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Ahmed Ezzat Fadl
Resident of Nephrology
(D.M.N.I)
1. DEFENITION
2. History of Renal biopsy
3. Indications
4. C.I
5. Preparation for biopsy
6. Procedure
7. Post procedure
8....
Definition:-
 A renal biopsy is a procedure used to obtain a segment
of renal tissue, usually through a needle or another...
History:-
 Before 1951, the only way of obtaining kidney tissue
from a live person was through an open operation.
 Danis...
Is the Biopsy Necessary?
 Always judge the balance of risk vs benefit
 Most nephrologists would agree that renal biopsy ...
Indications
1) Significant proteinuria (>1g/day)/Nephrotic
syndrome with two normal sized, non-
obstructed, kidneys and no...
3) Chronic Kidney Disease (CKD) with two normal
sized, non-obstructed, kidneys and no obvious cause
4) Renal transplant dy...
Less common (and more controversial) indications.
(Many of these patients may have normal renal function)
 Microscopic ha...
Diabetes and Renal Biopsy
 If the clinical presentation is consistent with diabetic
nephropathy
(ie ,signficant proteinur...
 Pediatric age group:
 Sedation is used (ketamine, midazolam, promethazine, BZDs)
 18-G gun is used
 Pregnancy: Indica...
Transplanted kidney
 Biopsy is performed from the transplanted kidney to
exclude rejection, BK nephropathy, drug-toxicity...
Age, Race and Renal Biopsy
 Moutzouris (2009) has published a series of biopsies
in the elderly (> 80 years) suggesting t...
Contraindications
•6
Absolute
•3
Relative
1) Uncorrectable bleeding diathesis
2) Uncontrollable severe hypertension (>160/95)
3) Active renal or perirenal infection...
1) Certain anatomical abnormalities of the kidney (eg
vascular lesion)
2) Medications that interfere with clotting (e.g.
w...
Prior to the procedure
 Informed consent is usually taken.
 Arrangements will also be made to ensure that
appropriate po...
Before biopsy
 NSAIDs should be stopped 24 hours before procedure.
 For elective biopsies, anti-platelet agents (aspirin &clopidogrel)...
Biopsy gun :
 14 G guns gives greater number of glomeruli per core
than 18-G cores, but the rates of adequate biopsies
we...
 Biopsy sample is divided and sent off for:
light microscopy , Immunoflourescence and Electron
microscopy
Procedure
 Patient in prone position with wedge or pillow below the abdomen
 Light sedation
 Local anesthesia with 1-2%...
 Renal biopsy is typically performed by a
nephrologist or interventional radiologist
Post procedure
 Bed rest flat on back(≈4 hr) is instructed
 BP and pulse are monitored in the following way:-
Every 15 m...
omplicationsC
1) Bleeding
2) AV fistula - these are common and can be demonstrated
by angiography in 10-20% of patients. S...
omplicationsCCont.
4) Biopsy of other organs (spleen, liver, pancreas, bowel,
gall bladder)
5) Calyceal-peritoneal fistula...
There is also an approximately 5% chance of obtaining an
inadequate tissue sample.
In other words, from the patients' pers...
Haemorrhage
The major complication of renal biopsy is bleeding. A
degree of peri-renal bleeding post-biopsy is inevitable...
of a major bleedanagementM
 Tachycardia may be the first sign of bleeding – take it seriously
 Classic signs of shock an...
Discharge & follow up
 Warn the patient they will feel sore around the biopsy
site for 3-4 days. Patients should be given...
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
Renal biopsy fadl
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Renal biopsy fadl

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HINT ON RENAL BIOPSY

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Renal biopsy fadl

  1. 1. Ahmed Ezzat Fadl Resident of Nephrology (D.M.N.I)
  2. 2. 1. DEFENITION 2. History of Renal biopsy 3. Indications 4. C.I 5. Preparation for biopsy 6. Procedure 7. Post procedure 8. Complications
  3. 3. Definition:-  A renal biopsy is a procedure used to obtain a segment of renal tissue, usually through a needle or another surgical instrument.
  4. 4. History:-  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.
  5. 5. 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 kidney disease  It can also be useful for prognostic purposes, as well as helping to direct or change treatment
  6. 6. Indications 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 interstitial nephritis) 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
  7. 7. 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
  8. 8. Less common (and more controversial) indications. (Many of these patients may have normal renal function)  Microscopic haematuria  Familial renal disease (where diagnosis in this patient, benefits them and their family)
  9. 9. Diabetes and Renal Biopsy  If the clinical presentation is consistent with diabetic nephropathy (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 diabetic nephropathy (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
  10. 10.  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 POG  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.
  11. 11. Transplanted kidney  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.
  12. 12. 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 appearances. For example, Hoy (2012) has described a wide range of atypical findings in Australian aborginal people.
  13. 13. Contraindications •6 Absolute •3 Relative
  14. 14. 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
  15. 15. 1) Certain anatomical abnormalities of the kidney (eg vascular lesion) 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)
  16. 16. 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 place  The patient has the right to consent or decline
  17. 17. Before biopsy
  18. 18.  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- biopsy.  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.
  19. 19. Biopsy gun :  14 G guns gives greater number of glomeruli per core than 18-G cores, but the rates of adequate biopsies were similar  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 clinical safety.
  20. 20.  Biopsy sample is divided and sent off for: light microscopy , Immunoflourescence and Electron microscopy
  21. 21. Procedure  Patient in prone position with wedge or pillow below the abdomen  Light sedation  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
  22. 22.  Renal biopsy is typically performed by a nephrologist or interventional radiologist
  23. 23. Post procedure  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 container  CBC & Hct monitored 6-8 hours and 18-24 hours after biopsy
  24. 24. omplicationsC 1) Bleeding 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
  25. 25. omplicationsCCont. 4) Biopsy of other organs (spleen, liver, pancreas, bowel, gall bladder) 5) Calyceal-peritoneal fistula 6) Dispersion of carcinoma 7) 'Page kidney' - compression of the kidney by peri-renal haematoma leading to renin-mediated hypertension
  26. 26. 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  
  27. 27. Haemorrhage 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 g/dL  Bleeds are usually small and self-limiting and manifest as:  Peri-renal haematoma (Manno, 2004). Peri-renal haematomas are common, and usually self limiting..  Non-visible haematuria (35%).  Visible haematuria (3%).
  28. 28. 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 of blood  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 active bleeding  Occassionally heavy haematuria may cause clot colic or acute urinary retention  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
  29. 29. 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 after discharge.  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

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