Saudi Journal of Kidney Diseases and Transplantation

: 2013  |  Volume : 24  |  Issue : 5  |  Page : 1039--1043

Allograft biopsy in kidney transplant recipients in the medical city of Baghdad

Ala A Ali1, Ali J.M. Al-Mudhaffer1, Qais Al-Taee1, Suad Al-Windawi2,  
1 The Renal Transplantation Center, Baghdad, Iraq
2 College of Medicine, Baghdad University, Baghdad, Iraq

Correspondence Address:
Ala A Ali
The Renal Transplantation Center, Baghdad


To determine the safety and efficacy of the practice of renal allograft biopsy and verify its impact on the management of kidney transplant patients presenting with graft dysfunction, we studied 50 renal allograft biopsies of 47 adult patients (38% males, mean age 32.4 ± 11 years) performed in the medical city complex from November 2008 to April 2011. All the biopsies were performed with a guidance of ultrasound. The procedure, complications, histological diagnoses and impact of the biopsy data on patients«SQ» management were recorded. Thirty percent of the biopsies were performed in the first 12 months post-transplantation and 24% were performed after the 60 th month. Adequate biopsy was achieved in 76% of the patients, with a 96% safety rate. Acute rejection was diagnosed in 38% of the biopsies and chronic allograft nephropathy in 38%, and they were the most common histological patterns in the study. The results of allograft biopsies positively impacted the management strategy in all study groups. Renal allograft biopsy was a useful and a relatively safe tool for the diagnosis of acute and chronic graft dysfunction in our experience.

How to cite this article:
Ali AA, Al-Mudhaffer AJ, Al-Taee Q, Al-Windawi S. Allograft biopsy in kidney transplant recipients in the medical city of Baghdad.Saudi J Kidney Dis Transpl 2013;24:1039-1043

How to cite this URL:
Ali AA, Al-Mudhaffer AJ, Al-Taee Q, Al-Windawi S. Allograft biopsy in kidney transplant recipients in the medical city of Baghdad. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Sep 22 ];24:1039-1043
Available from:

Full Text


Kidney transplantation is safe and cost-effective, and markedly improves the survival and quality of life for patients with end-stage renal disease (ESRD). [1],[2]

Renal allograft biopsies play a major role in the diagnosis and subsequent therapy of allograft dysfunction such as rejection, acute ischemic injury, drug toxicity and infection. [3],[4] Additionally, biopsies continue to be diagnostically useful in the late post-transplant period [5],[6],[7] or as protocol biopsies at pre-defined intervals after transplantation for early detection of graft dysfunction. [8],[9] Furthermore, biopsies can detect recurrences of the original disease in the allografts. [10],[11]

Localization of the graft and biopsy site can be determined by palpation or by ultrasound guidance, which offers the advantage of more precise localization of the graft and its depth, and may reduce the frequency of inadequate specimens. To be useful, the renal graft biopsy must first be adequate.

Core needle biopsy is not risk free. However, these risks must be weighed against the benefit of the information obtained from the procedure. [12]

We aim in this study to determine the safety and efficacy of the practice of renal allograft biopsy and verify its impact on the management of kidney transplant patients presenting with graft dysfunction.

 Patients and Methods

A cross-sectional study was conducted in the renal transplant center and the renal unit, Baghdad Teaching Hospital, the Medical City Complex, Baghdad, in the period from November 2008 to January 2011.

A total of 50 renal allograft biopsies of 47 renal transplant patients were performed (three patients underwent biopsy twice). Renal transplant recipients who have unexplained deterioration of renal function were enrolled in this study.

The exclusion criteria included any contraindication to renal biopsy, urinary tract infection, moderate to severe hydronephrosis on ultrasound study and renal cortical thickness less than 10 mm.

The benefits and risks of the procedure were fully explained to the patients and their families, and they signed a written consent form.

Before performing the kidney biopsies, detailed medical history was obtained from each patient with a comprehensive physical examination. Anticipated diagnosis with a proposed management plan were outlined and recorded.

Routine laboratory tests including renal function tests, electrolyte and general urine examination with quantification of albumin: Creatinine ratios were performed. Full hematology panel including platelet count and coagulation indices were obtained. The presence of uncorrected abnormal coagulation indices was an adequate cause to cancel any allograft biopsy. Therapeutic drug levels measurements were not done because they were not available.

An abdominal ultrasound with Doppler study was a prerequisite for an allograft biopsy to evaluate its size, cortical thickness and pelvicalceal system besides measurement of the renal resistive index.

A blood pressure reading >140/100 mmHg on the day of the procedure was an indication to postpone the allograft biopsy. The biopsies were performed in a supine position. The lower pole of the allograft was located by ultrasound and the site of insertion of the biopsy needle was marked. A true Cut semiautomated biopsy needle of 16- or 18-gauge and 15 cm length (GMS-CP) was used. At least two cores were obtained and 1-1.5 cm length of each specimen was targeted.

After biopsy, the patients were instructed to remain in bed, with their pulse rate and blood pressure monitored at hourly intervals. Urine output and its color were checked hourly for any evidence of macroscopic hematuria. The patients were discharged home 4-6 h post-biopsy as long as they were hemodynamically stable with no macroscopic hematuria and they were instructed to stay in bed for the next 24 h.

All specimens were preserved in a formal- saline solution (90% normal saline and 10% formaldehyde). Six microscopic slides were collected in serial sections cut at different levels of the tissue with two slides for hematoxylin and eosin stain, one slide for periodic acid Schiff stain, two slides for silver impregnation stain and one slide for Congo red stain.

 Statistical Analysis

Data analysis was computer assisted using SPSS 13 (Statistical Package for Social Sciences). Allograft biopsies were classified according to the Banff 2007 system. [7] Cases with more than one diagnoses were categorized according to the main diagnosis.


The mean age of the patients was 32.4 ± 11 years; 60% of the study group was between 20 and 40 years old. There were 38 males and 12 females. [Table 1] shows the baseline characteristics of the study group.{Table 1}

Five (10%) patients had biopsies in the first month post-transplant, while 25 (50%) patients had biopsies performed within the first two years. The other 20 (40%) patients biopsies 60 months post-transplant.

The mean serum creatinine was 4.1 mg/dL for those within the first eight months and in those after five years of transplantation. The mean urinary protein was 1.7 g/d, and it was the highest in those who underwent biopsies after five years post-transplantation.

The mean number of glomeruli was 10.02 ± 2 glomeruli in the specimens obtained from the biopsies, and they were adequate in 48% of the biopsies, while minimally acceptable samples were recorded in 28% of the biopsies.

The procedure was free of complications in 47 (94%) patients, with two (4%) patients who developed macroscopic hematuria and another (2%) patient who developed a peri-graft hematoma that was managed conservatively. [Figure 1] shows the frequency distribution of the study sample by diagnosis.{Figure 1}

Chronic allograft nephropathy (CAN) and acute cell-mediated rejection were the predominant histopathological patterns; 19 (38%) patients each. Antibody-mediated rejection was revealed in three (6%) patients, while de novo membranous glomerulonephritis was present in two (4%) patients.

De novo glomerular disease was associated with the highest urinary protein content (3.2 ± 0.83 g/d), while the urinary protein in the patients with CAN was 1.5 ± 0.3 g/d.

[Table 2] shows the management actions based on the histopathology results of the biopsies, which in 70% of the cases dictated a major change in the treatment strategy.{Table 2}


Many studies described the usefulness of renal allograft biopsies and its safety. [3],[13] To the best of our knowledge, this is the first study about renal allograft biopsy in Iraq.

Two issues represent major confounders to our study; the first is the small size sample and the second confounder is the only use of light microscopy in our study: Neither immunofluorescence nor electron microscopy was used as both were unavailable during the time of the study. With exception of using them in the diagnosis of some allograft histopathology, as in the detection of C4d deposition within the peri-tubular capillaries in antibody mediated rejection (AMR) and evaluating recurrent and de novo glomerular diseases, [14] immunofluorescence and electron microscopy have limited use in allograft histopathology when compared with their role in evaluating native kidney pathology. Furthermore, donor-specific antibody testing and therapeutic drug level were not performed due to their unavailability at the time of the study.

In this study, 40% of the biopsies were consistent with the increased risk of graft dysfunction mostly due to acute rejection episodes. [15]

The adequacy of kidney allograft biopsies had been addressed by many studies and by the Banff criteria. Anke Schwarz et al conducted a study that included 1171 biopsies, and 49% of the biopsies were inadequate especially with the use of the 18 gauge needle. [16] In our study, 24% of the biopsies were inadequate in terms of containing less than seven glomeruli or containing only one vessel. We used both 18 and 16 gauge needles, but the difference in the yield of each one of them was not studied.

Kidney allograft biopsies as an outpatient procedure in transplant has been reported in small series, and mainly in pediatric patients. Schwarz et al studied the ambulant graft biopsy in adult renal transplant patients. [16],[17] In the current study, all the biopsies were performed as a day case procedure; only one patient needed hospitalization. This is consistent with the rate of hospitalization in the German study (2% vs. 1.9%).

Introduction of ultrasound guidance makes renal biopsy a safe and easy procedure. [18] In this study, all biopsies were performed with ultrasound guidance using a spring-loaded needle.

Regarding the safety of the procedure, we had one patient who developed subcapsular hematoma (<2 cm × 2 cm) as revealed with ultrasound, and another two who developed microscopic hematuria. All the three patients were managed conservatively.

It is clear that the results of renal allograft biopsy mastered the plans of management of the study group regarding implementation of a new strategy (70%), optimizing the current treatment (4%) or even continuing on follow-up (20%) and perhaps stopping the medications (6%).

In conclusion, allograft biopsies form a useful, easy and relatively safe tool for the diagnosis of acute and chronic graft dysfunction. The result of allograft biopsies had a great positive impact on the management plan of renal transplant recipients, especially with the use of new biological agents or procedures in management.


Conflict of interest: Nothing to disclose.


1Keith DS, DeMattos A, Golconda M, et al. Factors associated with improvement in deceased donor renal allograft function in the 1990s. J Am Soc Nephrol 2005;16:1512-21.
2Meier-Kriesche HU, Schold JD, Kaplan B. Long-term renal allograft survival: Have we made significant progress or is it time to rethink our analytic and therapeutic strategies? Am J Transplant 2004;4:1289-95.
3Matas AJ, Tellis VA, Sablay L, Quinn T, Soberman R, Veith FJ. The value of needle renal allograft biopsy. III. A prospective study. Surgery 1985;98:922-6.
4Colvin RB. The renal allograft biopsy. Kidney Int 1996;50:1069-82.
5Kon SP, Templar J, Dodd SM, Rudge CJ, Raftery MJ. Diagnostic contribution of renal allograft biopsies at various intervals after transplantation. Transplantation 1997;63:547-50.
6Solez K, Colvin RB, Racusen LC, et al. Banff '05 Meeting Report: Differential diagnosis of chronic allograft injury and elimination of chronic allograft nephropathy ('CAN'). Am J Transplant 2007;7:518-26.
7Nankivell BJ, Chapman JR. Chronic allograft nephropathy: Current concepts and future directions. Transplantation 2006;81:643-54.
8Nankivell BJ, Chapman JR. The Significance of Subclinical Rejection and the Value of Protocol Biopsies. Am J Transplant 2006;6: 2006-12.
9Mengel M, Chapman JR, Cosio FG, et al. Protocol biopsies in renal transplantation: Insights into patient management and pathogenesis. Am J Transplant 2007;7:512-7.
10Golgert WA, Appel GB, Hariharan S. Recurrent glomerulonephritis after renal transplantation: An unsolved problem. Clin J Am Soc Nephrol 2008;3:800-7.
11Aline-Fardin A, Rifle G, Martin L, et al. Recurent and de novo membranous glomerulopathy after kidney transplantation. Transplant Proc 2009;41:669-71.
12Nast CC, Cohen AH. Pathology of Kidney Transplantation. In: Danovitch GM, edr. Handbook of Kidney Transplantation. 5 th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 311-29.
13Kiss D, Landman J, Mihatsch M, Huser B, Brunner F, Theil G. Risks and benefits of graft biopsy in renal transplantation under cyclosporin-A. Clin Nephrol 1992;38:132-4.
14John R, Herzenberg AM. Our approach to a renal transplant biopsy. J Clin Pathol 2010;63: 26-37.
15Sijpkens YW, Doxiadis II, Mallat MJ, et al. Early versus late acute rejection episodes in renal transplantation. Transplantation 2003;75: 204-8.
16Schwarz A, Gwinner W, Hiss M, Radermacher J, Mengel M, Haller H. Safety and Adequacy of Renal Transplant Protocol Biopsies. Am J Transplant 2005;5:1992-6.
17Birk PE, Blydt-Hansen TD, Dart AB, Kaita LM, Proulx C, Taylor G. Low incidence of adverse events in outpatient pediatric renal allograft biopsies. Pediatr Transplant 2007;2: 196-200.
18Burstein DM, Korbet SM, Schwartz MM. The use of the automatic core biopsy system in percutaneous renal biopsies: A comparative study. Am J Kidney Dis 1993;22:545-52.