| Abstract|| |
In this retrospective study, we reviewed the medical records, and histopathology findings of 191 patients who underwent renal biopsies at King Hussein Medical Center (KHMC) during a four-year period (1993-97). All were performed using Tru-Cut needles under ultrasound guidance. There were 119 males (62.3%) and 72 females (37.7%); the mean age was 29.1 years (range 5-76 years). Side effects of the renal biopsies included pain at the site of he biopsy in 17 (8.9%), gross hematuria in six (3.1%) and hematuria requiring blood transfusion in one (0.5%) patient. Nephrotic syndrome was the most common indication for biopsy followed by acute renal failure of unknown etiology. Among the nephritic patients, minimal change disease and post-infectious glomerulonephritis (GN) were the commonest findings in children below the age of 15 years, membrano-proliferative GN ranked first in adults whole membranous GN and amyloidosis were more common in the elderly. WE conclude that renal biopsy was associated with a n acceptably low rate of complications in our practice, and that the patterns of renal histology vary slightly from those reported from other countries.
|How to cite this article:|
Ghnaimat M, Akash N, El-Lozi M. Kidney Biopsy in Jordan: Complications and Histopathological Findings. Saudi J Kidney Dis Transpl 1999;10:152-6
|How to cite this URL:|
Ghnaimat M, Akash N, El-Lozi M. Kidney Biopsy in Jordan: Complications and Histopathological Findings. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2020 Feb 26];10:152-6. Available from: http://www.sjkdt.org/text.asp?1999/10/2/152/37221
| Introduction|| |
Histological examination of the biopsied kidneys remains the gold standard for renal diagnosis.
In 1951, Inverson and Brun reported the first large series of needle biopsies of eh kidney,  subsequently hundreds of papers have been published reporting on the technique, ease and safety of precautious renal biopsies in different age groups.
In this study we report our experience with renal biopsy and the histopathological patterns of renal disease in a referral hospital in Jordan over a four years period.
| Materials and Methods|| |
King Hussein Medical Center is the largest tertiary referral hospital in Jordan. On the average we perform 50-60 renal biopsies per year. A retrospective study of all patients who underwent percutaneous renal biopsies in our center over the last four year was performed.
The indications for performing the biopsies were nephritic syndrome, renal failure of unknown etiology and persistent or recurrent asymptomatic hematuria and/or proteinuria.
Patients were excluded if they had bleeding problems, uncontrolled hypertension, single kidney, and morbid obesity or were uncooperative. Prior to the biopsy procedure, clotting profile including platelet count, bleeding time, clotting time, prothrombin and partial thromboplastin time were performed. Only a small number of patients needed correction for one or more abnormalities of these parameters before performing the biopsies.
A nephrologists using Tru-cut® needles performed all biopsies guided by ultrasonographic localization of the kidneys. Specimens were subjected to only light and immunoflorescent microscopic studies. Electron microscopy was not available for use in this study. Biopsy samples were considered satisfactory for diagnosis if they contained five or more glomeruli.
| Results|| |
During the past four years, a total number of 191 renal biopsies were performed in our center. Twenty-seven patients (14.1%) were less than 15 years old (group I), 121 (63.4%) were 16-40 years (Group II), 30 (15.7%) wee 41-55 years (Group III0 and 13 patients (6.8%) were > 56 years (Group IV).
There were 119 males (62.3%) and 72 females (37.7%). Indications for performing the biopsies among different age groups were: the nephritic syndrome in 127 patients (66.5%); acute renal failure (ARF) in 31 patients (16.2%); asymptomatic hematuria in 12 (6.3%) patients evaluated for unknown etiology of renal failure. Eighty-three of the 127 patients with the nephritic syndrome (65%) were aged 16-40 years, while the rest were distributed between the other age groups [Table - 1]. As expected, minimal change disease and histopathologic findings comparable with post-infectious glomerulonephritis (GN) were the commonest patterns in children < 15 years of age.
Membranoproliferative GN ranked fist in adults while membranous GN and amyloidosis were more common in elderly [Table - 1]. [Table - 2],[Table - 3] and [Table - 4] summarize the frequency of ARF, asymptomatic hematuria and CRF respectively in the various age groups.
The most common complications of the procedure were pain at the biopsy site in 17 (8.9%) patients, gross hematuria in six (3.1%) and hematuria requiring blood transfusion in one (0.5%). None of the patients needed open surgical intervention or nephrectomy and there were no deaths due to the procedure [Table - 5].
| Discussion|| |
This retrospective study aimed at answering three questions: what are the indications of renal biopsy in our part of the world? Do we have a different complication rate? And does the pattern of renal disease differ from other countries?
In our study the nephritic syndrome was the commonest indication of performing biopsy (66.5% of cases). This was slightly higher in group II (young adults) and children (70% and 68.66% respectively) but less common in the old age groups designated in this study as group III and IV (56.7%, 61.5%). These percentages are similar to other studies, in which the nephritic syndrome was an indication for renal biopsies in children and adolescents in 83.3%. 
The overall complication rate in this study was 12.6%, of which severe pain at the biopsy site was in 8.9% and gross hematuria was in 3.2%. These rates are slightly higher than other studies, in which the overall complication rate was 7%, the rate of pain was 4% and that of gross hematuria was 3%. Figueroa and Frentz reported a case of prolonged intermittent hematuria, which lasted 61 days after renal biopsy of a transplanted kidney. Delayed bleeding, has also been reported in other studies.,
The incidence of arteriovenous fistula after renal biopsy varies from one study to another (0.1%-23%)., However, in this study we did not report any because renal arteriogram was not carried out for accurate diagnosis.
Retroperitoneal bleeding of variable degrees is a common complication, of which the incidence was not well appreciated till computerized tomography was used to detect it. Accordingly the incidence increased from 1% to 57% to 70%., In our study, we believe that retroperitoneal bleeding occurred in a considerable number of our patients though we did not specifically search for this possible complication.
The reported incidence of infection is very low in relation to renal biopsy,  and none of our patients developed this complication.
The patterns of glomerulopathy in our study differ among different age groups. Minimal change disease (MCD) was encountered in 47% of nephritic children (Group I), which is less than 76.5% reported by some studies , bur higher than others. ,,, The relatively low incidence of MCD among nephritic children in our study can be explained by the fact that patients in this group were given empirical courses of steroids first, biopsy was done only for those who did not respond showed poor response or had frequent relapses.
Membranoproliferative GN was the most common histological pattern encountered in the adult group (group II) followed by focal segmental glomerulosclerosis; both accounted for 25% and 24%, respectively. This is in contrast to lower incidence of these tow entities in the international and regional reports, , however the findings are similar to other studies.,
Nephrotic patients in the older and the elderly groups (group III and IV) has different histopathology. Membranous GN and amyloidosis accounted for the majority of cases (group III 35.3% and group IV 87.05%). Other researches have reported membranous nephropathy and minimal change disease as common patterns in these age groups. However, the reported incidence of amyloidosis is variable even in the same region.
In the acute renal failure patients in our study most of the crescentic GN was in the young adult group (44%) while it was low in the other age groups. Nevertheless, crescentic GN is reported to occur commonly in the older and the elderly age groups as well as adult age groups.,
IgA nephropathy was diagnosed in six (28%) patients of the group with asymptomatic hematuria. Young patients below age of 16 formed 9% of this group of patients. Al Menawy et al reported that 2.7% of children < 16 years had IgA nephropathy,  and in another study on 300 cases. Abdurrahman reported a 3% incidence of IgA nephropathy. 
We conclude that renal biopsy was with minimal rate of complications in our practice, and the patterns of renal disease differ among different age groups and vary slightly from other countries.
| References|| |
|1.||Inversen P, Brun C. Aspiration bipsy of the kidney. Am J Med 1951;11:324. |
|2.||Al Menawy L, Amousi J, Ramprasad KS, Shaheeen FAM. Percutaneous renal biopsy and its finding sin children and adolescents in Saudi Arabia: a single center experience. Saudi J Kidney Dis Transplant 1997;8(3):289-93. |
|3.||Parrish AE. Complications of percutaneous renal biopsy: a review of 37-year experience. Cli Nephrol 1992;38(3):135-41. |
|4.||Figueroa TE, Frentz GD. Anuria secondary to percutaneous needle biopsy of a transplant kidney: a case report. J Urol 1988;140:355-6. [PUBMED] |
|5.||Felton LM, Andrinaco JM. Delayed hemorrhage after percutaneous kidney biopsy. JAMA 1959;170:2183. |
|6.||Hampers CL, Prager D. Massive bleeding 10 days after renal biopsy. Arch Int Med 1964;114:782. |
|7.||O' Brien DP, Parrott TS, Walton KN, Lewis EL. Renal arteriouvenous fistulas. Surg Gynecol Obstet 1974;139:739-43. |
|8.||Maldonado JE, Sheps SG. Renal arteriovenous fistula. Postgrad Med 1966;40:263-9. [PUBMED] |
|9.||Alter AJ, Zimmerman S, Kirachaiwanich C. Computerized tomographic assess-ment of retroperitoneal hemorrhage after percutaneous renal biopsy. Arch Intern Med 1980;140:1323-6. [PUBMED] |
|10.||Ginsberg JC, Fransman SL, Singer MA, Cohanim M, Morrin PA. Use of computerized tomography to evaluate bleeding after renal biopsy. Nephron 1980;26:240. |
|11.||White RH, Glasgow EF, Mills RJ. Clinicopathological study of nephritic syndrome in childhood. Lancet 1970;1:1353-9. [PUBMED] |
|12.||Nephrotic syndrome in children: prediction of histopathology from clinical and laboratory characteristic ar time of diagnosis. A report of the International study of Kidney Disease in Children. Kidney Int 1978;13:159-65. |
|13.||Abdurrahman MB, Elidreissy AT. Childhood renal disorders in Saudi Arabia. Pediatr Nephrol 1988;2(3):368-72. |
|14.||Al-Sabban E. spectrum of glomerular disease among children in Saudi Arabia. Saudi J Kidney Dis Transplant 1997;8(3):285-8. |
|15.||Mattoo TK, Mahmood MA, AL Harbi MS. Nephrotic syndrome in Saudi children clinicopathological study of 150 cases. Pediarr Nephrol 1990;4(5):517-9. |
|16.||Tiebvosch AT, Walters J, Frederik PF, et al . Epidimiology of idiopathic glomerular diseses: a prospective study. Kidney Int 1987;32(1):112-6. |
|17.||Mitawalli AH, Al Wakeel JS, Al Mohaya SS, at al. Pattern of glomerular diseases in Saudi Arabia. Am J Kidney Dis 1996;27(6);797-802. |
|18.||Essamie MA, Soliman A, Fayed TM, Barsoum S, Kjellstrand CM. Serous renal disease in Egypt. Int J Artif Organs 1995;18(5):254-60. |
|19.||The New Zealand glomerulonephritis study: introductory report. Clin Nephrology 1989;31(5):239-46. |
|20.||Donadio JV Jr. Treatment of glomerulonephritis in the elderly. Am J Kidney Dis 1990;16(4):307-11. |
|21.||Greevska L, Polenakovic M. Crescentic glomerulonephritis as renal causes of acute renal failure. Ren Fail 1995;17(5):595-604. |
|22.||Abdurrahman MB. Percutaneous renal biopsy in a developing country: Experience with 300 cases. Ann Trop Paediatr 1984;4:25-30. [PUBMED] |
Department of Nephrology, King Hussein Medical Center, P.O. 540708, Abu-Nusair, Amman
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]