title: Interpretation of transbronchial lung biopsies from lung transplant recipients: inter- and intraobserver agreement.
abstract: BACKGROUND
  Transbronchial lung biopsy results are crucial for the management of lung transplant recipients. Little information is available regarding the reliability and reproducibility of the interpretation of transbronchial lung biopsies.
  
  
  OBJECTIVE
  To examine the inter-reader variability between two lung pathologists with expertise in lung transplantation.
  
  
  METHODS
  Fifty-nine transbronchial lung biopsy specimens were randomly selected. Active infection had been excluded in all cases. The original interpretations (as per the Lung Rejection Study Group) for acute rejection grade included 19 biopsies scored as A0 (none), 14 scored as A1 (minimal), 12 as A2 (mild), 11 as A3 (moderate) and three as A4 (severe). The pathologists worked independently without clinical information or knowledge of the original interpretation. The specimens were graded using the Lung Rejection Study Group criteria for acute rejection (grades A0 to A4), airway inflammation (grades B0 to B4) and bronchiolitis obliterans (C0 absent and C1 present). Between-reader agreement for each category was analyzed using a Kappa statistic.
  
  
  RESULTS
  Because many transplant specialists initiate augmented immunosuppression with biopsy grades of A2 or higher, results for each reader were dichotomized as A0/A1 versus A2/A3/A4. Using this dichotomy, there was only moderate agreement (kappa 0.470, P < 0.001) between readers. For categories B and C, the results were dichotomized for the absence or presence of airway inflammation and bronchiolitis obliterans, respectively. The level of agreement between readers was fair for category B (kappa 0.333, P = 0.014) and poor for category C (kappa 0.166, P = 0.108). The intrareader agreement for acute rejection was substantial (kappa 0.795, P = 0.0001; kappa 0.676, P = 0.0001).
  
  
  CONCLUSIONS
  Because the agreement between expert pathologists is only modest, optimum clinical decision-making requires that transbronchial lung biopsy results be used in an integrated clinical context.
authors.affiliation: Vancouver General Hospital, Vancouver, British Columbia, Canada.
authors.forename: Anne
authors.initials: A
authors.lastname: Stephenson
authors.forename: J
authors.initials: J
authors.lastname: Flint
authors.forename: J
authors.initials: J
authors.lastname: English
authors.forename: S
authors.initials: S
authors.lastname: Vedal
authors.forename: G
authors.initials: G
authors.lastname: Fradet
authors.forename: D
authors.initials: D
authors.lastname: Chittock
authors.forename: R D
authors.initials: RD
authors.lastname: Levy
mesh_terms: D001706:Biopsy; D003657:Decision Making; D006084:Graft Rejection / Q000473:pathology*; D006801:Humans; D008168:Lung / Q000473:pathology*; D016040:Lung Transplantation / Q000473:pathology*; D015588:Observer Variation; D015203:Reproducibility of Results