Contents

Reporting Sufficiency of Continuous Kidney Allograft Rejection Scores Across Cohort Workload and Lesion Composition

Clyde F. Barker1, Aneesha Agarwal2
1Hospital of the University of Pennsylvania, Philadelphia, United States
2Indian Institute of Science Education and Research Bhopal

Abstract

Graded rejection scores can provide additional information quantitatively regarding kidney allograft biopsy reports, but only if the claim about reporting this score is in line with the conditions of diagnosis under which the score is reported. In this study we investigate which continuous kidney allograft rejection scores maintain the reporting function in validation cohorts, which involve local workload annotation, and which ones require additional etiological evidence for interpretation. Analysis is based on aggregated values obtained from 6272 derivation biopsies, 11,043 European validation biopsies, and 2185 United States validation biopsies. No individual patient records were reconstructed. Cohort diagnostic workload was calculated as cases per 100 biopsies, cohort displacement was measured using Jensen-Shannon divergence and log2 load shift, task stability was estimated through stable discrimination load and portability-floor score, residual diagnostic signal was estimated through ancillary signal deficit, lesion composition was estimated using entropy-derived effective lesion number and dominant lesion share. Workload of TCMR/TI including PVAN tasks increased from 19.32 cases per 100 biopsies in the derivation cohort to 55.47 cases per 100 biopsies in the United States validation cohort. Jensen-Shannon divergence from the derivation profile is equal to 0.0094 for the European validation cohort and 0.0997 for the United States validation cohort. Tasks of broad rejection separation, Borderline TCMR/TCMR, TCMR, and AMR/MVI have high values of portability-floor, while PVAN has the highest value of ancillary signal deficit – 18.37 per 100 phenotype cases. Lesion composition further differentiates balanced and lesion-dominant scores – AMR/MVI and activity have effective lesion numbers 3.98 and 5.95, while TCMR/TI and chronicity have dominant lesion shares 46.3% and 40.0%, respectively. It should be noted that the answer to the research question is task-dependent: AMR/MVI and activity allow for direct composite scoring; TCMR/TI, chronicity, mixed rejection, and Borderline TCMR/TCMR require local and component-based scoring; while PVAN requires additional viral findings besides the inflammation score.

Keywords: kidney transplantation; Banff classification; allograft rejection; antibody-mediated rejection; T cell-mediated rejection; microvascular inflammation; continuous scoring; cohort validation; lesion composition; BK polyomavirus nephropathy.
Copyright © 2026 Clyde F. Barker, Aneesha Agarwal. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.