title: Multifocal renal allograft biopsy: impact on therapeutic decisions.
abstract: OBJECTIVE
  There are no data to support the suggestion that samples removed from one segment of the transplanted kidney are representative of the whole graft. The aim of this study was to compare the histological differences between biopsies obtained from different portions of the renal allograft and their impact on treatment recommendations.
  
  
  METHODS
  Two hundred percutaneous biopsies were performed on kidney allografts and samples were collected from the upper and lower poles (100 kidneys). All samples were randomized and blindly reviewed. We obtained the discordance rates between the poles for the grading of acute rejection and for the diagnosis of nephrotoxicity due to immunosuppression. We also checked if the differences found were sufficient to call for different clinical recommendations. These values were compared with the intrapathologist variation rates.
  
  
  RESULTS
  In 70 kidneys adequate sampling was obtained from both poles. The diagnosis of acute rejection were made in 17. The discordance rate between the upper and lower poles was 82.3% (kappa = 0.34), higher than the intrapathologist variation (P = .002). Nephrotoxicity was found in 14 kidneys. The discordance rate between the upper and lower poles was 28.6% (kappa = 0.88), with no difference compared with the intrapathologist variation. In 14 of the 70 kidneys (25.7%), discordances between poles had impact on clinical recommendations, most of these cases due to different gradings of acute rejection (78%). This number was higher than the intrapathologist variation (P = .04).
  
  
  CONCLUSIONS
  The histopathological changes in the kidney allograft are not always homogeneous. This heterogeneity may affect the therapeutic recommendations.
authors.affiliation: Department of Urology, School of Medicine, University of São Paulo, Brazil.
authors.forename: A C
authors.initials: AC
authors.lastname: Piovesan
authors.forename: A M
authors.initials: AM
authors.lastname: Lucon
authors.forename: D S R
authors.initials: DS
authors.lastname: David
authors.forename: W C
authors.initials: WC
authors.lastname: Nahas
authors.forename: I M
authors.initials: IM
authors.lastname: Antonopoulos
authors.forename: M
authors.initials: M
authors.lastname: Srougi
mesh_terms: D000293:Adolescent; D000328:Adult; D001331:Automation; D001707:Biopsy, Needle / Q000379:methods*; D001794:Blood Pressure; D006084:Graft Rejection / Q000139:chemically induced / Q000473:pathology*; D006801:Humans; D007166:Immunosuppressive Agents / Q000633:toxicity; D016030:Kidney Transplantation / Q000473:pathology* / Q000502:physiology; D007684:Kidney Tubules / Q000473:pathology; D009336:Necrosis; D015588:Observer Variation; D018579:Patient Selection; D011897:Random Allocation; D015203:Reproducibility of Results; D012189:Retrospective Studies; D014184:Transplantation, Homologous / Q000473:pathology / Q000502:physiology
chemical_list: D007166:Immunosuppressive Agents