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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 746-750
Percutaneous ultrasound-guided renal biopsy


1 Department of Radiology, National Organ Transplant Centre, Central Hospital, Tripoli, Libya
2 Department of Rheumatology, Tripoli Medical Centre, University of AlFateh, Tripoli, Libya
3 Department of Histopathology, Tripoli Medical Centre, Tripoli, Libya
4 Zawia Clinical laboratory, Tripoli Medical Centre, Tripoli, Libya
5 Department of General Surgery, Central Hospital, AlFateh University, Tripoli, Libya
6 Department of Nephrology, National Organ Transplant Centre, Tripoli, Libya
7 Department of Surgery and Transplant, Central Hospital, University of AlFateh, Tripoli, Libya

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Date of Web Publication9-Jul-2011
 

   Abstract 

This study was done to assess the safety and efficacy of real-time ultrasound-guided percutaneous renal biopsy (PRB) and to determine the optimal period of observation required as well as to ascertain the risk factors for any ensuing complications. Between 1 st February 2006 and 31 st January 2008, a total of 86 PRBs were performed by the radiologist using an automated biopsy gun with 16-gauge needle at the National Organ Transplant Centre, Central Hospital, Tripoli, Libya. Prior to the procedure coagulation profile was done in all the patients. All patients were kept on strict bed rest for 6-hours post-procedure. Of the 86 renal biopsies performed, 78 patients were referred from Rheumatology Department and 8 were post-kidney transplant recipients. There were 23 males with age ranging from 15 to 56 years and 63 females with age ranging from 16 to 66 years. A mean of 17.5 glomeruli were present in each specimen. A glomerular yield of less than five glomeruli was seen in only four biopsies. Class I lupus nephritis (LN) was seen in one patient, class II LN in seven patients, class III LN in 13 patients and class IV LN in 29 patients. All the eight renal allografts were diagnosed as either acute tubular necrosis or acute interstitial rejection. The overall complication rate was 5.8% and these complications were observed within 6 hours of biopsy. No late complications were seen. PRB under real-time ultra-sound guidance is a safe and efficacious procedure to establish the histological diagnosis of the renal disease and may be done as an out-patient procedure. A post-biopsy observation time of 6 hours appears to be optimal.

How to cite this article:
Mishra A, Tarsin R, ElHabbash B, Zagan N, Markus R, Drebeka S, AbdElmola K, Shawish T, Shebani A, AbdElmola T, ElUsta A, Ehtuish EF. Percutaneous ultrasound-guided renal biopsy. Saudi J Kidney Dis Transpl 2011;22:746-50

How to cite this URL:
Mishra A, Tarsin R, ElHabbash B, Zagan N, Markus R, Drebeka S, AbdElmola K, Shawish T, Shebani A, AbdElmola T, ElUsta A, Ehtuish EF. Percutaneous ultrasound-guided renal biopsy. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Jul 15];22:746-50. Available from: http://www.sjkdt.org/text.asp?2011/22/4/746/82675

   Introduction Top


Percutaneous renal biopsy (PRB), a procedure performed for histological diagnosis of the renal disease, plays a fundamental role in clinical practice, providing information about both the diagnosis and prognosis of various renal diseases. The first PRB was reported in 1951. [1] Renal tissue was usually obtained by use of a manual technique with a large bore cutting needle. [2] Like every invasive procedure, renal biopsy was fraught with several potential complications in the past. However, the introduction of automated biopsy guns and localization of the kidney by real-time ultrasound guidance have optimized the efficacy and safety of the PRB procedure, and the risk of complications has been dramatically reduced. PRB using automated biopsy guns under real-time ultrasound guidance has now become a routine procedure in most centers.

We performed 86 ultrasound-guided PRBs on 78 patients with suspected rheumatological diseases and in eight patients who had kidney transplantation. In our center, we now use the 16-gauge automated biopsy gun (C Rose Bard Inc., Murray Hill, NJ, USA) under real-time ultra-sound guidance as the sole method for PRB.


   Materials and Methods Top


This study was done as a prospective study. All PRBs performed at the National Organ Transplant Center, Central Hospital, Tripoli, Libya, between 1 st February 2006 and 31 st January 2008, were included in the study. All the biopsies were performed by the radiologist in concordance with the nephrologist or rheumatologist. An informed consent was mandatory and was obtained from all the patients.

During a 2-year period, 86 ultrasound-guided PRBs were performed at our institution. The biopsies were performed as an out-patient procedure in the radiology department. Coagulation profile including prothrombin time (PT), partial thromboplastin time (PTT) and International Normalized Ratio (INR), bleeding time, clotting time and total platelet count were tested in all the patients. Patients with INR >1.5 or total platelet count <50 × 103/mL were excluded. Each biopsy was performed with an automated biopsy gun with a 16-gauge needle (C Rose Bard Inc.). An ATL HDI 5000 ultrasound machine (Philips Medical Systems, The Netherlands) was used for localization of the lower pole of the kidney.

The procedure was done on all patients under local anesthesia, but pediatric patients received mild sedation in addition. The patients were placed in prone position for biopsy from the native kidney and in supine or decubitus position for post-transplant cases. The kidneys were scanned to determine the optimal biopsy site. The preferred site was the lateral aspect of lower pole of right kidney. The area was prepared, and after administering local anesthesia, the needle of the biopsy gun was inserted into the body under ultrasound guidance, taking care to keep it just outside the renal capsule. The patient was then asked to hold breath after a deep inspiration. The needle was then advanced until the tip was seen within the cortex and the gun was fired to obtain the core specimen. The number of needle insertion(s) (passes) was at the sole discretion of the person performing the procedure who, based on visual inspection of each core, estimated the number of samples needed for an adequate biopsy. A stereo microscope or a renal pathologist was not available at the site, and hence, none of the core specimens could be examined immediately for adequacy of glomerular yield.

All patients were kept on strict bed rest for six-hours post-procedure and at least one post-procedure ultrasound scan was performed prior to discharging the patient. Post-procedure complications that required surgical intervention/ blood transfusion were labeled as "major". The patients were followed up by ultrasound and urine examination, two weeks post-biopsy.


   Statistical Analysis Top


Statistical analysis was done compiling all the data and results using statistical software SPSS 11.0 (SPSS Inc., Chicago, IL, USA). Predictors of post-biopsy bleeding were assessed by multiple linear and multivariate logistic regression analysis.


   Results Top


A total of 86 renal biopsies were performed of which 78 patients were those referred from rheumatology department and eight were kidney transplant recipients. There were 23 males with age ranging from 15 to 56 years and 63 females with age ranging from 16 to 66 years. The main indication for renal biopsy was an elevation in serum creatinine (>2 mg/dL) in all the patients. Two "passes" were done in all the native kidney biopsies and also in one renal allograft and only a single "pass" was done in the remaining seven renal allografts. The radiologist's estimate of the number of core samples needed was found to be matching in 93% of cases with histopathologist's determination of sample adequacy. A mean of 17.5 glomeruli were present in each specimen. A glomerular yield of less than five glomeruli was seen in four biopsies. The core sample was reported as "inadequate for diagnoses" in two patients and "normal" in two patients. Class I lupus nephritis (LN) was seen in one patient, class II LN in seven patients, class III LN in 13 patients and class IV LN in 29 patients. Other diagnoses including focal mesangial proliferation, focal sclerosing glomerulosclerosis, chronic glomerulonephritis, mesangiocapillary glomerulonephritis, and Fabry's disease were seen in 23 patients. All the eight renal allografts were diagnosed as acute tubular necrosis.

The risk of post-biopsy bleeding was higher in women, older patients and those with relatively higher PTT. The overall complication rate was 5.8%. Minor complications in the form of small perinephric hematoma were noted in two patients. Major complication in the form of arteriovenuous fistula occurred in one patient, leading to loss of renal allograft. Macroscopic hematuria was seen in two renal allografts of which one developed urinary retention and required intervention viz. urinary catheterization and bladder irrigation, while the other was self-limiting. All the three complications were observed within six hours of biopsy. No late complications were seen in any of the patients. Elective native biopsies were significantly more likely to be associated with pain (P = 0.02).


   Discussion Top


PRB can be fraught with severe complications that may result in loss of kidney and rarely, even death. [3],[4] Selection of patients plays a crucial role in avoiding complications. Prior to the procedure, it is imperative to evaluate the patient for history of bleeding diathesis, recent non-steriodal anti-inflammatory drug (NSAID) use, hypertension control, recent pyelonephritis or skin infections near biopsy site and the ability to comply with instructions during biopsy. [5] Pre-biopsy laboratory tests should include complete blood count including platelets and PT/ INR, but bleeding time is optional as studies have shown it to have no significant correlation to surgical bleeding. [6] Stiles et al [7] reported complications in 112 renal biopsies done without evaluating bleeding time and concluded that the use of bleeding time does not significantly alter the major complication rates. Once a biopsy is scheduled, careful technique and selection of instrumentation mainly contribute to a successful procedure. Since 1990, most people have been performing renal biopsy using real-time ultra-sound guidance with a semiautomated spring-loaded needle to make it safe and reliable. [8] For patients with difficult landmarks and poor visualization on ultrasound, alternative methods include computed tomographic (CT)-guidance, transvenous, laparoscopic and open kidney biopsies. [9],[10],[11] Burstein et al [12] reported complications in 14.3% of 91 patients, out of which 6.6% were minor (macrohematuria not requiring transfusion) and 7.7% were major. Mendelssohn and Cole [13] found an overall complication rate of 5.3% in 544 consecutive PRBs. Transient gross hematuria occurred in 4.4% of their patients as opposed to 1.2% in our study. It may be due to the fact that the authors did not consistently do the biopsy with real-time ultrasound control.

Our data suggest that native kidney biopsies are significantly more likely to be associated with pain requiring analgesia compared to post-transplant biopsies. It is possible that differences between patients may have led to the differing requirements for pain relief. Post-renal transplant patients previously would have undergone several surgical procedures including the renal transplant itself and therefore they may have a higher threshold for pain. As opposed to this, patients undergoing elective native renal biopsy have no such experience and therefore may have a lower pain threshold. It is possible though that the native kidney with its intact innervations is more painful as compared to a denervated transplanted kidney. In our study, we also found that there was no difference in the rate of detection of complications whether the patients were observed for six hours or 24 hours post-biopsy.

Chan et al [14] performed PRB on 25 native kidneys and 70 allografts using a 16-gauge automated core biopsy device under real-time ultrasound guidance. They concluded that realtime ultrasound guidance in conjunction with an automated biopsy device is a safe and accurate method of performing PRB in the hands of radiologists and they were accurate in estimating sample adequacy in most cases. Manno et al [15] prospectively evaluated the predictive value of demographics, clinical data, baseline chemistry and needle size for the risk of post-renal biopsy complications in 471 patients. They concluded that only gender, age and baseline PTT showed a significant predictive value and the other variables investigated did not have any predictive value. Marwah et al [16] performed PRB in 394 native kidneys and concluded that observation of patients for 23-24 hours is optimal and that observation for eight hours or less risks missing approximately 20% of complications. On the contrary, our study has shown that an observation period of six hours is optimal and we did not encounter any missed late complications either after 24 hours or after two weeks of follow-up. Hergesell et al [17] retrospectively analyzed the results of 1,090 PRBs and found that ultrasound-guided PRB is a safe procedure and skilled operators obtain satisfactory amounts of kidney tissue in almost all cases. In our study, we had an adequate glomerular yield in 93% of biopsies despite the fact that we did not have the renal pathologist or the stereo microscope at the site to check for sample adequacy.

Real-time sonographic guidance in conjunction with an automated 16-gauge core biopsy system is a safe and accurate method in the hands of trained and experienced personnel for performing PRB and can be safely performed as an out-patient procedure. Observation of patients for a period of six hours post-biopsy seems to be optimal. The present study provides sufficient evidence to allow for the change of practice to perform renal biopsies as a day-care procedure.

 
   References Top

1.Madaio MP. Renal biopsy. Kidney Int 1990; 38:529-43.  Back to cited text no. 1
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2.Almkuist RD, Buckalew WM Jr. Techniques of renal biopsy. Urol Clin North Am 1979;6: 503-17.  Back to cited text no. 2
    
3.Kim D, Kim H, Shin G, et.al. A randomized, prospective, comparative study of manual and automated renal biopsies. Am J Kidney Dis 1998;32:426-31.  Back to cited text no. 3
    
4.Parrish AE. Complications of percutaneous renal biopsy: A review of 37 years' experience. Clin Nephrol 1992;38:135-41.  Back to cited text no. 4
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5.Korbet SM. Percutaneous renal biopsy. Semin Nephrol 2002;22:254-67.  Back to cited text no. 5
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6.Peterson P, Hayes TE, Arkin CF, et al. The preoperative bleeding time test lacks clinical benefit. College of American Pathologists' and American Society of Clinical Pathologists' position article. Arch Surg 1998;133:134-9.  Back to cited text no. 6
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7.Stiles KP, Hill C, LeBrun CJ, Reinmuth B, Yuan CM, Abbott KC. The impact of bleeding times on major complications rates after percutaneous real-time ultrasound-guided renal biopsies. J Nephrol 2001;14:275-9.  Back to cited text no. 7
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8.Wiseman DA, Hawkins R, Numerow LM, Taub KJ. Percutaneous renal biopsy utilizing real time, ultrasonic guidance and a semi-automated biopsy device. Kidney Int 1990;38:347-9.  Back to cited text no. 8
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9.Stiles KP, Yuan CM, Chung EM, Lyon RD, Lane JD, Abbott KC. Renal biopsy in high-risk patients with medical diseases of the kidney. Am J Kidney Dis 2000;36:419-33.  Back to cited text no. 9
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10.Gimenez LF, Micali S, Chen RN, Moore RG, Kavoussi LR, Scheel PJ Jr. Laparascopic renal biopsy. Kidney Int 1998;54:525-9.  Back to cited text no. 10
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11.Gupta M, Haluck RS, Yang HC, Holman MJ, Ahsan N. Laparoscopic-assisted renal biopsy: an alternative to open approach. Am J Kidney Dis 2000;36:636-9.  Back to cited text no. 11
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12.Burstein D, Korbet S, Schwartz M. The use of the automated core biopsy system in percutaneous renal biopsies. A comparative study. Am study. Am J Kidney Dis 1993;22:545-52.  Back to cited text no. 12
    
13.Mendelssohn DC, Cole EH. Outcomes of percutaneous kidney biopsy, including those of solitary native kidneys. Am J Kidney Dis 1995;26:580-5.  Back to cited text no. 13
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14.Chan R, Common AA, Marcuzzi D. Ultrasound-guided renal biopsy: Experience using an automated core biopsy system. Can Assoc Radiol J 2000;51:107-13.  Back to cited text no. 14
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15.Manno C, Strippoli GF, Arnesano L, et al. Predictors of bleeding complications in percutaneous ultrasound-guided renal biopsy. Kidney Int 2004;66:1570-7.  Back to cited text no. 15
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16.Marwah DS, Korbet SM. Timing of complications in percutaneous renal biopsy: what is the optimal period of observation? Am J Kidney Dis 1996;28:47-52.  Back to cited text no. 16
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17.Hergesell O, Felten H, Andrassy K, Kluhn K, Ritz E. Safety of ultrasound-guided percutaneous renal biopsy: retrospective analysis of 1090 consecutive cases. Nephrol Dial Transplant 1998;13:975-7.  Back to cited text no. 17
    

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Correspondence Address:
Ehtuish Faraj Ehtuish
Department of Surgery, National Organ Transplant Centre, Central Hospital, P.O. Box 84536, Tripoli
Libya
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PMID: 21743221

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