Insights into ChatGPT application in renal transplantation

Dear Editor,

In 2022, OpenAI (San Francisco, California, USA) launched a large-scale language model named Chat Generative Pretrained Transformer (ChatGPT), which garnered significant attention in the medical community. A recent study published in the International Journal of Surgery highlighted the potential applications, opportunities, and challenges of ChatGPT in surgical diagnosis and treatment¹. Notably, the potential for artificial intelligence in organ transplantation, particularly renal transplantation, has not been sufficiently explored. As an effective treatment for end-stage renal disease, renal transplantation plays an important role in organ transplantation, which allows recipients to avoid long-term dialysis treatment. This study aimed to evaluate the performance of ChatGPT in clinical decision-making for renal transplantation, with the goal of assessing its application in surgical settings.

We devised 45 renal transplantation-related questions based on guidelines from the European Association of Urology (EAU)², Kidney Disease: Improving Global Outcomes (KDIGO)³, and the European Best Practice Guideline group (EBPG)⁴. These questions encompassed the selection of surgical methods for renal transplantation, perioperative management in both general and special cases, and the identification and treatment of postoperative complications. ChatGPT furnished responses to these questions (accessed on 27 March, Supplementary Table S1, Supplemental Digital Content 1, http://links.lww.com/JS9/C459). Each response underwent independent review by three experienced renal transplantation specialists. Ratings were conducted using a 7-point Likert scale: 1 for ‘strongly disagree,’ 2 for ‘disagree,’ 3 for ‘somewhat disagree,’ 4 for ‘neither agree nor disagree,’ 5 for ‘somewhat agree,’ 6 for ‘agree,’ and 7 for ‘strongly agree.’ Scores of 6 and 7 indicated alignment with clinical guidelines and practice, thereby offering robust guidance. To mitigate bias stemming from individual subjectivity, the median score from the three expert reviews was employed as the final rating for ChatGPT responses.

The findings revealed that ChatGPT can provide accurate responses to the majority of renal transplantation-related clinical inquiries (Table 1). Specifically, among the 45 responses evaluated, 24 (53.3%) were rated as 7 (strongly agree), 10 (22.2%) as 6 (agree), and 9 (20.0%) as 5 (agree). It should be noted that the remaining two responses were not agreed by the experts and received 3 (somewhat disagree) or 4 (neither agree nor disagree). In the question ‘What is the purpose of unilateral access in adult bilateral renal transplantation?’ ChatGPT broadly discussed unilateral access, highlighting its role in enhancing spatial utilization and reducing surgical trauma. However, the latest EAU guidelines stress the importance of preserving the intact contralateral iliac fossa in case of graft loss for future transplantation and reducing cold ischemia time for the second renal transplantation. Furthermore, in the query ‘When is double renal transplantation preferred over single renal transplantation?’ the EAU guidelines explicitly mention en bloc retrieval when kidneys are harvested from children weighing less than 15 kg. Nevertheless, the response of ChatGPT completely ignores this crucial point.

Table 1.

7-Point Likert scale for assessing responses to 45 renal transplantation-related inquiries from ChatGPT.

Seven-point Likert scoresa
Questions	Expert 1	Expert 2	Expert 3	Median score
1. Should the extraperitoneal approach to the iliac fossa be used as the surgical approach in most first or second single renal transplant procedures?	7	7	7	7
2. What are the preferred techniques for living-donor nephrectomy in renal transplantation?	7	7	7	7
3. In single renal transplantation, does ligating the lymphatics around the iliac vessels help reduce the risk of postoperative lymphocele formation?	7	7	7	7
4. What is the standard surgical approach for a first or second single renal transplantation procedure?	7	7	7	7
5. Should alternate kidney donors be considered for living organ transplantation in the presence of three or more donor arteries?	7	6	6	6
6. What aspects should be considered in the medical evaluation of living kidney donors in renal transplantation?	5	6	5	5
7. Is informed consent required for both methods of using the donor’s gonadal vein or the great saphenous vein to lengthen the renal vein during the retrieval of the living donor kidney?	7	7	7	7
8. Is it necessary to preserve the Carrel patch on the deceased donor renal artery?	6	6	7	6
9. If rupture of the intima is found in the renal artery of the donor kidney and the recipient before arterial anastomosis in single renal transplantation, how should it be managed?	7	5	6	6
10. Is surgical exploration recommended for suspected graft renal vein thrombosis after transplantation of the kidney?	7	7	7	7
11. What are the standard preservation solutions currently used for kidney procurement?	7	7	6	7
12. How to view the application prospects of allogeneic transplantation in renal transplantation	5	4	5	5
13. Is kidney viability assessment required before initiating immunosuppressive therapy and anesthesia induction in deceased donor renal transplantation?	6	4	5	5
14. What are the advantages and disadvantages of needle puncture biopsy and wedge biopsy in post-mortem kidney biopsy.	6	6	5	6
15. Do perioperative antibiotics have an effect in renal transplantation?	6	7	6	6
16. When is double renal transplantation preferred over single renal transplantation?	3	4	3	3
17. Under what circumstances can HIV-infected individuals be listed in the recipient waiting list for renal transplantation?	4	5	5	5
18. Will alcohol and drug abuse by patients before transplantation affect patient or graft survival?	6	5	6	6
19. Which crossmatching technique should be used to optimize outcomes in renal transplantation candidates?	7	7	6	7
20. What are the challenges faced by robotic renal transplantation?	6	5	4	5
21. Must patients with in situ melanoma or prostate cancer with Gleason score ≤6 be excluded from renal transplantation candidates?	6	7	7	7
22. What is the purpose of unilateral access in adult bilateral renal transplantation?	4	3	3	3
23. Does performing extra-vesical ureteric anastomosis technique in renal transplant recipients with normal urinary tract anatomy help reduce urinary complications?	7	7	7	7
24. Is pyelo/uretero-ureteral anastomosis suitable for very short or poorly vascularized transplant renal ureters?	7	7	7	7
25. Is ureteral stent indispensable in transplanted ureteral anastomosis surgery?	6	7	6	7
26. What is the effect of using JJ stents during surgery on kidney prognosis in renal transplantation recipients?	7	7	6	7
27. What is the first-line treatment option for symptomatic arteriovenous fistulae or pseudo-aneurysm in recipient complications after renal transplantation?	7	7	7	7
28. What should be considered when performing renal transplantation in patients with ileal conduit?	5	5	5	5
29. Does the selection of the left or right side for living donor renal transplantation significantly affect the outcome of the transplanted kidney?	7	7	7	7
30. Is it necessary to administer routine or low molecular weight heparin for prophylactic anticoagulation in low-risk living donor kidney recipients after renal transplantation?	6	7	7	7
31.Are marginal kidneys generally used for pediatric renal transplantation?	7	7	7	7
32. Can pediatric donor kidneys be placed in pediatric recipients without tension compared to adult donor renals?	7	6	7	7
33. Is single renal transplantation preferred for pediatric recipients of pediatric donor kidneys?	7	7	7	7
34. In renal transplantation, which factor among the age, weight, and length of the donor kidney is the determining factor for the choice of surgical approach?	7	7	7	7
35. In a renal transplantation patient who was initially doing well but developed fever, decreased urine output, and transplant side pain three months post-surgery, what condition should be considered?	5	5	6	5
36. What is the target blood pressure for blood pressure management in renal transplantation recipients?	6	6	7	6
37. What are the main causes of early and late ureteral strictures after renal transplantation, respectively?	5	6	6	6
38. What is the optimal diagnostic method for diagnosing chronic transplant kidney disease?	7	7	7	7
39. Is sleeve gastrectomy necessary for severely obese (BMI >40 kg/m2) renal transplant recipients?	6	6	7	6
40. What is the first-line treatment for patients with large and symptomatic lymphocele after renal transplantation?	7	7	7	7
41. What should be done if a renal transplant recipient is suspected of developing renal artery thrombosis post-transplantation?	6	7	7	7
42. What factors are associated with the occurrence of tumors after renal transplantation?	5	6	6	6
43. Is surgery generally the preferred method for treating tumors in renal transplantation recipients post-operation?	5	5	6	5
44. Is it necessary to completely discontinue immunosuppressive agents for tumor treatment in renal transplantation recipients post-operation?	7	6	7	7
45. A 50-year-old female experiences pain and swelling in the transplant area, with a palpable fist-sized mass at the lower pole of the transplant kidney, one day after getting out of bed following a kidney biopsy. How should this be managed?	6	5	5	5

^aThe 1–7 scale corresponds to: ‘strongly disagree,’ ‘disagree,’ ‘somewhat disagree,’ ‘neither agree nor disagree,’ ‘somewhat agree,’ ‘agree,’ and ‘strongly agree,’ respectively.

BMI, body mass index; HIV, human immunodeficiency virus.

Our study suggests that ChatGPT can offer reasonable and reliable recommendations for various clinical decisions in renal transplantation, demonstrating promising potential for its application in organ transplantation. The utilization of ChatGPT may aid in the perioperative management of renal transplantation and contribute to enhancing the prognosis of renal transplant donors and recipients. However, ChatGPT encounters an informational lag as a language model and may not consistently align with the latest clinically recommended guidelines. Furthermore, many of the answers provided are overly generalized, offering limited value in guiding clinical decision-making across diverse clinical scenarios. The ethical and legal considerations surrounding the involvement of artificial intelligence in assuming the role of doctors, or supplementing even replacing doctors in clinical practice, also warrant careful deliberation. The further integration of ChatGPT across various medical disciplines necessitates the formulation of guidelines by relevant authorities to ensure responsible and effective utilization, thereby supporting its ongoing development.

Ethical approval

None.

Consent

None.

Sources of funding

This study was supported by the National Key R&D Program of China (2023YFC3403200), the National Natural Science Foundation of China (82070784 and 81702536), and the Science & Technology Department of Sichuan Province, China (2022JDRC0040).

Author contribution

Z.H., X.Y., J.L., and Y.T.: conceptualization and writing – original draft; D.L. and T.Z.: data curation; J.A.: writing – review and editing and also supervision. All authors contributed to and revised the submitted version of the paper.

Conflicts of interest disclosure

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Research registration unique identifying number (UIN)

None.

Guarantor

Jianzhong Ai.

Data availability statement

The authors of this article will make available the raw data that supports the conclusions presented herein.

Provenance and peer review

None.

Supplementary Material

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