The Renal Pathology Society (RPS) held a Board of Directors meeting on Sunday February 12, 2006 during the annual USCAP meeting at the Hyatt Regency Hotel in Atlanta, Georgia.

1. Meeting was called to order by RPS President Dr. Jan Bruijn.
2. Previous RPS meeting minutes prepared by Dr. Herrera were approved.
3. President’s agenda for the current meeting was approved.

In attendance were Drs Racusen, Liapis, Cook, Fogo, Haas, Bonsib, Alpers, Meleg-Smith, Seshan, Picken, Truong, Roberts and Nickeleit.

• Dr. Bruijn, RPS President, opened the meeting with a new proposal for the creation of an International committee. He asked Dr. Seshan to chair this committee and stated that the recently amended bylaws do not include this committee therefore the bylaws should be revised accordingly. Dr. Seshan presented a tentative mission statement (see under committee reports) and commented that this is provisional and may be too ambitious; it may have to be modified in the near future as members of this committee are appointed.
• Dr. Racusen on behalf of the nominations and awards committee announced that Dr. Maria Piken was elected to RPS councilor in a close election. She announced that the committee elected Dr. Helmut Renkee for the 2006 Jacob Churg award and Dr. John Killing for the Striker Young Investigator award. On future young investigator awards the committee discusses the possibility of giving two awards/year, one for clinical studies and a second for research projects. Dr. Bruijn suggested that the committee may develop guidelines as to which abstract is better and allow for the possibility for either 1 or 2 awards/per year. It was agreed that the young investigator awards will continue to be given at the USCAP annual meeting.  For the Pirani travel award, the committee will follow Dr. Pirani’s will to support expenses for a young American investigator to present at an international meeting or to bring a young speaker working outside the USA to an RPS sponsored meeting.
• Financial committee chair Dr. Truong presented the current balance of RPS funds (see financial committee report). He also presented new proposals to increase RPS income but no decision was made.  The finance committee agreed that RPS should pay for invited speakers but suggested $1,500 dollars maximum per invitee. Ian Roberts suggested that RPS also may support Americans going abroad or Europeans coming to the US or going elsewhere at an RPS sponsored event. The BOD was reluctant to endorse this proposal.
• Steve Bonsib discussed available KUFA funds for 2006 and 2007.  The amount of $15,000 promised in 2005, becomes available in June 2006. There is uncertainty as to the dollar amount KUFA may be able to provide the RPS in 2007. Dr. Bonsib who organized the satellite meeting in 2005 will re-establish contact with KUFA and discuss an estimated budget for the Montreal satellite meeting. Part of the total money KUFA gives to RPS is directed to the satellite meeting; the rest pays for research proposals. The satellite meeting of 2005 generated ~$5,000, of which 2,500 covered expenses and $2,500 were RPS income.
• Dr. Meleg-Smith chair of communications committee asked the BOD for feedback on the new look of the RPS website.
• Dr. Picken updated the BOD on 13 new RPS members the membership committee has approved bringing the total to 341 currently registered RPS members.
• Education committee chair Ian Roberts commented on the mission statement of his committee and proposed that RPS representation can be enhanced at the European Congress of Pathology and the International Society of Nephrology meetings (ISN) (see attached report). Dr. Bruijn called upon the BOD members to send recommendations to Ian Roberts to this regard.
• Program committee chair Charlie Alpers proposed a symposium on animal models in kidney disease for next year’s USCAP. Dr. Piken commented that the symposium should cater to the needs of the RPS membership at large and that the BOD should approve the final program.
• Dr. Cook, chair of research committee updated the board on the mission of his committee and ongoing projects such as IgA nephropathy and diabetic nephropathy classification (see attached report). Dr. Cook also proposed ideas for new studies to focus on the status of Renal Pathology around the world and on rare diseases such as Fibrillary glomerulopathy.
• Dr. Fogo reminded the BOD of issues on Renal Pathology certification and the fact that only 3 renal pathology fellowships are currently AGCME accredited.
• Dr. Bonsib presented the poll results on the 30 year anniversary of the RPS. A decision to have the event during the 2007 USCAP meeting was favored. He will work on the program.

• Medicare and Medicaid Services Proposed Edits Affecting Pathology
            Letter by Steve Bonsib on behalf of RPS

  Mr. John Scott
  College of American Pathologists
  1350 I Street NW
  Suite 590
  Washington, DC 20005

  Re: Centers for Medicare and Medicaid Services Proposed Edits Affecting Pathology

  Dear Mr. Scott,

  The Renal Pathology Society views with concern the proposed reimbursement limitation to four immunohistochemical tests per specimen. To satisfy current ‘Standard of Care’ practice for renal biopsy evaluation, an immunofluorescnece (IF) protocol testing for more than four antigens is required. A minimum of nine antigens are necessary and more antigen testing may be required depending upon the clinical context. The defense for a more extended staining protocol is that for each antigen tested, there are multiple renal diseases that could not be correctly diagnosed if testing did not include that antigen. Although this letter cannot explain all diagnostic nuances of immunohistochemical testing in renal pathology, a listing of specific antigens that must be tested for are displayed below. A brief statement is included of some of the diagnoses compromised should testing for that antigen not be performed.

  The usual immunofluorescnece panel includes a minimum of 9 antigens. Integration of the complex data generated, including antigen composition, location, and pattern of staining, determine the final diagnosis.

  IgG stain: A number of IgG immune complexes diseases are recognized by staining for this antigen. Anti-glomerular basement disease, a medical emergency, can only be rapidly diagnosed by testing for this antigen.

  IgA stain: IgA nephropathy is the most common glomerular disease in the world and accounts for at least 15% of glomerular diseases in the United States. It can only be diagnosed by staining for this antigen.

  IgM stain: This antigen is required to diagnose Waldenstrom’s macroglobulinemia and mixed cryoglobulinemic glomerulonephritis.

  C3 stain: Several glomerular diseases stain only for C3; for instance dense deposit disease, C3 mesangial glomerulonephritis, and resolving post infectious glomerulonephritis.

  C1q stain: C1q nephropathy can only be identified with this stain. This stain also is helpful in distinguishing lupus glomerulonephritis from similar lesions that occur in patients without lupus.

  Fibrin stain: This stain is used to identify necrotizing lesions in vasculitis and other glomerular diseases, and to diagnose a family of thrombotic diseases.

  Kappa and lambda stains: These stains are required to diagnose a family of monoclonal protein diseases that are often the initial manifestation of malignant disease.

  Albumin stain: This control stain is used to distinguish specific from non specific staining.

  In addition to the above standard panel of stains, antigen testing could include viral identification, C4d staining for humoral rejection, collagen stain for hereditary nephritis, amyloid AA protein, and lymphoid markers for post transplant lymphoproliferative disorders. Most of these diseases can be identified only by this form of testing. Furthermore, some patients will have more than one disease identified based upon testing for multiple antigens, and there are a group of diseases that are diagnosed only when all antigens tested are negative. In the final analysis, in order to create a 4 antigen protocol permitting accurate renal biopsy diagnosis, the diagnosis must be known in advance of the biopsy.

  The Renal Pathology Society believes that limitations on testing reimbursement would force pathologists to choose between three untenable options. One choice would be to maintain medical quality by adherence to published ‘Standard of Care’ practice guidelines. This means that hospitals and pathology laboratories would incur significant uncompensated expenses. The problem of uncompensated expenses is magnified because ‘Standard of Care’ for renal biopsies also mandates performance of multiple H&E stained levels and duplicates of several special stains, for which compensation is already not provided.

  The second choice would be to create a staining protocol commensurate with reimbursement levels. This would have a substantial deleterious impact upon the quality of medical care. As documented above, regardless of the antigens selected in a restricted protocol, a substantial number of renal diseases will not be diagnosable. Who will decide which renal diseases merit testing in a restricted staining protocol, and which renal diseases we can ignore? Who will assume responsibility for the litigation that results from misdiagnosis and improper treatment?

  The final choice for pathology laboratories would be to discontinue offering renal biopsy evaluation because there is a limit to the amount of uncompensated work that a laboratory can absorb. This would reduce the availability of a clinically important diagnostic service.

  The Renal Pathology Society recognizes the need for controlling medical costs. In response to that concern, the routine panel of immunohistochemical stains discussed above, and electron microscopy, are no longer routinely performed on renal transplant biopsies. However, restricting antigen testing reimbursement without regard for clinical necessity risks inadequate biopsy evaluation. This could ultimately contribute to increased medicals because cost effective medical care is dependant upon rendering a correct diagnosis to optimize therapy. Therefore, before restricting antigen testing reimbursement to an arbitrary number, please consider the minor savings for an improperly evaluated renal biopsy compared to the substantial medical costs that would result from misdiagnosis.

  Sincerely yours,

  Stephen M. Bonsib, MD
  Vice President, Renal Pathology Society
  Director, Surgical Pathology
  Indiana University School of Medicine
  317-274-7005 phone
  317-274-5346 fax
  sbonsib@iupui.edu