tissue usually submitted, one is unlikely to be faced with the problem of biopsy fragments with only two foci	Grade 1

Usual treatment threshold

‘Low’ mod rejection	3A	Multifocal aggressive infiltrates and/or myocyte damage. The multiple foci may be present in only one fragment or may be scattered through out several fragments.	Grade 3A
‘Low’ mod rejection	3B	Diffuse inflammatory process .The intensity of the lymphoid infiltrate varies considerably. It may be little more than grade 1B, the important distinguishing feature being the presence of myocyte damage. This damage must be present in at least two fragments, but some degree of infiltration is present in the majority of fragments.	Grade 3B
‘Severe’ acute rejection	4	A diffuse and polymorphous infiltrate with or without oedema, haemorrhage and vasculitis. The infiltrate is more intense and more widespread than 3B and myocyte is conspicuous. There are often neutrophils and/or haemorrhage, though neither is essential for diagnosis of this grade.	Grade 4

Abstracts:

Nodular endocardial infiltrates (Quilty lesions) cause significant variability in diagnosis of ISHLT Grade 2 and 3A rejection in cardiac allograft recipients.J Heart Lung Transplant. 2005 Jul;24(7 Suppl):S219-26

Effect of adopting a new histological grading system of acute rejection after heart transplantation.Heart. 1997 Dec;78(6):603-7.

A revision of the 1990 working formulation for the classification of lung allograft rejection. J Heart Lung Transplant 1996;15:1-15

Acute rejection: significance of lapsed time post transplant. J Heart Lung Transplant 1994;13:862-868

A classification of cardiac allograft rejection. A modification of the classification by Billingham. Am J Surg Pathol 1987;11(7):503-515

August 2009

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ISHLT SYSTEM FOR GRADING REJECTION

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