Clinical Case 67: Answers and Summary

WHICH TRANSPLANTED ORGAN HAD THE FIRST EVER CONSENSUS CLASSIFICATION ON ORGAN REJECTION AND PATHOLOGY ?

Pancreas

  0 (0%)

Kidney

  15 (65%)

 

Heart

  2 (8%)

 

Lung

  1 (4%)

 

Liver

  1 (4%)

 

Skin

  4 (17%)

 

Most of you said "Kidney". Perhaps we shouldn't be that "nephrocentric". In a recent history related paper in Kidney International, Dr.Kim Solez et al discuss the history of the Banff classification and how it came about. 

The need was as early as 1991 when the classification began.  Kidney transplant pathology had no mentors and no classifications. The first consensus guidelines that came for any organ was heart allograft rejection and that served as a model for the Banff Kidney transplant classification.  There began the history of pathology behind the kidney transplant.  So the historically accurate answer is the "heart". 

Kidney Biopsy in Heart Transplant Candidates?

A recent study in Transplantation highlights this issue in detail. Lot of times we have patients with severe CHF and are also going into acute renal failure due to pre renal or what we are now calling cardio renal syndrome sort of in the same fashion as hepatorenal syndrome? When do we think its just ATN or when is it intrinsic renal disease? When can we say this patient needs just a heart transplant and when a combined heart and kidney?

In this study, thirty heart transplant candidates with an GFR < 40 mL/min or proteinuria greater than 500 mg/day or a history of amyloidosis underwent kidney biopsies between June 2001 and March 2009. The renal pathologic diagnosis as well as the percent tubular atrophy and interstitial fibrosis on renal biopsy were assessed. On the basis of the biopsy results, nine patients were listed for only heart transplantation and eight patients were listed for heart and kidney.
Based on this small study, the conclusion was that renal biopsy provides useful diagnostic information to differentiate intrinsic renal disease from renal hypoperfusion and helps guide the decision for OHT alone versus combined HKT.

I think that it makes sense but the sample size here is too small to make a general statement. In general, clinically if the patient is not behaving like CHF induced hypoperfusion, most of us will get a kidney biopsy to make sure no other cause is lingering around.