ISHLT Scientific Statement on Pulmonary Antibody-Mediated Rejection and Proposed Graft, Antibody, and Pathology (GAP) Definition

Published 11 June 2026

Fiorella Calabrese, MD; Deborah Levine, MD; Benjamin Adam, MD, FRCPC; Sean Agbor-Enoh, MD, PhD; Christian Benden, MD, MBA, FCCP, FERS; Marie Budev, DO, MPH; Adam Cochrane, PharmD, MPH; Emanuele Cozzi, MD; David Darley, MBBS, BSc, FRACP; Gregory Fishbein, MD; Andrew Gelman, PhD; Allan Glanville, MBBS, MD, FRACP; John Greenland, MD, PhD; Michelle Hickey, PhD, F(ACHI); Fabio Ius, MD; Peter Jaksch, MD; Annette Jackson, PhD; John Joerns, MD; Hong Lor, BPharm; Erin Lowery, MD, MS; Massimo Mangiola, PhD; Letizia Morlacchi, MD; Michelle Murray, MD, MSc, FRCPI, FRCP; Arun Nair, MD, FRCP, Edin; Honoria Ocagli, PhD; Jasvir Parmar, BM, PhD, FRCP; Elizabeth Pavlisko, MD; Michael Perch, MD; Franck Rahaghi, MD, MHS; Anja Roden, MD; Antoine Roux, MD, PhD; Laurie Snyder, MD; Stuart Sweet, MD, PhD; Stijn Verleden, PhD; Gary Visner, DO; Robin Vos, MD, PhD; Kathryn Wikenheiser-Brokamp, MD, PhD; Adriana Zeevi, PhD, ABHI; Ramsey R. Hachem, MD

J Heart Lung Transplant. June 2026.

• Advanced Lung Failure & Transplantation
• Consensus Document
• Infectious Diseases
• Pathology
• Publications & Journals
• Pulmonology
• Standards & Guidelines

Antibody-mediated rejection (AMR) is an increasingly recognized form of rejection and cause of graft failure after lung transplantation and has been the focus of extensive research over the past decade. Despite increased awareness and intensive research in pulmonary AMR over the past decade, clinical outcomes remain dismal, with most patients developing severe CLAD or dying within 2 years of the diagnosis.

The 2016 document Antibody-Mediated Rejection of the Lung: A Consensus Report from ISHLT provided a standardized definition and nomenclature, which increased the awareness of AMR as a potential cause of graft dysfunction and facilitated important research in the field. However, this progress has not resulted in improved clinical outcomes, and important areas of uncertainty remain.

The ISHLT convened an international, multidisciplinary workgroup of experts to review the literature and update the definition of AMR with the ultimate objective of improving clinical outcomes through (1) enhanced our understanding of the mechanisms that lead to AMR, and (2) identification and testing novel treatments in multicenter clinical trials. As a result, a multidimensional definition was developed to enhance precision by reporting the specific presenting features. This Graft, Antibody, and Pathology (GAP) definition is based on the presence of Graft dysfunction, the presence and characteristics of Antibodies, and Pathological findings.

Read at JHLT