Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia.
Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia.
Clin J Am Soc Nephrol. 2020 Jul 1;15(7):1015-1023. doi: 10.2215/CJN.13611119.
The published tissue adequacy requirement of kidney medulla for BK virus allograft nephropathy diagnosis lacks systematic verification and competes against potential increased procedural risks from deeper sampling.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We evaluated whether the presence of kidney medulla improved the diagnostic rate of BK nephropathy in 2244 consecutive biopsy samples from 856 kidney transplants with detailed histologic and virologic results.
Medulla was present in 821 samples (37%) and correlated with maximal core length (=0.35; <0.001). BK virus allograft nephropathy occurred in 74 (3% overall) but increased to 5% (42 of 821) with medulla compared with 2% (32 of 1423) for cortical samples (<0.001). Biopsy medulla was associated with infection after comprehensive multivariable adjustment of confounders, including core length, glomerular number, and number of cores (adjusted odds ratio, 1.81; 95% confidence interval, 1.02 to 3.21; =0.04). In viremic cases (=275), medulla was associated with BK virus nephropathy diagnosis (39% versus 19% for cortex; <0.001) and tissue polyomavirus load (Banff polyomavirus score 0.64±0.96 versus 0.33±1.00; =0.006). Biopsy medulla was associated with BK virus allograft nephropathy using generalized estimating equation (odds ratio, 2.04; 95% confidence interval, 1.05 to 3.96; =275) and propensity matched score comparison (odds ratio, 2.24; 95% confidence interval, 1.11 to 4.54; =0.03 for 156 balanced pairs). Morphometric evaluation of Simian virus 40 large T immunohistochemistry found maximal infected tubules within the inner cortex and medullary regions (<0.001 versus outer cortex).
Active BK virus replication concentrated around the corticomedullary junction can explain the higher detection rates for BK virus allograft nephropathy with deep sampling. The current adequacy requirement specifying targeting medulla can be justified to minimize a missed diagnosis from undersampling.
已有文献报道，诊断 BK 病毒移植肾肾病需要有足够的肾髓质组织，但这种说法尚未经过系统验证，且可能会增加取材过深带来的额外风险。
方法、设置、参与者和测量：我们评估了 856 例肾移植患者的 2244 例连续活检样本中，肾髓质组织的存在是否会提高 BK 肾病的诊断率。这些患者的肾组织有详细的组织病理学和病毒学结果。
821 例（37%）样本中存在肾髓质，且与最大芯长呈正相关（=0.35；<0.001）。总体 BK 病毒移植肾肾病发生率为 3%（74 例），但存在肾髓质时为 5%（42/821），而无肾髓质时为 2%（32/1423）（<0.001）。在全面调整混杂因素（包括芯长、肾小球数量和芯数量）后，活检有肾髓质与感染相关（校正优势比，1.81；95%置信区间，1.02 至 3.21；=0.04）。在病毒血症病例中（=275 例），肾髓质与 BK 病毒肾病的诊断相关（肾髓质为 39%，皮质为 19%；<0.001），且与组织多瘤病毒载量相关（Banff 多瘤病毒评分 0.64±0.96 与 0.33±1.00；=0.006）。使用广义估计方程（优势比，2.04；95%置信区间，1.05 至 3.96；=275）和倾向评分匹配比较（优势比，2.24；95%置信区间，1.11 至 4.54；=0.03 用于 156 对匹配对），均表明活检有肾髓质与 BK 病毒移植肾肾病相关。Simian 病毒 40 大 T 免疫组化的形态计量评估发现，最大感染的管状结构位于内皮质和髓质区域（<0.001 与外皮质相比）。
围绕皮质-髓质交界处的 BK 病毒复制活跃，可解释深部取样时 BK 病毒移植肾肾病检测率更高的原因。目前的组织学充分性要求指定采集肾髓质，可以避免因取材过浅导致漏诊。
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