The role of procurement biopsies in acceptance decisions for kidneys retrieved for transplant

Abstract

Background and objectives: There is a shortage of kidneys for transplant, and many patients on the deceased donor kidney transplant waiting list would likely benefit from kidneys that are currently being discarded. In the United States, the most common reason given for discarding kidneys retrieved for transplant is procurement biopsy results. This study aimed to compare biopsy results from discarded kidneys with discard attributed to biopsy findings, with biopsy results from comparable kidneys that were successfully transplanted.

Design, setting, participants, & measurements: In this retrospective, observational, case-control study, biopsy reports were examined from 83 kidneys discarded in 2010 due to biopsy findings (cases), 83 contralateral transplanted kidneys from the same donor (contralateral controls), and 83 deceased donors randomly matched to cases by donor risk profile (randomly matched controls). A second procurement biopsy was obtained in 64 of 332 kidneys (19.3%).

Results: The quality of biopsy reports was low, with amounts of tubular atrophy, interstitial inflammation, arteriolar hyalinosis, and acute tubular necrosis often not indicated; 69% were wedge biopsies and 94% used frozen tissue. The correlation between first and second procurement biopsies was poor; only 25% of the variability (R(2)) in glomerulosclerosis was explained by biopsies being from the same kidney. The percentages of glomerulosclerosis overlapped substantially between cases, contralateral controls, and randomly matched controls: 17.1%±15.3%, 9.0%±6.6%, and 5.0%±5.9%, respectively. Of all biopsy findings, only glomerulosclerosis>20% was independently correlated with discard (cases versus contralateral controls; odds ratio, 15.09; 95% confidence interval, 2.47 to 92.41; P=0.003), suggesting that only this biopsy result was used in acceptance decisions. One-year graft survival was 79.5% and 90.7% in contralateral and randomly matched controls, respectively, versus 91.6% among all deceased donor transplants in the Scientific Registry of Transplant Recipients.

Conclusions: Routine use of biopsies could lead to unnecessary kidney discards.

Figure 1.

Study population selection. The figure shows the disposition of kidneys from United States deceased donors in 2010 and their relation to the 83 discarded kidneys in this study.

Figure 2.

Comparison of the percentage of globally sclerotic glomeruli in two biopsies from the same kidney. The figure shows the percentage of globally sclerotic glomeruli in first and second biopsies from 64 kidneys that underwent two biopsies. The linear trend equation was First Biopsy=0.4933×Second Biopsy+6.1434; R²=0.2532; P<0.001.

Figure 3.

Percentage of globally sclerotic glomeruli in discarded kidneys (cases), transplanted contralateral kidneys from the same donor (contralateral controls), and randomly matched controls. Horizontal lines indicate group means: 17.0%, 9.0%, and 5.0% for cases, contralateral controls, and randomly matched controls, respectively. P<0.001 for cases versus contralateral controls and for cases versus randomly matched controls.

Figure 4.

Graft (top) and patient (bottom) survival for recipients of contralateral control kidneys and randomly matched control kidneys. Unadjusted Kaplan–Meier survival curves are shown.