1. Utility of morphometry in the study of donor and protocol biopsies D. Serón Servicio de Nefrología Hospital Bellvitge Barcelona

2. Morphometry Disadvantages Advantages

3. When is morphometry redundant? When may it be useful? When is it necessary?

4. Topics Redundant Morphometry applied to the study of donor biopsies Potential utility Mophometric evaluation of protocol biopsies in clinical trials Necessary Glomerular adaptation after renal transplantation

5. Topics Redundant Morphometry applied to the study of donor biopsies Potential utility Mophometric evaluation of protocol biopsies in clinical trials Necessary Glomerular adaptation after renal transplantation

6. Preexisting donor damage and outcome yearparameter ____________________________________________________________ LeunissenTransplantation 1989sum of scores Serón NDT 1993Vvint/cortex WangNDT 1998ah, GS Gaber L Transplantation 1995% GS Abdi RTransplantation 1998glomerular size Karpinski Transplantation 1999donor vasculopathy Parmjeet RTransplantation 2000ci, GS Escofet XTransplantation 2003GS _________________________________

7. Is there any advantage in the morphometric evaluation of donor biopsies?

8. Evaluation of donor biopsies (June 2000-Dec 2001, N = 77 (  10 glom,  1 art) Banff criteria cg ci ct cv ah mm Quantitative parameters % glomerulosclerosis Vvint/c (%) Vvglom/c (%) Vg x 10 6  3 Vvintima/artery Lopes JA et al. Kidney Int 2005; 67: 1595

9. Results (1)

10. Results (2)

11. Results (3)

12. Results (4) Multivariate analysis: histologic lesions and 3m CrCl All variables _____________________ 1. Vvint/cortexR=0.57 2. GlomerulosclerosisR=0.62 _____________________ Not including morphometric variables ______________________ 1. Glomerulosclerosis R=0.52 2. cvR=0.60 3. ciR=0.64 ______________________

13. Conclusions Morphometric evaluation of donor biopsies does not improve the prediction of outcome

14. Topics Redundant Morphometry applied to the study of donor biopsies Potential utility Mophometric evaluation of protocol biopsies in clinical trials Necessary Glomerular adaptation after renal transplantation

15. CAN and sequential protocol biopsies Donor biopsies15% 4 th month protocol bx42 % 1 st year protocol bx52% % CAN 036912 m 50 25 0

16. Prevention trial and protocol biopsies 0 123456 m Donor Bx Protocol Bx placebo treatment  Fibrosis  CAN  cv  Vvinterstitium/c  Vvintima/artery

17. Minimum sample size (50% reduction) (  =0.05,  =0.20) VariablePatients per group ____________________________________  CAN300  Transplant vasc (cv)1200  Vvint/cortex63  Vvintima/artery49 ____________________________________ Serón, Transplantation 2000; 69(9): 1849Moreso et al. Am J Transplantation 2001; 1(1): 82

18. Conclusions Morphometric evaluation of protocol biopsies in trials aimed to prevent CAN may allow to reduce minimum sample size

19. Topics Redundant Morphometry applied to the study of donor biopsies Potential utility Mophometric evaluation of protocol biopsies in clinical trials Necessary Glomerular adaptation after renal transplantation

20. Glomerular number (Ng) Disector /fraccionator (n=56) 0.23-1.82 x 10 6 Hughson M et al Kidney Int 2003; 63: 2113

21. Ng and Vg in humans Ng/Vg/BSA Hoy WE et al, Kidney Int Suppl 2003; 83, S31

22. Renal adaptation after transplantation adaptation Ng Vg

23. Ng RadiologyHistology Morfometry New parameters

24. Ng in vivo V cortex MRI V vglom/cortex Vg Biopsy Fulladosa X et al J Am Soc Nephrol 2003 ; 14: 2662

25. Vren and Vcortex by means of a MRI

26. Volumen renal Vren Volumen cortical Vcort

27. V glom/cortex y Vg Fulladosa X et al J Am Soc Nephrol 2003

28. Estimación del número de V cortex * V vglom/cortex Ng =__________________ Vg

29. Characteristics of patients SCr < 200 mmol/l and proteinuria < 1g/24h 4m protocol biopsy (n=39) Mean  SD ______________________________________ N39 Donor age38  18 Donor sex (male / female)26 / 13 Recipient age46  14 Recipient sex (male / female)24 / 15 Recipient BSA a (sqm)1.74  0.19 Cold ischemia time (hours)20  5 Delayed graft function (no / yes)37 / 2 Serum Creatinine (  mol/l)123  30 Proteinuria g/day0.38  0.47 ______________________________________ Fulladosa X et al J Am Soc Nephrol 2003; 14: 2662

30. Relationship between Ng and GFR Fulladosa X et al J Am Soc Nephrol 2003; 51: 310

31. Ng is a major determinant of GFR 2GFR = 9 Ng

32. Glomerular enlargement after transplantation (n=41) Donor biopsy Recipient biopsy  Vg 04 Alperovich G et al, AJT 2004; 4 : 650

33. Vg after transplantation Vg Donor BiopsyRecipient Biopsyp _______________________________________________ Ah0.15  0.420.29  0.56NS cg0.10  0.300.15  0.36NS ci0.19  0.450.49  0.640.0006 ct0.15  0.420.49  0.670.0002 cv0.02  0.160.19  0.600.087 Vg4.1  1.45.1  2.40.021 _______________________________________________ Alperovich G et al, AJT 2004; 4 : 650

34. Vg y FG a los 4m CrClml/min Vg (x10 6  3 ) Alperovich G et al, AJT 2004; 4 : 650 R=0.38, p=0.01

35. Glomerular enlargement may be a necessary condition to achieve a good renal function

36. Epidemiological paradox

37.  Vg  GFR  Graft Survival  Glomerulosclerosis  Graft Survival ¿Graft Survival?

38. Vg, GFR and graft survival n=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 mismatches0.6  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)

39. Vg, FG y Sup inj n=144 patients protocol biopsy at 4m RR ICp ________________________________ Vg >5 x 10 6  3 2.41.0-5.60.04 CrCl <60 ml/min 3.51.0-11.90.04 ________________________________

40. Vg, CrCl and Graft survival n=144 biopsia de protocolo 6m > 10 glom CrCl (Cockroft & Gault  60 ml/min/1.73m2 < 60 ml/min/1.73m2 High Low  5 x 10 6  3 < 5 x 10 6  3 Large Small Vg (Weibel & Gomez)

41. Vg, FG, GS 0,2,4,6,8 1 Cum. Survival 0255075100125150175200 Time (months) Vg > 5 & GFR > 60 GS 73% Vg 60GS 95% Vg > 5 & GFR < 60GS 45% Vg < 5 & GFR < 60GS 78%

42. Conclusion Glomerular volume and renal function are independent predictors of graft survival

43. Summary

44. Acknoledgements Francesc Moreso Xavier Fulladosa Miguel Hueso José Antonio Lopes Meritxell Ibernon Gabriela Alperovich Montserrat Gomà Marta Carrera Josep Maria Cruzado Salvador Gil-Vernet Josep Maria Grinyó

45. Vg small CrCl highn=24(17%) Vg small CrCl lown=60(42%) Vg large CrCl highn=20(20%) Vg large CrCl lown=31(21%)