Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions
The study aimed to identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy before transplant is selectively performed to identify chronic or irreversible organ damage.
A recent analysis of United States transplants registry data (2005–2014) for kidneys with a kidney donor profile index >85% found that discards rose from 34% with 0%–10% GS to 77.4% with > 20% GS
But among kidneys transplanted, 5-year death-censored graft survival differences were: 75.8% for 0%–10% GS, 70.9% for > 10% GS, and 74.8% for kidneys without biopsy.
The frozen section biopsy helps in the selection of organs for transplantation. However, general pathologist evaluation may not correlate with outcomes, and expert pathologists may preclude up to 20% of examined kidneys.
Studies found that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard. An assessment of agreement between 3 renal pathologists in reading 100 photomicrographs of frozen section biopsy images found moderate agreement on GS but poor agreement on fibrosis and acute tubular injury.
The artificial intelligence system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%.
Despite 20 years of data found that biopsies performed at the time of kidney recovery did not correlate with the eventual outcome of renal allografts, >50% of kidneys removed for transplant still undergo a biopsy.
Please reflect on your practice
Our deceased donor program do not do selection through kidney biopsy as it may take a longer time and the scarcity of donor pool make us not to consider kidney biopsy which directly will increase the discard rate.
Mohamed Fouad
2 years ago
Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions
The ongoing shortage of organs available for transplant contributes to prolonged waiting times, death on the waiting list, and higher costs of care for patients with ESKD. To identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify chronic or irreversible organ damage. The primary reason given for discarding a kidney removed for transplant is “quality,” a determination frequently made based on frozen section biopsy results.
The use of frozen section biopsy results to guide organ acceptance decisions has been widely and appropriately challenged. Frozen section biopsies are generally limited to review of a few sections using hematoxylin and eosin staining and may be evaluated by on-call pathologists who lack specialized renal pathology training.
To address the limitations inherent in pretransplant biopsy results, multiple scoring systems have been developed, combining various pathologic findings (with or without additional donor factors) to better predict likelihood of early graft failure. The 2014 Maryland Aggregate Pathology Index (MAPI) was developed based on wedge biopsies to combine GS, arterial wall-to-lumen ratio, scar/fibrosis in at least ten tubules, and arteriolar hyalinosis.9 Increasing scores were associated with similar 1-year survival but reduced 3-year survival.
Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, .50% of kidneys removed for transplant still undergo a biopsy. Obtaining a biopsy is strongly associated with kidney discard rates. Pursuit of evidence to guide appropriate biopsy use and development of strategies to improve the quality of kidneys at higher risk for discard (intervention research), motivate acceptance, and expedite placement are vital priorities to reduce unnecessary discard and increase access to transplant for patients in need
Mohammed Sobair
2 years ago
To identify kidneys at risk of primary nonfunctional or early graft failure, frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify chronic or irreversible organ damage.
The discard rate of recovered, potentially transplantable kidneys in the United States increased markedly in the late 1990s, and remains at approximately 20%.
The primary reason given for discarding a kidney removed for transplant is “quality,” a determination frequently made based on frozen section biopsy results.
After adjustment for donor factors and organ procurement organization characteristics, performance of a glomerular sclerosis (GS) MORE THAN 20%, Kidney biopsy is associated with more than three times the odds of kidney discard.
Its associated with 87% experienced delayed graft function, and 38% developed graft failure within 6 months, but less difference in regard of 5 years death censored graft survival.
. Thus, selected kidneys with high GS can offer benefit to patients on the waiting list with outcomes superior to dialysis.
These and other studies support the conclusion that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
The AI system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%..
Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, .50% of kidneys removed for transplant still undergo a biopsy. Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age and kidney donor profile index).
Pursuit of evidence to guide appropriate biopsy use and development of strategies to improve the quality of kidneys at higher risk for discard (intervention research), motivate acceptance, and expedite placement are vital priorities to reduce unnecessary discard and increase access to transplant for patients in need.
Please reflect on your practice
In our practice we don’t used cadaveric kidney transplant ,till now but there is plan in the
future, may be more evidence will come out ,but i think more reliability on clinical ground
Hamdy Hegazy
2 years ago
Please provide a summary of this article
Fifth of potentially transplantable kidneys in the USA are rejected because of frozen section biopsy findings. Pre-transplant biopsy of 65 kidneys revealed that delayed graft function was seen in 87% and graft failure within 6 months was noticed in 38% of kidneys with more than 20% glomerulosclerosis (GS). There was no difference in 5 years graft survival between kidneys without pre-transplant biopsy and those with 0%-10% GS and more than 10 % GS in pre-transplant biopsies. Frozen section biopsies limitations: 1- Few sections using H&E stain. 2- Sometimes done by on-call pathologist who is not expert in renal pathology. 3- 1/5 were considered not transplantable by on call pathologist then were deemed transplantable after being reviewed by expert pathologist. Other scoring system have been developed like MAPI, However, they were not able to predict the risk of DGF or graft loss. The artificial intelligence system lowered the percentage of inappropriately rejected grafts from 14% to 2%.
Please reflect on your practice
We don’t do pre-donation biopsy, and depend on clinical data.
Amit Sharma
2 years ago
Please provide a summary of this article
There is a demand-supply mismatch with respect to kidney transplant. The discard rate of kidneys is approximately 20% in USA. Performing a kidney biopsy increases the odds of discarding kidneys by 3 times. Kidneys with >20% glomerular sclerosis (GS) were shown to be associated with increased risk of delayed graft function and graft failure, leading to accepting the cut-off of >20% GS for discarding kidneys.
Recent analysis has shown that the graft survival did not differ much between those with no GS, GS >10%, and those transplanted without pre-transplant biopsy. Hence implanting kidneys with higher GS could be beneficial in certain patients as compared to remaining on waiting list.
Frozen section biopsies have their inherent drawbacks in form of small number of sections, evaluated by on-call non-renal pathologists, with poor inter-rater agreement. Hence relying on pathological findings alone leads to inappropriate organ discard. The Maryland Aggregate Pathology Index (MAPI), developed on the basis of GS, arterial wall-to-lumen ratio, arteriolar hyalinosis, and scar/fibrosis in at least 10 tubules in wedge biopsies did not correlate with graft dysfunction or graft failure.
Photomicrograph evaluation was also associated with disagreement among the pathologists. Artificial intelligence algorithms might help in this aspect. As a kidney biopsy is strongly associated with increased discard rate, it is recommended to curtail or discard use of biopsies in standard criteria donors, and biopsy alone should not be the criteria to discard the kidneys. A randomized controlled trial is the need of the hour to decide about the role of biopsy in deciding the decision to accept or reject an organ.
2. Please reflect on your practice
Ours is a living related transplant program, hence the need for this did not arise. But as and when we start a deceased donor program, the utilization of frozen section would be in a very selective group. The donor characteristics would be more important to decide it, like elderly donor, with history of long standing diabetes and hypertension (expanded criteria donors).
Hussam Juda
2 years ago
Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions
· To identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy before transplant is selectively performed to identify chronic or irreversible organ damage.
· A recent analysis of United States transplant registry data (2005–2014) for kidneys with a kidney donor profile index >85% found that discards rose from 34% with 0%–10% GS to 77.4% with > 20% GS
· However, among kidneys transplanted, 5-year death-censored graft survival differences were modest: 75.8% for 0%–10% GS, 70.9% for > 10% GS, and 74.8% for kidneys without biopsy.
· The frozen section biopsy helps in the selection of organs for transplantation.
· General pathologist evaluation may not correlate with outcomes, and expert pathologists may preclude up to 20% of examined kidneys.
· Many studies found that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
· An assessment of agreement between 3 renal pathologists in reading 100 photomicrographs of frozen section biopsy images found moderate agreement on GS but poor agreement on fibrosis and acute tubular injury.
· The artificial intelligence (AI) system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%.
· All current United States studies of biopsy results and outcomes are limited by selection bias.
· Despite 20 years of data found that biopsies performed at the time of kidney recovery did not correlate with the eventual outcome of renal allografts, >50% of kidneys removed for transplant still undergo a biopsy.
RESEARCH NEEDS
• Randomized controlled trials:
-Patient & surgeon acceptance of donor organs without biopsy
-Patient-centered outcomes (access to transplant, renal function, graft survival, patient survival)
• Validation of whole slide/multi-level review including AI-supported reading
Please reflect on your practice
We don’t have a deceased kidney donation program, and even for living kidney donation we never did a kidney biopsy before the transplant.
Wael Jebur
2 years ago
This article discussed thoroughly the current practice of havinf allograft biopsy before implantation to determine suitability and secure prognosis post transplantation. The common trend in daily practice was to perform allograft biopsy for deceased donors kidneys, and discard ones with glomerulosclerosis of more than 20 %. This common practice was stemmed from a study conducted in 1995 on 65 patients to examine pre implantation allograft biopsy findings in correlation to post transplant prognosis.They concluded that in 8 patients with more than 20 % glomerulosclerosis , prevalence of delayed graft function was noted in 87% and graft failure was observed in 38% within 6 months, henceforth , all kidnys biopsied pretransplant with more than 20 % glomerulosclerosis were discarded.With resultant potential loss of huge number of donated kidneys .This finding was not consistent on further and subsequent studies,
Furthermore, frozen biopsy credibility was frequently questioned as a mere indicator of allograft suitability .
In one recent study aimed at comparing clinical parameters in records of 496 diseased kidney donors whom having their kidneys discarded after allograft biopsy showed 20% glomerulosclerosis in USA to counterparts with matched parameters in Europe whom kidneys got transplanted without biopsy.surprisingly graft survival was 93, 80 and 68%,in 1 , 5 and 10 years respectively. in addition to that , skepticism was growing about credibility of allograft biopsy and the examination thereof.
Cumulative data over time are debating the validity of having biopsy of allograft prior to transplantation and its interpretation. As its hampering kidney transplantation from expanded pool of deceased kidney donors.
CARLOS TADEU LEONIDIO
2 years ago
Please provide a summary of this article
This article attempts to evaluate the efficiency of frozen section analysis of kidney biopsy prior to transplant to identify chronic or irreversible organ damage that may lead to the decision to discard the organ. However, factors such as: – low interclass correlation coefficient, mainly for glomerular sclerosis – limiting validation of pathologic scoring systems with large registry trials as detailed pathologic findings; – Marked variation in indication for biopsy, technique, and expertise in interpretation They led to an increase in the rate of discards of grafts, but without a significant increase in the prediction of results better than the clinical criteria already used. Despite this, apparently the use of Artificial Intelligence (AI) seems to be promising because it dramatically reduced the proportion of grafts inappropriately deemed not transplantable
2.Please reflect on your practice
If there were better results in identifying appropriate recipes using frozen section analysis of kidney biopsy In Brazil, we would have many difficulties, because the cost is high and the number of specialists is low, which would also end up being a limiting factor in the number of transplants, increasing the queue waiting time.
rindhabibgmail-com
2 years ago
There is 20 years data which shows that the graft biopsy may provide limited information about the outcomes. Biopsy may lead to higher discard rate up-to >20%.
there is huge waiting list of recipient to be transplanted.
Still we don’t use diseased organ donation.
Balaji Kirushnan
2 years ago
Many patients are waiting in the deceased donor cadaver list across various countires…Efforts are being tried to reduce the incidence of organ wasting due to so called poor quality of kidneys by performing implantation/procurement renal biopsies….The rate of implantation renal biopsy are varied according to various centers in the US ranging from 23-78%…Frozen section of the kidney biopsy samples have been done in the US from a long time…in 1995, a study was performed with frozen section biopsies on 65 kidneys…and they found that those with more than 20% of glomerulosclerosis are associated with 87% graft failure in 6 months…Based on this study many deceased donor kidneys were rejected with > 20% glomerulosclerosis….A more recent transplant data from the United states transplant registry for kidneys with KDPI >85% the discard rate rose from 34% with 0-10% glomerulosclerosis to 88.5% with 20% glomerulosclerosis However the death censored graft survival among were modest for those renal biopsies even with glomerulosclerosis ; 75.8% with 0-10% glomerulosclerosis and 74.5% with 10-20% glomerulosclerosis. So if we compare the waiting time on transplant this is acceptable and we may proceed…
The use of frozen section biopsies have been questioned and critically analyzed….The frozen sections are only a small representation of the entire kidney specimen.. Moreover the sections are reported only by the on call pathologists who may not be trained in renal pathology…There have been comparison studies and proven that kidneys which have been rejected by the percentage of GS or IFTA on a night call have been later shown to be accepted by another pathologist by a detailed examination..
In an effort to address this issue multiple scoring systems have been developed to predict the development of graft failure based on histopathology and donor factors….The Maryland Aggregate Pathology Index (MAPI) was developed on wedge biopsies to include glomerulosclerosis, arterial/wall lumen ratio, scar/fibrosis in 10 tubules and arteriolar hyalinosis…The scores were divided into high MAPI , intermediate MAPI and low MAPI score…The increasing scores were associated with similar 1 year survival rates but low 3 year and 5 year graft survival rates….But these pathological scoring systems were never reported in large trials and all the findings are not carefully reported across various centers…
Many centers have now started using Artificial Intelligence to reduce the rate of kidney rejection and increase the acceptance rate by integrating approach of various pathologists….
All the outcomes for the United states renal pathology reports are not accurate due to selection bias…The only transplanted organs are included in the analysis…To avoid the bias, they have compared organs to the Europe transplant centers where kidney biopsies were not done routinely before transplant and found that nearly 496 kidneys from the US were found to be associated with good 1 year and 5 year post transplant survival in Europe
In other words the use of protocol biopsies in isolation is not recommended to discard the kidneys…We have to use to donor clinical criteria and KDPI to assess the overall risk before the decision
Esraa Mohammed
2 years ago
Considerations for Defining Appropriate Use of Procurement Biopsies in Kidney Transplantation CURRENT STATE
• ≈ 100,000 Americans await kidney transplant
• ~ 20% recovered are kidneys discarded
• Biopsied kidneys are 3-times more likely to be discarded • Marked variation in indication for biopsy, technique, and expertise in interpretation • Limited reliability of standard frozen section biopsy and uncertain prognostic value
RESEARCH NEEDS • Randomized controlled trials:
• Patient & surgeon acceptance of donor organs without biopsy
• Patient-centered outcomes (access to transplant, renal function, graft survival, patient survival)
• Validation of whole slide/multi-level review including AI-supported reading
FUTURE STATE
• Selective use of biopsy to guide selection &placement of high-risk kidneys
• Less discrd of transplantable and potentially beneficial kidneys
• Expanded use of high-KDPI organs in appropriate candidates
Zahid Nabi
2 years ago
Expanding donor pool is the way to overcome organ shortage. In Europe almost 150000 patients are on waiting list and about 21 day each day waiting for a transplant.Discarding donor kidney after frozen section biopsy is considered standard operating procedure. Many of these kidneys be used if there is a uniform approach to address this issue.
Currently 100,000 Americans await kidney transplant
• 20% recovered kidneys are discarded
• Biopsied kidneys are 3-times more likely to
be discarded
• Marked variation in indication for biopsy, technique, and expertise in interpretation
• Limited reliability of standard frozen section biopsy and uncertain prognostic value.
Frozen section biopsies are generally limited to review of a few sections using hematoxylin and eosin staining and may be evaluated by on-call pathologists who lack specialized renal pathology training.
Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, .50% of kidneys removed for transplant still undergo a biopsy.
Appropriate use of biopsies to assess donor kidneys histology is very important to reduce discard rates. Trained Nephro Histo pathologist should be the one to evaluate these biopsies.
We don’t have a deceased donor program at our center so this will not have on any impact on our current practicing style.
Muntasir Mohammed
2 years ago
1. Please provide a summary of this article There is expanding deceased donor waiting list despite increasing number of transplantations from deceased donors. On the other side a lot of kidneys are discarded despite its need, reaching 20%. The main reason for discard is poor quality of the organ as found in the frozen section biopsy. There is significant variation in biopsy reporting between pathologist ranging from 23-75%. Performance of biopsy was found to be associated increasing rate of discarding. In 1995 a study of 65 kidneys, procurement biopsy and graft survival analysed. Glomerulosclerosis of 20% increase rate of delayed graft function to 87% and 38% of grafts failed within 6months. After this study a lot of kidneys were discarded. Recent USA study included data between 2005-2014, found high discard rate. But when analysed the difference between those kidneys with biopsies showing high glomerulosclerosis and those with less and those without biopsies, was modest, with 5 years graft survival between 70-80%. Thus, some of those discarded kidneys could have been transplanted and benefit those on the waiting list with better out come than dialysis. Frozen section biopsies have a lot of limitations and usually analysed by non-specialist on call whose assessment was found to increase discard rate unnecessary by 20%. Even among experts the interclass coefficient in frozen section was found to be poor 0.41, which far below the acceptable number of 0.75. Trials of making scoring systems on biopsies to give better results but did not correlate well with graft out comes. Sending photomicrographs to transplant centers although gave good corelation for glomerulosclerosis did not do for other finding. Artificial Intelligence in a pilot study showed better correlation waiting for further studies to confirm that. Most studies done in USA for biopsies have limitations somehow. When compared with similar transplanted kidneys from France and Belgium, discarded kidneys in USA could have given 93%, 80 % and 68% graft survival at one, five and 10years respectively. Thus, avoiding doing biopsy as much as possible may reduce discard rate. Also doing randomised controlled trial to better find the answer. 2. Please reflect on your practice Reducing procurement biopsies to reduce discard rate is the way to go. Exception may be those marginal kidneys with high suspicious of cortical necrosis.
Mahmud Islam
2 years ago
Kidney biopsy before transplantation was found to affect the discarding of more kidneys. The quality of kidneys was based on frozen biopsies. With the increase of discarding kidneys, the transplanted kidneys had modest graft survival after 5 years (U.S trans-plant registry data (2005–2014)). On-call pathologists’ reports based on wedge biopsies did not correlate with practising nephropathologists opinions. . sone biopsies were deemed suitable when re-evaluated. For that reason, soring systems like MAPI were developed.
Naglaa Abdalla
2 years ago
There is no deceased organ donation in our country, but Iam not supporting this approach as the history and clinical evaluation can be very helpful in taking decision whether to take the graft or not.
Naglaa Abdalla
2 years ago
Frozen section biopsy examination results can guide organ acceptance decision, which is widely used, has certain challenges like:
1- Limitation of the frozen sections reviewed in few seconds using hematoxylin and eosin staining.
2- It may be evaluated by unspecialized renal on-call pathologist.
A recent study found poor agreement on an aggregate overall kidney quality score.
20% of discarded renal grafts graded as unacceptable by on-call pathologists were found to be transplantable after being reviewed by trained pathologists.
Also the inter-rater agreement among those experts is limited.
In a seminal publication on the Banff histopathological
consensus criteria for preimplantation kidney biopsies, Liapis et al, reported the inter-rater agreement for a sample of 19 preimplantation biopsies (frozen and permanent) reviewed by 32 trained pathologists.
So there should be considerations and guidelines for this approach and definition of high risk kidney to minimize the discard of transplantable kidneys
Marius Badal
2 years ago
The article is one that demonstrates that the ongoing shortage of organs available for transplantation is limited and there is still an increasing number of patients on the waiting list, and the cost of dialysis remains elevated. This is why studies like extended criteria donors have been used and reviewed, and now to see how valuable the kidneys may be, the research on procurement biopsies in kidney transplantation is introduced to select kidneys that may seem not acceptable and as such be used once the biopsy reveals as acceptable. The study was conducted in 1995 of about 65 kidneys were used and pre-transplant biopsies were done. The study was to identify the risk of primary nonfunction kidneys, to see if there was an early risk of graft failure and finally to identify chronic kidney disease and if the damages were reversible. It was found that: 1) 8 kidneys were found with more than 20% with GS 2) About 87% developed DGF 3) 38% with time developed graft failure within a duration of 6 months. During the study, several problems were identified regarding whether or not to accept or reject the kidneys and they were: 1) The biopsy taken was limited to a section of the kidneys to review so there were a few sections only using the hematoxylin and eosin staining. 2) There was a lack of pathologists to review the biopsy and experiences were not as the mature pathologist. 3) As such the result or report given was not in accordance. With the different problems facing more studies and different kinds of predictive scoring were developed like the Maryland Aggregate Pathology Index (MAPI).
The study showed that the association between using scores and graft survival had controversial results and as such better ways to accept kidneys must be developed. There is now the artificial intelligence system that has been used and shows promising the study as it has demonstrated a reduction in the proportion of grafts that is not considered not usable from about 14% to 2%. So it must newer methods of organ testing must continue to develop as the need for organ transplantation is needed and increasing.
Currently, in my practice, there are no active kidney transplantations due to limited factors but using clinical and laboratory judgment is important and a kidney biopsy will greatly help to decide to transplant one or both kidneys based on what is seen.
Yashu Saini
2 years ago
This study discusses about the utility of pre implantation biopsy and how it can reduce the discard rates of the retrieved kidneys.
This study discusses the American population where there is significant shortage of the organs and waiting list is quite large.
Similarly, discard rates are also high to the tune of 20% when more and more marginal donors are being included from which non standard organs are retrieved.
primary reason of discard: poor ” quality” of organ as established on the basis of frozen section biopsy results.
Pre implantation kidney biopsy has increased the discard rates of the organ.
Kidneys with > 20% glomerulosclerosis are discarded. But the death centered graft survival showed minimal differences between kidneys with < 10% GS vs > 20% glomerulosclerosis are transplanted .
hence use of frozen section biopsies to guide the decision to accept or reject the organ has been widely challenged.
the main reason is that on call pathologists are non-specialty pathologists and their findings do not correlate with outcomes.
various scoring systems are also being devised to standardize the reporting of frozen section kidney biopsies but has not been much helpful.
But artificial intelligence algorithms likely provide promising future.
Conclusion
Obtaining a biopsy increases the discard rates
It does not augment the prediction of outcomes
A RCT of pre implantation biopsies is needed for further clarification
Abdul Rahim Khan
2 years ago
Please provide a summary of this article. There is shortage of organs for donation and transplant waiting list is increasing, e.g. in US it is around 100000 . There is evidence that non standard organs which are discarded may be beneficial. Discard rate f organs which may be beneficial may be 20%. The main reason of discarding is quality standard based on frozen section. To predict graft outcome , biopsy is performed to identify chronic damage etc. There is 20 year data which shows that graft biopsy may provide limited information about outcomes. Biopsy may lead to higher discard rate as to predict outcomes may not be accurate. The studies up till now were biased as the organs selected for transplant were included in the studies. So these studies have not been able to accurately assess the role of biopsies. The authors proposes that US transplant centres should curtail or eliminate biopsy for standard criteria donors. There should be new trials to evaluate the role of procurement biopsies if benefits are more than harm and use is judicious. Evidence to guide use of biopsies should be sought and new strategies should e developed to decrease the risk of discard of kidneys. Please reflect on your practice In my country only living donor transplantation is practiced. Unfortunately we have no such experience.
Abhijit Patil
2 years ago
Summary of the article:
There are around 100,000 Americans awaiting kidney transplant
~ 20% recovered kidneys discard rate
Biopsied kidneys are 3-times more likely to be discarded with the primary reason for discarding being “quality” of the kidney, which is frequently made on the basis of frozen section biopsy results.
Marked variation in indication for biopsy, technique, and expertise in interpretation
Limited reliability of standard frozen section biopsy and uncertain prognostic value
A recent analysis of United States transplant registry data (2005–2014) for kidneys with a kidney donor profile index 85% found
Discard rate of 34% for 0%–10% GS
Discard rate of 77.4% for 20% GS.
However, among kidneys transplanted, 5-year death-censored graft survival differences were modest: 75.8% for 0%–10% GS, 70.9% for .10% GS, and 74.8% for kidneys without biopsy.
These and other studies support the conclusion that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
Hence, transplant centers should curtail or eliminate the use of biopsies for standard criteria donors and avoid discard on the basis of biopsy data alone.
Reflection on my practice:
I would avoid routine procurement biopsies for standard criteria donors and would limit it to only marginal donors.
Mohamad Habli
2 years ago
With the increase in ESRD patients worldwide, there is a considerable waiting list for transplantation because the demand of kidney allografts overcome the availability of kidney offers. Over the last 2 decades, with the implementation of ECD,there has been an increase in the number of deceased donor kidney offers, however this number does not yet meet the required kidneys for those on the waiting list.
Moreover, receiving a kidney transplant from a deceased donor is preferable than continuing dialysis, which puts the patient at increased risk for cardiovascular complications and even death.
SUMMARY
There are a few drawbacks associated with doing a frozen section biopsy on a donated kidney, particularly in relation to reducing the number of donations from deceased donors or restricting the number of transplants from deceased donors:
– It was demonstrated that the non-biopsied kidneys were donated three times more than biopsied kidney. Biopsied kidneys have higher chance to be discarded for transplantation.
– More than 20% of deceased kidneys were rejected because of glomerulosclerosis
– There is likely to be a significant variation in the evaluation and interpretation of the kidney biopsy, particularly given that the biopsy was stained with H&E, and it was examined by an on-call pathologist who was not a renal specialty pathologist.
– The purpose of the frozen section biopsy is to determine whether or not to accept a donor since it anticipates a delayed graft function or a non-functioning graft.
– Additional clinical donor variables that were not taken into account here but could have significant impact on the decision of donation rather than the biopsy result itself.
-There is no international consensus or standard for determining when to discard a kidney based on its pathology, and commonly is center based. As a result, number of deceased kidney donors will be reduced. Practically speaking, kidney donors who have 20% or more glomerulosclerosis could be the treatment of choice for ESRD being for long time on the waiting list.
Sahar elkharraz
2 years ago
This article address role of frozen section renal biopsy which done pre transplant to identify non function kidney and early graft failure and irreversible organ damage. Despite increasing incidence of waiting list for kidney transplant and increase kidney donation from deceased persons and using of frozen renal biopsy help in deciding for acceptance of donation from deceased persons but rate of acceptance with this protocol low by increasing rate of discarded removed kidney from donation. In 1995 shows > 20% of cases is glomerulosclerosis and it’s discarded from donation.
In recent study from 2005 to 2014 shows increase discarded kidney to 85% . Difference opinions even from experts pathologist in presence of slight changes in frozen slices of interstitial fibrosis/ arteriolar hyalinosis and tubular injury less than 0.1 it’s may lead to inappropriate discard.
Limitations of this study can not assess accuracy of biopsy in assessing outcome of all recovered organs. This study shows Obtaining biopsy is associated with increase rate of discard kidney .
KAMAL ELGORASHI
2 years ago
Despite the donor pool were expanded with time, still there are large number of patients in the waiting list,
A study done in 1995 of 65 kidneys with pre transplant biopsies, found that, 8 kidneys with > 20% GS.;
87% develop DGF
38% develop graft failure within 6 months.
This study led to increasing discard of kidney if GS > 20% till today.
Recent analysis (2005-2014) in the US with donor kidney profile >85%, found that the discard rate rose from 34% with 0-10% GS, to 77.4% with GS > 20%. 5 years death-censored graft survival rate differences were modest.;
75.8% for 0-10%, GS
70.9% for >10% GS
74.8% for kidneys without biopsy
Thus, selected kidney with high GS can offer benefit to patient on the waiting list with outcome superior to dialysis. Multiple scoring system developed, combining pathologic finding (with or without donor factor) to better predict of early graft failure, MAPI (Maryland Aggregate Pathology Index) score combine.;
Arterial wall to lumen ratio.
Scar/fibrosis.
Arterial hyalinosis.
MAPI score as follow, (based on similar 1 year survival, but reduce 3 years survival rate).;
Low MAPI; 84.3%
Intermediate MAPI; 56.5%
High MAPI; 50%.
In other study (142 DCD recipients); Neither MAPI nor other studies, can predict the risk of DGF or graft loss. Finally;
No clear-cut standard criteria for Acceptance/discard kidney from DCD.
Many study done with difference methods, criteria, and limitation.
biopies directly associated with high discard ratio
Abdullah hindawy
2 years ago
introduction :
The use of frozen section biopsy results to guide organ acceptance decisions has been widely and appropriately challenged.
results
studies support the conclusion that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
All current United States studies of biopsy results and outcomes are limited by selection bias.
United States transplant centers should curtail or eliminate the use of biopsies for standard criteria donors and avoid discard on the basis of biopsy data alone.
Please reflect on your practice
yes , i agree with the study , in our center we have a small pathology section with little experince and alot of un reiable result (depending on the pathologist )
so i think it is not reiable , however other centers may have a powerfull pathologist section
Huda Saadeddin
2 years ago
Importantly, after adjustment for donor factors and organ procurement organization characteris- tics, performance of a kidney biopsy is associated with more than three times the odds of kidney discard.
To identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify chronic or irreversible organ damage.
Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, .50% of kidneys removed for transplant still undergo a biopsy. Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age and kidney donor profile index).
We believe that United States transplant centers should curtail or eliminate the use of biopsies for standard criteria donors and avoid discard on the basis of biopsy data alone.
New approaches to procurement biopsy should also be tested in appropriate trials to determine if and when benefits of biopsy (e.g., improved quality-adjusted life-years on the waiting list) outweigh the harms (e.g., death on the waiting list and misuse of scarce resources).
Pursuit of evidence to guide appropriate biopsy use and development of strategies to improve the quality of kidneys at higher risk for discard (intervention research), motivate acceptance, and expedite placement are vital priorities to reduce unnecessary discard and increase access to transplant for patients in need.
Reem Younis
2 years ago
Please provide a summary of this article
-The primary reason given for discarding a kidney removed for transplant is “quality,” a determination frequently made on the basis of frozen section biopsy results.
– Selected kidneys with high GS can offer benefit to patients on the waiting list with outcomes superior to dialysis.
– Pathologic evaluation by nonspecialty trained pathologists did not correlate with outcomes, and critically, 20% of grafts graded as unacceptable for transplant by on-call pathologists were deemed transplantable upon retrospective review by trained pathologists.
– The reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
-In an effort to address the limitations inherent in pretransplant biopsy results,
multiple scoring systems have been developed, combining various pathologic
findings to better predict likelihood of early graft failure.
-Providing transplant centers with images of photomicrographs for evaluation by the accepting center is another proposed solution, but it has also proven problematic in practice.
-A more promising approach may be to apply artificial intelligence (AI) algorithms
to allow robust assessment of multilayer sections.
– Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age and kidney donor profile index).
– New approaches to procurement biopsy should be tested in appropriate trials
to determine if and when the benefits of biopsy (e.g., improved quality-adjusted
life-years on the waiting list) outweigh the harms (e.g., death on the waiting Please reflect on your practice
In Sudan, we have living donor transplants only, and we have no experience with DD transplants.
Heba Wagdy
2 years ago
Although the number of patients waiting for kidney transplantation is increasing, the discard rate of potentially transplantable kidneys is approximately 20%, discarding is usually due to quality based on frozen section biopsy results.
Biopsy practice is variable among centers, it is performed pre-transplant to assess the risk of primary non function or early graft failure
Previously kidneys with GS >20% were commonly discarded but a recent study suggested that selected kidneys with high GS were associated with better outcome than that associated with remaining on dialysis.
Frozen section biopsy aims to guide organ acceptance but have several limitations as few sections are evaluated by on-call pathologist who is not specialized in renal pathology as well as inter-rater agreement is limited even among experts.
Depending on pathology findings alone may lead to inappropriate discard of kidneys.
Several scoring systems were developed to improve prediction of early graft failure as the 2014 Maryland Aggregate Pathology index, however, the association between biopsy scores and graft failure or graft function was not well determined.
A study showed that no scoring system could predict the risk of DGF or graft loss.
Providing transplant centers with images of photomicrographs for evaluation by the accepting center was a difficult option
Artificial intelligence algorithms is a promising approach to assess multilayer sections.
Studies couldn’t assess accuracy of biopsies in assessing outcomes of recovered organs due to selection bias.
A study showed that pre transplant biopsies have no predictive value over the estimates from donor records.
Performing biopsy is strongly associated with kidney discard rates.
The article suggest stopping performing biopsies in standard criteria donors and avoiding the discard of organs based on biopsy alone.
Further studies are needed to determine when benefits of biopsy outweigh the harms and to decrease unnecessary discard of organs and to increase access to transplantation.
saja Mohammed
2 years ago
Summary
This article addresses the limitation and variations in the practice for kidney biopsy indication at the time of transplantation, the main indication for the use of kidney biopsy which is still being used in > 50% of the center in the US is to assess the quality of the organ to be accepted for donation, Frozen section biopsies at the time of donation can increase the rate of organ waste by 3 times due to the limited view of the sections of Biopsied kidneys in addition to the obvious variation in indication for biopsy technique, and the need of expertise pathologist interpretation which is not the case most of the time so lead to limited reliability of such frozen sections and make it very challenging in real practice and should be limited for selective cases of donors with a comorbid and associated uncertain prognosis like a marginal kidney with the risk of irreversible organ damage. However, based on a recent study from the US still selection of kidneys with high GS can offer an advantage and better outcomes compared to those waiting on dialysis. Different scoring systems have evolved over time for the interpterion of the histology of the kidneys like the MAPI index (Maryland aggregate pathology index based on wedge biopsies to assess for GS, arterial wall–lumen ratio, scar/fibrosis in at least 10 tubules plus arteriolar hyalinoses, and classified to low, intermediated, and high MAPI scores, only 5% of cases have a high index based on a systemic review by wang et al., and half of the 15 studies reviewed confirmed the association between the biopsy index score and graft failure. However, another study failed to show any correlation between the biopsies score by any mean and the predictor risk of graft failure or loss, most of the available data are limited by selection bias so we need RCT to assess such limitations. Including validation and reading at multilevel review including supporting photomicrographs images for further evaluation by accepting centers
Also, patients’ and surgeons’ acceptance of the donor organs without biopsies will help in less discard of transplantable and possibly valued kidneys and also augment the use of high KDPI in suitable cases.
Please reflect on your practice
our center mainly deals with LD transplantation, we did a few cases of DD but we did not perform biopsies for them however we have a good setting of the renal histopathology team including a renal consultant pathologist
abosaeed mohamed
2 years ago
– Performance of kidney biopsy in addition to adjustment for donor factors & organ procurement characteristics is associated with > 3 times the odds of kidney discard.
– frozen section is performed prior to transplantation to identify the risk of primary or early graft failure. based on recent analysis of US transplant registry , the selected kidneys with high Glomerulosclerosis can offer benefit to patients on waiting list better than being on dialysis.
– the use of fresh frozen section biopsy results to evaluate for organ acceptance has been widely challenged. in trial to decrease the limitations. so, multiple scoring systems have been developed combining the pathological findings with or without additional donor factors like MAPI in 2014 . involvement of AI system, it reduces the proportion of graft inappropriately considered not transplantable.
– consideration for defining appropriate use of procurement biopsies in kidney transplantation by selective use of biopsy to guide selection & placement of high risk ones, less discard of transplantable & potentially beneficial kidneys & to expand use of high KDPI organs in appropriate candidates.
Nandita Sugumar
2 years ago
Summary : Procurement biopsies in kidney transplant
This study revitalizes the perspective on kidney donor acceptance. Many times the performance of kidney biopsies leads to increased rate of organ discard. Frozen section analysis of kidney biopsy prior to transplant is performed in some cases to identify chronic or irreversible organ damage.
Due to the variation in standards for choosing kidneys which need to be biopsied, there is a lot of organ wastage. Limited value of frozen section biopsy and uncertain prognostic value further adds to the perspective of wastage.
Research needs to be done based on accepting donor kidneys without biopsy and the graft outcomes of such. Patient centered outcomes need to be focussed on such as access to transplant, renal function, graft survival and patient survival.
This study may be limited in results accuracy because of selection bias – only kidneys which were accepted for organ donation were studied. Hence the accuracy of results in assessing kidney outcomes may be limited.
To repair this limitation, the study mentioned the results of another analysis wherein they found that there was no predictive value of kidney biopsies on outcome. Graft survival had been good for most of their participants even at 10 years post kidney transplant.
This study recommends curtailing the use of biopsies for standard criteria kidneys that come up for organ donation. This can avoid organ discard based on biopsy alone.
Isaac Abiola
2 years ago
SUMMARY
Introduction
The demand for kidney by patient with ESKD on waiting list is increasing while the shortage of organ is also increasing despite the use of diseased donors’ organs. In spite of the above challenge, the discard rate of potential kidney for donation from the diseased donor was about 20%.
Indications for frozen section of kidney biopsy
to identify risk of primary non function
to identify the risk of early graft failure
to identify chronic or irreversible organ damage
A study on 65 kidneys in 1995 shows that 8 kidneys with > 20% GS, 87% of them experienced DGF, while 38% developed graft failure within 6 months and these has been seen as the criteria to reject potential kidney.
Reason for challenging frozen section analysis for accepting or rejection kidney
limited section of biopsy for review
lack of renal pathologist on call to review the micrograph
discordant review/ report on frozen section analysis by pathologist
The 2014 Maryland Aggregate Pathology Index
Glomerulosclerosis
arteria wall to lumen ratio
scar/ fibrosis in at least 10 tubules
arteriolar hyalinosis
A more promising way of reporting frozen section analysis is the use of artificial intelligence that has been found to be significantly more accurate in reporting GS versus doctors on call. This has reduced the incidence kidneys deemed unsuitable from 14% to 2%. Obtaining a kidney biopsy has been associated with high discard rate of kidney and may not augment prediction of outcome beyond clinical criteria
Rehab Fahmy
2 years ago
Actually I donot have deceased kidney donation in my center .
Rehab Fahmy
2 years ago
This topic recommend against discard of deceased donor grafts based on frozen section biopsies
As there is no reliable scoring systems ,MAPI (2014 Maryland Aggregate Pathology Index) which includes : GS, arterial wall-to-lumen ratio, scar/fibrosis in at least ten tubules, and arteriolar hya- linosis.,
But studies showed that neither MAPI or other scoring systems can predict graft survival or delayed graft function .
And when compared between USA the study country to Belgium and they have no frozen biopsies results showed almost similar results in 1st year and 3rd year survival
And they see that even if there is high percentage of glomerular sclerosis >20% still the risks are less than keeping patients on dialysis
Rihab Elidrisi
2 years ago
In this articles we can see that 20% discard of the organ because of GS ,and accordingly the rate of discarding organ increase with frozen section biopsy of the transplanted organ ,as you all know the intense need for organ donation . for that in this article we found that a study of 65 kidneys with pretransplant biopsies reported that 87% of kidneys with more than 20% GS experienced DGF, and 38% developed graft failure within 6 months
However, 5-year graft survival differences of kidneys transplanted were modest:
75.8% for 0%–10% GS,
70.9% for .10% GS,
and 74.8% for kidneys without biopsy.
AS you all know that frozen section biopsy is associated with lots factors of limitation
Nahla Allam
2 years ago
· The discard rate of recovered, potentially transplantable kidneys in the United States increased markedly in the late 1990s and remained at approximately 20%. The primary reason for discarding a kidney removed for transplant is “quality,” a determination frequently made based on frozen section biopsy results.
· A study of 65 kidneys with pre-transplant biopsies reported that among eight kidneys with .20% glomerular sclerosis (GS), 87% experienced delayed graft function, and 38% developed graft failure within six months.
This study was followed by a trend of increasing discard of kidneys with .20% GS that persists to this day.
·A recent analysis of United States transplant registry data (2005–2014) for kidneys with a kidney donor profile index of .85% found that discards rose from 34% with 0%–10% GS to 77.4% with .20% GS.5
However, 5-year death-censored graft survival differences among kidney transplants were modest: 75.8% for 0%–10% GS, 70.9% for .10% GS, and 74.8% for kidneys without biopsy.
Thus, selected kidneys with high GS can benefit patients on the waiting list with outcomes superior to dialysis.
Frozen section biopsies are generally limited to a review of a few sections using hematoxylin and eosin staining. They may be evaluated by on-call pathologists who lack specialized renal pathology training.
Other studies conclude that reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
pathologic scoring systems have not been evaluated with large registry trials as detailed pathologic findings are not reported in field-defined data, limiting validation within large representative populations.
A recent study compared organ allocation in the United States with that in France and Belgium— where kidneys are not routinely biopsied during distribution—and found no predictive value of biopsies over what is regularly available from donor medical records
Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment the prediction of outcomes beyond estimates using clinical criteria and kidney donor profile index)
In Sudan, the deceased donor transplant program has not been established. Therefore, if set, we do not do a biopsy, depending on the clinical assessment of the donor.
Ghalia sawaf
2 years ago
There is imbalance between the shortage of organs available and the prolonged waiting times, and death.
But 20% of of the recovered, potentially transplantable kidneys in Us are discarded
basis of frozen section biopsy results
a study of 65 kidneys with pretransplant biopsies reported that 87% of kidneys with more than 20% GS experienced DGF, and 38% developed graft failure within 6 months
However, 5-year graft survival differences of kidneys transplanted were modest:
75.8% for 0%–10% GS,
70.9% for .10% GS,
and 74.8% for kidneys without biopsy.
Limitations of frozen section biopsies
few sections using hematoxylin and eosin staining
may be evaluated by on-call pathologists who lack specialized renal pathology training.
20% of grafts graded as unacceptable for transplant by on-call pathologists were deemed transplantable upon retrospective review by trained pathologists.
studies concluded that the reliance on pathology findings alone, leads to inappropriate discard.
Recently multiple scoring systems have been developed rather than GS such as; MAPI;
GS,
arterial wall-to-lumenratio,
scar/fibrosis in at least ten tubules,
and arteriolar hyalinosis.
(((Increasing scores were associated with similar 1-year survival but reduced 3-year survival))))
However, study of 142 deceased donor allograft recipients, concluded neither the MAPI nor other scoring systems predicted the risk of DGF or graft loss.
the (AI ) artificial intelligence system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%.
a recent study compared organ allocation in the US with that in France and Belgium and found no predictive value of biopsies over what is routinely available from donor medical records.
To further inform this debate, a randomized, controlled trial of biopsy use should be performed to determine if and when a procurementbiopsy should beusedin thedecision to accept or decline an organ offer.
In my practice, if deceased donation program available, we can rely on clinically and laboratory rather than pathologically judgment.
The demand of kidneys is greater than the available accepted donors. Putting in mind that large number of patients die while on the waiting list and that the cost of being on renal replacement therapy is high, this increase the need for accepting nonstandard organs. After harvesting the organs, some were discarded mainly due to poor quality of organ which is determined mostly through biopsy. kidneys with more than 20% glomerular sclerosis are discarded. A recent analysis showed that the -year death-censored graft survival was approximately similar to some extent between 0-10% ,more than 10% glomerular sclerosis and no biopsy organs. This practice depends on frozen section biopsy, but many factors affect the results of these. The pathologist may lack experience as they are usually the on-call pathologists. When the grafts rejected by them were reviewed by trained pathologist, 20% of the grafts were found transplantable. Even between trained pathologists there is still little inter-rater agreement of the results. This is why scoring system gained more popularity to predict the likelihood of early graft failure e.g. 2014 Maryland Aggregate Pathology Index (MAPI). The studies conducted to assess the association between using scores and graft survival have controversial results. Using artificial intelligence algorithms could solve a lot of problems like the disagreement between pathologists and furthermore, their use has decreased the rate of discarded organs. When the discarded kidneys in USA were compared with transplanted organs in countries which do not practice this, the survival of the transplanted kidneys was approaching 68% at 10 years. The authors suggested the elimination of using biopsies for standard criteria donors and avoid discarding kidneys on the basis of results of the biopsy data alone.
In Sudan, kidneys are biopsied at table only for a limited number of grafts. the results of interpretations take usually up to 10 days to be released. so this practice does not affect the rate of discarding organs.
Discard rate of recovered, potentially transplantable kidneys is around 20%. The main cause is quality (based on the basis of frozen section biopsy results)
Frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify kidneys at risks (primary nonfunction or early graft failure)
DGF and graft failure are related to glomerular sclerosis (GS) on kidney biobsy (discard of kidneys with 20% GS). However, 5-year death-censored graft survival was modest (75.8% for 0%–10% GS, 70.9% for .10% GS, and 74.8% for kidneys with- out biopsy). Thus, selected kidneys with high GS may be better than waiting list with outcomes superior to dialysis
Use of frozen section biopsy to guide acceptance decisions is challenging (H & E stain, on-call pathologist lack experience). Reliance on pathology findings alone may leads to inappropriate discard
Multiple scoring systems developed to better predict early graft failure
MAPI (combine GS, arterial wall to lumen ratio, scar/fibrosis). Increasing scores were associated with similar 1-year survival but reduced 3-year survival
A more promising approach is to apply artificial intelligence (AI) algorithms. AI systems were significantly more accurate in assessing GS versus for on-call pathologists and thus reduce the risk of discard
A waiting randomized, controlled trial to determine when a procurement biopsy should be used in the decision to accept or decline an organ Please reflect on your practice
The program of deceased donor transplantation not initiated yet in our country
No, I will not do routinely
Kidney biobsy is susceptible to sampling error
To do biopsy, it is very important to ask for the past history of any renal disease and the current senario (WIT).
Manal Malik
2 years ago
1Based on frozen section biopsy results ,the removal of transplant kidney is determined,
To identify kidneys at risk of primary nonfunction or early graft failure ,frozen section analysis of kidney biopsy prior to transplant is done ot identify chronic or irreversible organ damage.
In 1995,65 kidneys with pretransplant biopsies done:
>20% glomerular sclerosis,87%had delay graft function
38% develop graft failure within 6 month.
It is hard to have a decision for organ acceptance by using frozen section biopsy result.
In a systemic review, Wang et al reported that only half of the 15 studies examined an association between biopsy scores and graft failure or graft function
MAPI and scoring system are accurately predicted the risk of delay graft function or graft loss.
The A1ystem were significantly more accurate in assessing GS.
496 United States discarded kidneys were matched to transplanted organs from Europe, had graft survival rate of 93.1% at 1 year 80.7% at 5 years and 68.9%.
A randomized controlled trial of biopsy use should be performed to decide if and when a procurement biopsy should be used in the decision to accept or decline an organ offer .
New approaches to procurement biopsy should also be tested in appropriate trials to determine if and when benefits of biopsy outweigh the harm.-Summary of this article
2- in our centre we did not have deceased donor but if there is randomized studies to weight the risk versus the benefit to expand the donor pool
Despite the organ donation pool shortage, the rate of discarding kidneys remained high at 20 %, primarily due to organ quality, which is determined by biopsy results.
There is a significant variation in biopsy practice in transplant centers, and performing kidney biopsy is associated with a three times increase in discard rate.
The aim of performing a kidney biopsy prior to transplant is to identify chronic or irreversible organ damage and to guide organ acceptance decisions. There is a trend of increasing discard of kidneys with >20% GS that persists to this day.
There were modest variations in 5-year death-censored graft survival; 75.8% for 0%–10% GS, 70.9% for 10% GS, and 74.8% for kidneys without biopsy. Therefore, kidneys with high GS can benefit patients on the waiting list with outcomes superior to dialysis.
Limited sections of frozen section biopsies using H&E are evaluated by an on-call who may not be a specialized pathologist. 20% of grafts considered unsuitable by on-call pathologists were found to be transplantable on retrospective review by trained pathologists. Keep in mind the inter-rater agreement is limited even among experts. Studies showed the reliance on pathology findings alone, regardless of the individual reading the slide, leads
to inappropriate discard.
Several biopsy scoring systems were developed, combining various pathologic findings to better predict the likelihood of early graft failure. Some studies showed a good correlation, while others did not. Pathologic scoring systems
have not been evaluated with large registry trials as detailed pathologic findings are not reported in field-defined
data, limiting validation within large representative populations
An approach that may be applied to improve agreement on biopsy findings includes using photomicrograph images or artificial intelligence (AI) algorithms to allow robust assessment of multilayer sections.
Currently, all biopsy results and outcomes studies are limited by selection bias, as only organs that were
accepted for transplant were included in these analyses. A recent study compared organ allocation in the US with that in France and Belgium, where kidneys are not routinely biopsied during allocation and found no predictive value of biopsies over what is routinely available from donor medical records
Obtaining a biopsy may not accurately predict the outcome and lead to increase organ discard rates. To reduce unnecessary discard and increase access to transplants, evidence to guide appropriate biopsy use and more prognostic criteria to be established.
Please reflect on your practice
The clinical and laboratory criteria for organ acceptance correlate well with graft and patient survival. Pre-implantation biopsy of value when there is significant damage and clear finding to preclude donation as cortical necrosis.
This discussion makes a critique and reassessment of the need for pre-transplant biopsy to assess the quality of the kidney to be donated before being submitted in queue. Despite being used in the United States, this practice is not common in Europe and South America and makes a comparison with countries that would have similar donor characteristics and the impact on graft survival.
It is believed that there is a three-fold loss of kidneys available for donation due to histopathological findings that could suggest a non-viable organ in the medium or long term.
Percentage of glomerulosclerosis, frozen biopsy, availability of specialist pathologists. Studies show the discrepancy between pathologists with different degrees of experience, increasing the number of unnecessary losses due to excessive discard of kidneys that could be viable.
In an attempt to minimize these losses, several scores have been submitted, but when there are several models, none of them is really effective. Models with artificial intelligence have been used and shown to be effective in reducing these losses considerably.
This article suggests that biopsies be restricted to organs with expanded criteria or individually, no longer being the rule.
Although here in Brazil we have a large number of deceased donors, we do not have a pre-transplant biopsy to define the feasibility of the transplant process.
Professor, I believe that we still don’t have solid safety criteria to define the rejection of an organ. I believe that to become viable it is necessary to have an extremely specialized team that can provide quick information.
At the moment I would not perform biopsies of these organs, but if I were to choose the profile of patients in which I would perform, it would certainly be organs that meet expanded criteria donation or with recent reversible acute kidney injuries.
Mahmoud Wadi
2 years ago
VI. Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions
The shortage of organs available for transplant contributes to prolonged waiting times, death on the waiting list, and higher costs of care for patients with ESKD.
To identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify chronic or irreversible organ damage.
Importantly, after adjustment for donor factors and organ procurement organization characteristics, performance of a kidney biopsy is associated with more than three times the odds of kidney discard.
-In 1995, a study of 65 kidneys with pretransplant biopsies reported
Among 8 kidneys with >20% glomerular sclerosis (GS).
87% experienced delayed graft function.
And 38% developed graft failure within 6 months.
This study was followed by a trend of increasing discard of kidneys with >20% GS that persists to this day.
-A recent analysis of United States transplant registry data (2005–2014) for kidneys with a kidney donor.
>85% found that discards rose from 34% with 0%–10% GS to 77.4% with >20% GS.
However, among kidneys transplanted, 5-year death-censored graft survival differences were modest: 75.8% for 0%–10% GS, 70.9% for >10% GS, and 74.8% for kidneys without biopsy.
Thus, selected kidneys with high GS can offer benefit to patients on the waiting list with outcomes superior to dialysis.
==================================================================== CURRENT STATE • ≈ 100,000 Americans await kidney transplant • ~ 20% recovered are kidneys discarded. • Biopsied kidneys are 3-times more likely to be discarded • Marked variation in indication for biopsy, technique, and expertise in interpretation.
The limitations inherent in pretransplant biopsy results,multiple scoring systems have been developed, combining various patho- logic findings (with or without additional donor factors) to better predict likelihood of early graft failure.
• Limited reliability of standard frozen section biopsy and uncertain prognostic value
RESEARCH NEEDS
• Randomized controlled trials: • Patient & surgeon acceptance of donor organs without biopsy • Patient-centered outcomes (access to transplant, renal function, graft survival, patient survival) • Validation of whole slide/multi-level review including AI-supported reading.
FUTURE STATE • Selective use of biopsy to guide selection & placement of high-risk kidneys. • Less discrd of transplantable and potentially beneficial kidneys. • Expanded use of high-KDPI organs in appropriate candidates.
==================================================================== Please reflect on your practice
My practice, we have only a living and related donation in our country .
In the event that a central center for organ transplantation is available in Palestine and it is approved to allow dealing with deceased donors, we will have another treatment for the benefit of kidney recipients in elderly patients with HTN ,DM, and impaired eGFR).
Thanks you very much Prof.Halawa
I will not do renal biobsy Becuase a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age ,e GFR and kidney donor profile index).
Mohamed Mohamed
2 years ago
1. Please provide a summary of this article Current state
≈ 100,000 Americans await KTX, although the total number of deceased donors has increased
~ 20% recovered kidneys are discarded
Primary cause for discard is “quality of a kidney (based on results of frozen section biopsy)
Variable biopsy practice across the US (23% -78%)
Biopsied kidneys 3-times more likely to be discarded
A study (1995) of 65 kidneys with pre-transplant biopsies found 8 kidneys with >20% glomerular sclerosis (GS), 87% had DGF, & 38% graft failure within 6 months
This study led to a trend of increasing discard of kidneys with>20% GS; a practice persisting today. Limitations
Biopsy indications, techniques, & expertise are greatly variable
Biopsies limited to review of a few sections with only H&E staining
Biopsy evaluated by non-specialty trained on-call pathologists; 20% of kidneys deemed unacceptable by on-call pathologists were transplantable when review by trained pathologists.
However, inter-rater agreement is limited even trained pathologists
So, reliance on biopsy alone leads to inappropriate discard.
Reliability of standard frozen section biopsy: limited Prognostic value: Uncertain Solutions
Scoring systems (combining pathology+/-other donor factors) to predict early graft failure.
The MAPI (2014) scoring combines GS, arterial wall-to-lumen ratio, scar/fibrosis in at least 10 tubules, & arteriolar hyalinosis.
Increasing MAPI scores associated with similar 1-yr but reduced 3-year survival; however, only 5% had a high MAPI score.
Wang et al (systemic review) shows that only half of the 15 studies found an association between biopsy scores & graft failure or graft function.
A study of 142 deceased donor graft recipients: neither MAPI or other scoring systems accurately predicted the risk of DGF or graft loss.
Providing accepting centers with pathology images suggested as a solution, but proved impractical.
A pilot artificial intelligence (AI) algorithm compared AI reading to on-call results & subsequent “gold standard” consensus assessment by 3 renal pathologists; AI was significantly more accurate in assessing GS & markedly reduced discard able grafts from 14% to 2%. Research needs
• RCT s andomized controlled trials:
-Patient & surgeon acceptance of organs without biopsy
-Patient-centered outcomes (access to TX, graft survival, patient survival)
• Validation of whole slide/multi-level review
including AI-supported reading Future state
• Selective use of biopsy to guide selection & placement of high-risk kidneys
• Less discard of transplantable & potentially beneficial kidneys
• Expanded use of high-KDPI organs in appropriate
patients. =============================== 2. Please reflect on your practice
We do not perform deceased donation kidney transplantation in our country.
However, there are some preliminary movements by policy makers & local professional bodies & societies, in addition to some individual efforts, to establish such a program in the near future.
The invaluable information provided in this article would, undoubtedly, help us in our future plans.
‘’Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions’’
1. On the Banff histopathological consensus, Liapis et al study supported theconclusion that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
2. To date, pathologic scoring systems have not been evaluated with large registry trials as detailed pathologic findings are not reported in field-defined data, limiting validation within large representative populations.
3. In a systemic review, Wang et al. reported that only half of the 15 studies examined demonstrated an association between biopsy scores and graft failure or graft function.
4. Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, 50% of kidneys removed for transplant still undergo a biopsy.
5. Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age and kidney donor profile index).
6. A randomized, controlled trial of biopsy use should be performed to determine if and when a procurement biopsy should be used in the decision to accept or decline an organ offer.
The shortage of organs available for transplant contributes to prolonged waiting times, death on the waiting list, and higher costs of care for patients with ESRD.
The total number of deceased donors is increasing, and the waiting list is still long.
Kidney discarding rate is high due to quality determined by frozen section biopsy.
To identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify chronic or irreversible organ damage.
Studies showed that kidneys with more than 20% GS are associated with a high rate of DGF and the development of graft failure within 6 months.
later studies showed that kidneys with high GS can offer benefits to patients on the waiting list with outcomes superior to dialysis.
The use of frozen section biopsy results to guide organ acceptance decisions has been widely and appropriately challenged as it is mostly reviewed by pathologists on call and by the use of H & E stain and this leads to inappropriate discard.
The 2014 Maryland Aggregate Pathology Index was developed on the basis of wedge biopsies to combine GS, arterial wall-to-lumen ratio, scar/fibrosis in at least ten tubules, and arteriolar hyalinosis, increasing scores were associated with similar 1-year survival but reduced 3-year survival.
To date, pathologic scoring systems have not been evaluated with large registry trials as detailed pathologic findings are not reported in field-defined data, limiting validation within large representative populations.
A more promising approach may be to apply artificial intelligence (AI) algorithms to allow robust assessment of multilayer sections.
the AI system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%.
In my practice, we have only a living donation program.
there is an evidence that non-standard organs are usually beneficial to some recipients. however, the discard rate of potentially transplantable grafts are markedly increased, about 20 %, based on graft quality as evidenced by biopsy results.
to identify grafts at risk of early graft failure, biopsy is done to check for chronic or irreversible changes. however, there are some challenges and limitations for this practice, including the following :
1- the limitations related to use of only Hematoxylin and Eosin statins without other specific stains, IF and EM studies.
2- the limitations related to evaluation of biopsy by on-call pathologists who are not specialized in renal histopathology.
some solutions were provided for managing such limitations, including the following :
1- providing transplant centers with images of photomicrographs to help pathologists for proper description and evaluation of biopsies.
2- multiple scoring system were developed to predict the likelihood of early graft failure.
all current studies of biopsy results and outcomes are limited by selective bias as only accepted organs for transplantation were included in such studies. these studies can’t truly assess accuracy of biopsies in assessing outcomes of all recovered organs.
20 years of data demonstrate that biopsies performed at times of kidney recovery provide limited insight regarding the eventual outcome.
obtaining biopsy is strongly associated with a discard rate.
transplant centers in Unites States should eliminate the use of biopsies for standard criteria donors and avoid discard on basis of biopsy alone.
new approaches to procurement biopsy should be tested in appropriate trials to know when benefits of biopsy outweigh harms.
Please reflect on your practice :
I will still adhere to the usual criteria of donor selection based on clinical and laboratory data without the need for biopsy evaluation to avoid such debates until being resolved with more accurate standards
Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions.
Discarding of removed kidney was mainly depends on the quality of renal biopsy frozen section result which identify chronic or irreversible organ damage and kidney with GS>20% usually discarded and so biopsied kidneys are 3-times more likely to be discarded.
According to Glomerulosclerosis, 5-year death-censored graft survival differences were modest: 75.8% for 0%–10% GS, 70.9% for .10% GS, and 74.8% for kidneys.
Many studies conclude that reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard, this is mainly because the difference in the grading/scoring of the pathologist which is mainly subjective factors from one to one and from center to center.
To overcome this problem, Validation of whole slide/multi-level review including AI-supported reading is considered for defining Appropriate Use of Procurement Biopsies in Kidney Transplantation.
Biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts as 50% of kidneys removed for transplant still undergo a biopsy, so obtaining kidney biopsy still an obstacle as it is not correlates with graft outcome.
Now, selective use of biopsy to guide selection &placement of high-risk kidneys, try not to discard of transplantable and potentially beneficial kidneys and expanded use of high-KDPI organs in appropriate candidates.
Waiting Randomized controlled trials to detect patient-centered outcomes (access to transplant, renal function, graft survival, patient survival).
We don’t have like this program in our practice but I think we should out weight benefit versus risk for our recipient before accepting kidney with low quality.
Thank you. I like your reflection on your practice.
Alaa eddin salamah
2 years ago
This article examines whether performing a biopsy on the deceased donor kidneys before transplantation improves the outcome!!
The likelihood of discarding biopsied kidneys is three times higher after performing a biopsy.
Pathologic screening by non-specialty trained pathologists did not predict outcomes, and more importantly, 20% of grafts that were ruled unsuitable for transplant by on-call pathologists were later found to be transplantable.
There is a noticeable variance in biopsy indication, procedure, and interpreting skill.
Standard frozen section biopsy has low reliability and has no clear prognostic value.
There is an urge for randomized controlled trials to better delineate the need for renal biopsy pre-transplant and its clinical outcome.
Although, we do not have such a program in our practice, I do not believe that we have to stick to this practice with no enough evidence of its benefits.
This article is evaluating if there is a better outcome when we do biopsy for the deceased donor kidneys before transplantation or not
Previous reports found an increase in the risk of DGF and graft loss when using deceased donor kidneys with glomerulosclerosis > 20 %
In spite of that, the authors answer was No and as they stated, “more Information may not lead to better decisions”
And they explain this by the following
The pathologist may be not qualified in interpreting the biopsy, and when the biopsy revised by highly specialized pathologist experienced in renal transplantation, it was found that > 20 % of the kidneys discarded (due to higher degree of glomerulosclerosis reported by general on call pathologist) were transplantable, and to improve this issue, Maryl and Aggregate Pathology Index (MAPI) was developed in which at least 10 glomeruli were assessed regarding glomerulosclerosis, GS, arterial wall-to-lumen ratio, scar/fibrosis and arteriolar hyalinosis, and although it is correlated with 3 years graft survival this finding was not consistent with further studies
It was found that implementation of renal biopsy before transplantation is associated with 3 fold more increase in the discard rate of the kidneys which is not good as we need to expand donor pool.
A study that was addressing 5-year death-censored graft survival found no significant difference between those using biopsied deceased donor kidneys with glomerulosclerosis ranging from 0% to > 10 % and those without biopsy
Clinical criteria can give us information more reliable than biopsy on the outcome including donor age and kidney donor profile index
So.. the authors recommended against doing renal biopsy for the assessment of recipient outcome since obtaining a biopsy is strongly associated with an increase in the donor kidney discard rate and instead we should rely on donor clinical and laboratory data
In my practice we do not have deceased donor kidney transplantation
In my opinion I will not do donor renal biopsy except for ECD kidneys with GFR 30-60 ml/min for assessment of dual kidney transplantation
Thank you. I like your reflection on your practice.
Weam Elnazer
2 years ago
Despite an increase in dead donors, the kidney transplant waiting list remains huge, with approximately 100,000 applicants.
Despite evidence that many nonstandard organs are helpful for eligible recipients, the US discard rate of potentially transplantable kidneys climbed in the late 1990s and remains at 20%.
“Quality” is often cited as the rationale for discarding a kidney extracted for transplant. Between 23% and 78% of kidneys retrieved in the US are biopsied. After adjusting for donor and organ procurement organization criteria, a kidney biopsy triples the likelihood of kidney discard.
Frozen section biopsy data have been criticized for guiding organ acceptance choices.
Frozen section analysis of kidney biopsy before transplant is used to detect chronic or irreparable organ disease. A 1995 study of 65 kidneys with pretransplant biopsies found that 87% of kidneys with.20% of GS had delayed graft function and 38% failed after 6 months. This investigation led to an ongoing tendency of discarding kidneys with 20% GS.
-Despite 20 years of evidence showing that kidney recovery biopsies give minimal insight into renal transplant outcomes, 50% of donated kidneys are biopsied. The biopsy is substantially related to kidney discard rates and may not considerably improve outcome prediction beyond clinical criteria.
Please reflect on your practice
In my practice, we are doing day0 biopsies for all deceased donors. we do not discard too many kidneys because we use highly selective criteria for the deceased donors(we are not using NHBD, h/o of DM or HTN and age less than 50). we discard kidneys.
Thank you. I like your reflection on your practice, but your discard rate is high. Think of the scenarios will come across in this module. You may start accepting these kidneys you used to reject.
Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions
The study aimed to identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy before transplant is selectively performed to identify chronic or irreversible organ damage.
A recent analysis of United States transplants registry data (2005–2014) for kidneys with a kidney donor profile index >85% found that discards rose from 34% with 0%–10% GS to 77.4% with > 20% GS
But among kidneys transplanted, 5-year death-censored graft survival differences were: 75.8% for 0%–10% GS, 70.9% for > 10% GS, and 74.8% for kidneys without biopsy.
The frozen section biopsy helps in the selection of organs for transplantation. However, general pathologist evaluation may not correlate with outcomes, and expert pathologists may preclude up to 20% of examined kidneys.
Studies found that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard. An assessment of agreement between 3 renal pathologists in reading 100 photomicrographs of frozen section biopsy images found moderate agreement on GS but poor agreement on fibrosis and acute tubular injury.
The artificial intelligence system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%.
Despite 20 years of data found that biopsies performed at the time of kidney recovery did not correlate with the eventual outcome of renal allografts, >50% of kidneys removed for transplant still undergo a biopsy.
Please reflect on your practice
Our deceased donor program do not do selection through kidney biopsy as it may take a longer time and the scarcity of donor pool make us not to consider kidney biopsy which directly will increase the discard rate.
Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions
The ongoing shortage of organs available for transplant contributes to prolonged waiting times, death on the waiting list, and higher costs of care for patients with ESKD. To identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify chronic or irreversible organ damage. The primary reason given for discarding a kidney removed for transplant is “quality,” a determination frequently made based on frozen section biopsy results.
The use of frozen section biopsy results to guide organ acceptance decisions has been widely and appropriately challenged. Frozen section biopsies are generally limited to review of a few sections using hematoxylin and eosin staining and may be evaluated by on-call pathologists who lack specialized renal pathology training.
To address the limitations inherent in pretransplant biopsy results, multiple scoring systems have been developed, combining various pathologic findings (with or without additional donor factors) to better predict likelihood of early graft failure. The 2014 Maryland Aggregate Pathology Index (MAPI) was developed based on wedge biopsies to combine GS, arterial wall-to-lumen ratio, scar/fibrosis in at least ten tubules, and arteriolar hyalinosis.9 Increasing scores were associated with similar 1-year survival but reduced 3-year survival.
Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, .50% of kidneys removed for transplant still undergo a biopsy. Obtaining a biopsy is strongly associated with kidney discard rates. Pursuit of evidence to guide appropriate biopsy use and development of strategies to improve the quality of kidneys at higher risk for discard (intervention research), motivate acceptance, and expedite placement are vital priorities to reduce unnecessary discard and increase access to transplant for patients in need
To identify kidneys at risk of primary nonfunctional or early graft failure, frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify chronic or irreversible organ damage.
The discard rate of recovered, potentially transplantable kidneys in the United States increased markedly in the late 1990s, and remains at approximately 20%.
The primary reason given for discarding a kidney removed for transplant is “quality,” a determination frequently made based on frozen section biopsy results.
After adjustment for donor factors and organ procurement organization characteristics, performance of a glomerular sclerosis (GS) MORE THAN 20%, Kidney biopsy is associated with more than three times the odds of kidney discard.
Its associated with 87% experienced delayed graft function, and 38% developed graft failure within 6 months, but less difference in regard of 5 years death censored graft survival.
. Thus, selected kidneys with high GS can offer benefit to patients on the waiting list with outcomes superior to dialysis.
These and other studies support the conclusion that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
The AI system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%..
Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, .50% of kidneys removed for transplant still undergo a biopsy. Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age and kidney donor profile index).
Pursuit of evidence to guide appropriate biopsy use and development of strategies to improve the quality of kidneys at higher risk for discard (intervention research), motivate acceptance, and expedite placement are vital priorities to reduce unnecessary discard and increase access to transplant for patients in need.
In our practice we don’t used cadaveric kidney transplant ,till now but there is plan in the
future, may be more evidence will come out ,but i think more reliability on clinical ground
Please provide a summary of this article
Fifth of potentially transplantable kidneys in the USA are rejected because of frozen section biopsy findings.
Pre-transplant biopsy of 65 kidneys revealed that delayed graft function was seen in 87% and graft failure within 6 months was noticed in 38% of kidneys with more than 20% glomerulosclerosis (GS).
There was no difference in 5 years graft survival between kidneys without pre-transplant biopsy and those with 0%-10% GS and more than 10 % GS in pre-transplant biopsies.
Frozen section biopsies limitations:
1- Few sections using H&E stain.
2- Sometimes done by on-call pathologist who is not expert in renal pathology.
3- 1/5 were considered not transplantable by on call pathologist then were deemed transplantable after being reviewed by expert pathologist.
Other scoring system have been developed like MAPI, However, they were not able to predict the risk of DGF or graft loss.
The artificial intelligence system lowered the percentage of inappropriately rejected grafts from 14% to 2%.
Please reflect on your practice
We don’t do pre-donation biopsy, and depend on clinical data.
There is a demand-supply mismatch with respect to kidney transplant. The discard rate of kidneys is approximately 20% in USA. Performing a kidney biopsy increases the odds of discarding kidneys by 3 times. Kidneys with >20% glomerular sclerosis (GS) were shown to be associated with increased risk of delayed graft function and graft failure, leading to accepting the cut-off of >20% GS for discarding kidneys.
Recent analysis has shown that the graft survival did not differ much between those with no GS, GS >10%, and those transplanted without pre-transplant biopsy. Hence implanting kidneys with higher GS could be beneficial in certain patients as compared to remaining on waiting list.
Frozen section biopsies have their inherent drawbacks in form of small number of sections, evaluated by on-call non-renal pathologists, with poor inter-rater agreement. Hence relying on pathological findings alone leads to inappropriate organ discard. The Maryland Aggregate Pathology Index (MAPI), developed on the basis of GS, arterial wall-to-lumen ratio, arteriolar hyalinosis, and scar/fibrosis in at least 10 tubules in wedge biopsies did not correlate with graft dysfunction or graft failure.
Photomicrograph evaluation was also associated with disagreement among the pathologists. Artificial intelligence algorithms might help in this aspect. As a kidney biopsy is strongly associated with increased discard rate, it is recommended to curtail or discard use of biopsies in standard criteria donors, and biopsy alone should not be the criteria to discard the kidneys. A randomized controlled trial is the need of the hour to decide about the role of biopsy in deciding the decision to accept or reject an organ.
2. Please reflect on your practice
Ours is a living related transplant program, hence the need for this did not arise. But as and when we start a deceased donor program, the utilization of frozen section would be in a very selective group. The donor characteristics would be more important to decide it, like elderly donor, with history of long standing diabetes and hypertension (expanded criteria donors).
Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions
· To identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy before transplant is selectively performed to identify chronic or irreversible organ damage.
· A recent analysis of United States transplant registry data (2005–2014) for kidneys with a kidney donor profile index >85% found that discards rose from 34% with 0%–10% GS to 77.4% with > 20% GS
· However, among kidneys transplanted, 5-year death-censored graft survival differences were modest: 75.8% for 0%–10% GS, 70.9% for > 10% GS, and 74.8% for kidneys without biopsy.
· The frozen section biopsy helps in the selection of organs for transplantation.
· General pathologist evaluation may not correlate with outcomes, and expert pathologists may preclude up to 20% of examined kidneys.
· Many studies found that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
· An assessment of agreement between 3 renal pathologists in reading 100 photomicrographs of frozen section biopsy images found moderate agreement on GS but poor agreement on fibrosis and acute tubular injury.
· The artificial intelligence (AI) system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%.
· All current United States studies of biopsy results and outcomes are limited by selection bias.
· Despite 20 years of data found that biopsies performed at the time of kidney recovery did not correlate with the eventual outcome of renal allografts, >50% of kidneys removed for transplant still undergo a biopsy.
RESEARCH NEEDS
• Randomized controlled trials:
-Patient & surgeon acceptance of donor organs without biopsy
-Patient-centered outcomes (access to transplant, renal function, graft survival, patient survival)
• Validation of whole slide/multi-level review including AI-supported reading
Please reflect on your practice
We don’t have a deceased kidney donation program, and even for living kidney donation we never did a kidney biopsy before the transplant.
This article discussed thoroughly the current practice of havinf allograft biopsy before implantation to determine suitability and secure prognosis post transplantation. The common trend in daily practice was to perform allograft biopsy for deceased donors kidneys, and discard ones with glomerulosclerosis of more than 20 %. This common practice was stemmed from a study conducted in 1995 on 65 patients to examine pre implantation allograft biopsy findings in correlation to post transplant prognosis.They concluded that in 8 patients with more than 20 % glomerulosclerosis , prevalence of delayed graft function was noted in 87% and graft failure was observed in 38% within 6 months, henceforth , all kidnys biopsied pretransplant with more than 20 % glomerulosclerosis were discarded.With resultant potential loss of huge number of donated kidneys .This finding was not consistent on further and subsequent studies,
Furthermore, frozen biopsy credibility was frequently questioned as a mere indicator of allograft suitability .
In one recent study aimed at comparing clinical parameters in records of 496 diseased kidney donors whom having their kidneys discarded after allograft biopsy showed 20% glomerulosclerosis in USA to counterparts with matched parameters in Europe whom kidneys got transplanted without biopsy.surprisingly graft survival was 93, 80 and 68%,in 1 , 5 and 10 years respectively. in addition to that , skepticism was growing about credibility of allograft biopsy and the examination thereof.
Cumulative data over time are debating the validity of having biopsy of allograft prior to transplantation and its interpretation. As its hampering kidney transplantation from expanded pool of deceased kidney donors.
This article attempts to evaluate the efficiency of frozen section analysis of kidney biopsy prior to transplant to identify chronic or irreversible organ damage that may lead to the decision to discard the organ.
However, factors such as:
– low interclass correlation coefficient, mainly for glomerular sclerosis
– limiting validation of pathologic scoring systems with large registry trials as detailed pathologic findings;
– Marked variation in indication for biopsy, technique, and expertise in interpretation
They led to an increase in the rate of discards of grafts, but without a significant increase in the prediction of results better than the clinical criteria already used.
Despite this, apparently the use of Artificial Intelligence (AI) seems to be promising because it dramatically reduced the proportion of grafts inappropriately deemed not transplantable
2.Please reflect on your practice
If there were better results in identifying appropriate recipes using frozen section analysis of kidney biopsy In Brazil, we would have many difficulties, because the cost is high and the number of specialists is low, which would also end up being a limiting factor in the number of transplants, increasing the queue waiting time.
There is 20 years data which shows that the graft biopsy may provide limited information about the outcomes. Biopsy may lead to higher discard rate up-to >20%.
there is huge waiting list of recipient to be transplanted.
Still we don’t use diseased organ donation.
Many patients are waiting in the deceased donor cadaver list across various countires…Efforts are being tried to reduce the incidence of organ wasting due to so called poor quality of kidneys by performing implantation/procurement renal biopsies….The rate of implantation renal biopsy are varied according to various centers in the US ranging from 23-78%…Frozen section of the kidney biopsy samples have been done in the US from a long time…in 1995, a study was performed with frozen section biopsies on 65 kidneys…and they found that those with more than 20% of glomerulosclerosis are associated with 87% graft failure in 6 months…Based on this study many deceased donor kidneys were rejected with > 20% glomerulosclerosis….A more recent transplant data from the United states transplant registry for kidneys with KDPI >85% the discard rate rose from 34% with 0-10% glomerulosclerosis to 88.5% with 20% glomerulosclerosis However the death censored graft survival among were modest for those renal biopsies even with glomerulosclerosis ; 75.8% with 0-10% glomerulosclerosis and 74.5% with 10-20% glomerulosclerosis. So if we compare the waiting time on transplant this is acceptable and we may proceed…
The use of frozen section biopsies have been questioned and critically analyzed….The frozen sections are only a small representation of the entire kidney specimen.. Moreover the sections are reported only by the on call pathologists who may not be trained in renal pathology…There have been comparison studies and proven that kidneys which have been rejected by the percentage of GS or IFTA on a night call have been later shown to be accepted by another pathologist by a detailed examination..
In an effort to address this issue multiple scoring systems have been developed to predict the development of graft failure based on histopathology and donor factors….The Maryland Aggregate Pathology Index (MAPI) was developed on wedge biopsies to include glomerulosclerosis, arterial/wall lumen ratio, scar/fibrosis in 10 tubules and arteriolar hyalinosis…The scores were divided into high MAPI , intermediate MAPI and low MAPI score…The increasing scores were associated with similar 1 year survival rates but low 3 year and 5 year graft survival rates….But these pathological scoring systems were never reported in large trials and all the findings are not carefully reported across various centers…
Many centers have now started using Artificial Intelligence to reduce the rate of kidney rejection and increase the acceptance rate by integrating approach of various pathologists….
All the outcomes for the United states renal pathology reports are not accurate due to selection bias…The only transplanted organs are included in the analysis…To avoid the bias, they have compared organs to the Europe transplant centers where kidney biopsies were not done routinely before transplant and found that nearly 496 kidneys from the US were found to be associated with good 1 year and 5 year post transplant survival in Europe
In other words the use of protocol biopsies in isolation is not recommended to discard the kidneys…We have to use to donor clinical criteria and KDPI to assess the overall risk before the decision
Considerations for Defining Appropriate Use of Procurement Biopsies in Kidney Transplantation
CURRENT STATE
• ≈ 100,000 Americans await kidney transplant
• ~ 20% recovered are kidneys discarded
• Biopsied kidneys are 3-times more likely to be discarded
• Marked variation in indication for biopsy, technique, and expertise in interpretation
• Limited reliability of standard frozen section biopsy and uncertain prognostic value
RESEARCH NEEDS
• Randomized controlled trials:
• Patient & surgeon acceptance of donor organs without biopsy
• Patient-centered outcomes (access to transplant, renal function, graft survival, patient survival)
• Validation of whole slide/multi-level review including AI-supported reading
FUTURE STATE
• Selective use of biopsy to guide selection &placement of high-risk kidneys
• Less discrd of transplantable and potentially beneficial kidneys
• Expanded use of high-KDPI organs in appropriate candidates
Expanding donor pool is the way to overcome organ shortage. In Europe almost 150000 patients are on waiting list and about 21 day each day waiting for a transplant.Discarding donor kidney after frozen section biopsy is considered standard operating procedure. Many of these kidneys be used if there is a uniform approach to address this issue.
Currently 100,000 Americans await kidney transplant
• 20% recovered kidneys are discarded
• Biopsied kidneys are 3-times more likely to
be discarded
• Marked variation in indication for biopsy, technique, and expertise in interpretation
• Limited reliability of standard frozen section biopsy and uncertain prognostic value.
Frozen section biopsies are generally limited to review of a few sections using hematoxylin and eosin staining and may be evaluated by on-call pathologists who lack specialized renal pathology training.
Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, .50% of kidneys removed for transplant still undergo a biopsy.
Appropriate use of biopsies to assess donor kidneys histology is very important to reduce discard rates. Trained Nephro Histo pathologist should be the one to evaluate these biopsies.
We don’t have a deceased donor program at our center so this will not have on any impact on our current practicing style.
1. Please provide a summary of this article
There is expanding deceased donor waiting list despite increasing number of transplantations from deceased donors. On the other side a lot of kidneys are discarded despite its need, reaching 20%.
The main reason for discard is poor quality of the organ as found in the frozen section biopsy. There is significant variation in biopsy reporting between pathologist ranging from 23-75%. Performance of biopsy was found to be associated increasing rate of discarding.
In 1995 a study of 65 kidneys, procurement biopsy and graft survival analysed. Glomerulosclerosis of 20% increase rate of delayed graft function to 87% and 38% of grafts failed within 6months. After this study a lot of kidneys were discarded.
Recent USA study included data between 2005-2014, found high discard rate. But when analysed the difference between those kidneys with biopsies showing high glomerulosclerosis and those with less and those without biopsies, was modest, with 5 years graft survival between 70-80%. Thus, some of those discarded kidneys could have been transplanted and benefit those on the waiting list with better out come than dialysis.
Frozen section biopsies have a lot of limitations and usually analysed by non-specialist on call whose assessment was found to increase discard rate unnecessary by 20%. Even among experts the interclass coefficient in frozen section was found to be poor 0.41, which far below the acceptable number of 0.75.
Trials of making scoring systems on biopsies to give better results but did not correlate well with graft out comes.
Sending photomicrographs to transplant centers although gave good corelation for glomerulosclerosis did not do for other finding.
Artificial Intelligence in a pilot study showed better correlation waiting for further studies to confirm that.
Most studies done in USA for biopsies have limitations somehow.
When compared with similar transplanted kidneys from France and Belgium, discarded kidneys in USA could have given 93%, 80 % and 68% graft survival at one, five and 10years respectively.
Thus, avoiding doing biopsy as much as possible may reduce discard rate. Also doing randomised controlled trial to better find the answer.
2. Please reflect on your practice
Reducing procurement biopsies to reduce discard rate is the way to go. Exception may be those marginal kidneys with high suspicious of cortical necrosis.
Kidney biopsy before transplantation was found to affect the discarding of more kidneys. The quality of kidneys was based on frozen biopsies. With the increase of discarding kidneys, the transplanted kidneys had modest graft survival after 5 years (U.S trans-plant registry data (2005–2014)). On-call pathologists’ reports based on wedge biopsies did not correlate with practising nephropathologists opinions. . sone biopsies were deemed suitable when re-evaluated. For that reason, soring systems like MAPI were developed.
There is no deceased organ donation in our country, but Iam not supporting this approach as the history and clinical evaluation can be very helpful in taking decision whether to take the graft or not.
Frozen section biopsy examination results can guide organ acceptance decision, which is widely used, has certain challenges like:
1- Limitation of the frozen sections reviewed in few seconds using hematoxylin and eosin staining.
2- It may be evaluated by unspecialized renal on-call pathologist.
A recent study found poor agreement on an aggregate overall kidney quality score.
20% of discarded renal grafts graded as unacceptable by on-call pathologists were found to be transplantable after being reviewed by trained pathologists.
Also the inter-rater agreement among those experts is limited.
In a seminal publication on the Banff histopathological
consensus criteria for preimplantation kidney biopsies, Liapis et al, reported the inter-rater agreement for a sample of 19 preimplantation biopsies (frozen and permanent) reviewed by 32 trained pathologists.
So there should be considerations and guidelines for this approach and definition of high risk kidney to minimize the discard of transplantable kidneys
The article is one that demonstrates that the ongoing shortage of organs available for transplantation is limited and there is still an increasing number of patients on the waiting list, and the cost of dialysis remains elevated. This is why studies like extended criteria donors have been used and reviewed, and now to see how valuable the kidneys may be, the research on procurement biopsies in kidney transplantation is introduced to select kidneys that may seem not acceptable and as such be used once the biopsy reveals as acceptable.
The study was conducted in 1995 of about 65 kidneys were used and pre-transplant biopsies were done. The study was to identify the risk of primary nonfunction kidneys, to see if there was an early risk of graft failure and finally to identify chronic kidney disease and if the damages were reversible.
It was found that:
1) 8 kidneys were found with more than 20% with GS
2) About 87% developed DGF
3) 38% with time developed graft failure within a duration of 6 months.
During the study, several problems were identified regarding whether or not to accept or reject the kidneys and they were:
1) The biopsy taken was limited to a section of the kidneys to review so there were a few sections only using the hematoxylin and eosin staining.
2) There was a lack of pathologists to review the biopsy and experiences were not as the mature pathologist.
3) As such the result or report given was not in accordance.
With the different problems facing more studies and different kinds of predictive scoring were developed like the Maryland Aggregate Pathology Index (MAPI).
The study showed that the association between using scores and graft survival had controversial results and as such better ways to accept kidneys must be developed. There is now the artificial intelligence system that has been used and shows promising the study as it has demonstrated a reduction in the proportion of grafts that is not considered not usable from about 14% to 2%.
So it must newer methods of organ testing must continue to develop as the need for organ transplantation is needed and increasing.
Currently, in my practice, there are no active kidney transplantations due to limited factors but using clinical and laboratory judgment is important and a kidney biopsy will greatly help to decide to transplant one or both kidneys based on what is seen.
This study discusses about the utility of pre implantation biopsy and how it can reduce the discard rates of the retrieved kidneys.
This study discusses the American population where there is significant shortage of the organs and waiting list is quite large.
Similarly, discard rates are also high to the tune of 20% when more and more marginal donors are being included from which non standard organs are retrieved.
Conclusion
Please provide a summary of this article.
There is shortage of organs for donation and transplant waiting list is increasing, e.g. in US it is around 100000 . There is evidence that non standard organs which are discarded may be beneficial. Discard rate f organs which may be beneficial may be 20%.
The main reason of discarding is quality standard based on frozen section. To predict graft outcome , biopsy is performed to identify chronic damage etc.
There is 20 year data which shows that graft biopsy may provide limited information about outcomes. Biopsy may lead to higher discard rate as to predict outcomes may not be accurate.
The studies up till now were biased as the organs selected for transplant were included in the studies. So these studies have not been able to accurately assess the role of biopsies.
The authors proposes that US transplant centres should curtail or eliminate biopsy for standard criteria donors.
There should be new trials to evaluate the role of procurement biopsies if benefits are more than harm and use is judicious.
Evidence to guide use of biopsies should be sought and new strategies should e developed to decrease the risk of discard of kidneys.
Please reflect on your practice
In my country only living donor transplantation is practiced. Unfortunately we have no such experience.
Summary of the article:
Reflection on my practice:
I would avoid routine procurement biopsies for standard criteria donors and would limit it to only marginal donors.
With the increase in ESRD patients worldwide, there is a considerable waiting list for transplantation because the demand of kidney allografts overcome the availability of kidney offers. Over the last 2 decades, with the implementation of ECD,there has been an increase in the number of deceased donor kidney offers, however this number does not yet meet the required kidneys for those on the waiting list.
Moreover, receiving a kidney transplant from a deceased donor is preferable than continuing dialysis, which puts the patient at increased risk for cardiovascular complications and even death.
SUMMARY
There are a few drawbacks associated with doing a frozen section biopsy on a donated kidney, particularly in relation to reducing the number of donations from deceased donors or restricting the number of transplants from deceased donors:
– It was demonstrated that the non-biopsied kidneys were donated three times more than biopsied kidney. Biopsied kidneys have higher chance to be discarded for transplantation.
– More than 20% of deceased kidneys were rejected because of glomerulosclerosis
– There is likely to be a significant variation in the evaluation and interpretation of the kidney biopsy, particularly given that the biopsy was stained with H&E, and it was examined by an on-call pathologist who was not a renal specialty pathologist.
– The purpose of the frozen section biopsy is to determine whether or not to accept a donor since it anticipates a delayed graft function or a non-functioning graft.
– Additional clinical donor variables that were not taken into account here but could have significant impact on the decision of donation rather than the biopsy result itself.
-There is no international consensus or standard for determining when to discard a kidney based on its pathology, and commonly is center based. As a result, number of deceased kidney donors will be reduced. Practically speaking, kidney donors who have 20% or more glomerulosclerosis could be the treatment of choice for ESRD being for long time on the waiting list.
This article address role of frozen section renal biopsy which done pre transplant to identify non function kidney and early graft failure and irreversible organ damage. Despite increasing incidence of waiting list for kidney transplant and increase kidney donation from deceased persons and using of frozen renal biopsy help in deciding for acceptance of donation from deceased persons but rate of acceptance with this protocol low by increasing rate of discarded removed kidney from donation. In 1995 shows > 20% of cases is glomerulosclerosis and it’s discarded from donation.
In recent study from 2005 to 2014 shows increase discarded kidney to 85% . Difference opinions even from experts pathologist in presence of slight changes in frozen slices of interstitial fibrosis/ arteriolar hyalinosis and tubular injury less than 0.1 it’s may lead to inappropriate discard.
Limitations of this study can not assess accuracy of biopsy in assessing outcome of all recovered organs. This study shows Obtaining biopsy is associated with increase rate of discard kidney .
Despite the donor pool were expanded with time, still there are large number of patients in the waiting list,
A study done in 1995 of 65 kidneys with pre transplant biopsies, found that, 8 kidneys with > 20% GS.;
This study led to increasing discard of kidney if GS > 20% till today.
Recent analysis (2005-2014) in the US with donor kidney profile >85%, found that the discard rate rose from 34% with 0-10% GS, to 77.4% with GS > 20%.
5 years death-censored graft survival rate differences were modest.;
Thus, selected kidney with high GS can offer benefit to patient on the waiting list with outcome superior to dialysis.
Multiple scoring system developed, combining pathologic finding (with or without donor factor) to better predict of early graft failure,
MAPI (Maryland Aggregate Pathology Index) score combine.;
MAPI score as follow, (based on similar 1 year survival, but reduce 3 years survival rate).;
In other study (142 DCD recipients); Neither MAPI nor other studies, can predict the risk of DGF or graft loss.
Finally;
introduction :
The use of frozen section biopsy results to guide organ acceptance decisions has been widely and appropriately challenged.
results
studies support the conclusion that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
All current United States studies of biopsy results and outcomes are limited by selection bias.
United States transplant centers should curtail or eliminate the use of biopsies for standard criteria donors and avoid discard on the basis of biopsy data alone.
yes , i agree with the study , in our center we have a small pathology section with little experince and alot of un reiable result (depending on the pathologist )
so i think it is not reiable , however other centers may have a powerfull pathologist section
Importantly, after adjustment for donor factors and organ procurement organization characteris- tics, performance of a kidney biopsy is associated with more than three times the odds of kidney discard.
To identify kidneys at risk of primary nonfunction or early graft failure, frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify chronic or irreversible organ damage.
Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, .50% of kidneys removed for transplant still undergo a biopsy. Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age and kidney donor profile index).
We believe that United States transplant centers should curtail or eliminate the use of biopsies for standard criteria donors and avoid discard on the basis of biopsy data alone.
New approaches to procurement biopsy should also be tested in appropriate trials to determine if and when benefits of biopsy (e.g., improved quality-adjusted life-years on the waiting list) outweigh the harms (e.g., death on the waiting list and misuse of scarce resources).
Pursuit of evidence to guide appropriate biopsy use and development of strategies to improve the quality of kidneys at higher risk for discard (intervention research), motivate acceptance, and expedite placement are vital priorities to reduce unnecessary discard and increase access to transplant for patients in need.
Please provide a summary of this article
-The primary reason given for discarding a kidney removed for transplant is “quality,” a determination frequently made on the basis of frozen section biopsy results.
– Selected kidneys with high GS can offer benefit to patients on the waiting list with outcomes superior to dialysis.
– Pathologic evaluation by nonspecialty trained pathologists did not correlate with outcomes, and critically, 20% of grafts graded as unacceptable for transplant by on-call pathologists were deemed transplantable upon retrospective review by trained pathologists.
– The reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
-In an effort to address the limitations inherent in pretransplant biopsy results,
multiple scoring systems have been developed, combining various pathologic
findings to better predict likelihood of early graft failure.
-Providing transplant centers with images of photomicrographs for evaluation by the accepting center is another proposed solution, but it has also proven problematic in practice.
-A more promising approach may be to apply artificial intelligence (AI) algorithms
to allow robust assessment of multilayer sections.
– Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age and kidney donor profile index).
– New approaches to procurement biopsy should be tested in appropriate trials
to determine if and when the benefits of biopsy (e.g., improved quality-adjusted
life-years on the waiting list) outweigh the harms (e.g., death on the waiting
Please reflect on your practice
In Sudan, we have living donor transplants only, and we have no experience with DD transplants.
Although the number of patients waiting for kidney transplantation is increasing, the discard rate of potentially transplantable kidneys is approximately 20%, discarding is usually due to quality based on frozen section biopsy results.
Biopsy practice is variable among centers, it is performed pre-transplant to assess the risk of primary non function or early graft failure
Previously kidneys with GS >20% were commonly discarded but a recent study suggested that selected kidneys with high GS were associated with better outcome than that associated with remaining on dialysis.
Frozen section biopsy aims to guide organ acceptance but have several limitations as few sections are evaluated by on-call pathologist who is not specialized in renal pathology as well as inter-rater agreement is limited even among experts.
Depending on pathology findings alone may lead to inappropriate discard of kidneys.
Several scoring systems were developed to improve prediction of early graft failure as the 2014 Maryland Aggregate Pathology index, however, the association between biopsy scores and graft failure or graft function was not well determined.
A study showed that no scoring system could predict the risk of DGF or graft loss.
Providing transplant centers with images of photomicrographs for evaluation by the accepting center was a difficult option
Artificial intelligence algorithms is a promising approach to assess multilayer sections.
Studies couldn’t assess accuracy of biopsies in assessing outcomes of recovered organs due to selection bias.
A study showed that pre transplant biopsies have no predictive value over the estimates from donor records.
Performing biopsy is strongly associated with kidney discard rates.
The article suggest stopping performing biopsies in standard criteria donors and avoiding the discard of organs based on biopsy alone.
Further studies are needed to determine when benefits of biopsy outweigh the harms and to decrease unnecessary discard of organs and to increase access to transplantation.
Summary
This article addresses the limitation and variations in the practice for kidney biopsy indication at the time of transplantation, the main indication for the use of kidney biopsy which is still being used in > 50% of the center in the US is to assess the quality of the organ to be accepted for donation, Frozen section biopsies at the time of donation can increase the rate of organ waste by 3 times due to the limited view of the sections of Biopsied kidneys in addition to the obvious variation in indication for biopsy technique, and the need of expertise pathologist interpretation which is not the case most of the time so lead to limited reliability of such frozen sections and make it very challenging in real practice and should be limited for selective cases of donors with a comorbid and associated uncertain prognosis like a marginal kidney with the risk of irreversible organ damage. However, based on a recent study from the US still selection of kidneys with high GS can offer an advantage and better outcomes compared to those waiting on dialysis. Different scoring systems have evolved over time for the interpterion of the histology of the kidneys like the MAPI index (Maryland aggregate pathology index based on wedge biopsies to assess for GS, arterial wall–lumen ratio, scar/fibrosis in at least 10 tubules plus arteriolar hyalinoses, and classified to low, intermediated, and high MAPI scores, only 5% of cases have a high index based on a systemic review by wang et al., and half of the 15 studies reviewed confirmed the association between the biopsy index score and graft failure. However, another study failed to show any correlation between the biopsies score by any mean and the predictor risk of graft failure or loss, most of the available data are limited by selection bias so we need RCT to assess such limitations. Including validation and reading at multilevel review including supporting photomicrographs images for further evaluation by accepting centers
Also, patients’ and surgeons’ acceptance of the donor organs without biopsies will help in less discard of transplantable and possibly valued kidneys and also augment the use of high KDPI in suitable cases.
our center mainly deals with LD transplantation, we did a few cases of DD but we did not perform biopsies for them however we have a good setting of the renal histopathology team including a renal consultant pathologist
– Performance of kidney biopsy in addition to adjustment for donor factors & organ procurement characteristics is associated with > 3 times the odds of kidney discard.
– frozen section is performed prior to transplantation to identify the risk of primary or early graft failure. based on recent analysis of US transplant registry , the selected kidneys with high Glomerulosclerosis can offer benefit to patients on waiting list better than being on dialysis.
– the use of fresh frozen section biopsy results to evaluate for organ acceptance has been widely challenged. in trial to decrease the limitations. so, multiple scoring systems have been developed combining the pathological findings with or without additional donor factors like MAPI in 2014 . involvement of AI system, it reduces the proportion of graft inappropriately considered not transplantable.
– consideration for defining appropriate use of procurement biopsies in kidney transplantation by selective use of biopsy to guide selection & placement of high risk ones, less discard of transplantable & potentially beneficial kidneys & to expand use of high KDPI organs in appropriate candidates.
Summary : Procurement biopsies in kidney transplant
This study revitalizes the perspective on kidney donor acceptance. Many times the performance of kidney biopsies leads to increased rate of organ discard. Frozen section analysis of kidney biopsy prior to transplant is performed in some cases to identify chronic or irreversible organ damage.
Due to the variation in standards for choosing kidneys which need to be biopsied, there is a lot of organ wastage. Limited value of frozen section biopsy and uncertain prognostic value further adds to the perspective of wastage.
Research needs to be done based on accepting donor kidneys without biopsy and the graft outcomes of such. Patient centered outcomes need to be focussed on such as access to transplant, renal function, graft survival and patient survival.
This study may be limited in results accuracy because of selection bias – only kidneys which were accepted for organ donation were studied. Hence the accuracy of results in assessing kidney outcomes may be limited.
To repair this limitation, the study mentioned the results of another analysis wherein they found that there was no predictive value of kidney biopsies on outcome. Graft survival had been good for most of their participants even at 10 years post kidney transplant.
This study recommends curtailing the use of biopsies for standard criteria kidneys that come up for organ donation. This can avoid organ discard based on biopsy alone.
SUMMARY
Introduction
The demand for kidney by patient with ESKD on waiting list is increasing while the shortage of organ is also increasing despite the use of diseased donors’ organs. In spite of the above challenge, the discard rate of potential kidney for donation from the diseased donor was about 20%.
Indications for frozen section of kidney biopsy
A study on 65 kidneys in 1995 shows that 8 kidneys with > 20% GS, 87% of them experienced DGF, while 38% developed graft failure within 6 months and these has been seen as the criteria to reject potential kidney.
Reason for challenging frozen section analysis for accepting or rejection kidney
The 2014 Maryland Aggregate Pathology Index
A more promising way of reporting frozen section analysis is the use of artificial intelligence that has been found to be significantly more accurate in reporting GS versus doctors on call. This has reduced the incidence kidneys deemed unsuitable from 14% to 2%. Obtaining a kidney biopsy has been associated with high discard rate of kidney and may not augment prediction of outcome beyond clinical criteria
Actually I donot have deceased kidney donation in my center .
This topic recommend against discard of deceased donor grafts based on frozen section biopsies
As there is no reliable scoring systems ,MAPI (2014 Maryland Aggregate Pathology Index) which includes : GS, arterial wall-to-lumen ratio, scar/fibrosis in at least ten tubules, and arteriolar hya- linosis.,
But studies showed that neither MAPI or other scoring systems can predict graft survival or delayed graft function .
And when compared between USA the study country to Belgium and they have no frozen biopsies results showed almost similar results in 1st year and 3rd year survival
And they see that even if there is high percentage of glomerular sclerosis >20% still the risks are less than keeping patients on dialysis
In this articles we can see that 20% discard of the organ because of GS ,and accordingly the rate of discarding organ increase with frozen section biopsy of the transplanted organ ,as you all know the intense need for organ donation . for that in this article we found that a study of 65 kidneys with pretransplant biopsies reported that 87% of kidneys with more than 20% GS experienced DGF, and 38% developed graft failure within 6 months
However, 5-year graft survival differences of kidneys transplanted were modest:
75.8% for 0%–10% GS,
70.9% for .10% GS,
and 74.8% for kidneys without biopsy.
AS you all know that frozen section biopsy is associated with lots factors of limitation
· The discard rate of recovered, potentially transplantable kidneys in the United States increased markedly in the late 1990s and remained at approximately 20%. The primary reason for discarding a kidney removed for transplant is “quality,” a determination frequently made based on frozen section biopsy results.
· A study of 65 kidneys with pre-transplant biopsies reported that among eight kidneys with .20% glomerular sclerosis (GS), 87% experienced delayed graft function, and 38% developed graft failure within six months.
This study was followed by a trend of increasing discard of kidneys with .20% GS that persists to this day.
·A recent analysis of United States transplant registry data (2005–2014) for kidneys with a kidney donor profile index of .85% found that discards rose from 34% with 0%–10% GS to 77.4% with .20% GS.5
However, 5-year death-censored graft survival differences among kidney transplants were modest: 75.8% for 0%–10% GS, 70.9% for .10% GS, and 74.8% for kidneys without biopsy.
Thus, selected kidneys with high GS can benefit patients on the waiting list with outcomes superior to dialysis.
Frozen section biopsies are generally limited to a review of a few sections using hematoxylin and eosin staining. They may be evaluated by on-call pathologists who lack specialized renal pathology training.
Other studies conclude that reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
pathologic scoring systems have not been evaluated with large registry trials as detailed pathologic findings are not reported in field-defined data, limiting validation within large representative populations.
A recent study compared organ allocation in the United States with that in France and Belgium— where kidneys are not routinely biopsied during distribution—and found no predictive value of biopsies over what is regularly available from donor medical records
Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment the prediction of outcomes beyond estimates using clinical criteria and kidney donor profile index)
In Sudan, the deceased donor transplant program has not been established. Therefore, if set, we do not do a biopsy, depending on the clinical assessment of the donor.
There is imbalance between the shortage of organs available and the prolonged waiting times, and death.
But 20% of of the recovered, potentially transplantable kidneys in Us are discarded
basis of frozen section biopsy results
a study of 65 kidneys with pretransplant biopsies reported that 87% of kidneys with more than 20% GS experienced DGF, and 38% developed graft failure within 6 months
However, 5-year graft survival differences of kidneys transplanted were modest:
75.8% for 0%–10% GS,
70.9% for .10% GS,
and 74.8% for kidneys without biopsy.
Limitations of frozen section biopsies
studies concluded that the reliance on pathology findings alone, leads to inappropriate discard.
Recently multiple scoring systems have been developed rather than GS such as; MAPI;
(((Increasing scores were associated with similar 1-year survival but reduced 3-year survival))))
However, study of 142 deceased donor allograft recipients, concluded neither the MAPI nor other scoring systems predicted the risk of DGF or graft loss.
the (AI ) artificial intelligence system dramatically reduced the proportion of grafts inappropriately deemed not transplantable, from 14% to 2%.
a recent study compared organ allocation in the US with that in France and Belgium and found no predictive value of biopsies over what is routinely available from donor medical records.
To further inform this debate, a randomized, controlled trial of biopsy use should be performed to determine if and when a procurementbiopsy should beusedin thedecision to accept or decline an organ offer.
In my practice, if deceased donation program available, we can rely on clinically and laboratory rather than pathologically judgment.
Thank you, Ghalia for your excellent summary
The demand of kidneys is greater than the available accepted donors. Putting in mind that large number of patients die while on the waiting list and that the cost of being on renal replacement therapy is high, this increase the need for accepting nonstandard organs. After harvesting the organs, some were discarded mainly due to poor quality of organ which is determined mostly through biopsy. kidneys with more than 20% glomerular sclerosis are discarded. A recent analysis showed that the -year death-censored graft survival was approximately similar to some extent between 0-10% ,more than 10% glomerular sclerosis and no biopsy organs. This practice depends on frozen section biopsy, but many factors affect the results of these. The pathologist may lack experience as they are usually the on-call pathologists. When the grafts rejected by them were reviewed by trained pathologist, 20% of the grafts were found transplantable. Even between trained pathologists there is still little inter-rater agreement of the results. This is why scoring system gained more popularity to predict the likelihood of early graft failure e.g. 2014 Maryland Aggregate Pathology Index (MAPI). The studies conducted to assess the association between using scores and graft survival have controversial results. Using artificial intelligence algorithms could solve a lot of problems like the disagreement between pathologists and furthermore, their use has decreased the rate of discarded organs. When the discarded kidneys in USA were compared with transplanted organs in countries which do not practice this, the survival of the transplanted kidneys was approaching 68% at 10 years. The authors suggested the elimination of using biopsies for standard criteria donors and avoid discarding kidneys on the basis of results of the biopsy data alone.
In Sudan, kidneys are biopsied at table only for a limited number of grafts. the results of interpretations take usually up to 10 days to be released. so this practice does not affect the rate of discarding organs.
Thank you Hinda
Nice to see you back
Please provide a summary of this article
Discard rate of recovered, potentially transplantable kidneys is around 20%. The main cause is quality (based on the basis of frozen section biopsy results)
Frozen section analysis of kidney biopsy prior to transplant is selectively performed to identify kidneys at risks (primary nonfunction or early graft failure)
DGF and graft failure are related to glomerular sclerosis (GS) on kidney biobsy (discard of kidneys with 20% GS). However, 5-year death-censored graft survival was modest (75.8% for 0%–10% GS, 70.9% for .10% GS, and 74.8% for kidneys with- out biopsy). Thus, selected kidneys with high GS may be better than waiting list with outcomes superior to dialysis
Use of frozen section biopsy to guide acceptance decisions is challenging (H & E stain, on-call pathologist lack experience). Reliance on pathology findings alone may leads to inappropriate discard
Multiple scoring systems developed to better predict early graft failure
MAPI (combine GS, arterial wall to lumen ratio, scar/fibrosis). Increasing scores were associated with similar 1-year survival but reduced 3-year survival
A more promising approach is to apply artificial intelligence (AI) algorithms. AI systems were significantly more accurate in assessing GS versus for on-call pathologists and thus reduce the risk of discard
A waiting randomized, controlled trial to determine when a procurement biopsy should be used in the decision to accept or decline an organ
Please reflect on your practice
The program of deceased donor transplantation not initiated yet in our country
Thank you, suppose it will start soon. Will biopsy or no biopsy?
No, I will not do routinely
Kidney biobsy is susceptible to sampling error
To do biopsy, it is very important to ask for the past history of any renal disease and the current senario (WIT).
1Based on frozen section biopsy results ,the removal of transplant kidney is determined,
To identify kidneys at risk of primary nonfunction or early graft failure ,frozen section analysis of kidney biopsy prior to transplant is done ot identify chronic or irreversible organ damage.
In 1995,65 kidneys with pretransplant biopsies done:
>20% glomerular sclerosis,87%had delay graft function
38% develop graft failure within 6 month.
It is hard to have a decision for organ acceptance by using frozen section biopsy result.
In a systemic review, Wang et al reported that only half of the 15 studies examined an association between biopsy scores and graft failure or graft function
MAPI and scoring system are accurately predicted the risk of delay graft function or graft loss.
The A1ystem were significantly more accurate in assessing GS.
496 United States discarded kidneys were matched to transplanted organs from Europe, had graft survival rate of 93.1% at 1 year 80.7% at 5 years and 68.9%.
A randomized controlled trial of biopsy use should be performed to decide if and when a procurement biopsy should be used in the decision to accept or decline an organ offer .
New approaches to procurement biopsy should also be tested in appropriate trials to determine if and when benefits of biopsy outweigh the harm.-Summary of this article
2- in our centre we did not have deceased donor but if there is randomized studies to weight the risk versus the benefit to expand the donor pool
Thank you
Please provide a summary of this article
Despite the organ donation pool shortage, the rate of discarding kidneys remained high at 20 %, primarily due to organ quality, which is determined by biopsy results.
There is a significant variation in biopsy practice in transplant centers, and performing kidney biopsy is associated with a three times increase in discard rate.
The aim of performing a kidney biopsy prior to transplant is to identify chronic or irreversible organ damage and to guide organ acceptance decisions. There is a trend of increasing discard of kidneys with >20% GS that persists to this day.
There were modest variations in 5-year death-censored graft survival; 75.8% for 0%–10% GS, 70.9% for 10% GS, and 74.8% for kidneys without biopsy. Therefore, kidneys with high GS can benefit patients on the waiting list with outcomes superior to dialysis.
Limited sections of frozen section biopsies using H&E are evaluated by an on-call who may not be a specialized pathologist. 20% of grafts considered unsuitable by on-call pathologists were found to be transplantable on retrospective review by trained pathologists. Keep in mind the inter-rater agreement is limited even among experts. Studies showed the reliance on pathology findings alone, regardless of the individual reading the slide, leads
to inappropriate discard.
Several biopsy scoring systems were developed, combining various pathologic findings to better predict the likelihood of early graft failure. Some studies showed a good correlation, while others did not. Pathologic scoring systems
have not been evaluated with large registry trials as detailed pathologic findings are not reported in field-defined
data, limiting validation within large representative populations
An approach that may be applied to improve agreement on biopsy findings includes using photomicrograph images or artificial intelligence (AI) algorithms to allow robust assessment of multilayer sections.
Currently, all biopsy results and outcomes studies are limited by selection bias, as only organs that were
accepted for transplant were included in these analyses. A recent study compared organ allocation in the US with that in France and Belgium, where kidneys are not routinely biopsied during allocation and found no predictive value of biopsies over what is routinely available from donor medical records
Obtaining a biopsy may not accurately predict the outcome and lead to increase organ discard rates. To reduce unnecessary discard and increase access to transplants, evidence to guide appropriate biopsy use and more prognostic criteria to be established.
Please reflect on your practice
The clinical and laboratory criteria for organ acceptance correlate well with graft and patient survival. Pre-implantation biopsy of value when there is significant damage and clear finding to preclude donation as cortical necrosis.
Thank you. Good summary
This discussion makes a critique and reassessment of the need for pre-transplant biopsy to assess the quality of the kidney to be donated before being submitted in queue. Despite being used in the United States, this practice is not common in Europe and South America and makes a comparison with countries that would have similar donor characteristics and the impact on graft survival.
It is believed that there is a three-fold loss of kidneys available for donation due to histopathological findings that could suggest a non-viable organ in the medium or long term.
Percentage of glomerulosclerosis, frozen biopsy, availability of specialist pathologists. Studies show the discrepancy between pathologists with different degrees of experience, increasing the number of unnecessary losses due to excessive discard of kidneys that could be viable.
In an attempt to minimize these losses, several scores have been submitted, but when there are several models, none of them is really effective. Models with artificial intelligence have been used and shown to be effective in reducing these losses considerably.
This article suggests that biopsies be restricted to organs with expanded criteria or individually, no longer being the rule.
Although here in Brazil we have a large number of deceased donors, we do not have a pre-transplant biopsy to define the feasibility of the transplant process.
Thank you, Filipe Will you recommend a biopsy or not and why?
Professor, I believe that we still don’t have solid safety criteria to define the rejection of an organ. I believe that to become viable it is necessary to have an extremely specialized team that can provide quick information.
At the moment I would not perform biopsies of these organs, but if I were to choose the profile of patients in which I would perform, it would certainly be organs that meet expanded criteria donation or with recent reversible acute kidney injuries.
VI. Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions
====================================================================
-In 1995, a study of 65 kidneys with pretransplant biopsies reported
-A recent analysis of United States transplant registry data (2005–2014) for kidneys with a kidney donor.
====================================================================
CURRENT STATE
• ≈ 100,000 Americans await kidney transplant
• ~ 20% recovered are kidneys discarded.
• Biopsied kidneys are 3-times more likely to be discarded
• Marked variation in indication for biopsy, technique, and expertise in interpretation.
• Limited reliability of standard frozen section biopsy and uncertain prognostic value
RESEARCH NEEDS
• Randomized controlled trials:
• Patient & surgeon acceptance of donor organs without biopsy
• Patient-centered outcomes (access to transplant, renal function, graft survival, patient survival)
• Validation of whole slide/multi-level review including AI-supported reading.
FUTURE STATE
• Selective use of biopsy to guide selection & placement of high-risk kidneys.
• Less discrd of transplantable and potentially beneficial kidneys.
• Expanded use of high-KDPI organs in appropriate candidates.
====================================================================
Please reflect on your practice
Thank you, Mahmoud Will you recommend a biopsy or not and why?
Thanks you very much Prof.Halawa
I will not do renal biobsy
Becuase a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age ,e GFR and kidney donor profile index).
1. Please provide a summary of this article
Current state
≈ 100,000 Americans await KTX, although the total number of deceased donors has increased
~ 20% recovered kidneys are discarded
Primary cause for discard is “quality of a kidney (based on results of frozen section biopsy)
Variable biopsy practice across the US (23% -78%)
Biopsied kidneys 3-times more likely to be discarded
A study (1995) of 65 kidneys with pre-transplant biopsies found 8 kidneys with >20% glomerular sclerosis (GS), 87% had DGF, & 38% graft failure within 6 months
This study led to a trend of increasing discard of kidneys with>20% GS; a practice persisting today.
Limitations
Biopsy indications, techniques, & expertise are greatly variable
Biopsies limited to review of a few sections with only H&E staining
Biopsy evaluated by non-specialty trained on-call pathologists; 20% of kidneys deemed unacceptable by on-call pathologists were transplantable when review by trained pathologists.
However, inter-rater agreement is limited even trained pathologists
So, reliance on biopsy alone leads to inappropriate discard.
Reliability of standard frozen section biopsy: limited Prognostic value: Uncertain
Solutions
Scoring systems (combining pathology+/-other donor factors) to predict early graft failure.
The MAPI (2014) scoring combines GS, arterial wall-to-lumen ratio, scar/fibrosis in at least 10 tubules, & arteriolar hyalinosis.
Increasing MAPI scores associated with similar 1-yr but reduced 3-year survival; however, only 5% had a high MAPI score.
Wang et al (systemic review) shows that only half of the 15 studies found an association between biopsy scores & graft failure or graft function.
A study of 142 deceased donor graft recipients: neither MAPI or other scoring systems accurately predicted the risk of DGF or graft loss.
Providing accepting centers with pathology images suggested as a solution, but proved impractical.
A pilot artificial intelligence (AI) algorithm compared AI reading to on-call results & subsequent “gold standard” consensus assessment by 3 renal pathologists; AI was significantly more accurate in assessing GS & markedly reduced discard able grafts from 14% to 2%.
Research needs
• RCT s andomized controlled trials:
-Patient & surgeon acceptance of organs without biopsy
-Patient-centered outcomes (access to TX, graft survival, patient survival)
• Validation of whole slide/multi-level review
including AI-supported reading
Future state
• Selective use of biopsy to guide selection & placement of high-risk kidneys
• Less discard of transplantable & potentially beneficial kidneys
• Expanded use of high-KDPI organs in appropriate
patients.
===============================
2. Please reflect on your practice
We do not perform deceased donation kidney transplantation in our country.
However, there are some preliminary movements by policy makers & local professional bodies & societies, in addition to some individual efforts, to establish such a program in the near future.
The invaluable information provided in this article would, undoubtedly, help us in our future plans.
Thank you, Mohamed, very clear
Summary of the article
‘’Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions’’
1. On the Banff histopathological consensus, Liapis et al study supported the conclusion that the reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard.
2. To date, pathologic scoring systems have not been evaluated with large registry trials as detailed pathologic findings are not reported in field-defined data, limiting validation within large representative populations.
3. In a systemic review, Wang et al. reported that only half of the 15 studies examined demonstrated an association between biopsy scores and graft failure or graft function.
4. Despite 20 years of data demonstrating that biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts, 50% of kidneys removed for transplant still undergo a biopsy.
5. Obtaining a biopsy is strongly associated with kidney discard rates, and it may not significantly augment prediction of outcomes beyond estimates using clinical criteria (e.g., age and kidney donor profile index).
6. A randomized, controlled trial of biopsy use should be performed to determine if and when a procurement biopsy should be used in the decision to accept or decline an organ offer.
Thank you
Summary:
In my practice, we have only a living donation program.
Thank you, Huda
Please provide a summary of this article :
1- the limitations related to use of only Hematoxylin and Eosin statins without other specific stains, IF and EM studies.
2- the limitations related to evaluation of biopsy by on-call pathologists who are not specialized in renal histopathology.
1- providing transplant centers with images of photomicrographs to help pathologists for proper description and evaluation of biopsies.
2- multiple scoring system were developed to predict the likelihood of early graft failure.
Please reflect on your practice :
Thank you
Procurement Biopsies in Kidney Transplantation: More Information May Not Lead to Better Decisions.
Discarding of removed kidney was mainly depends on the quality of renal biopsy frozen section result which identify chronic or irreversible organ damage and kidney with GS>20% usually discarded and so biopsied kidneys are 3-times more likely to be discarded.
According to Glomerulosclerosis, 5-year death-censored graft survival differences were modest: 75.8% for 0%–10% GS, 70.9% for .10% GS, and 74.8% for kidneys.
Many studies conclude that reliance on pathology findings alone, regardless of the individual reading the slide, leads to inappropriate discard, this is mainly because the difference in the grading/scoring of the pathologist which is mainly subjective factors from one to one and from center to center.
To overcome this problem, Validation of whole slide/multi-level review including AI-supported reading is considered for defining Appropriate Use of Procurement Biopsies in Kidney Transplantation.
Biopsies performed at the time of kidney recovery provide limited insight regarding the eventual outcome of renal allografts as 50% of kidneys removed for transplant still undergo a biopsy, so obtaining kidney biopsy still an obstacle as it is not correlates with graft outcome.
Now, selective use of biopsy to guide selection &placement of high-risk kidneys, try not to discard of transplantable and potentially beneficial kidneys and expanded use of high-KDPI organs in appropriate candidates.
Waiting Randomized controlled trials to detect patient-centered outcomes (access to transplant, renal function, graft survival, patient survival).
We don’t have like this program in our practice but I think we should out weight benefit versus risk for our recipient before accepting kidney with low quality.
Thank you. I like your reflection on your practice.
This article examines whether performing a biopsy on the deceased donor kidneys before transplantation improves the outcome!!
The likelihood of discarding biopsied kidneys is three times higher after performing a biopsy.
Pathologic screening by non-specialty trained pathologists did not predict outcomes, and more importantly, 20% of grafts that were ruled unsuitable for transplant by on-call pathologists were later found to be transplantable.
There is a noticeable variance in biopsy indication, procedure, and interpreting skill.
Standard frozen section biopsy has low reliability and has no clear prognostic value.
There is an urge for randomized controlled trials to better delineate the need for renal biopsy pre-transplant and its clinical outcome.
Although, we do not have such a program in our practice, I do not believe that we have to stick to this practice with no enough evidence of its benefits.
Thank you. I like your reflection.
This article is evaluating if there is a better outcome when we do biopsy for the deceased donor kidneys before transplantation or not
Previous reports found an increase in the risk of DGF and graft loss when using deceased donor kidneys with glomerulosclerosis > 20 %
In spite of that, the authors answer was No and as they stated, “more Information may not lead to better decisions”
And they explain this by the following
So.. the authors recommended against doing renal biopsy for the assessment of recipient outcome since obtaining a biopsy is strongly associated with an increase in the donor kidney discard rate and instead we should rely on donor clinical and laboratory data
In my practice we do not have deceased donor kidney transplantation
In my opinion I will not do donor renal biopsy except for ECD kidneys with GFR 30-60 ml/min for assessment of dual kidney transplantation
Thank you. I like your reflection on your practice.
Despite an increase in dead donors, the kidney transplant waiting list remains huge, with approximately 100,000 applicants.
Despite evidence that many nonstandard organs are helpful for eligible recipients, the US discard rate of potentially transplantable kidneys climbed in the late 1990s and remains at 20%.
“Quality” is often cited as the rationale for discarding a kidney extracted for transplant. Between 23% and 78% of kidneys retrieved in the US are biopsied. After adjusting for donor and organ procurement organization criteria, a kidney biopsy triples the likelihood of kidney discard.
Frozen section biopsy data have been criticized for guiding organ acceptance choices.
Frozen section analysis of kidney biopsy before transplant is used to detect chronic or irreparable organ disease. A 1995 study of 65 kidneys with pretransplant biopsies found that 87% of kidneys with.20% of GS had delayed graft function and 38% failed after 6 months. This investigation led to an ongoing tendency of discarding kidneys with 20% GS.
-Despite 20 years of evidence showing that kidney recovery biopsies give minimal insight into renal transplant outcomes, 50% of donated kidneys are biopsied. The biopsy is substantially related to kidney discard rates and may not considerably improve outcome prediction beyond clinical criteria.
In my practice, we are doing day0 biopsies for all deceased donors. we do not discard too many kidneys because we use highly selective criteria for the deceased donors(we are not using NHBD, h/o of DM or HTN and age less than 50). we discard kidneys.
Thank you. I like your reflection on your practice, but your discard rate is high. Think of the scenarios will come across in this module. You may start accepting these kidneys you used to reject.