UK National Renal Transplant EQA Scheme

Ian Roberts

Department of Cellular Pathology,

Oxford Radcliffe Hospitals

The National Renal Transplant EQA Scheme is sponsored by Fujisawa Ltd

EQA in Histopathology

• maintenance & improvement of diagnostic standards

• education vs performance assessment

• required for CPD and CPA

• RCPath EQA steering committee -

sets performance standards

investigates substandard performance

EQA in Histopathology

• substandard performance:

anonymous letter of enquiry

NQA Advisory panel informed and determine whether low EQA scores reflect standards of routine practice

site visit

review panel

Medical Director informed

EQA in Histopathology

“ these procedures should be activated only in exceptional circumstances, and should cause no more concern to EQA participants than the possibility of being reported for incompetence by a colleague”

slides circulated to participants

responses submitted to scheme organiser

feedback of group diagnoses to participants

cases discussed at participants meeting

diagnoses scored

persistent substandard performers identified

remedial action

EQA in Histopathology

slides circulated to participants

responses submitted to scheme organiser

feedback of group diagnoses to participants

cases discussed at participants meeting

Renal Transplant EQA Scheme

slides circulated to participants

responses submitted to scheme organiser

feedback of group diagnoses to participants

cases discussed at participants meeting

diagnoses scored

persistent substandard performers identified

remedial action

Renal Transplant EQA Scheme

• 44 participants from 31 centres

• Case submission:

7 sets of slides (H&E and PAS/silver)

diagnostic lesion is present in all slides

biopsy is adequate by Banff criteria

NATIONAL RENAL TRANSPLANT EQA SCHEMECASE SUBMISSION FORM

Provided by: Original lab No.

Donor age Transplant date

Recipient age Biopsy date

Best creatinine Creatinine at biopsy

Donor type cadaveric Cause of recipientÕs renal failure(tick) living

non-heart beating

Delayed graft function Y / N HLA mismatches

Immunosuppressive regimen:

Prednisolone Mycophenolate

Azathioprine ATG, etc

Cyclosporine Other (please specify below)

FK/Prograf

Number of previous acute rejections

Is this acute rejection? (retrospective diagnosis when follow-up makes it clearwhat the ÒtrueÓ diagnosis is)

Major diagnosis

Supplementary diagnosis

Banff codes

Clinical information available at the time the original report was produced:

Clinical follow-up:

Renal Transplant EQA Scheme

• participants divided into 6 cells

• Circulations organised using Genpath software:

sets circulation dates

automatic reminder letters

RESPONSE SHEET Please return to the EQA secretary: Mrs Lynn Bradbury

NB: Please write something in every box, either a precise number (not more or less than),+/- or Banff score, as indicated.

Participant code number Circulation letter Case number

Information provided Slides

Tubules Interstitium

Tubulitis (Banff t0-3) oedema (+/-)

Tubules with tubilitis/10 hpf mononuclear cell infiltration (%) (number)Tubular atrophy (%) nucleolated lymphocytes (+/-)

Glomeruli eosinophils (+/-)

Glomerulitis (Banff g0-3) neutrophils (+/-)

Other interstitial haemorrhage (%)

Vessels interstitial fibrosis (%)

Intimal/transmural arteritis(Banff v0-3)Arteriolitis (+/-)

Arteriolar hyalinosis (Banff 0-3)

Major diagnosis

Supplementary diagnosis

Banff codes

Comments

Educational value

• enables pathologists to compare their diagnoses and their Banff grading with the whole group

• identifies differences in use of terminology

• identifies misunderstanding of the Banff classification and its application

• ongoing measure of the reproducibility of Banff criteria

• highlights areas of diagnostic difficulty

TerminologyCase 4 Number of responses 26

Diagnoses Numberacute rejection* 22Banff IB 11Banff IA 5Banff I 3severe acute rejection 4III 1chronic nephropathy 1interstitial nephritis 1

*acute cellular rejection 9*acute rejection, grade 1 6*acute tubulointerstitial rejection 3*acute rejection NOS 1*acute parenchymal rejection 1*acute tubular rejection 1*active rejection 1*severe acute rejection, 4I 1

ApplicationCase 5 Number of responses 26

Diagnoses Numberacute rejection* 13Banff IA 9Banff IB 1Banff II 1borderline changes* 6no rejection (infection 6, ATN4) 7

*On the basis of the Banff t and i scores provided:acute rejection 6borderline changes 13

Supplementary diagnosesinfection 20acute tubular necrosis 8donor vascular disease 6?CyA toxicity 2

Reproducibility

0%

20%

40%

60%

80%

100%

I t g vBanff criteria

Case 6

3

2

1

0

Reproducibility

mononuclear cell interstitial inflammation i1 (i2,t0,v0)

acute cellular rejection, type IA (i1,t1,v1)

acute rejection mild grade 1 (i1,t2,v0)

acute rejection, typeIA

acute rejection, typeIIA

acute rejection, typeIIB

acute vascular rejection, NOS

1

1

1

1

15

8

1

acute tubular necrosis

donor vascular disease

2

1

Case 21

Reproducibility

Case 22 borderline changes/suspicious of rejection

acute rejection, typeIA (i2/3,t1,v0)

acute rejection, typeIA

acute rejection, typeIB

severe acute parenchymal rejection, type IIA (i3,t2,v0)

acute rejection, moderate grade 2 (i3,t3,v0)

acute cellular rejection

chronic allograft nephropathy

?polyoma virus infection

3

5

9

3

1

1

1

4

1

CAN

?CsA/tacrolimus toxicity

acute tubular injury

arteriolitis

7

2

1

1

Difficult diagnoses

acute pyelonephritis, no rejection

borderline changes/suspicious of rejection

acute rejection (i?,t1)

acute rejection, typeIA

acute rejection, typeIB

chronic allograft nephropathy

inadequate specimen

Case 23 11

4

1

9

1

1

1

12

8

4

2

1

1

acute pyelonephritis

donor vascular disease

chronic allograft nephropathy

CsA toxicity

exclude obstruction

?interstitial nephritis

Difficult diagnoses

Case 25 hyperacute rejection 6

antibody-mediated rejection (Banff 2B) 2

acute rejection, typeIIB ?antibody mediated 1

acute rejection, typeIII 6

infarction ?large vessel thrombosis ?antibody-mediated rejection 7

arterial/venous thrombosis +/- infarction 2

macroscopic polyangiitis/vasculitis with infarction 3

Renal Transplant EQA Scheme

• identifies practical difficulties in the application of the Banff schema in routine practice

• identifies areas of diagnostic difficulty that should be specifically addressed in the future

Renal Transplant EQA Scheme

• identifies practical difficulties in the application of the Banff schema in routine practice

• identifies areas of diagnostic difficulty that should be specifically addressed in the future

• for the patients:

improves the diagnostic accuracy of the pathologist looking at their biopsy