UK National Renal Transplant EQA Scheme

Ian Roberts Department of Cellular Pathology, Oxford Radcliffe Hospitals

The National Renal Transplant EQA Scheme is sponsored by

Fujisawa Ltd

EQA in Histopathology

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maintenance & improvement of diagnostic standards

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education vs performance assessment

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required for CPD and CPA

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RCPath EQA steering committee sets performance standards investigates substandard performance

EQA in Histopathology

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substandard performance: anonymous letter of enquiry NQA Advisory panel informed and determine whether low EQA scores reflect standards of routine practice site visit review panel Medical Director informed

EQA in Histopathology

“ these procedures should be activated only in exceptional circumstances, and should cause no more concern to EQA participants than the possibility of being reported for incompetence by a colleague”

EQA in Histopathology

slides circulated to participants responses submitted to scheme organiser feedback of group diagnoses to participants cases discussed at participants meeting diagnoses scored persistent substandard performers identified remedial action

Renal Transplant EQA Scheme

diagnoses scored persistent substandard performers identified remedial action

Renal Transplant EQA Scheme

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44 participants from 31 centres

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Case submission: 7 sets of slides (H&E and PAS/silver) diagnostic lesion is present in all slides biopsy is adequate by Banff criteria

NATIONAL RENAL TRANSPLANT EQA SCHEME CASE SUBMISSION FORM

Provided by: Donor age Recipient age Best creatinine Donor type

(tick)

Original lab No.

Transplant date Biopsy date Creatinine at biopsy Cause of recipient Õs renal failure

cadaveric livi ng non-heart beating

Delayed graft function

Y / N

Immunosuppressive regimen: Prednisolone HLA m ismatches Azathioprine Cyclosporine FK/Prograf Number of previous acute rejections Mycophenolate ATG, etc Other (please specify below) Is this acute rejection?

(retrospective diagnosis when f ollow-up makes i t clear what t he ÒtrueÓ diagnosis is)

Clinical information available at the time the original report was produced: Clinical follow-up: Major diagnosis Supplementary diagnosis Banff codes

Renal Transplant EQA Scheme

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participants divided into 6 cells

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Circulations organised using Genpath software: sets circulation dates automatic reminder letters

RESPONSE SHEET

Please return to the EQA secretary: Mrs Lynn Bradbury NB: Please write something in every box, either a precise number (not more or less than), +/- or Banf f score, as indicated.

Participant code number

Information provided

Circulation letter Slides Case numbe r

Tubules

Tubulitis (Ban ff t0-3) Tubules with tubilitis/10 hpf (number) Tubular atrophy (%)

Glomeruli

Glomerulitis (Ban ff g0-3) Other

Vessels

Intimal/transmural arteritis (Ban ff v0-3) Arteriolitis (+/-) Arteriolar hyalinosis (Ban ff 0-3)

Major diagnosis Supplementary diagnosis Banff codes Comme nts Interstitium

oedema (+/-) mononuclear cell infiltration (%) nucleolated lymphocytes (+/-) eosinophils (+/-) neutrophils (+/-) interstitial haemo rrhage (%) interstitial fibrosis (%)

Educational value

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enables pathologists to compare their diagnoses and their Banff grading with the whole group

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identifies differences in use of terminology

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identifies misunderstanding of the Banff classification and its application

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ongoing measure of the reproducibility of Banff criteria

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highlights areas of diagnostic difficulty

Terminology

Cas e 4

Numb er of resp onse s

Dia gnos es

acute reje cti on* Ban ff IB Ban ff IA Ban ff I se ve re acute reje cti on 4 III chroni c n ephro path y in terstitia l ne phritis 11 5 3 *acute cel lula r reje cti on *acute rejectio n, g rade 1 *acute tubu loin terstitia l rej ection *acute rejectio n NOS *acute paren chyma l rej ection *acute tubu lar re jection *active re jection *severe acute rejectio n, 4 I 26

Num ber

22 1 1 1 1 1 1 9 6 3 1 1

Application

Cas e 5

Numb er of resp onse s

Dia gnos es

acute reje cti on* Ban ff IA Ban ff IB 9 1 Ban ff II bo rderli ne chan ges* 1 no reje cti on (i nfectio n 6, ATN4) *On th e ba sis of the Ba nff t an d i sco res p rovided : acute reje cti on bo rderli ne chan ges

Supplem entary dia gnos es

in fection acute tub ular necrosis do nor vas cul ar di seas e ?CyA toxici ty 26

Num ber

13 6 7 6 13 20 8 6 2

80% 60% 40% 20% 0% 100%

Reproducibility

Case 6

I t

Banff criteria

g v 3 2 1 0

Reproducibility

Case 21

mononuclear cell interstitial inflammation i1 (i2,t0,v0) 1 acute cellular rejection, type IA (i1,t1,v1) 1 acute rejection mild grade 1 (i1,t2,v0) 1 acute rejection, typeIA acute rejection, typeIIA 1 15 acute rejection, typeIIB 8 acute vascular rejection, NOS 1 acute tubular necrosis 2 donor vascular disease 1

Reproducibility

Case 22

borderline changes/suspicious of rejection acute rejection, typeIA (i2/3,t1,v0) acute rejection, typeIA acute rejection, typeIB severe acute parenchymal rejection, type IIA (i3,t2,v0) acute rejection, moderate grade 2 (i3,t3,v0) acute cellular rejection chronic allograft nephropathy ?polyoma virus infection 3 5 9 3 1 1 1 4 1 CAN ?CsA/tacrolimus toxicity acute tubular injury arteriolitis 7 2 1 1

Difficult diagnoses

Case 23

acute pyelonephritis, no rejection borderline changes/suspicious of rejection acute rejection (i?,t1) acute rejection, typeIA acute rejection, typeIB chronic allograft nephropathy inadequate specimen 11 4 1 9 1 1 1 acute pyelonephritis donor vascular disease chronic allograft nephropathy 4 CsA toxicity 8 2 exclude obstruction 12 1 ?interstitial nephritis 1

Difficult diagnoses

Case 25

hyperacute rejection antibody-mediated rejection (Banff 2B) acute rejection, typeIIB ?antibody mediated acute rejection, typeIII infarction ?large vessel thrombosis ?antibody-mediated rejection arterial/venous thrombosis +/- infarction macroscopic polyangiitis/vasculitis with infarction 6 2 1 6 7 2 3

Renal Transplant EQA Scheme

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identifies practical difficulties in the application of the Banff schema in routine practice

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identifies areas of diagnostic difficulty that should be specifically addressed in the future

Renal Transplant EQA Scheme

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identifies practical difficulties in the application of the Banff schema in routine practice

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identifies areas of diagnostic difficulty that should be specifically addressed in the future

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for the patients: improves the diagnostic accuracy of the pathologist looking at their biopsy