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Defining Preimplantation Renal Allograft Quality
Is biopsy: helpful or harmful?
Michael J. Goldstein MD
Director, Kidney/Pancreas Transplantation
RMTI/Mount Sinai Medical Center
Strategies for Defining Preimplantation Renal Allograft
Quality
• Donor demographics and history• Donor renal function• Medical management of the donor• Renal anatomy• Renal histology• Machine perfusion characteristics
Strategies for Improving Organ Assessment - KDRI
• Sixteen clinical trials• involving 8,122 kidney transplants • 6 were prospective studies.
Strategies for Improving Organ Assessment - Biopsy
CONCLUSIONS
• Early graft outcome which may affect long-term outcomes, such as DGF and ATN, is associated more with abnormal IB histology.
• The relative impact of GS, IF, and arteriolar hyalinosis present in IB on long- term graft outcome remains limited to the extent that the prognostic information obtained from IB can be modified by other donor and recipient factors. Post-transplant biopsies are usually required to enhance the use of IB to predict the long-term outcomes. As such, no accurate single consistent proxy has so far been identified in the IB to accurately predict long-term graft outcome.
Strategies for Improving Organ Assessment - Biopsy
Strategies for Improving Organ Assessment - Biopsy
Sharing the Biopsy Results
Wedge biopsy technique
Core-Needle biopsy technique
Imported or “undesirable” kidney experience
• July 2005 to June 2006• 107 patients transplanted with 117
imported kidneys
0
10
20
30
40
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60
Undesirable Donor Risk Factors
ECDTerm Creat >1.5Arterial plaqueBiopsy GS >10%Pump flowHigh risk behaviorAge>65SerologyParenchymal injury/Mult vesselsInfection
%
Strategies to Transplant More Kidneys
• Broaden acceptance criteria for GS
0
20
40
60
80
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120
140
Creatinine Clearance for Control (N=88) vs Allografts with GS>10% (N=24)
cc/m
in
1M 3M 6M 1Y
Con GS Con GS Con GS Con GS
Biopsy Failures
• Differences in techniques• Frozen section artifacts• Experience and training of pathologist• Lack of standardization of reports
46yo man creat 1.4-2.0, CVA, no PMH
Machine Measured Renal Resistance
Strategies for Improving Organ Assessment – Renal Resistance and Biopsy
Predicted Probability Plots
The ordinal regression demonstrates significance when scarring is 25-50% (p=0.02), no significance between MMRR and vascular narrowing, as well with glomerulosclerosis
P=0.62 P=0.02.1.2
.3.4
.5P
redi
cte
d P
rob
abili
ties
<10% 11-25% 26-50%Scarring
resistance <0.2 resistance 0.2-0.3resistance >0.3
Predicted Probabilities: Resistance at 5 hours v. Scarring %
P=0.46 P=0.01
.1.2
.3.4
.5P
redi
cte
d P
rob
abili
ties
<10% 11-25% 26-50%Scarring %
resistance <0.2 resistance 0.2-0.3resistance >0.3
Predicted Probabilities: Resistance at 3 hours v Scarring %
P=0.15 P=0.66.1.2
.3.4
.5P
redi
cte
d P
rob
abili
ties
<10% 11-25% 26-50%Vasc. Narrowing %
resistance <0.2 resistance 0.2-0.3resistance >0.3
Predicted Probabilities: Resistance at 5 hours v Vasc. Narr. %
P=0.29 P=0.51
.1.2
.3.4
.5P
redi
cte
d P
rob
abili
ties
<10% 11-25% 26-50%Vasc. Narrowing %
resistance <0.2 resistance 0.2-0.3resistance >0.2
Predicted Probabilities: Resistance at 3 hours v. Vasc. Narr. %
P=0.40.1.2
.3.4
.5
0 10 20 30 40 50 60 70Glomeruli Obsolete%
resistance <0.2 resistance 0.2-0.3resistance >0.3
Predicted Probabilities: Resistance at 3 hours v. Glom. %
P=0.06.1.2
.3.4
.5
0 10 20 30 40 50 60 70Glomeruli Obsolete%
resistance <0.2 resistance 0.2-0.3resistance >0.3
Predicted Probabilities: Resistance at 5 hours v. Glom. %
Glomerulosclerosis Vascular NarrowingTubulointerstitial Scarring
Strategies for Improving Organ Assessment – Renal Resistance and Biopsy
Policy Creation
Policy Creation
Conclusions• Donor history, function, biopsy, and renal
resistance are all interrelated• All 4 are useful tools in defining donor renal
allograft quality prior to transplantation• The biopsy technique, processing, and the
histologic report can lead to errors in reporting and interpretation of data.
• We should strive to have consistency in reporting by experienced renal pathologists
• Biopsy alone, with other favorable predictors, should be questioned before an organ is declined
