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Renal biopsy seminar


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Presentation on the various aspects of renal biopsy
Author: Vishal Golay, DM trainee in Nephrology, IPGMER, Kolkata

Published in: Health & Medicine, Technology

Renal biopsy seminar

  1. 1. RENAL BIOPSY DR. VISHAL GOLAY 28-10-10 DM Seminar
  2. 2. History of renal biopsy <ul><li>Iverson and Brun (1951)- first renal biopsy description. Aspiration biopsy of kidney. Am J Med 11:324—330, 1951 </li></ul><ul><li>Kark and Muehrcke (1954)-blind prone biopsy. </li></ul><ul><li>Biopsy of kidney in prone position. Lancet 1:1047—1049, 1954 </li></ul><ul><li>New era - biopsy guns & imaging </li></ul>
  3. 3. Vim-Silverman needle
  4. 4. OVERVIEW <ul><li>Indications & contraindications </li></ul><ul><li>The procedure </li></ul><ul><li>Tissue processing and staining </li></ul><ul><li>Brief introduction to microscopy </li></ul><ul><li>Some clinical examples </li></ul>
  5. 5. Indications of renal biopsy <ul><li>Nephrotic syndrome: </li></ul><ul><ul><li>Adult NS </li></ul></ul><ul><ul><li>Children with atypical features </li></ul></ul><ul><li>Acute renal failure: </li></ul><ul><ul><li>Undiagnosed </li></ul></ul><ul><ul><li>Non resolving clinical ATN >3-4 weeks </li></ul></ul><ul><li>Systemic diseases with renal dysfunction </li></ul>
  6. 6. Indications of renal biopsy CONtd…. <ul><li>Sub-nephrotic proteinuria </li></ul><ul><ul><li>>2g/d in DM, early MGN, FSGS, IgAN </li></ul></ul><ul><ul><li><2g/d needs clinicians discretion </li></ul></ul><ul><li>Hematuria </li></ul><ul><ul><li>Isolated ( Q J Med 2004; 97:739–745) </li></ul></ul><ul><ul><li>Associated with proteinuria and abnormal urine sedimen t </li></ul></ul>
  7. 7. Indications of renal biopsy CONtd…. <ul><li>Post transplant </li></ul><ul><li>CKD- </li></ul><ul><ul><li>generally contraindicated </li></ul></ul><ul><ul><li>In moderate dysfunction-potential reversibility and basic disease </li></ul></ul><ul><li>Diabetes Mellitus </li></ul><ul><ul><li>Microscopic hematuria </li></ul></ul><ul><ul><li>Absence of retinopathy and neuropathy </li></ul></ul><ul><ul><li>Onset of proteinuria <5years from diagnosis </li></ul></ul><ul><ul><li>Acute worsening of renal function </li></ul></ul><ul><ul><li>Systemic features </li></ul></ul>
  8. 8. Renal biopsy; a necessary evil? <ul><li>276 native renal biopsies; management was altered in 42% of cases overall. Nephrol Dial Transplant. 1994;9(9):1255-9 </li></ul><ul><li>3 year prospective study involving 80 patients; Pre-biopsy predicted histologic diagnosis was changed in 44% of the patients as a result of the biopsy. Prognosis changed in 57% of the patients. Therapy changed in 31% of the patients. Clin Nephrol. 1986 Nov;26(5):217-21 </li></ul><ul><li>111 renal biopsies in childern; biopsy altered diagnosis in 24.5%. Post biopsy, treatment was changed in 22.6%. 18.9% had a change in both the diagnosis and treatment. Zhonghua Min Guo. 1998 Jan-Feb;39(1):43-7 </li></ul>
  9. 9. contraindications
  10. 10. Preparation of the patient <ul><li>Prerequisites </li></ul><ul><ul><li>Relevant history & examination </li></ul></ul><ul><ul><li>USG KUB </li></ul></ul><ul><ul><li>Hemogram and Hct </li></ul></ul><ul><ul><li>PT/aPTT </li></ul></ul><ul><ul><li>Urine RE/ME & culture </li></ul></ul><ul><ul><li>Bleeding time </li></ul></ul><ul><li>Current Opinion in Nephrology & Hypertension 1999;8: 715-718 </li></ul>
  11. 12. Biopsy gun
  12. 13. Biopsy gun choice <ul><li>14 G guns gives greater number of glomeruli per core than 18-G cores, but the rates of adequate biopsies were similar </li></ul><ul><li>Larger needle provided more tissue and glomeruli but were associated with more pain. </li></ul><ul><li>16-gauge needles are used as a compromise between the need of a sufficient size of tissue and the need of clinical safety. </li></ul><ul><li>Adequate quantity of tissue for diagnosis may be obtained with this needle size in 98.9 per cent of biopsies either in native or in transplanted kidneys. </li></ul><ul><li>OTCN </li></ul>
  13. 14. Procedure <ul><li>Informed consent </li></ul><ul><li>Patient in prone position with wedge or pillow below the abdomen </li></ul><ul><li>Light sedation </li></ul><ul><li>Local anesthesia with 1-2% lignocaine from the skin down to the capsule </li></ul><ul><li>Stab incision can be given to ease biopsy gun entry </li></ul><ul><li>Advance the biopsy gun, when the capsule is reached, instruct patient to take a deep breath and fire the gun </li></ul><ul><li>2-3 cores can be taken from the lower pole of the left kidney </li></ul><ul><li>Press on wound for 2-5 minutes </li></ul>
  14. 16. Procedure
  15. 17. Procedure
  16. 18. USG guided vs blind biopsies <ul><li>Worldwide the trend is towards USG guided biopsies </li></ul><ul><li>129 renal biopsies, </li></ul>Semin Dial. 2007 Jul-Aug;20(4):355-8 USG guided Blind P Mean number of glomeruli 18±9 11±9 0.0001 Repeat biopsy 0% 16% 0.0006 Hematoma requiring intervention 0% 11% 0.006 24 hour Hct 32±5% 30±4% 0.04
  17. 19. USG guide to nephrologist <ul><li>Safer and more efficient then blind biopsy </li></ul><ul><li>In one study of 101 biopsies nephrologists used a portable ultrasound machine for location and depth of the kidney. The results are similar to those of previous studies using automatic devices but under direct ultrasound guidance. </li></ul><ul><li>AJKD 1999;34:955-959 </li></ul>
  18. 20. Post procedure <ul><li>Hand held lens/dissecting microscope can be used to check for the presence of cortical tissue </li></ul>
  19. 21. Post procedure <ul><li>Bed rest is instructed for 18-24 hours </li></ul><ul><li>BP and pulse are monitored in the following way- </li></ul><ul><ul><ul><li>Every 15 mins for 1 hour f/b </li></ul></ul></ul><ul><ul><ul><li>Every 30 mins for 1 hour f/b </li></ul></ul></ul><ul><ul><ul><li>Every hour for 4 hours f/b </li></ul></ul></ul><ul><ul><ul><li>4 hourly for next remaining 24 hours </li></ul></ul></ul><ul><li>Save aliquots of each voided urine sample in clear specimen jars </li></ul><ul><li>Hct monitored 6-8 hours and 18-24 hours after biopsy </li></ul>
  20. 22. Complications of renal biopsy <ul><li>Complications of percutaneous renal biopsy: a review of 37 years experience. Clin Nephrol 1992;38:135-41 . </li></ul>
  21. 23. Complications of renal biopsy Ateriovenous fistula-post biopsy
  22. 24. Complications of renal biopsy <ul><li>Page kidney : compression of kidney by a hematoma leads to high renin hypertension. It is believed to result from microvascular ischemia and alteration of small-vessel hemodynamics from external compression. </li></ul>
  23. 25. Outpatient renal biopsy <ul><li>750 biopsies; Complications were identified 42% patients by 4 h, in 67% patients by 8 h, in 85% patients by 12 h, and in 89% patients at 24 h. After biopsy, an observation time of up to 24 h remains optimal. </li></ul><ul><li>J Am Soc Nephrol 15:142-147, 2004 </li></ul><ul><li>Maya and Allon et al; 100 renal biopsies. 8 hour observation is safe. </li></ul><ul><li>Semin. Dial. 20, 355–358 (2007) </li></ul>
  24. 26. Specimen processing <ul><li>Specimen division </li></ul><ul><li>>8mm - LM/IF/EM </li></ul><ul><li>4-8mm - EM/IF </li></ul><ul><li><4mm - EM </li></ul>
  25. 27. Specimen processing <ul><li>Adequacy of the sample: </li></ul><ul><ul><li>two biopsy cylinders with a minimal length of 1 cm and a diameter of at least 1.2 mm. </li></ul></ul><ul><ul><li>10–15 glomeruli are optimal; very often 6–10 glomeruli are sufficient </li></ul></ul><ul><ul><li>some cases even one glomerulus is enough </li></ul></ul><ul><ul><li>Nephrol Dial Transplant (2006) 21: 1157–1161 </li></ul></ul>
  26. 28. Biopsy tissue examination
  27. 29. Light microscopy <ul><li>1. Fixative: </li></ul><ul><ul><li>Buffered, 10% aqueous formaldehyde solution (formalin)-most commonly used </li></ul></ul><ul><ul><li>Bouin’s </li></ul></ul><ul><ul><li>Duboscq-Brasil </li></ul></ul><ul><ul><li>Zenker’s </li></ul></ul><ul><ul><li>4% paraformaldehyde </li></ul></ul><ul><ul><li>The material processed for LM can serve as reserve material for IHC or EM if either of these other modalities is found lacking glomeruli. </li></ul></ul>
  28. 30. Light microscopy <ul><li>2 . Dehydration: done with a series of alcohols, say 70% to 95% to 100%. </li></ul><ul><li>3. Clearing: xylene, toluene, chloroform, limolene </li></ul><ul><li>4. Embedding : </li></ul><ul><ul><ul><li>Paraffin </li></ul></ul></ul><ul><ul><ul><li>Paraplast </li></ul></ul></ul><ul><ul><ul><li>Plastics- methyl methacrylate, glycol methacrylate, araldite, and epon . </li></ul></ul></ul><ul><ul><li>5. Sectioning: manual/microtome. 2 µm sections are used </li></ul></ul>
  29. 31. Light microscopy <ul><li>Routine stains (paraffin sections) </li></ul><ul><ul><li>Haematoxylin and eosin (HE) </li></ul></ul><ul><ul><li>Periodic acid–Schiff’s (PAS) </li></ul></ul><ul><ul><li>Fibrous tissue stain (i.e. Sirius red, Trichrome, Ladewig, etc.) </li></ul></ul><ul><ul><li>Silver stain </li></ul></ul><ul><ul><li>Protein stain- acid fuchsin–Orange G stain (SFOG). </li></ul></ul><ul><li>Optional stains </li></ul><ul><ul><li>Kossa stain (calcifications) </li></ul></ul><ul><ul><li>Congo red stain (amyloid) </li></ul></ul>
  30. 32. Light microscopy <ul><li>H&E: composition of the tissue (i.e. renal cortex vs medulla, number of glomeruli, cellular infiltration, etc.). </li></ul><ul><li>PAS: delineates in great detail </li></ul><ul><ul><li>glomerular cells, </li></ul></ul><ul><ul><li>mesangial matrix and potential expansion, as well as potential modifications of the composition of the matrix, </li></ul></ul><ul><ul><li>changes of the GBM, i.e. thickening, irregularities, doubling, rupture </li></ul></ul><ul><ul><li>fibrinoid necrosis of the glomerular tuft </li></ul></ul><ul><ul><li>alterations of the vessels, particularly arterial hyalinosis and fibrinoid necrosis. </li></ul></ul>
  31. 33. Light microscopy <ul><li>Protein stains : Immune deposits </li></ul><ul><li>Silver stain : permits the detection of changes of the GBM </li></ul><ul><li>Fibrous tissue stain : extent of fibrosis in the glomerulus or tubular interstitium </li></ul>
  32. 34. Light microscopy-normal
  33. 36. Immunohistochemistry-IF/IP <ul><li>Preparation : </li></ul><ul><ul><li>IF is best performed on unfixed, frozen sections. Tissues can be transported to the laboratory fresh on saline-soaked gauze or in Michel’s fixative. Serial sections are cut at 2–4 mm in a cryostat. </li></ul></ul><ul><ul><li>IP staining requires no special tissue preparation in that the same formalin-fixed, paraffin- embedded material used for LM is also used for IP. </li></ul></ul>
  34. 37. Immunohistochemistry-IF/IP <ul><li>Staining: The antigens that should be routinely examined include: </li></ul><ul><ul><li>immunoglobulins (primarily IgG, IgM and IgA), </li></ul></ul><ul><ul><li>complement components (primarily C3, C1q, and C4), </li></ul></ul><ul><ul><li>fibrin, </li></ul></ul><ul><ul><li>κ - and – λ light chains </li></ul></ul><ul><ul><li>collagen IV alpha chains </li></ul></ul><ul><ul><li>IgG subclasses, </li></ul></ul><ul><ul><li>virus identification, </li></ul></ul><ul><ul><li>lymphocyte </li></ul></ul><ul><ul><li>phenotyping in allografts in suspected cases of PTLD, </li></ul></ul><ul><ul><li>C4d in allograft biopsies </li></ul></ul>
  35. 38. Immunohistochemistry-IF/IP <ul><li>Reported as: </li></ul><ul><ul><li>reaction is positive , </li></ul></ul><ul><ul><li>pattern of staining, e.g. mesangial vs capillary staining pattern, </li></ul></ul><ul><ul><li>linear (or pseudolinear) vs granular staining. </li></ul></ul><ul><ul><li>describe where the deposits are located , e.g. in a subendothelial, intramembranous or subepithelial position </li></ul></ul>
  36. 39. Immunohistochemistry-IF/IP
  37. 40. IgG IgA Idiopathic MGN IgA Nephropathy
  38. 41. Electron Microscopy <ul><li>Fixative : 2-3% glutaraldehyde, 1-4 % paraformaldehyde. </li></ul><ul><li>Processing : </li></ul><ul><ul><li>Instead of the clearing fluid, “transitional fluid”- 1,2 Epoxypropane is used. </li></ul></ul><ul><ul><li>E mbedding done in epon. </li></ul></ul><ul><ul><li>Sections must be less than 80 nm thick in order to allow at least 50% of the electron beam to penetrate the sample. </li></ul></ul><ul><ul><li>Toluidine blue stained 1µm thick sections are used as an initial guide </li></ul></ul><ul><li>Stains : uranyl acetate (stains DNA), lead citrate, gold. </li></ul>
  39. 42. Electron Microscopy <ul><li>Electron microscopy permits assessment of the following: </li></ul><ul><ul><li>The presence and degree of cell proliferation (mesangial vs endothelial cell proliferation) </li></ul></ul><ul><ul><li>Changes in cell structure (i.e. podocyte foot process fusion or podocyte vacuolization) </li></ul></ul><ul><ul><li>Necrosis or apoptosis of cells </li></ul></ul><ul><ul><li>Changes of glomerular basement membrane (i.e. thickening, thinning, splicing, irregularities) </li></ul></ul><ul><ul><li>Localization of immunoglobulin deposits (i.e. mesangial, subendothelial or subepithelial) </li></ul></ul><ul><ul><li>In some renal diseases, specific morphological changes tubuloreticular structures. </li></ul></ul>
  40. 43. Electron Microscopy <ul><li>Immunohistology is essential for diagnosis in 21% of cases and Electron Microscopy is essential in the diagnosis of 8% of cases OTCN </li></ul>
  41. 44. Electron Microscopy
  42. 45. Reporting a Renal Biopsy <ul><li>The final report of a kidney biopsy should include information on: </li></ul><ul><ul><li>The adequacy of the specimen </li></ul></ul><ul><ul><li>A description of the morphological changes in a systematic fashion for each of the compartments of interest (glomeruli, tubules, interstititum, vessels </li></ul></ul><ul><ul><li>The results of immunofluorescence /immunohistochemical studies. </li></ul></ul><ul><ul><li>The results of the electron microscopy </li></ul></ul><ul><li>It is useful to give two types of diagnosis: </li></ul><ul><li>Descriptive </li></ul><ul><li>Final </li></ul>
  43. 46. Reporting a Renal Biopsy
  44. 47. Reporting a Renal Biopsy
  45. 48. Reporting a Renal Biopsy
  46. 49. Reporting a Renal Biopsy
  47. 50. Biopsy in special situations <ul><li>Pediatric age group : </li></ul><ul><ul><li>Sedation is used (ketamine, midazolam, promethazine, BZDs) </li></ul></ul><ul><ul><li>18-G gun is used </li></ul></ul><ul><li>Pregnancy : Indications of biopsy </li></ul><ul><ul><li>Sudden unexplained deterioration of renal function before 30-32 weeks POG </li></ul></ul><ul><ul><li>Symptomatic NS before 30-32 weeks POG </li></ul></ul><ul><ul><li>Active urinary sediments, proteinuria and borderline renal function </li></ul></ul><ul><li>renal biopsy in pregnancy is safe before 30 weeks of pregnancy. </li></ul><ul><li>Acta Obstetricia Gynecologica Scandinavica 2001;80:888–893 </li></ul>
  48. 51. Biopsy in special situations <ul><li>Allograft biopsy : </li></ul><ul><li>Indications- </li></ul><ul><ul><li>Failure of the graft to function in the first 7-10 days after surgery </li></ul></ul><ul><ul><li>Rapid deterioration of renal function of unknown cause after initial good function </li></ul></ul><ul><ul><li>Absence of response to antirejection therapy </li></ul></ul><ul><ul><li>Unexplained nephrotic range proteinuria </li></ul></ul><ul><ul><ul><li>Biopsy technique is the same </li></ul></ul></ul><ul><ul><ul><li>Supine position </li></ul></ul></ul><ul><ul><ul><li>USG guidance is necessary-for position and localisation, and also to exclude presence of intestinal loops, fluid collections </li></ul></ul></ul><ul><ul><ul><li>2 cores of tissue is recommended- the sensitivity of a single core for rejection is 91%; the addition of the second core improves the sensitivity to about 99% </li></ul></ul></ul><ul><ul><ul><li>Half the tissue is used for frozen section </li></ul></ul></ul>
  49. 53. <ul><li>CLINICAL EXAMPLES </li></ul>
  50. 54. <ul><li>SHEIKH ABDUL HALIM </li></ul><ul><li>Kala Azar with Nephrotic Syndrome </li></ul>
  51. 56. Sushmita Das (SLE Class IV) Wire loops
  52. 57. Cellular crescent Fibrinoid necrosis Global proliferation with neutrophilic infiltration
  53. 58. <ul><li>Naima Khatoon </li></ul><ul><li>Lupus nephritis Class IV G( A/C) </li></ul><ul><li>Activity index: 19/24 </li></ul><ul><li>Chronicity index: 4/12 </li></ul>
  54. 59. Kalpana Das (FSGS)
  55. 60. Amal Panja (Crescentic GN)
  56. 61. Sabita Majumdar (Pauci-immune CrGN)
  57. 62. Sukumar Bodhak (IgA Nephropathy) IgA
  58. 63. <ul><li>THANK YOU </li></ul>