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Liang PI, Lin WC, Wen MC, Huang SC, Fang PW, Chuang HW, Lin YJ, Chien HP, Chen HD, Chen TD. Learning more from the inter-rater reliability of interstitial fibrosis assessment beyond just a statistic. Sci Rep 2023; 13:13260. [PMID: 37582967 PMCID: PMC10427633 DOI: 10.1038/s41598-023-40221-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/07/2023] [Indexed: 08/17/2023] Open
Abstract
Interstitial fibrosis assessment by renal pathologists lacks good agreement, and we aimed to investigate its hidden properties and infer possible clinical impact. Fifty kidney biopsies were assessed by 9 renal pathologists and evaluated by intraclass correlation coefficients (ICCs) and kappa statistics. Probabilities of pathologists' assessments that would deviate far from true values were derived from quadratic regression and multilayer perceptron nonlinear regression. Likely causes of variation in interstitial fibrosis assessment were investigated. Possible misclassification rates were inferred on reported large cohorts. We found inter-rater reliabilities ranged from poor to good (ICCs 0.48 to 0.90), and pathologists' assessments had the worst agreements when the extent of interstitial fibrosis was moderate. 33.5% of pathologists' assessments were expected to deviate far from the true values. Variation in interstitial fibrosis assessment was found to be correlated with variation in interstitial inflammation assessment (r2 = 32.1%). Taking IgA nephropathy as an example, the Oxford T scores for interstitial fibrosis were expected to be misclassified in 21.9% of patients. This study demonstrated the complexity of the inter-rater reliability of interstitial fibrosis assessment, and our proposed approaches discovered previously unknown properties in pathologists' practice and inferred a possible clinical impact on patients.
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Affiliation(s)
- Peir-In Liang
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Chin Wen
- Department of Pathology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Shun-Chen Huang
- Department of Anatomic Pathology, Chang Gung Memorial Hospital Kaohsiung Branch, Kaohsiung, Taiwan
| | - Pei-Wei Fang
- Department of Pathology, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Hao-Wen Chuang
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yi-Jia Lin
- Department of Pathology, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hui-Ping Chien
- Department of Pathology and Laboratory Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Huan-Da Chen
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tai-Di Chen
- Department of Anatomic Pathology, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan.
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2
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Zaza G, Cucchiari D, Becker JU, de Vries APJ, Eccher A, Florquin S, Kers J, Rabant M, Rossini M, Pengel L, Marson L, Furian L. European Society for Organ Transplantation (ESOT)-TLJ 3.0 Consensus on Histopathological Analysis of Pre-Implantation Donor Kidney Biopsy: Redefining the Role in the Process of Graft Assessment. Transpl Int 2023; 36:11410. [PMID: 37470063 PMCID: PMC10353313 DOI: 10.3389/ti.2023.11410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/31/2023] [Indexed: 07/21/2023]
Abstract
The ESOT TLJ 3.0. consensus conference brought together leading experts in transplantation to develop evidence-based guidance on the standardization and clinical utility of pre-implantation kidney biopsy in the assessment of grafts from Expanded Criteria Donors (ECD). Seven themes were selected and underwent in-depth analysis after formulation of PICO (patient/population, intervention, comparison, outcomes) questions. After literature search, the statements for each key question were produced, rated according the GRADE approach [Quality of evidence: High (A), Moderate (B), Low (C); Strength of Recommendation: Strong (1), Weak (2)]. The statements were subsequently presented in-person at the Prague kick-off meeting, discussed and voted. After two rounds of discussion and voting, all 7 statements reached an overall agreement of 100% on the following issues: needle core/wedge/punch technique representatively [B,1], frozen/paraffin embedded section reliability [B,2], experienced/non-experienced on-call renal pathologist reproducibility/accuracy of the histological report [A,1], glomerulosclerosis/other parameters reproducibility [C,2], digital pathology/light microscopy in the measurement of histological variables [A,1], special stainings/Haematoxylin and Eosin alone comparison [A,1], glomerulosclerosis reliability versus other histological parameters to predict the graft survival, graft function, primary non-function [B,1]. This methodology has allowed to reach a full consensus among European experts on important technical topics regarding pre-implantation biopsy in the ECD graft assessment.
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Affiliation(s)
- Gianluigi Zaza
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University/Hospital of Foggia, Foggia, Italy
| | - David Cucchiari
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Barcelona, Spain
| | - Jan Ulrich Becker
- Institut für Pathologie und Molekularpathologie, University Hospital of Cologne, Cologne, Germany
| | - Aiko P. J. de Vries
- Division of Nephrology, Department of Medicine, Transplant Center, Leiden University Medical Center, Leiden, Netherlands
| | - Albino Eccher
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, Verona, Italy
| | - Sandrine Florquin
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Jesper Kers
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades University Hospital, Paris, France
| | - Michele Rossini
- Nephrology, Dialysis and Transplantation Unit, University/Hospital of Bari, Bari, Italy
| | - Liset Pengel
- Centre for Evidence in Transplantation, Oxford, United Kindom
| | - Lorna Marson
- Department of Surgery, University of Edinburgh, Edinburgh, United Kingdom
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, University of Padova, Padova, Italy
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3
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Keijbeck A, Raaijmaakers A, Hillen L, Gelens M, van Kuijk S, Cleutjens JPM, Peutz-Kootstra C, Christiaans M. Visual interstitial fibrosis assessment as continuous variable in protocol renal transplant biopsies. Histopathology 2023; 82:713-721. [PMID: 36579371 DOI: 10.1111/his.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/30/2022]
Abstract
AIMS In current renal transplant pathology practice, interstitial fibrosis is visually assessed in categories according to the Banff classification. As this has a moderate reproducibility, which is little ameliorated by morphometric analysis, we investigated whether visual renal fibrosis assessment is feasible on a continuous scale, i.e. as a percentage of affected area of the cortex. METHODS AND RESULTS Protocol renal biopsies taken at transplantation (n = 125), three (n = 73) and 12 months (n = 88) after transplantation were visually scored in categories (Banff) and percentages for interstitial fibrosis (ci). Interobserver variation (ICC and weighted κ) was assessed, and morphometric analysis on Sirius red-stained sections was performed. Correlations between the different methods and their association with donor age and eGFR 1 and 5 years post-transplant were analysed using Pearson's or Spearman's rho. Interobserver agreement was equivalent for Banff and %ci (κ = 0.713 versus ICC = 0.792), and for Banff IF/TA and %IF/TA (κ = 0.615 versus ICC = 0.743). Both Banff and %ci were associated with Sirius red morphometry in 3 and 12 months. With all three methods, a significant correlation was found between donor age and fibrosis in the implantation biopsy and between fibrosis in the 12 months' biopsy and eGFR at 1 and 5 years (eGFR at 1 year: Sirius red ρ = 0.487, %ci ρ = 0.393, Banff ρ = 0.413, all P < 0.01, eGFR at 5 years: Sirius red ρ = 0.392, %ci ρ = 0.333, Banff ρ = 0.435, all P < 0.01). CONCLUSION Interstitial fibrosis assessment on a continuous scale can be used next to scoring in categories according to the Banff classification in protocol renal transplant biopsies.
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Affiliation(s)
- Anke Keijbeck
- Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Anniek Raaijmaakers
- Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lisa Hillen
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marielle Gelens
- Department of Internal Medicine, Division of Nephrology, School of Nutrition and Translational Research in Metabolism University Maastricht (NUTRIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jack P M Cleutjens
- Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Carine Peutz-Kootstra
- Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Maarten Christiaans
- Department of Internal Medicine, Division of Nephrology, School of Nutrition and Translational Research in Metabolism University Maastricht (NUTRIM), Maastricht University Medical Centre, Maastricht, the Netherlands
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4
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Ayorinde JOO, Citterio F, Landrò M, Peruzzo E, Islam T, Tilley S, Taylor G, Bardsley V, Liò P, Samoshkin A, Pettigrew GJ. Artificial Intelligence You Can Trust: What Matters Beyond Performance When Applying Artificial Intelligence to Renal Histopathology? J Am Soc Nephrol 2022; 33:2133-2140. [PMID: 36351761 PMCID: PMC9731632 DOI: 10.1681/asn.2022010069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Although still in its infancy, artificial intelligence (AI) analysis of kidney biopsy images is anticipated to become an integral aspect of renal histopathology. As these systems are developed, the focus will understandably be on developing ever more accurate models, but successful translation to the clinic will also depend upon other characteristics of the system.In the extreme, deployment of highly performant but "black box" AI is fraught with risk, and high-profile errors could damage future trust in the technology. Furthermore, a major factor determining whether new systems are adopted in clinical settings is whether they are "trusted" by clinicians. Key to unlocking trust will be designing platforms optimized for intuitive human-AI interactions and ensuring that, where judgment is required to resolve ambiguous areas of assessment, the workings of the AI image classifier are understandable to the human observer. Therefore, determining the optimal design for AI systems depends on factors beyond performance, with considerations of goals, interpretability, and safety constraining many design and engineering choices.In this article, we explore challenges that arise in the application of AI to renal histopathology, and consider areas where choices around model architecture, training strategy, and workflow design may be influenced by factors beyond the final performance metrics of the system.
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Affiliation(s)
- John O O Ayorinde
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | | | | | | | | | | | - Victoria Bardsley
- Department of Histopathology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Pietro Liò
- Department of Computer Science and Technology, University of Cambridge, Cambridge, United Kingdom
| | - Alex Samoshkin
- Office for Translational Research, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Gavin J Pettigrew
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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5
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Identification of glomerulosclerosis using IBM Watson and shallow neural networks. J Nephrol 2022; 35:1235-1242. [PMID: 35041197 PMCID: PMC8765108 DOI: 10.1007/s40620-021-01200-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/03/2021] [Indexed: 11/26/2022]
Abstract
Background Advanced stages of different renal diseases feature glomerular sclerosis at a histological level which is observed by light microscopy on tissue samples obtained by performing a kidney biopsy. Computer-aided diagnosis (CAD) systems leverage the potential of artificial intelligence (AI) in healthcare to support physicians in the diagnostic process. Methods We propose a novel CAD system that processes histological images and discriminates between sclerotic and non-sclerotic glomeruli. To this goal, we designed, tested, and compared two artificial neural network (ANN) classifiers. The former implements a shallow ANN classifying hand-crafted features extracted from Regions of Interest (ROIs) by means of image-processing procedures. The latter, instead, employs the IBM Watson Visual Recognition System, which uses a deep artificial neural network making decisions taking the images as input, without the need to design any procedure for describing images with features. The input dataset consisted of 428 sclerotic glomeruli and 2344 non-sclerotic glomeruli derived from images of kidney biopsies scanned by the Aperio ScanScope System. Results Both AI approaches allowed to very accurately distinguish (mean MCC 0.95 and mean Accuracy 0.99) between sclerotic and non-sclerotic glomeruli. Although the systems may seem interchangeable, the approach based on feature extraction and classification would allow clinicians to gain information on the most discriminating features. In fact, further procedures could explain the classifier’s decision by analysing which subset of features impacted the most on the final decision. Conclusions We developed a customizable support system that can facilitate the work of renal pathologists both in clinical and research settings. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01200-0.
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6
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Ginley B, Jen KY, Han SS, Rodrigues L, Jain S, Fogo AB, Zuckerman J, Walavalkar V, Miecznikowski JC, Wen Y, Yen F, Yun D, Moon KC, Rosenberg A, Parikh C, Sarder P. Automated Computational Detection of Interstitial Fibrosis, Tubular Atrophy, and Glomerulosclerosis. J Am Soc Nephrol 2021; 32:837-850. [PMID: 33622976 PMCID: PMC8017538 DOI: 10.1681/asn.2020050652] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 12/14/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Interstitial fibrosis, tubular atrophy (IFTA), and glomerulosclerosis are indicators of irrecoverable kidney injury. Modern machine learning (ML) tools have enabled robust, automated identification of image structures that can be comparable with analysis by human experts. ML algorithms were developed and tested for the ability to replicate the detection and quantification of IFTA and glomerulosclerosis that renal pathologists perform. METHODS A renal pathologist annotated renal biopsy specimens from 116 whole-slide images (WSIs) for IFTA and glomerulosclerosis. A total of 79 WSIs were used for training different configurations of a convolutional neural network (CNN), and 17 and 20 WSIs were used as internal and external testing cases, respectively. The best model was compared against the input of four renal pathologists on 20 new testing slides. Further, for 87 testing biopsy specimens, IFTA and glomerulosclerosis measurements made by pathologists and the CNN were correlated to patient outcome using classic statistical tools. RESULTS The best average performance across all image classes came from a DeepLab version 2 network trained at 40× magnification. IFTA and glomerulosclerosis percentages derived from this CNN achieved high levels of agreement with four renal pathologists. The pathologist- and CNN-based analyses of IFTA and glomerulosclerosis showed statistically significant and equivalent correlation with all patient-outcome variables. CONCLUSIONS ML algorithms can be trained to replicate the IFTA and glomerulosclerosis assessment performed by renal pathologists. This suggests computational methods may be able to provide a standardized approach to evaluate the extent of chronic kidney injury in situations in which renal-pathologist time is restricted or unavailable.
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Affiliation(s)
- Brandon Ginley
- Departments of Pathology and Anatomical Sciences, University at Buffalo - The State University of New York, Buffalo, New York
| | - Kuang-Yu Jen
- Department of Pathology and Laboratory Medicine, University of California at Davis, Sacramento, California
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Luís Rodrigues
- University Clinic of Nephrology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Nephrology Unit, Coimbra Hospital and University Center, Coimbra, Portugal
| | - Sanjay Jain
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Agnes B Fogo
- Departments of Pathology, Microbiology, and Immunology, and Medicine, Vanderbilt University, Nashville, Tennessee
| | - Jonathan Zuckerman
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Vighnesh Walavalkar
- Department of Pathology, University of California at San Francisco, San Francisco, California
| | - Jeffrey C Miecznikowski
- Department of Biostatistics, University at Buffalo - The State University of New York, Buffalo, New York
| | - Yumeng Wen
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Felicia Yen
- Department of Pathology and Laboratory Medicine, University of California at Davis, Sacramento, California
| | - Donghwan Yun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Avi Rosenberg
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chirag Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pinaki Sarder
- Departments of Pathology and Anatomical Sciences, University at Buffalo - The State University of New York, Buffalo, New York.,Department of Biomedical Engineering, University at Buffalo - The State University of New York, Buffalo, New York
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7
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The Association Between Macroscopic Arteriosclerosis of the Renal Artery, Microscopic Arteriosclerosis, Organ Discard, and Kidney Transplant Outcome. Transplantation 2021; 104:2567-2574. [PMID: 33215902 PMCID: PMC7668327 DOI: 10.1097/tp.0000000000003189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background. During organ retrieval, surgeons estimate the degree of arteriosclerosis and this plays an important role in decisions on organ acceptance. Our study aimed to elucidate the association between macroscopic renal artery arteriosclerosis, donor kidney discard, and transplant outcome. Methods. We selected all transplanted and discarded kidneys in the Netherlands between January 1, 2000, and December 31, 2015, from deceased donors aged 50 y and older, for which data on renal artery arteriosclerosis were available (n = 2610). The association between arteriosclerosis and kidney discard, the relation between arteriosclerosis and outcome, and the correlation between macroscopic and microscopic arteriosclerosis were explored. Results. Macroscopic arteriosclerosis was independently associated with kidney discard (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.02-1.80; P = 0.03). Arteriosclerosis (any degree) was not significantly associated with delayed graft function (OR, 1.16; 95% CI, 0.94-1.43; P = 0.16), estimated glomerular filtration rate 1-y posttransplant (B, 0.58; 95% CI, –2.07 to 3.22; P = 0.67), and long-term graft survival (hazard ratio, 1.07; 95% CI, 0.86-1.33; P = 0.55). There was a significant association between mild arteriosclerosis and primary nonfunction (OR, 2.14; 95% CI, 1.19-3.84; P = 0.01). We found no correlation between macroscopic and histological arteriosclerosis, nor between histological arteriosclerosis and transplant outcome. Conclusions. Macroscopic arteriosclerosis of the renal artery was independently associated with kidney discard and somewhat associated with primary nonfunction posttransplant. However, there was no effect of arteriosclerosis on delayed graft function, estimated glomerular filtration rate at 1 y, or long-term graft survival. Our results are valid only after inevitable exclusion of discarded kidneys that had on average more arteriosclerosis. Hence, conclusions should be interpreted in the light of this potential bias.
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8
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Live Confocal Tissue Assessment With SYTO16/PI and WGA Staining Visualizes Acute Organ Damage and Predicts Delayed Graft Function in Kidney Transplantation. Ann Surg 2019; 270:915-922. [DOI: 10.1097/sla.0000000000003511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Pre-implantation kidney biopsy: value of the expertise in determining histological score and comparison with the whole organ on a series of discarded kidneys. J Nephrol 2019; 33:167-176. [PMID: 31471818 DOI: 10.1007/s40620-019-00638-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/10/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Evidence about the reliability of pre-implantation biopsy is still conflicting, depending on both biopsy type and pathologist's expertise. Aim of the study is to evaluate the agreement of general v specialist pathologists and to compare scores on biopsy and whole organs in a set of discarded kidneys. METHODS 46 discarded kidneys were identified with their corresponding biopsies. The biopsies were reviewed by three general and two specialist pathologists, blinded to the original report, according to Remuzzi score. The intraclass correlation coefficient (ICC) was calculated for both groups. Discarded kidneys were scored according to Remuzzi score by a single specialist pathologist. Biopsies and organs were compared by Wilcoxon signed rank test. Weighted κ coefficients between biopsy and organ scores were also calculated. RESULTS Specialist pathologists achieved higher values of ICC, reaching excellent or good agreement in most of the parameters, while general pathologists values were mainly fair or good. On whole organs, scores were consistently lower than biopsies, with a significant difference in most of the parameters. Weighted κ coefficient was slight or fair for most of the parameters. CONCLUSIONS Our data suggests that the creation of a pool of specialist pathologists would improve organ utilization. Moreover, biopsies are not representative of the whole organ. As the Remuzzi score on biopsy is a major reasons for discard, a quota of transplantable kidneys may be erroneously discarded. Refinement in Remuzzi cut-offs based on expert reporting and recognition of sampling error of biopsies in correlation with clinical outcome data should be undertaken.
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10
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Chiang PJ, Tang SH, Li CC, Chou MH, Lin YC, Wu ST. Kidney Transplantation from an extracorporeal membrane oxygenation-supported brain-dead donor: A case report. Medicine (Baltimore) 2018; 97:e11106. [PMID: 29952950 PMCID: PMC6039615 DOI: 10.1097/md.0000000000011106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) can deliver effective respiratory and circulatory maintenance to organ donors, improve organ function, and shorten warm ischemic time before harvesting. However, ECMO-supported brain-dead donors (DBDs) still have a high risk of acute kidney injury related to decreased renal oxygen delivery and inflammatory damage, which may cause early graft failure. PATIENT CONCERNS Kidney transplantation from an ECMO-supported DBD. DIAGNOSES We found an extremely abnormal "very dark blue" appearance of the graft kidneys from an ECMO-supported DBD during kidney procurement. INTERVENTIONS Rather than discarding the graft kidneys, we performed an on-table biopsy. Pretransplant biopsy results revealed minimal interstitial fibrosis in the section of these graft kidneys. OUTCOMES Two candidates received graft kidneys, and the two grafts remained functional until the 8-month follow-up. LESSONS Currently, there is no standard method for evaluating graft kidney function of ECMO-supported DBDs. Regardless of the donors' preoperative serum creatinine (SCr) level, estimated glomerular filtration rate (eGFR), or gross appearance of the graft kidney, we believe that it is more reliable to include pretransplant biopsy as a criterion in clinical practice to safely accept kidneys from ECMO-supported DBDs.
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Affiliation(s)
| | | | | | | | - Yu-Chun Lin
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Nei-Hu, Taipei, Taiwan
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11
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Pretransplant Midodrine Use: A Newly Identified Risk Marker for Complications After Kidney Transplantation. Transplantation 2017; 100:1086-93. [PMID: 26950718 DOI: 10.1097/tp.0000000000001113] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Midodrine is prescribed to prevent symptomatic hypotension and decrease complications associated with hypotension during dialysis. We hypothesized that midodrine use before kidney transplantation may be a novel marker for posttransplant risk. METHODS We analyzed integrated national US transplant registry, pharmacy records, and Medicare claims data for 16 308 kidney transplant recipients transplanted 2006 to 2008, of whom 308 (1.9%) had filled midodrine prescriptions in the year before transplantation. Delayed graft function (DGF), graft failure, and patient death were ascertained from the registry. Posttransplant cardiovascular complications were identified using diagnosis codes on Medicare billing claims. Adjusted associations of pretransplant midodrine use with complications at 3 and 12 months posttransplant were quantified by multivariate Cox or logistic regression, including propensity for midodrine exposure. RESULTS At 3 months, patients who used midodrine pretransplant had significantly (P < 0.05) higher rates of DGF, 32% versus 19%; hypotension, 14% versus 4%; acute myocardial infarction, 4% versus 2%; cardiac arrest, 2% versus 0.9%, graft failure, 5% versus 2%; and death, 4% versus 1% than nonusers. After multivariate adjustment including recipient and donor factors, as well as for the propensity of midodrine exposure, pretransplant midodrine use was independently associated with risks of DGF (adjusted odds ratio, 1.78; 95% confidence interval [CI], 1.36-2.32), and 3 month death-censored graft failure (adjusted hazard ratio, 2.0; 95% CI, 1.18-3.39), and death (adjusted hazard ratio, 3.49; 95% CI, 1.95-6.24). Patterns were similar at 12 months. CONCLUSIONS Although associations may in part reflect underlying conditions, the need for midodrine before kidney transplantation is a risk marker for complications including DGF, graft failure, and death.
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12
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Sagasta A, Sánchez-Escuredo A, Oppenheimer F, Paredes D, Musquera M, Campistol JM, Solé M. Pre-implantation analysis of kidney biopsies from expanded criteria donors: testing the accuracy of frozen section technique and the adequacy of their assessment by on-call pathologists. Transpl Int 2015; 29:234-40. [DOI: 10.1111/tri.12709] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 08/20/2015] [Accepted: 10/23/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Amaia Sagasta
- Pathology Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Ana Sánchez-Escuredo
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Frederic Oppenheimer
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - David Paredes
- Transplant Service Fundation; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Mireia Musquera
- Urology Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Josep Maria Campistol
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Manel Solé
- Pathology Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
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13
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van Heurn LWE, Talbot D, Nicholson ML, Akhtar MZ, Sanchez-Fructuoso AI, Weekers L, Barrou B. Recommendations for donation after circulatory death kidney transplantation in Europe. Transpl Int 2015; 29:780-9. [PMID: 26340168 DOI: 10.1111/tri.12682] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/19/2015] [Accepted: 08/26/2015] [Indexed: 12/29/2022]
Abstract
Donation after circulatory death (DCD) donors provides an invaluable source for kidneys for transplantation. Over the last decade, we have observed a substantial increase in the number of DCD kidneys, particularly within Europe. We provide an overview of risk factors associated with DCD kidney function and survival and formulate recommendations from the sixth international conference on organ donation in Paris, for best-practice guidelines. A systematic review of the literature was performed using Ovid Medline, Embase and Cochrane databases. Topics are discussed, including donor selection, organ procurement, organ preservation, recipient selection and transplant management.
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Affiliation(s)
| | - David Talbot
- Department of Liver/Renal Transplant, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Michael L Nicholson
- Department of Surgery, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | | | - Laurent Weekers
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Benoit Barrou
- Department of Urology - Transplantation, GHzu Pitié Salpêtriere, Paris, France
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Tavares da Silva E, Oliveira R, Castelo D, Marques V, Sousa V, Moreira P, Simões P, Bastos CA, Figueiredo A, Mota A. Pretransplant biopsy in expanded criteria donors: do we really need it? Transplant Proc 2015; 46:3330-4. [PMID: 25498046 DOI: 10.1016/j.transproceed.2014.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Renal transplantation is the best treatment for end-stage renal disease, including when using expanded criteria donors (ECD) kidneys. However, these suboptimal kidneys should be evaluated rigorously to meet their usefulness. Opinions differ about the best way to evaluate them. MATERIALS AND METHODS We retrospectively reviewed kidneys from ECD harvested by a single academic institution between January 2008 and September 2013. Needle biopsies were performed at the time of the harvest when considered relevant by the transplant team. Two pathologists where responsible for their analysis; the Remuzzi classification has been used in all cases. RESULTS We evaluated 560 ECD kidneys. Biopsies were made in 197 (35.2%) organs, 20 of which were considered not usable and 36 good only for double transplantation. Sixty-three kidneys (11.3%) were discarded by the transplant team based on the biopsy result and clinical criteria. Donors who underwent a biopsy were older (P < .001) and had a worse glomerular filtration rate (GFR; P = .001). Comparing donors approved and rejected by the biopsy, the rejected donors were heavier (P = .003) and had a lower GFR (P = .002). Cold ischemia time was longer for the biopsy group (P < .001). Regarding graft function, the biopsy overall score correlated with the transplant outcome in the short and long term. Separately, glomeruli and interstitium scores were correlated with recipient's GFR in the earlier periods (3 months; P = .025 and .037), and the arteries and tubules correlated with GFR in the longer term (at 3 years P = .004 and .010). CONCLUSION The decision on the usability of ECD grafts is complex. At our center, we chose a mixed approach based on donor risk. Low-risk ECD do not require biopsy. In more complex situations, especially older donors or those with a lower GFR, prompted a pretransplant biopsy. The biopsy results proved to be useful as they relate to subsequent transplant outcomes, thereby allowing us to exclude grafts whose function would most probably be less than optimal.
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Affiliation(s)
- E Tavares da Silva
- Urology and Renal Transplantation Department, Coimbra's Hospital and University Center, Coimbra, Portugal.
| | - R Oliveira
- Pathology Department, Coimbra's Hospital and University Center, Coimbra, Portugal
| | - D Castelo
- Urology and Renal Transplantation Department, Coimbra's Hospital and University Center, Coimbra, Portugal
| | - V Marques
- Urology and Renal Transplantation Department, Coimbra's Hospital and University Center, Coimbra, Portugal
| | - V Sousa
- Pathology Department, Coimbra's Hospital and University Center, Coimbra, Portugal
| | - P Moreira
- Pathology Department, Coimbra's Hospital and University Center, Coimbra, Portugal
| | - P Simões
- Urology and Renal Transplantation Department, Coimbra's Hospital and University Center, Coimbra, Portugal
| | - C A Bastos
- Pathology Department, Coimbra's Hospital and University Center, Coimbra, Portugal
| | - A Figueiredo
- Urology and Renal Transplantation Department, Coimbra's Hospital and University Center, Coimbra, Portugal
| | - A Mota
- Urology and Renal Transplantation Department, Coimbra's Hospital and University Center, Coimbra, Portugal
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15
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Lledó-García E, Riera L, Passas J, Paredes D, Morales JM, Sánchez-Escuredo A, Burgos-Revilla FJ, de Andrés Belmonte A, Oppenheimer F, Rodríguez-Ferrero ML, Solé M, Matesanz R, Valentín M, Pascual J. Spanish consensus document for acceptance and rejection of kidneys from expanded criteria donors. Clin Transplant 2014; 28:1155-66. [PMID: 25109314 DOI: 10.1111/ctr.12434] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2014] [Indexed: 01/20/2023]
Abstract
In the recent years, more than 60% of available deceased donors are either older than 50 yr or have significant vascular comorbidities. This makes the acceptance and rejection criteria of renal allografts very rigorous, especially in cases of younger recipients, and at the same time encourages live donations. In our country, there is a lack of homogeneity in the percentages of use of expanded criteria donor (ECD) allografts between the different autonomous communities. Furthermore, the criteria vary greatly, and in some cases, great importance is given to the biopsy while in others very little. In this study, we present a unified and homogenous criteria agreed upon by consensus of a 10-member Panel representing major scientific societies related to renal transplantation in Spain. The criteria are to be used in accepting and/or rejecting kidneys from the so-called ECDs. The goal was to standardize the use of these organs, to optimize the results, and most importantly to provide for the maximum well being of our patients. Finally, we believe that after taking into account the Panel's thorough review of specific scientific literature, this document will be adaptable to other national renal transplant programmes.
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16
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Preoperative assessment of the deceased-donor kidney: from macroscopic appearance to molecular biomarkers. Transplantation 2014; 97:797-807. [PMID: 24553618 DOI: 10.1097/01.tp.0000441361.34103.53] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Variation in deceased-donor kidney quality can significantly affect outcomes after kidney transplantation. Suboptimal organ selection for a given recipient can result in primary nonfunction, premature graft failure, or inappropriate discard of a suitable organ. Appraisal and appropriate selection of deceased-donor kidneys for use in transplantation is therefore critical. A number of predictive tools have been developed to assist the transplant team in evaluating the suitability of a deceased-donor kidney for transplantation to a given recipient. These include stratification of donors into "standard-" or "expanded-criteria" categories based on clinical parameters, pre-implantation biopsy scores, donor risk scores, machine perfusion characteristics, functional kidney weight, donor biomarkers and molecular diagnostic tools, ex vivo viability assessment using postmortem normothermic perfusion, and overall macroscopic appraisal by the surgical team. Consensus as to the role and predictive value of each of these tools is lacking and clinical practice regarding evaluation and selection of kidneys varies considerably.In this review, we seek to critically appraise the literature and evaluate the levels of evidence for tools used to assess deceased-donor kidneys. Although a plethora of appraisal tools exist, very few demonstrate desirable predictive power to be useful in clinical decision-making. Further research using large, well-designed prospective studies is urgently needed to advance this important field of transplantation science.
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Pre-implant biopsy predicts outcome of single-kidney transplantation independent of clinical donor variables. Transplantation 2014; 97:426-32. [PMID: 24285339 DOI: 10.1097/01.tp.0000437428.12356.4a] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pre-implant biopsy findings account for the discard of many donor kidneys although their clinical value is not fully understood. We retrospectively investigated the predictive value of pre-implant histology, which in our center was obtained for protocol purposes, not for transplant decisions, on long-term allograft and recipient outcome after single-kidney transplantation. METHODS This single-center study included 628 consecutive adult recipients of 174 Expanded Criteria Donor (ECD) and 454 Standard Criteria Donor kidneys. Chronic donor organ injury was assessed applying a chronic lesion score differentiating between mild, moderate, and severe histologic organ injury based on the integration of glomerular, vascular, tubular, and interstitial lesions. Recipients were followed over a median time of 7.8 years. RESULTS Donor kidneys exhibiting mild or moderate chronic lesions yielded almost identical graft and recipient survival independent of ECD status or other clinical covariables (HR 1.20, 95% CI 0.83-1.74, P=0.326, and HR 1.27, 95% CI 0.83-1.95, P=0.274, respectively). However, if allograft injury was severe, occurring in 3% of transplanted kidneys, graft and recipient survival was significantly reduced (HR 3.13, 95% CI 1.61-6.07, P<0.001 and HR 2.42, 95% CI 1.16-5.04, P=0.005, respectively). CONCLUSION The results suggest that donor kidneys displaying moderate chronic injury can safely be transplanted as single kidneys, while organs displaying severe injury should be discarded. Thus, pre-implant biopsy might offer an effective approach to increase the utilization of renal donor organs, especially from ECD and donors with cerebrovascular accident as cause of death, and to improve overall graft outcome.
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18
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Lionaki S, Kapsia H, Makropoulos I, Metsini A, Skalioti C, Gakiopoulou H, Zavos G, Boletis JN. Kidney transplantation outcomes from expanded criteria donors, standard criteria donors or living donors older than 60 years. Ren Fail 2014; 36:526-33. [PMID: 24456131 DOI: 10.3109/0886022x.2013.876348] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To evaluate outcomes in kidney allograft recipients from donors with expanded criteria (ECD) versus standard criteria (SCD) or living donors (LD) >60 years. METHODS We studied all patients who received a kidney between 2005 and 2011, focusing in recipients of kidneys from deceased ECD, SCD and LD >60 years. ECD was any deceased donor >60 years or >50 years with two of the following: hypertension (HTN), stroke as the cause of death, or serum creatinine >1.5 mg/dL. We recorded characteristics of the transplant procedure, patient, graft survival and renal function 1 year after transplantation and at the end of follow-up. RESULTS Six-hundred and five patients were transplanted between 2005 and 2011 in our department. There were 142 (25.1%) transplantations from ECD, 192 (33.98%) from SCD and 96 (16.99%) from LDs older than 60 years. In a mean follow-up time of 36.4 months, graft survival rates were similar for all groups. Calculated GFR was found statistically different between the ECD and SCD groups, but still satisfactory at first year, and at end of follow-up time. Comparison of the patients, who received transplants from ECD, even older than 70 years, and those from LD >60 years revealed equivalent renal function in short and long term. CONCLUSIONS Utilization of marginal kidneys effectively doubled our deceased transplant volume in the period 2005-2011. Patients' and graft survival were shown similar at the end of follow-up for all groups. Renal outcomes were shown equivalent between the ECD and LD >60 years groups, and although significantly lower between the ECD and the SCD group, were still very satisfactory.
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Affiliation(s)
- Sophia Lionaki
- Nephrology and Transplantation Department, Laiko Hospital , Athens , Greece and
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Abstract
PURPOSE OF REVIEW To provide an up-to-date overview about the assessment of donor biopsies and to discuss the current problems and chances of preimplantation biopsies for transplant allocation with a focus on the technical work up and the histological variables scored. RECENT FINDINGS Preimplantation biopsy results are the major reason for discarding procured extended donor criteria kidneys in the USA. There is neither a consensus on the work up, nor the reporting of preimplantation donor biopsies, nor the importance of the biopsy findings in the process of allocation. The best available data have been collected in the context of single vs. double kidney transplantation. A clinical risk factor score may help to define kidneys when a preimplantation biopsy is warranted. Punch biopsies using a skin punch device appear to be a reasonable alternative for surgeons fearing needle biopsies. SUMMARY Donor biopsies are very useful as zero-hour biopsies establishing baseline information for comparison with subsequent transplant biopsies. As none of the histological variables and scores provides perfect prediction, preimplantation biopsy results have to be interpreted in the context of all available donor and recipient information.
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Pierobon ES, Sefora PE, Sandrini S, Silvio S, De Fazio N, Nicola DF, Rossini G, Giuseppe R, Fontana I, Iris F, Boschiero L, Luigino B, Gropuzzo M, Maria G, Gotti E, Eliana G, Donati D, Donato D, Minetti E, Enrico M, Gandolfo MT, Teresa GM, Brunello A, Anna B, Libetta C, Carmelo L, Secchi A, Antonio S, Chiaramonte S, Stefano C, Rigotti P, Paolo R. Optimizing utilization of kidneys from deceased donors over 60 years: five-year outcomes after implementation of a combined clinical and histological allocation algorithm. Transpl Int 2013; 26:833-41. [PMID: 23782175 DOI: 10.1111/tri.12135] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 11/02/2012] [Accepted: 05/16/2013] [Indexed: 01/16/2023]
Abstract
This 5 year observational multicentre study conducted in the Nord Italian Transplant programme area evaluated outcomes in patients receiving kidneys from donors over 60 years allocated according to a combined clinical and histological algorithm. Low-risk donors 60-69 years without risk factors were allocated to single kidney transplant (LR-SKT) based on clinical criteria. Biopsy was performed in donors over 70 years or 60-69 years with risk factors, allocated to Single (HR-SKT) or Dual kidney transplant (HR-DKT) according to the severity of histological damage. Forty HR-DKTs, 41 HR-SKTs and 234 LR-SKTs were evaluated. Baseline differences generally reflected stratification and allocation criteria. Patient and graft (death censored) survival were 90% and 92% for HR-DKT, 85% and 89% for HR-SKT, 88% and 87% for LR-SKT. The algorithm appeared user-friendly in daily practice and was safe and efficient, as demonstrated by satisfactory outcomes in all groups at 5 years. Clinical criteria performed well in low-risk donors. The excellent outcomes observed in DKTs call for fine-tuning of cut-off scores for allocation to DKT or SKT in high-risk patients.
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Affiliation(s)
- Elisa Sefora Pierobon
- Kidney - Pancreas Transplant Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Pierobon Elisa Sefora
- Kidney - Pancreas Transplant Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
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Hoogland ERP, Snoeijs MGJ, Habets MAW, Brandsma DS, Peutz-Kootstra CJ, Christiaans MHL, van Heurn LWE. Improvements in kidney transplantation from donors after cardiac death. Clin Transplant 2013; 27:E295-301. [PMID: 23464536 DOI: 10.1111/ctr.12107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2013] [Indexed: 11/29/2022]
Abstract
To reduce the growing waiting list for kidney transplantation, we explored the limits of kidney transplantation from donors after cardiac death by liberally accepting marginal donor kidneys for transplantation. As the percentage of primary non-function (PNF) increased, we evaluated our transplantation program and implemented changes to reduce the high percentage of PNF in 2005, followed by a second evaluation over the period 2006-2009. Recipients of a kidney from a donor after cardiac death between 1998 and 2005 were analyzed, with PNF as outcome measure. During the period 2002-2005, the percentage of PNF increased and crossed the upper control limits of 12% which was considered as unacceptably high. After implementation of changes, this percentage was reduced to 5%, without changing the number of kidney transplantations from donors after cardiac death. Continuous monitoring of the quality of care is essential as the boundaries of organ donation and transplantation are sought. Meticulous donor, preservation, and recipient management make extension of the donor potential possible, with good results for the individual recipient. Liberal use of kidneys from donors after cardiac death may contribute to a reduction in the waiting list for kidney transplantation and dialysis associated mortality.
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Affiliation(s)
- E R Pieter Hoogland
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
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Bago-Horvath Z, Kozakowski N, Soleiman A, Bodingbauer M, Mühlbacher F, Regele H. The cutting (w)edge--comparative evaluation of renal baseline biopsies obtained by two different methods. Nephrol Dial Transplant 2012; 27:3241-8. [PMID: 22492825 DOI: 10.1093/ndt/gfs066] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The assessment of donor-derived damage of transplanted kidneys might be instrumental for estimating donor organ quality and for predicting short- and long-term organ outcome. In the present study, we report a new standardized method for obtaining pre-transplant kidney biopsy specimens. Instead of taking wedge biopsies (WBs), a skin punch biopsy (PB) tool was utilized to obtain standardized biopsy samples that also represented deeper cortical zones. METHODS We compared 147 PB specimens and 114 WBs with respect to the number of glomeruli and arterial vessels they contained. The performance of the two biopsy methods in detecting glomerular damage, interstitial fibrosis/tubular atrophy (IF/TA) and arteriosclerosis was determined by evaluation of subsequent transplant core biopsies of the patients. Statistical comparison employed Kruskal-Wallis and kappa (κ) tests. RESULTS Significantly more PB samples (89%) than WBs (66%) were diagnostically adequate according to the Banff criteria. Despite a higher number of glomeruli in WBs (34.6 versus 21.7 in punch biopsies), arteries were present in only 68% of WBs but could be found in 93% of punch biopsies. The comparison of findings in pre-transplant biopsies with lesions in corresponding post-transplant core biopsies revealed a superior diagnostic concordance for IF/TA and arteriosclerosis for punch biopsies than for WBs, reaching kappa values of 0.823 versus 0.729 and 0.661 versus 0.516, respectively. CONCLUSION The use of skin PB tools for obtaining baseline biopsies from transplanted kidneys is a safe and effective method for assessment of donor-derived damage of the organ.
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Gelens MACJ, Steegh FMEG, van Hooff JP, van Suylen RJ, Nieman FHM, van Heurn LWE, Peutz-Kootstra CJ, Christiaans MHL. Immunosuppressive regimen and interstitial fibrosis and tubules atrophy at 12 months postrenal transplant. Clin J Am Soc Nephrol 2012; 7:1010-7. [PMID: 22490875 DOI: 10.2215/cjn.09030911] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Chronic renal transplant dysfunction is histopathologically characterized by interstitial fibrosis and tubular atrophy. This study investigated the relative contribution of baseline donor, recipient, and transplant characteristics to interstitial fibrosis and tubular atrophy score at month 12 after renal transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective study includes all 109 consecutive recipients with adequate implantation and month 12 biopsies transplanted between April of 2003 and February of 2007. Immunosuppression regimen was tacrolimus and steroids (10 days) plus either sirolimus or mycophenolate mofetil. RESULTS Average interstitial fibrosis and tubular atrophy score increased from 0.70 to 1.65 (P<0.001). In an adjusted multiple linear regression analysis, interstitial fibrosis and tubular atrophy score at month 12 was significantly related to donor type (donors after cardiac death versus living donor had interstitial fibrosis and tubular atrophy score+0.41, 95% confidence interval=0.05-0.76, P=0.02), baseline interstitial fibrosis and tubular atrophy, and immunosuppression regimen. Because of interaction between the latter two variables (P=0.002), results are given separately: recipients with a baseline interstitial fibrosis and tubular atrophy score of zero had a 0.60 higher score at month 12 (95% confidence interval=0.09-1.10, P=0.02) when mycophenolate mofetil-treated, whereas recipients with a baseline interstitial fibrosis and tubular atrophy score more than zero had a 0.38 higher score at month 12 (95% confidence interval=0.01-0.74, P=0.04) when sirolimus-treated. A higher score at month 12 correlated with a lower estimated GFR (ρ=-0.45, P<0.001). CONCLUSIONS These findings suggest that histologic assessment of a preimplantation biopsy may guide choice of immunosuppresion to maximize transplant survival and its interaction with type of immunosuppression.
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Affiliation(s)
- Mariëlle A C J Gelens
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Abstract
Acute kidney injury occurs with kidney transplantation and too frequently progresses to the clinical diagnosis of delayed graft function (DGF). Poor kidney function in the first week of graft life is detrimental to the longevity of the allograft. Challenges to understand the root cause of DGF include several pathologic contributors derived from the donor (ischemic injury, inflammatory signaling) and recipient (reperfusion injury, the innate immune response and the adaptive immune response). Progressive demand for renal allografts has generated new organ categories that continue to carry high risk for DGF for deceased donor organ transplantation. New therapies seek to subdue the inflammatory response in organs with high likelihood to benefit from intervention. Future success in suppressing the development of DGF will require a concerted effort to anticipate and treat tissue injury throughout the arc of the transplantation process.
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Affiliation(s)
- Andrew Siedlecki
- Nephrology Division, Department of Internal Medicine, Washington University in St. Louis School of Medicine, St Louis, MO
| | - William Irish
- CTI, Clinical Trial and Consulting Services, Raleigh, NC
| | - Daniel C. Brennan
- Nephrology Division, Department of Internal Medicine, Washington University in St. Louis School of Medicine, St Louis, MO
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Graft quality assessment in kidney transplantation: not an exact science yet! Curr Opin Organ Transplant 2011; 16:174-9. [PMID: 21383549 DOI: 10.1097/mot.0b013e3283446b31] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW The enduring donor shortage necessitates the development of tools capable of objectively assessing kidney graft quality and thereby allowing the safer and wider use of expanded criteria donors and kidneys donated after cardiac death. We summarize current assessment tools available prior to procurement and during preservation. RECENT FINDINGS Several donor risk scores, combining donor and recipient risk factors of inferior graft outcome, exist but all lack predictive power. Histological scoring of glomerulosclerosis, tubular atrophy, interstitial fibrosis, and vascular damage in pretransplantation kidney biopsies can supply reliable, reproducible data on the actual kidney state but prospective data on their use in graft assessment are lacking. Renal resistance and certain perfusate biomarker concentrations during machine perfusion are independent risk factors of delayed graft function, but neither method has sufficient predictive power to allow kidney discard. SUMMARY Available tools for graft quality assessment have their intrinsic value but none offer the necessary power to predict graft outcome for a specific donor-recipient pair. This is probably due to the multitude of donor, preservation, and recipient factors at stake. Only combining these factors might improve prediction of graft outcome and allow safer use of expanded criteria donors and kidneys donated after cardiac death.
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