Diabetic nephropathy (DN), a common complication of diabetes mellitus, remains a leading cause of endstage renal disease. Histopathological assessment of renal biopsy remains the gold standard for diagnosis. Accurate diagnosis is crucial for timely intervention and personalized management plans. Machine learning (ML) models can analyze digital pathology slides, learn DN biomarkers, and aid in DN staging. Developing ML models can be challenging for the limited availability of annotated images, subjectivity in histopathology interpretation, and histology artifacts. Molecular profiling such as single-cell RNA sequencing (SC) and spatial transcriptomics (ST) can contribute to better understanding of cellular heterogeneity and molecular pathways. Clinical use of molecular tests is limited due to the absence of well-established protocols specific to DN diagnosis. In this study, we propose a framework for correlating glomerular histomorphometry with spatially resolved transcriptomics to better understand the histologic spectrum of DN. The framework uses manual tissue labels by experienced users, and hybrid labels by combining user input and unsupervised clustering of molecular data. Clustering is performed on the gene expression levels of disease biomarkers and on the cell type decomposition of tissue by integration with SC reference data from KPMP. We used a dataset of 6 DN and 3 normal cases, with frozen section histology, ST, and SC collected at Seoul National University Hospital, Seoul, South Korea. Our initial experiments identified a correlation between the imaging features histomorphometry and disease label. Our cloud-based prototype visualizes both gene markers and cell type decomposition as a heatmap on histology, enables molecular-informed validation of structures, enables adding manual labels, and visualizes the clusters on histology. In conclusion, our framework can analyze the correlation between histomorphometry and tissue labels generated in a molecular-informed environment. Our cloud-based prototype can aid the diagnosis process by visualizing these correlations overlaid on digital slides.
Diabetic nephropathy (DN) in the context of type 2 diabetes is the leading cause of end-stage renal disease (ESRD) in the United States. DN is graded based on glomerular morphology and has a spatially heterogeneous presentation in kidney biopsies that complicates pathologists’ predictions of disease progression. Artificial intelligence and deep learning methods for pathology have shown promise for quantitative pathological evaluation and clinical trajectory estimation; but, they often fail to capture large-scale spatial anatomy and relationships found in whole slide images (WSIs). In this study, we present a transformer-based, multi-stage ESRD prediction framework built upon nonlinear dimensionality reduction, relative Euclidean pixel distance embeddings between every pair of observable glomeruli, and a corresponding spatial self-attention mechanism for a robust contextual representation. We developed a deep transformer network for encoding WSI and predicting future ESRD using a dataset of 56 kidney biopsy WSIs from DN patients at Seoul National University Hospital. Using a leave-one-out cross-validation scheme, our modified transformer framework outperformed RNNs, XGBoost, and logistic regression baseline models, and resulted in an area under the receiver operating characteristic curve (AUC) of 0.97 (95% CI: 0.90-1.00) for predicting two-year ESRD, compared with an AUC of 0.86 (95% CI: 0.66-0.99) without our relative distance embedding, and an AUC of 0.76 (95% CI: 0.59-0.92) without a denoising autoencoder module. While the variability and generalizability induced by smaller sample sizes are challenging, our distance-based embedding approach and overfitting mitigation techniques yielded results that suggest opportunities for future spatially aware WSI research using limited pathology datasets.
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