Safety and efficacy of percutaneous renal biopsy by physicians-in-training in an academic teaching setting. The data on the effect of high BP on PRB complication rates are not consistent, and a selection bias exists, because hypertension (usually defined as >140/90 mmHg) is an exclusion criteria in much of the biopsy literature. Computed tomography (CT) may be used as a primary imaging modality or may be preferred in obese patients, those with complicated anatomies (e.g., cysts or horseshoe kidney), and those for whom kidney visualization with ultrasound is difficult (16,17). Laparoscopic renal biopsy: A 9-year experience. Potential contraindications for kidney biopsy in individual patients are listed in Table 1. One small prospective study compared complication rates after PRB between age groups and found a higher incidence of gross hematuria in patients 61–78 years old (n=26; 15%) versus those <60 years old (n=184; 0.03%) but no difference in hemodynamic compromise, perinephric hematoma, or need for vascular intervention (59). Four guidelines for renal biopsy were identified; two from the United States,3,5 4one from Europe, and one from Australia.2 The guidelines suggest that kidney biopsy may be appropriate: when evaluating an infected cyst or abscess3 or identifying lymphoma or metastasis in a kidney,3,5 A renal biopsy is used to obtain a segment of renal tissue, usually through a needle or another surgical instrument. In the case of Open Renal Biopsy it is performed in the operating theatre. The treatments for these diseases differ between diagnoses that are made by kidney biopsy (i.e., one therapy does not exist for all renal diseases for which a biopsy is performed). Relative contraindications to percutaneous renal biopsy. Because a gravid uterus can affect a patient’s ability to lie prone, alternate positioning (sitting upright or lying in the lateral decubitus position) for PRB may be preferred. In another case series, Ishikawa et al. Real-time ultrasound-guided percutaneous renal biopsy with needle guide by nephrologists decreases post-biopsy complications. According to the AUA guideline, a renal mass biopsy should be considered when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious (Clinical … Nephrologists’ input on the basis of the biopsy indication can ensure proper specimen division for optimum diagnostic and prognostic yield. Postural change during venous blood collection is a major source of bias in clinical chemistry testing. Clinicopathologic correlations of renal pathology in Spain. A health care provider will perform a kidney biopsy to evaluate any of the following conditions: hematuria—blood in the urine, which can be a sign of kidney … No data exist to guide how long manual compression should be applied after kidney biopsy. Patients with a horseshoe kidney may be at increased risk of bleeding after PRB because of anomalous vasculature and proximity to the aorta. Safety of kidney biopsy in elderly: A prospective study. Fluoroscopy-guided percutaneous biopsy of kidney: An alternative to open or laparoscopic approaches. All biopsies were performed by using coaxial core biopsy needles. This study is limited in that it is comprised of mostly retrospective case series and that only one half of the published literature on PRB in pregnancy reported complication rates. Kidney Biopsy Training and the Future of Nephrology: What about the Patient? RENAL MASS BIOPSY (RMB) 10. Safety of ultrasound-guided percutaneous renal biopsy-retrospective analysis of 1090 consecutive cases. Given that most patients’ BPs can be controlled with medications on the day of the biopsy, and that many patients getting biopsies have a history of hypertension, we attempt to control the BP to <160/100 mmHg and preferably, <140/90 mmHg. Desmopressin acetate in percutaneous ultrasound-guided kidney biopsy: A randomized controlled trial. Minor complications occurred in 8% of patients, and major complications occurred in 8% of patients (transfusion, n=12; radiologic intervention, n=2); 69% of patients with minor complications and 87% of patients with major complications had a detectable hematoma. One series found a statistically increased risk of bleeding in patients who had renal amyloidosis (69), but the definition of bleeding was a hemoglobin decrease >1 g/dl and did not include need for transfusion or intervention. Analysis of this tissue is then … A laparoscopic (through a retro- or transperitoneal approach) or open kidney biopsy may be the best option in selected circumstances, such as morbid obesity, solitary kidney, coagulopathy, failed PRB, polycystic kidney disease with rapidly progressive GN, high location of the kidney, and/or poor visualization with imaging (26–29). Safety and diagnostic yield of transjugular renal biopsy. Am J Nephrol. In one survey of nephrologists who completed their fellowship training from 2004 to 2008, 15%–20% indicated that they did not feel competent performing native and transplant PRBs (75). The introduction of renal biopsy into nephrology from 1901 to 1961: A paradigm of the forming of nephrology by technology. Newer imaging techniques, such as CT fluoroscopy and fusion ultrasonography, may be useful in the future in certain patients undergoing PRB (21). One series found no difference in diagnostic yield or major complications in patients undergoing PRB (n=400) or TJKB (n=400; 303 of whom had bleeding disorders) (23). Fiorentino M, Bolignano D, Tesar V, et al; Renal Biopsy in 2015 - From Epidemiology to Evidence-Based Indications. However, given the limited data exploring this question and that most kidney biopsies are elective procedures, we hold antiplatelet agents for 7 days before the procedure when possible. Patients were not biopsied if they had a BP>160/90 mmHg, international normalized ratio >1.4, or platelet count <100×109/L. The kidney biopsy can be invaluable in assessing the extent of disease activity (e.g., inflammatory cell proliferation, crescent formation, and necrosis) and chronicity (e.g., sclerosis and fibrosis), which may help guide prognosis and therapy, as well as establishing renal involvement of systemic diseases, such as autoimmune and paraprotein disorders (2). Anxious, uncooperative, and/or pediatric patients may require anxiolytics or general anesthesia to safely perform the procedure. Renal mass biopsy is a diagnostic test. A prospective randomized trial of three different sizes of core-cutting needle for renal transplant biopsy. Post-PRB, we prescribe bed rest for 6 hours, and we monitor vital signs every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then, hourly for the remainder of the observation period. (45) retrospectively analyzed 317 PRBs at one center with an ultrasound performed 10 minutes after biopsy; 86% of patients had a detectable hematoma (13% had hematoma >2 cm). Timing of complications in percutaneous renal biopsy. Therefore, like any diagnostic test, it should be … (44) analyzed 162 patients with native, ultrasound–guided PRBs (automated needle) who had an ultrasound 1 hour postprocedure. Incidence of bleeding after 15,181 percutaneous biopsies and the role of aspirin. Acquired von Willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation. One controversial prospective study compared complication rates in 36 pregnant women who underwent PRB for hypertensive disease with 18 healthy pregnant women as controls, finding only one major complication in a patient with severe preeclampsia (64). Percutaneous renal biopsy with localization by retrograde pyelography. The guidelines would first be reviewed by the Executive Board of the Renal Pathology Society and subsequently submitted to the member- In the meta-analysis by Corapi et al. How long is strict bed rest necessary after renal biopsy? The percutaneous renal biopsy (PRB) is the current standard of care, and most large case series describe ultrasound-guided PRBs performed by nephrologists or radiologists (3). Although post-PRB ultrasonography or CT is routinely performed in some centers, its utility in predicting relevant clinical complications or altering management has not been shown. Here, we review kidney biopsy indications, techniques, and complications in the modern era. The strengths of these studies include the large patient numbers (500–2000) and uniform intrainstitution operators, expertise, and technique. Laparoscopic renal biopsy via retroperitoneal approach. It is common practice before kidney biopsies to obtain a complete blood count, international normalized ratio/prothrombin time, activated partial thromboplastin time, serum creatinine, and a type and screen. Outcomes of percutaneous kidney biopsy, including those of solitary native kidneys. Despite this, there is limited evidence regarding patients' experiences and requirements when undergoing a renal biopsy. (13), the rate of transfusion did not differ between patients in whom antiplatelet agents were held for ≥7 days (nine studies; 2116 biopsies) and patients in whom antiplatelet agents were not held for ≤7 days (seven studies; n=4009; 0.5% versus 0.7%, P=0.7). When size matters: Diagnostic value of kidney biopsy according to the gauge of the biopsy needle. Desmopressin use was associated with fewer (13.7% versus 31%) and smaller ultrasound–detected hematomas after biopsy but did not result in fewer transfusions or interventions, and no serious adverse events were observed. KDIGO guidelines focus on topics related to the prevention or management of individuals with kidney diseases. CHRONIC KIDNEY DISEASE GUIDELINES GUIDELINE SUMMARIES MacGinely R, … Accreditation Council for Graduate Medical Education: ACGME Program Requirements for Graduate Medical Education in Nephrology (Internal Medicine). In a smaller retrospective series, Simard-Meilleur et al. Nephrologists and biopsy operators should also be competent at biopsy specimen division and processing (14,15). Risk factors and timing of native kidney biopsy complications. Available at: Thank you for your help in sharing the high-quality science in CJASN. Smaller renal masses (less than 4 cm) are often benign, and most tumors that we ablate are less than 4 cm. However, it can also be done in a radiology department if an ultrasound or CT scan is … This is particularly important in centers that send their biopsies to outside pathology laboratories, because specimens for light, immunofluorescence, and electron microscopies require different processing and fixation methods. A biopsy should be avoided when the potential risk to the patient exceeds any likely benefit from procuring kidney tissue. What you should know about the work-up of a renal biopsy. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Renal mass biopsy should be offered to patients with a renal mass when the result of the biopsy will alter their management. Figure 1 Renal biopsy specimen as seen with a dissecting microscope. What happens during a kidney biopsy procedure? Fusion imaging of real-time ultrasonography with CT or MRI for hepatic intervention. Black arrows point to glomeruli (wet prep, ×10). Data on PRB complications with a solitary kidney are limited. However, contrast-induced nephropathy is a TJKB complication that is not encountered with PRBs, occurring in 7.8% of patients in one study (24), and some studies report high rates of capsular perforation that may require coil embolization (25). NKF KDOQI clinical practice guidelines NKF KDOQI clinical practice guidelines World renown for improving the diagnosis and treatment of kidney disease, these guidelines have changed the practices of healthcare professionals and improved thousands of lives. Committee on Renal Biopsy Guidelines to develop recommendations regarding the processing and evaluation of renal biopsy specimens. Importantly, this review found that PRB changed management in 66% of patients. Although the complication rates of PRBs in solitary kidneys may not be higher, the consequence of a major complication can be more severe in these individuals. However, this difference was not observed when patients with a history of hypertension were stratified by prebiopsy BP level, indicating that a history of hypertension was the independent risk factor. Percutaneous native renal biopsy: Comparison of a 1.2-mm spring-driven system with a traditional 2-mm hand-driven system. Although the presence of a >2-cm hematoma was associated with a greater absolute decrease in hemoglobin (6.9% versus 2.9% for <2 cm and 2.0% for no hematoma) and a hemoglobin decrease >10%, it was not associated higher rates of transfusion or intervention. Fluoroscopy-guided PRB with or without retrograde contrast injection through a urethral catheter has also been used for localization (18–20). Additionally, a retrospective, single–center analysis found that patients with prolonged bleeding time tests continued to be at increased risk for PRB complications, despite preprocedure correction with desmopressin (51). Minor complications (hematomas not requiring transfusion or macrohematuria with loin pain) occurred in 5% of intragestational PRBs. Although the development of Page kidney after allograft kidney biopsy has been described (0.8% of patients in a recent case series [40]), no patients with Page kidney after native kidney biopsy have been reported (41). Other factors, such as patient characteristics (e.g., kidney size) and operator experience, may also affect diagnostic yield. We perform real–time, ultrasound–guided PRBs using an automated, spring–loaded, 16-gauge biopsy needle as described previously (3). There are no data on the effect of newer anticoagulants on PRB complication rates. These data are presented to develop best practice strategies for this essential procedure. Renal mass biopsy should be considered when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. create evidence-based guidelines for the follow-up and surveillance of clinically localized renal cancers treated with surgery or renal ablative procedures, biopsy-proven untreated clinically localized renal cancers followed on surveillance and radiographically suspicious but biopsy-unproven renal … During the study period, 474 consecutive CT-guided native medical renal biopsies were performed. Physicians must consider the risks of a kidney biopsy in the context of the perceived benefit that an individual patient may derive from having a histologic diagnosis. Renal biopsy in the elderly and very elderly: Useful or not? This may be because of some PRBs being performed by nephrology trainees and more high-risk patients undergoing PRBs at large academic centers. Corapi et al. The data on biopsy of horseshoe kidney are limited to case reports. Is it necessary to stop antiplatelet agents before a native renal biopsy? It should go without saying that a kidney biopsy should only be done by someone skillful in performing the procedure and when the tissue can be processed and interpreted by those with the skills necessary to do so (14). Generally, a kidney needle biopsy follows this process: A second study by Atwell et al. We consider a major bleeding complication as one that results in an alteration of clinical practice, leading to significant pain, extended hospital stay, urinary obstruction, requirement for blood transfusion, intervention, surgery, or death. Since its introduction in the 1950s, advancements have been made in biopsy technique to improve diagnostic yield while minimizing complications. Use of computerized tomography to evaluate bleeding after renal biopsy. Nephrology and the percutaneous renal biopsy: A procedure in jeopardy of being lost along the way. However, these perceptions are not supported by the literature. Indications for a kidney biopsy in pregnancy include unexplained renal failure, symptomatic nephrotic syndrome, to help guide management of patients with lupus nephritis (62), and to make/exclude the diagnosis of preeclampsia. Another series found no increased risk of PRB complications for patients with monoclonal gammopathies versus controls (without monoclonal gammopathy; 4.1% versus 3.9%; P=0.88) (71). Given these data, we use automated 16-gauge needles, and we immediately evaluate the adequacy of biopsy sampling with a light or dissecting microscope, which allows for appropriate division for light, immunofluorescence, and electron microscopic studies (Figure 1) (14,15). 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