Related Experiment Video
Updated: Feb 3, 2026
Kidney Procurement in a Preclinical Large Animal Model
Published on: May 2, 2025
Reliability of deceased-donor procurement kidney biopsy images uploaded in United Network for Organ Sharing
Sherry G Mansour1,2, Isaac E Hall3, Peter P Reese4
1Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.
Abstract:
Prior studies demonstrate poor agreement among pathologists' interpretation of kidney biopsy slides. Reliability of representative images of these slides uploaded to the United Network of Organ Sharing (UNOS) web portal for clinician review has not been studied. We hypothesized high agreement among pathologists' image interpretation, since static images eliminate variation induced by viewing different areas of movable slides. To test our hypothesis, we compared the assessments of UNOS-uploaded images recorded in standardized forms by three pathologists. We selected 100 image sets, each having at least two images from kidneys of deceased donors. Weighted Cohen's kappa was used for inter-rater agreement. Mean (SD) donor age was 50 (13). Acute tubular injury had kappas of 0.12, 0.14, and 0.19; arteriolar hyalinosis 0.16, 0.27, and 0.38; interstitial inflammation 0.30, 0.33, and 0.49; interstitial fibrosis 0.28, 0.32, and 0.67; arterial intimal fibrosis 0.34, 0.42, and 0.59; tubular atrophy 0.35, 0.41, and 0.52; glomeruli thrombi 0.32, 0.53, and 0.85; and global glomerulosclerosis 0.68, 0.70, and 0.77. Pathologists' agreement demonstrated kappas of 0.12 to 0.77. The lower values raise concern about the reliability of using images. Although further research is needed to understand how uploaded images are used clinically, the field may consider higher-quality standards for biopsy photomicrographs.
Insights
Pathologists showed poor agreement when interpreting kidney biopsy images uploaded online. This suggests current image quality standards may need improvement for reliable clinical assessment.
Area of Science:
- Nephrology
- Pathology
- Medical Imaging
Background:
- Previous research indicates significant variability in pathologists' interpretation of physical kidney biopsy slides.
- The reliability of static images from kidney biopsies, uploaded to platforms like the United Network of Organ Sharing (UNOS) web portal, has not been adequately assessed.
Purpose of the Study:
- To evaluate the inter-rater reliability among pathologists when interpreting static images of kidney biopsy slides.
- To test the hypothesis that static images would yield higher agreement compared to viewing movable slides.
Main Methods:
- A set of 100 image sets, each containing at least two images from deceased donor kidneys, was selected.
- Three pathologists independently assessed the UNOS-uploaded images using standardized forms.
- Inter-rater agreement was quantified using weighted Cohen's kappa statistics for various histological features.
Main Results:
- Pathologists' agreement varied widely across different histological findings, with kappa values ranging from 0.12 (acute tubular injury) to 0.77 (global glomerulosclerosis).
- Lower kappa values were observed for features such as acute tubular injury, arteriolar hyalinosis, interstitial inflammation, interstitial fibrosis, arterial intimal fibrosis, tubular atrophy, and glomeruli thrombi.
- Overall agreement was suboptimal for several key diagnostic indicators, raising concerns about image reliability.
Conclusions:
- The study highlights significant concerns regarding the reliability of pathologists' interpretations based on uploaded kidney biopsy images.
- The observed variability suggests that current standards for biopsy photomicrographs may be insufficient for consistent clinical assessment.
- Further research is recommended to understand the clinical utility of these images and to establish higher quality standards for biopsy imaging.
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