Utility of morphometry in the study of donor and protocol

biopsies

D. SerónServicio de Nefrología Hospital BellvitgeBarcelona

Morphometry

DisadvantagesAdvantages

When is morphometry redundant?

When may it be useful?

When is it necessary?

TopicsRedundant

Morphometry applied to the study of donor biopsies

Potential utilityMophometric evaluation of protocol biopsies in clinical trials

NecessaryGlomerular adaptation after renal transplantation

TopicsRedundant

Morphometry applied to the study of donor biopsies

Potential utilityMophometric evaluation of protocol biopsies in clinical trials

NecessaryGlomerular adaptation after renal transplantation

Preexisting donor damage and outcome

year parameter

____________________________________________________________

Leunissen Transplantation 1989 sum of scores

Serón NDT 1993 Vvint/cortex

Wang NDT 1998 ah, GS

Gaber L Transplantation 1995 % GS

Abdi R Transplantation 1998 glomerular size

Karpinski Transplantation 1999 donor vasculopathy

Parmjeet R Transplantation 2000 ci, GS

Escofet X Transplantation 2003 GS

_________________________________

Is there any advantage in the morphometric evaluation of

donor biopsies?

Evaluation of donor biopsies (June 2000-Dec 2001, N = 77 (10 glom, 1 art)

Banff criteria

cgcictcvahmm

Quantitative parameters

% glomerulosclerosis

Vvint/c (%)Vvglom/c (%)Vg x 106 3

Vvintima/artery

Lopes JA et al. Kidney Int 2005; 67: 1595

Results (1)

0

20

40

60

80

100

120

140

-5 0 5 10 15 20 25 30 35 40 45 50

Glomerulosclerosis (%)

CrCl at 3 m (mL/min)

R=0.52P<0.001

Results (2)

0

20

40

60

80

100

120

140

0 1 2

ci

CrCl at 3 m (mL/min)

Rho = 0.41P = 0.005

0

20

40

60

80

100

120

140

-,25 0 1 2

ct

Rho = 0.38P = 0.0014

CrCl at 3 m (mL/min)

0

20

40

60

80

100

120

140

0 1 2

cv

CrCl at 3 m (mL/min)

Rho = 0.48P < 0.001

0

20

40

60

80

100

120

140

0 1 2 3 4 5 6

ci+ct+cv

CrCl at 3 m (mL/min)

Rho = 0.51P < 0.001

Results (3)

0

20

40

60

80

100

120

140

0 2 4 6 8 10 12 14

Vg (um3 x 106)

CrCl at 3m (mL/min)

R=0.30P=0.010

0

20

40

60

80

100

120

140

CrCl at 3 m (mL/min)

0 5 10 15 20 25 30

Vvint/cortex (%)

R=0.57P<0.001

CrCl at 3m (mL/min)

0

20

40

60

80

100

120

140

5 10 15 20 25 30 35

Vvintima/art (%)

R=0.26P=0.021

Results (4)

Multivariate analysis:histologic lesions and 3m CrCl

All variables

_____________________

1. Vvint/cortex

R=0.57

2. Glomerulosclerosis

R=0.62

_____________________

Not including

morphometric variables

______________________

1. Glomerulosclerosis R=0.52

2. cv R=0.60

3. ci R=0.64

______________________

Conclusions

Morphometric evaluation of donor biopsies does not improve the prediction of outcome

TopicsRedundant

Morphometry applied to the study of donor biopsies

Potential utilityMophometric evaluation of protocol biopsies in clinical trials

NecessaryGlomerular adaptation after renal transplantation

CAN and sequential protocol biopsies

Donor biopsies 15%4th month protocol bx 42 %1st year protocol bx 52%

% CAN

0 3 6 9 12 m

50

25

0

Prevention trial and protocol biopsies

0 1 2 3 4 5 6 m

Donor Bx Protocol Bx

placebo

treatment

Fibrosis CAN cv Vvinterstitium/c Vvintima/artery

Minimum sample size (50% reduction) (=0.05, =0.20)

Variable Patients per group____________________________________CAN 300Transplant vasc (cv) 1200

Vvint/cortex 63Vvintima/artery 49____________________________________

Serón, Transplantation 2000; 69(9): 1849Moreso et al. Am J Transplantation 2001; 1(1): 82

Conclusions

Morphometric evaluation of protocol biopsies in trials aimed to prevent CAN may allow to reduce

minimum sample size

TopicsRedundant

Morphometry applied to the study of donor biopsies

Potential utilityMophometric evaluation of protocol biopsies in clinical trials

NecessaryGlomerular adaptation after renal transplantation

Glomerular number (Ng)Disector /fraccionator (n=56)

0.23-1.82 x 106

Hughson M et al Kidney Int 2003; 63: 2113

Ng and Vg in humans

Ng/Vg/BSA

Hoy WE et al, Kidney Int Suppl 2003; 83, S31

Renal adaptation after transplantation

adaptation

Ng

Vg

Ng

RadiologyHistology

Morfometry

New parameters

Ng in vivo

Vcortex MRI

Vvglom/cortex Vg Biopsy

Fulladosa X et al J Am Soc Nephrol 2003 ; 14: 2662

Vren and Vcortex by means of a MRI

Volumen renal VrenVolumen cortical Vcort

Vglom/cortex y Vg

Fulladosa X et al J Am Soc Nephrol 2003

Estimación del número de

Vcortex * Vvglom/cortex Ng = __________________

Vg

Characteristics of patientsSCr < 200 mmol/l and proteinuria < 1g/24h

4m protocol biopsy (n=39)Mean SD ______________________________________ N 39 Donor age 38 18Donor sex (male / female) 26 / 13Recipient age 46 14Recipient sex (male / female) 24 / 15Recipient BSAa (sqm) 1.74 0.19Cold ischemia time (hours) 20 5 Delayed graft function (no / yes) 37 / 2Serum Creatinine (mol/l) 12330Proteinuria g/day 0.38 0.47______________________________________

Fulladosa X et al J Am Soc Nephrol 2003; 14: 2662

Relationship between Ng and GFR

0

20

40

60

80

100

120

0 0.4 0.8 1.2 1.6

Ng-W&G (x 106)6

GFR

(m

l/m

in)

Fulladosa X et al J Am Soc Nephrol 2003; 51: 310

Ng is a major determinant of GFR

2GFR = 9 Ng

Glomerular enlargement after transplantation

(n=41)

Donor biopsy Recipient biopsyVg

0 4

Alperovich G et al, AJT 2004; 4 : 650

Vg after transplantationVg

Donor Biopsy Recipient Biopsy p_______________________________________________Ah 0.150.42 0.290.56 NScg 0.100.30 0.15 0.36 NSci 0.190.45 0.49 0.64 0.0006ct 0.15 0.42 0.49 0.67 0.0002cv 0.02 0.16 0.19 0.60 0.087Vg 4.1 1.4 5.1 2.40.021_______________________________________________

Alperovich G et al, AJT 2004; 4 : 650

Vg y FG a los 4mCrClml/min

Vg (x1063)

Alperovich G et al, AJT 2004; 4 : 650

R=0.38, p=0.01

Glomerular enlargement may be

a necessary condition to achieve

a good renal function

Epidemiological paradox

Vg

GFR Graft Survival

Glomerulosclerosis Graft Survival

¿Graft Survival?

Vg, GFR and graft survivaln=144 patients, protocol biopsy at 4m

Donor age (years) 37 16 (12 – 76)

Donor gender (male/female) 101 / 43

Patient age (years) 47 13 (15 – 72)

Patient gender (male/female) 95 / 49

Panel reactive antibodies (%) 7 18 (0 – 100)

DR mismatches 0.6 0.6 (0 – 2)

Cold ischemia time (hours) 22 5 (7 – 38)

Delayed graft function (no/yes) 121 / 23

Acute rejection (no/yes) 114 / 30

Time of protocol biopsy (days) 125 52 (25 – 261)

Serum creatinine (mol/l) 140 44 (72– 298)

Proteinuria (g/day) 0.34 0.28 (0.03 – 1.00)

Vg, FG y Sup injn=144 patients protocol biopsy at 4m

RR IC p________________________________Vg > 5 x 1063 2.4 1.0-5.6 0.04

CrCl <60 ml/min 3.5 1.0-11.9 0.04________________________________

Vg, CrCl and Graft survivaln=144

biopsia de protocolo 6m > 10 glom

CrCl (Cockroft & Gault

60 ml/min/1.73m2

< 60 ml/min/1.73m2

HighLow

5 x 1063

< 5 x 1063 LargeSmallVg

(Weibel & Gomez)

Vg, FG, GS

0

,2

,4

,6

,8

1

Cum. Survival

0 25 50 75 100 125 150 175 200 Time (months)

Vg > 5 & GFR > 60 GS 73%

Vg < 5 & GFR > 60 GS 95%

Vg > 5 & GFR < 60 GS 45%

Vg < 5 & GFR < 60 GS 78%

Conclusion

Glomerular volume and renal function are independent predictors of graft survival

Summary

Acknoledgements

Francesc MoresoXavier FulladosaMiguel HuesoJosé Antonio LopesMeritxell IbernonGabriela AlperovichMontserrat GomàMarta CarreraJosep Maria CruzadoSalvador Gil-VernetJosep Maria Grinyó

Vg small CrCl high n=24 (17%)

Vg small CrCl low n=60 (42%)

Vg large CrCl high n=20 (20%)

Vg large CrCl low n=31 (21%)