preimplantation analysis of kidney biopsies from expanded criteria donors
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Preimplantation analysis of kidney biopsies from expanded criteria donors. Amaia Sagasta, Ana Sánchez-Escuredo, Frederic Oppenheimer, Manel Solé Department of Pathology and Kidney Transplant Unit, Hospital Clínic, Barcelona, Spain. - PowerPoint PPT PresentationTRANSCRIPT
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Preimplantation analysis of kidney biopsies from
expanded criteria donorsAmaia Sagasta, Ana Sánchez-Escuredo,
Frederic Oppenheimer, Manel Solé
Department of Pathology and Kidney Transplant Unit, Hospital Clínic, Barcelona, Spain
* DISCLOSURE OF INTEREST: The authors report no conflicts of interest.
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Introduction I• Patients with end-stage renal disease attain longer life
expectancy and better quality of life through kidney transplantation
• Critical shortage of kidneys for transplantation
ONT 2011
> 60 y
45-60 y
30-45 y
15-30 y
< 15 y
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Introduction IIECD group definition
Efforts to expand the kidney donor pool
Incorporation of expanded criteria donors (ECD)
Age ≥ 60 years OR
Age 50-59 years with ≥ 2 risk factors :• Death by cerebrovascular accident• History of hypertension• Creatinine level > 1.5 mg/dL
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Introduction IIIECD group associated problems
#ONT 2011
Implanted Discarded (total)
Discarded (due to bx)
USA (ECD) * 59% 41% 51%
Spain (>60y) # 67.5% 32.5% 41.5%
*Sung RS, et al. Transplantation. 2005 May 15;79(9):1257-61
Suboptimal post-transplant function
Shorter graft survival Careful selection of the
grafts before
trasplantation
Preimplantation kidney
biopsy in ECD
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Introduction IVIB practice and interpretation
• Scores in use:– Remuzzi score (Rs):
• Glomerular global esclerosis (GS), tubular atrophy (TA), interstitial fibrosis (IF), arterial and arteriolar narrowing (CV)
– Banff score based modifications:• Arteriolar hyalinosis (AH), mononuclear
cell interstitial inflammation (ii)
• Techniques in use: – Frozen sections, Paraffin sections
Interobserver variability
Lack of universally accepted practice guidelines for biopsy
processing and interpretation of the histological findings
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Aim of the study
1. To analyze the correlation between:
a. Different observers, using frozen sections
b. Different techniques: paraffin vs. frozen (same observer)
2. To analyze if the modification of the score
parameters could improve the correlation:
1. Analysis of an alternative score (As)
1. Alternative GS parameter
2. Combined tubulo-interstitial parameter
3. AH parameter
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Materials and Methods I Study design
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Original report
• Pathologist-on-call: Several
general pathologists
• Time of transplantation
• Frozen section
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Materials and Methods II Scoring of biopsies
GS: Rs As 0= none 0= none1= <20% 1= 1-10%2= 20-50% 2= 11-20%3= > 50% 3= > 21%
TA:0= absent1= ≤ 25%2= 26-50%3= > 50%.
IF:0= ≤ 5%1= 6-25%2= 26-50%3= > 50%.
CV:0= absent1= ≤ 25%2= 26-50%3= > 50%.
AH: 0= absent1= mild to moderate in at least one2= moderate to severe in >13= severe in many
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Materials and Methods IIIElegibility; statistics
• Elegibility for transplant or discard (biopsy): – ≤ 4 points Remuzzi score: acceptance / >4 : discard
• Statistics for concordance in organ elegibility analysis: – Kappa index (K): values between 0 (no agreement) and 1 (perfect
agreement)
• Statistics for correlation analysis (parameters, scores): – Kendall’s Tau b (KTb): values between -1 (perfect disagreement)
and 1 (perfect agreement), 0 (absence of association)
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Results I - Parameters
Interobserver
correlation
(frozen sections)
correlation between techniques: PS/FS
(same observer)
Kendall’sTau b Lower C.I.,KTb Upper C.I.,KTb Kendall’s Taub Lower C.I.,KTb Upper C.I.,KTb
GS (Rs) 0.19 -0.06 0.45 0.36 0.13 0.59
GS (As) - - - 0.30 0.11 0.50
TA 0.10 -0.09 0.30 0.16 -0.13 0.45
IF 0.24 0.03 0.44 0.35 0.15 0.55
TA/IF (As) - - - 0.16 -0.13 0.45
CV 0.21 0.005 0.41 0.31 0.11 0.51
AH (As) - - - 0.32 0.18 0.46
PS: parraffin sections (PAS); FS: frozen sections (H/E)
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Results II - Scores
Interobserver
correlation
(frozen sections)
correlation between techniques: PS/FS
(same observer)
Kendall’s
Tau b
Lower C.I.,
KTb
Upper C.I.,
KTb
Kendall’s
Taub
Lower C.I.,
KTb
Upper C.I.,
KTb
Remuzzi score 0.10 -0.09 0.30 0.31 0.15 0.47
Alternative sc. 0.29 0.12 0.47
PS: parraffin sections (PAS); FS: frozen sections (H/E)
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Results IIIConcordance in organ acceptance
Interobserver
concordance
(frozen sections)
concordance between techniques:
PS/FS
(same observer)
Kappa value(95% CI)
0.33(0.05-0.61)
0.35(0.11-0.59)
PS: parraffin sections (PAS); FS: frozen sections (H/E); ORFS: original report frozen section (H/E)
Importance of observed differences in organ acceptance:
• FS revision a posteriori by single observer would have resulted in 9.75% more discard than ORFS
• FS revision would have resulted in 7.6% more discard than PS revision by the same observer
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Conclusions
• The evaluation of the score items by a single, trained observer improved the correlation in all values, despite the use of different techniques
• Remuzzi score was the parameter with the best improvement in correlation
• Given the relevance of the observed differences in organ acceptance, specific training is advisable irrespective of the technique used
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References
• Remuzzi G, Grinyo J, Ruggenenti P et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. Double Kidney Transplant Group (DKG). J. Am. Soc.Nephrol. 1999; 10; 2591–2598.
• Perico N, Ruggenenti P, Scalamogna M, Remuzzi G.Tackling the shortage of donor kidneys: how to use the best that we have. Am.J.Nephrol.2003;23:245-259.
• Munivenkatappa RB, Schweitzer EJ, Papadimitriou JC et al. The Maryland aggregate pathology index: a deceased donor kidney biopsy scoring system for predicting graft failure. Am. J.Transplant. 2008; 8; 2316–2324.
• El-Husseini A, Sabry A, Zahran A et al.Can Donor implantation renal biopsy predict long-term renal allograft outcome?Am.J.Nephrol.2007;27:144-151
• Snoeijs MG, Boonstra LA, Buurman WA et al.Histological assessment of pre-transplant kidney biopsies is reproducible and representative. Histopathology 2010;56;198-202.
• Sung RS, Christensen LL, Leichtman AB et al.Determinatns of discard of expanded criteria donor kidneys: impact of biopsy and machine perfusion. Am.J.Transplant.2008;8:738-792.
• Furness PN, Taub N, Assmann KJ et al. International variation in histologic grading is large, and persistent feedback does not improve reproducibility. Am. J. Surg. Pathol. 2003; 27; 805–810.
• Organización Nacional de Transplantes (ONT) Database