Ahmed Ezzat Fadl
Resident of Nephrology
2. History of Renal biopsy
5. Preparation for biopsy
7. Post procedure
A renal biopsy is a procedure used to obtain a segment
of renal tissue, usually through a needle or another
Before 1951, the only way of obtaining kidney tissue
from a live person was through an open operation.
Danish physicians Poul Iversen and Claus Brun
described a method involving needle biopsy which has
become the new standard.
Recent widespread availability of real-time imaging
guidance using ultrasound or CT scanning having
improved safety of the procedure.
Is the Biopsy Necessary?
Always judge the balance of risk vs benefit
Most nephrologists would agree that renal biopsy is
more likely to change management in symptomatic
It can also be useful for prognostic purposes, as well as
helping to direct or change treatment
1) Significant proteinuria (>1g/day)/Nephrotic
syndrome with two normal sized, non-
obstructed, kidneys and no obvious cause (usually
considering the diagnosis of a glomerulo- or
2) Acute Kidney Injury (AKI) with two normal
sized, non-obstructed, kidneys and no obvious cause
(pre and post-renal causes excluded)or non resolving
clinical ATN>3-4 weeks
3) Chronic Kidney Disease (CKD) with two normal
sized, non-obstructed, kidneys and no obvious cause
4) Renal transplant dysfunction
5) Systemic disease with renal dysfunction
Less common (and more controversial) indications.
(Many of these patients may have normal renal function)
Familial renal disease (where
diagnosis in this patient, benefits
them and their family)
Diabetes and Renal Biopsy
If the clinical presentation is consistent with diabetic
(ie ,signficant proteinuria [often nephrotic range], CKD3b-
4, diabetes of over 10 years duration, presence of other
microvascular complications [eg retinopathy and neuropathy])
biopsy is not necessary and it can be assumed that the patient has
(THE NEW TERM DKD) why!
When to biopsy diabetic patient :
1) Microscopic hematuria
2) Absence of retinopathy and neuropathy
3) Onset of significant proteinuria <5 years from diagnosis
4) Acute worsening of renal function
5) Systemic features
Pediatric age group:
Sedation is used (ketamine, midazolam, promethazine, BZDs)
18-G gun is used
Pregnancy: Indications of biopsy
Sudden unexplained deterioration of renal function before 30-32 weeks
Symptomatic N.S before 30-32 weeks POG
Active urinary sediments, proteinuria and borderline renal function
renal biopsy in pregnancy is safe before 30
weeks of pregnancy.
Biopsy is performed from the transplanted kidney to
exclude rejection, BK nephropathy, drug-toxicity or
recurrence of the disease that caused kidney failure
For surveillance of hidden disease involving the
transplant kidney, so-called protocol renal biopsy
undertaken at fixed intervals post-transplantation.
Age, Race and Renal Biopsy
Moutzouris (2009) has published a series of biopsies
in the elderly (> 80 years) suggesting that this is still a
useful technique with results that affect management
in a significant number of patients.
There are racial differences between biopsy
For example, Hoy (2012) has described a wide range of
atypical findings in Australian aborginal people.
1) Uncorrectable bleeding diathesis
2) Uncontrollable severe hypertension (>160/95)
3) Active renal or perirenal infection
4) Skin infection at biopsy site
5) Presence of a solitary native kidney(except in …… )
6) Renal neoplasm, multiple cysts, abscess or pyelonephritis
1) Certain anatomical abnormalities of the kidney (eg
2) Medications that interfere with clotting (e.g.
warfarin or heparin)
3) Pregnancy(safe before 30 w)
4) Uncooperative patient (some consider absolute C.I)
Prior to the procedure
Informed consent is usually taken.
Arrangements will also be made to ensure that
appropriate post-biopsy care and supervision is in
The patient has the right to consent or decline
NSAIDs should be stopped 24 hours before procedure.
For elective biopsies, anti-platelet agents (aspirin &clopidogrel)
should be stopped 7 days before the biopsy.
Warfarin should ideally be stopped 7 days before the procedure
and the patient converted to heparin if clinically indicated.
Heparin (including prophylactic and LMW) should be stopped at
least 24 hours pre-procedure.
Ideally anticoagulation should not be restarted for 1 week post-
If clinically indicated anticoagulation can be started after 24
hours, but this should be delayed further if there is macroscopic
haematuria or a drop in haemoglobin.
Biopsy gun :
14 G guns gives greater number of glomeruli per core
than 18-G cores, but the rates of adequate biopsies
Larger needle provided more tissue and glomeruli but
were associated with more pain.
16-gauge needles are used as a compromise between
the need of a sufficient size of tissue and the need of
Biopsy sample is divided and sent off for:
light microscopy , Immunoflourescence and Electron
Patient in prone position with wedge or pillow below the abdomen
Local anesthesia with 1-2% lignocaine subcutaneous
Stab incision can be given to ease biopsy gun entry
Advance the biopsy gun, when the capsule is reached, instruct patient
to take a deep breath and fire the gun
2-3 cores can be taken from the lower pole of the left kidney & placed
in 10ml of normal saline 0.9% and taken to the laboratory.
Press on wound for 2-5 minutes
Renal biopsy is typically performed by a
nephrologist or interventional radiologist
Bed rest flat on back(≈4 hr) is instructed
BP and pulse are monitored in the following way:-
Every 15 mins for 1 hour
Every 30 mins for 1 hour
Every hour for 4 hours
4 hourly for next remaining 24 hours
Save each voided urine sample in clear specimen
CBC & Hct monitored 6-8 hours and 18-24 hours after
2) AV fistula - these are common and can be demonstrated
by angiography in 10-20% of patients. Such lesions are
usually clinically silent, and more than 95% resolve
spontaneously within 2 years. In rare
instances, embolisation or surgical correction of the
fistula is required because of severe
hypertension, persistent hematuria, congestive heart
failure, or hydronephrosis
3) Aneurysm - these occur in less than 1% of patients and
the majority resolve spontaneously Rarely they can lead to
significant ischaemic problems and may require
4) Biopsy of other organs (spleen, liver, pancreas, bowel,
5) Calyceal-peritoneal fistula
6) Dispersion of carcinoma
7) 'Page kidney' - compression of the kidney by peri-renal
haematoma leading to renin-mediated hypertension
There is also an approximately 5% chance of obtaining an
inadequate tissue sample.
In other words, from the patients' perspective, the most
important common complication of biopsy is
having to do it agaaaaaain
The major complication of renal biopsy is bleeding. A
degree of peri-renal bleeding post-biopsy is inevitable
and the mean fall in haemoglobin after a renal biopsy is 1
Bleeds are usually small and self-limiting and manifest as:
Peri-renal haematoma (Manno, 2004).
Peri-renal haematomas are common, and usually self
Non-visible haematuria (35%).
Visible haematuria (3%).
of a major bleedanagementM
Tachycardia may be the first sign of bleeding – take it seriously
Classic signs of shock and back pain may happen much later
If shock develops call your blood bank and X-match 2 (or more) units
Ensure the patient has good (wide bore) IV access, replace volume
loss with IV saline/colloid in the first instance
Arrange an urgent ultrasound to see if there is any bleed around the
kidney (peri-renal haematoma). A CT angiogram can be useful to
identify both a peri-renal haematoma and also the presence and site of
Occassionally heavy haematuria may cause clot colic or acute urinary
Prolonged or severe bleeding may require angiography and coil
embolisation. It is sensible to inform the urologists at this stage - if
angiography and embolisation fail to stop the bleeding.Nephrectomy
will be required
Discharge & follow up
Warn the patient they will feel sore around the biopsy
site for 3-4 days. Patients should be given clear
(written) instructions regarding pain and haematuria
before they go home. These should include 24 hour
contact numbers in case of complications that arise
All patients who have had a renal biopsy should be
seen in clinic soon after discharge:
Transplant biopsy: 1-2 days
Native biopsy: 2 weeks