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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 88-92
Comparison of diagnostic quality of kidney biopsy obtained using 16g and 18g needles in patients with diffuse renal disease


1 Department of Pathology, Government Medical College and Hospital, Chandigarh, India
2 Department of Internal Medicine, Government Medical College and Hospital, Chandigarh, India

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Date of Web Publication3-Jan-2012
 

   Abstract 

To determine the diagnostic quality and complication rates of 16G and 18G needles in biopsy of the kidney, we performed renal biopsy using a biopsy gun under ultrasound guidance in 50 patients who were prospectively and evenly assigned to one of the two needle biopsy methods from April 2007 until May 2008. Two cores of renal biopsy specimen were obtained in each case and subjected to histopathological and immunoflourescence (IF) examination. Pain associated with the procedure was assessed using a visual analog scale. The number of glomeruli retrieved using the 16G needle ranged from 0 to 30 (mean 9.42 ± 5.5) and those retrieved using 18G needle ranged from 0 to 19 (mean 7.72 ± 4.4), P <0.05. The quality of biopsy was poorer with 18G needle as compared with 16G needles because of a higher amount of fragmentation and crushing artifact. There was no difference in the compli-cation rates between the two needles (2% each). The 16G needle was associated with significantly more pain than the 18G needle. We conclude that our study demonstrates the benefit of the larger 16G needle in providing more tissue and glomeruli, which is more diagnostically useful. However, the use of 16G needle was associated with significantly more pain than the 18G needle, and may be a better compromise for diagnostic usefulness and patient acceptability.

How to cite this article:
Arora K, Punia RS, D'Cruz S. Comparison of diagnostic quality of kidney biopsy obtained using 16g and 18g needles in patients with diffuse renal disease. Saudi J Kidney Dis Transpl 2012;23:88-92

How to cite this URL:
Arora K, Punia RS, D'Cruz S. Comparison of diagnostic quality of kidney biopsy obtained using 16g and 18g needles in patients with diffuse renal disease. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Sep 20];23:88-92. Available from: http://www.sjkdt.org/text.asp?2012/23/1/88/91308

   Introduction Top


In patients with renal disease, renal biopsy provides a tool to determine the cause of the disease, predict the prognosis and direct treatment. Histological examination of the biopsied kidneys remains the gold standard for diagnosis of renal diseases. Since the first description of percutaneous kidney biopsy in 1951, [1] the introduction of real-time ultrasound guidance [2] and use of spring-loaded biopsy guns have rendered this procedure increasingly safe and effective. [3],[4] However, percutaneous kidney biopsy is not without risk. The most important requirement of any biopsy procedure is that it should be safe with low incidence of clinically significant pain and hemorrhage. Significant changes in the design of biopsy needles have simplified the biopsy procedure and further enhanced the ability to attain adequate tissue for diagnosis. Continuous ultrasound monitoring during the biopsy procedure facilitates visualization of the needle tip and permits improved retrieval rates. [3] Furthermore, the success rate depends upon the needle type and size. In the histological evaluation of renal parenchymal diseases, two primary features comprise an ideal tissue core. First, there should be a large number of glomeruli, which is related to the volume of the retrieved tissue. Second, the tissue core quality should be high and without crush artifacts or fragmentation, [5] and retrieval of five to 10 intact glomeruli is generally required to establish a definitive histological diagnosis. The aim of this study was to compare the success and complication rates of renal biopsy obtained using two needles of different sizes.


   Patients and Methods Top


We studied 50 patients who underwent renal biopsies in a prospective, randomized manner at the Government Medical College and Hospital, Chandigarh, India, from April 2007 until May 2008. After obtaining written consents and noting the relevant clinical history and diagnosis, percutaneous renal biopsies were performed under ultrasound guidance using 16G and 18G needles alternately, and the obtained specimens were processed for pathological examination. The patients were randomized evenly to group I, with even numbers, and group II, with odd numbers. The 25 patients assigned to group I underwent their percutaneous renal biopsies using a 16G needle and those assigned to group II underwent their biopsies with an 18G needle. There was no statistically significant difference between the two groups in terms of age and sex. The patient characteristics were well matched in the two study groups.

Before starting the procedure, the patients were taught in a standard way by the clinician how to use a visual analogue scale (VAS), scoring from 0 to 100 mm, to grade the intensity of pain experienced during the renal biopsy. On that scale, the left end point, 0, was defined as no pain and the right end point, 100, as the worst pain the patients could imagine. After the biopsy procedure, the patients were monitored closely for 24 hours for any complications. Two cores were taken in each case. The biopsy material for histopathological examination was fixed in 10% formalin and further processing was accomplished in the Department of Pathology.

The size and number of cores were noted. One to two blocks were prepared in each case and sections of 2-μ thickness were obtained by the paraffin embedding technique using the routine procedure. Immunofluorescence examination was also done. Microscopic examination was done by the same pathologists. The final pathological reports were based on the histopathological examination and the IF results and was correlated with the clinical diagnosis.


   Statistical Analysis Top


The chi-square and the Student's t-test were used to compare the differences between the study groups. The results were expressed as mean ± standard deviation. A P-value less than 0.05 was considered statistically significant.


   Results Top


The clinical indications for renal biopsy were proteinuria in 68% (34 patients), systemic lupus erythematosus in 18% (nine patients), proteinuria and hematuria in 8% (four patients) and acute renal failure in 6% (three patients).

Two cores of renal biopsy were obtained in each case; one core was subjected for histopathological microscopy and the other for IF examination. A total of 100 cores were analyzed from 50 cases. The number of glomeruli obtained using the 16G needle ranged from 0 to 30, with a mean of 9.42 ± 5.5, and those obtained using the 18G needle ranged from 0 to 19, with a mean of 7.72 ± 4.4. There was a statistically significant difference in the total number of glomeruli from each needle. Of the total of 100 cores, five or more glomeruli were present in 43 (86%) of the 50 specimens of 16G needle biopsies and in 36 (72%) of the 50 specimens of 18G needle biopsies. A histological diagnosis was obtained in all the 25 cases (100%) of 16G needle biopsy specimens and in 24 (96%) of 25 cases of 18G needle biopsy specimens.

There were no failed procedures that yielded medulla only or failed to obtain renal tissue. Specimen adequacy was a problem using the 18G biopsy needle. Also, more amount of fragmentation and crushing artifact was noted in 15 (30%) of 18G biopsy specimens as compared with five (10%) of 16G biopsy specimens. The distribution of diseases' histological diagnosis was similar between the two groups [Table 1], and the clinical and pathological diagnoses were concordant in 35 (70%) cases [Table 2].
Table 1: Histological diagnosis of the renal biopsies (n = 50).

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Table 2: Concordance between clinical diagnosis and pathological diagnosis (n = 50).

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All the cases were monitored closely for 24 hours for the development of any complication; the overall complication rate was 4%. In group I, one case (2%) developed macroscopic hematuria; however, it was transient and lasted less than 6 hours. In group II, one case (2%) developed subcapsular hematoma, which was managed conservatively. All the cases tolerated the procedure well and there were no major complications observed in any of the 50 cases.

Linear analog pain scores were relatively low in both the groups [Table 3], but statistical analysis demonstrated that the 16G needle was asso ciated with significantly more pain than the 18G needle (P-value = 0.00014).
Table 3: Patients' assessment of pain during the renal biopsy procedure (n = 50).

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   Discussion Top


The most important requirement of any biopsy procedure is that it should be safe and, particularly, that there is a low incidence of clinically significant hemorrhage. [6],[7] In experienced hands, renal biopsy has an extremely low mortality, but it is rarely a painless procedure. [8] The renal biopsy, although a relatively safe medical procedure, should be undertaken only after serious consideration of possible morbidity and rare mortality that can occur with this invasive procedure. [9] There has been a debate as to whether the benefit gained from the knowledge of renal histology outweighs the risks to patients from the biopsy procedure. [10]

The biopsy procedure is an invasive technique designed to sample living tissues.

The procedure has, until recently, involved the use of 12G to 14G needle devices, such as the Franklin Vim-Silverman biopsy needle, which are associated with a small but significant risk of hemorrhagic complications. [11] Large gauge needles have fallen out of favor with the development and popularization of various biopsy gun devices, which are typically equipped with smaller 16G to 18G needles. [12] These devices reduce patient morbidity, but they yield smaller biopsy specimens. [13] Because the assessment of glomerular pathology remains one of the most important objectives of the renal biopsy procedure, it is essential that each biopsy contains an adequate number of glomeruli. However, the mean yield from large diameter biopsy cores is approximately 15 glomeruli per core, [14] the mean yield from small diameter cores is often reported as seven or less. [12] Because the consensus of an international panel of experts defines an adequate biopsy as one that contains at least seven glomeruli to make a proper diagnosis, [15] there are persistent concerns about the adequacy of small diameter core biopsies for assessing glomerular pathology. Most investigators have reported adequate tissue sampling in 80-95% of percutaneous renal biopsies, regardless of the technique used. The definition of tissue adequacy varies among different investigators. Some insist on a minimum of two tissue cores.

The number of glomeruli necessary to facilitate an adequate diagnosis ranges from 3 to 12. [16] Oberholzer et al [16] believed that six to 10 glomeruli were necessary, Riehl et al [17] believed that three may be the minimum number and Tisher and Croker [18] believed that 12 were adequate. However, it is difficult to be dogmatic in terms of the absolute number of glomeruli necessary to make a definitive diagnosis. It may require only one glomerulus to make the diagnosis of membranous glomerulopathy, whereas more than six glomeruli may not be sufficient in early focal glomerulosclerosis or in lupus nephropathy. In several studies, more glomeruli were obtained with lower gauge needles. [19],[20],[21] In our study, we found that five or more glomeruli were present in 43/50 (86%) 16G needle biopsy specimens and in 36/50 (72%) of 18G needle biopsy specimens.

The complication rates were similar with both needle sizes in our study. As there was no demonstrable difference in the safety profiles of smaller and larger needles, the usual justification for using a smaller needle (fewer complications) may not be justified. Furthermore, the findings of the present study also indicate that renal biopsy has become a relatively safe procedure with the use of automated biopsy gun and ultrasound for localization of the kidney. The 16G needle was associated with significantly more pain than the 18G needle. However, all the pain scores were relatively low and at a level that should be regarded as reasonable for an invasive procedure.

We conclude that our study demonstrates the benefit of the larger 16G needle in providing more tissue and glomeruli, which is more diagnostically useful. However, the use of the 16G needle was associated with significantly more pain than the 18G needle, and may be a better compromise for diagnostic usefulness and patient acceptability.

 
   References Top

1.Iverson P, Brun C. Aspiration biopsy of the kidney. Am J Med 1951;11:324-30.  Back to cited text no. 1
    
2.Saitoh M. Selective renal biopsy under ultrasonic real-time guidance. Urol Radiol 1984;6:30-7.  Back to cited text no. 2
    
3.Wiseman DA, Hawkins R, Numerow LM, Taub KJ. Percutaneous renal biopsy utilizing real time, ultrasonic guidance and a semiautomated biopsy device. Kidney Int 1990;38:347-9.  Back to cited text no. 3
    
4.Donovan KL, Thomas DM, Wheeler DC, MacDougall IC, Williams JD. Experience with a new method for percutaneous renal biopsy. Nephrol Dial Transplant 1991;6:731-3.  Back to cited text no. 4
    
5.Pokieser P, Kain R, Helbich T, et al. Renal biopsy: In vitro and in vivo comparison of a new automatic biopsy device and conventional biopsy systems. Radiology 1993;186:573-6.  Back to cited text no. 5
    
6.Olson JL. The nephrotic syndrome and minimal change disease. In: Jennette JC, Olson JL, Schwartz MM, Silva FG, eds. Heptinstall's Pathology of The Kidney. 6 th ed. Philadelphia: Lippincott Williams & Wilkins, 2007; 125-54.  Back to cited text no. 6
    
7.Nicholson ML, Wheatley TJ, Doughman TM, et al. A prospective randomized trial of three different sizes of core-cutting needle for renal transplant biopsy. Kidney Int 2000;58(1):390-5.  Back to cited text no. 7
    
8.Gwyn NB. Biopsies and the completion of certain surgical procedures. Can Med Assoc J 1923;13:820-3.  Back to cited text no. 8
    
9.Ordüñez NG, Rosai J. Urinary tract. In: Rosai J, ed. Rosai and Ackerman's Surgical Pathology. 9 th ed. St Louis: Mosby, 2004; 1163-316.  Back to cited text no. 9
    
10.Madaio MP. Renal biopsy. Kidney Int 1990; 38:529-43.  Back to cited text no. 10
    
11.Matyas JR, Rattner JB, Benediktsson H. Enhanced glomerular retrieval for renal biopsies. Am J Kidney Dis 1996;27(6):834-43.  Back to cited text no. 11
    
12.Hopper KD, Abendroth CS, Sturtz KW, Matthews YL, Stevens LA, Shirk SJ. Automated biopsy devices: A blinded evaluation. Radiology 1993; 187(3):653-60.  Back to cited text no. 12
    
13.Kolb LG, Velosa JA, Bergstralh EJ, Offord KP. Percutaneous renal allograft biopsy. A comparison of two needle types and analysis of risk factors. Transplantation 1994;57(12):1742-6.  Back to cited text no. 13
    
14.Doyle AJ, Gregory MC, Terreros DA. Percutaneous native renal biopsy: Comparison of a 1.2mm spring-driven system with a traditional 2mm hand-driven system. Am J Kidney Dis 1994;23:498-503.  Back to cited text no. 14
    
15.Solez K, Axelsen RA, Benediktsson H, et al. International standardization of criteria for the histologic diagnosis of renal allograft rejection: The Banff working classification of kidney transplant pathology. Kidney Int 1993;44:411-21.  Back to cited text no. 15
    
16.Oberholzer M, Torhorst J, Perret E, Mihatsch MJ. Minimum sample size of kidney biopsies for semiquantitative and quantitative evaluation. Nephron 1983;34:192-5.  Back to cited text no. 16
    
17.Riehl J, Maigatter S, Kierdorf H, Schmitt H, Maurin N, Sieberth HG. Percutaneous renal biopsy: comparison of manual and automated puncture techniques with native and transplanted kidneys. Nephrol Dial Transplant 1994; 9:1568-74.  Back to cited text no. 17
    
18.Tisher CC, Croker BP. Indications for and interpretation of the renal biopsy: Evaluation by light, electron and immunofluorescence microscopy. In: Schrier RW, Gottschalk CW, eds. Diseases of the Kidney 6 th ed. Boston, MA, Little Brown, 1997;435-61.  Back to cited text no. 18
    
19.Mostbeck GH, Wittich GR, Derfler K, et al. Optimal needle size for renal biopsy: In vitro and in vivo evaluation. Radiology 1989;173: 819-22.  Back to cited text no. 19
    
20.Bondestam S, Kontkanen T, Taavitsainen M, Tiula E. Technique of renal biopsy by ultrasound guided percutaneous puncture with a spring loaded "gun". Scand J Urol Nephrol 1992;26(3): 265-7.  Back to cited text no. 20
    
21.Song JH, Cronan JJ. Percutaneous biopsy in diffuse renal disease: comparison of 18- and 14-gauge automated biopsy devices. J Vasc Interv Radiol 1998;9(4):651-5.  Back to cited text no. 21
    

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Correspondence Address:
Komal Arora
Department of Pathology, Government Medical College and Hospital, Chandigarh
India
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PMID: 22237225

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    Tables

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    Abstract
   Introduction
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   Statistical Analysis
   Results
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