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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1997  |  Volume : 8  |  Issue : 1  |  Page : 11-15
The Impact of Renal Biopsy in the Clinical Management of Childhood Renal Disease


Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia

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   Abstract 

This study was carried out to determine whether renal biopsy altered patient management or expected prognosis among children with renal disease. A retrospective analysis of case records of 106 children with renal disease having adequate renal biopsies was made. The diagnosis was altered in 47.2% and therapeutic approach was changed in 33% of the patients after obtaining the renal biopsy findings. Also, the estimate of prognosis was altered in 31.1% of the cases. These results were greater for patients with steroid resistant and congenital nephrotic syndrome, acute renal failure, asymptomatic urinary abnormalities and mixed nephritic-nephrotic syndrome. Subsequent management and prognosis was least affected by the biopsy results in patients with steroid sensitive nephrotic syndrome and chronic renal failure.

Keywords: Renal biopsy, Children, Diagnosis, Treatment, Prognosis.

How to cite this article:
Al-Rasheed SA. The Impact of Renal Biopsy in the Clinical Management of Childhood Renal Disease. Saudi J Kidney Dis Transpl 1997;8:11-5

How to cite this URL:
Al-Rasheed SA. The Impact of Renal Biopsy in the Clinical Management of Childhood Renal Disease. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2021 Apr 16];8:11-5. Available from: https://www.sjkdt.org/text.asp?1997/8/1/11/39397

   Introduction Top


Percutaneous renal biopsy has been extensively evaluated and found to be a relatively safe procedure [1],[2] . It is useful in arriving at a diagnosis, in evaluating response to therapy and in the assessment of prognosis [3],[4] . However there is no consensus among clinicians on the indications of the procedure. Also renal biopsy is extensive needing pre-biopsy preparation and labo­ratory assessment, an experienced pathologist to interpret the biopsy specimen as well as a localizing procedure. In addition there is the associated discomfort and risk of the technique.

Over the past several years, questions and controversies regarding renal biopsy as a diagnostic tool have arisen [5],[6],[7] . Several reports have addressed the diagnostic, prog­nostic and therapeutic implications of renal biopsy in adults [8],[9],[10] but only few studies have addressed this issue in children [7] . This prompted us to perform a retrospective review of 106 adequate renal biopsies performed at the King Khalid University Hospital (KKUH), Riyadh. The goal of the review was to identify those cases in whom a definitive change in therapy or expected prognosis occurred on the basis of biopsy results.


   Materials and Methods Top


The medical records of 106 patients in whom adequate renal biopsies had been obtained were reviewed. The biopsy was judged to be adequate if at least five glomeruli were seen on light microscopy. The data that were obtained from each patient included the following:

a) clinical history and physical examination

b) pre-biopsy laboratory and radiological investigations including urinalysis, hemo­globin, blood urea, serum creatinine, serum C3 and C4 levels, serological markers like anti-streptolysin O titer, HBsAg, anti-nuclear antibodies, anti- DNA antibodies, anti­neutrophil cytoplasmic antibodies (when available), creatinine clearance, 24-hours urinary protein level, renal and bladder ultrasound and other available radiological investigations

c) pre-biopsy diagnosis

d) pathological diagnosis

e) final clinical diagnosis

f) any change in treatment on the basis of biopsy findings.

Renal biopsy was performed in order to establish the diagnosis, plan for specific therapy and to counsel on the expected prognosis. All the renal biopsies were evaluated by light, immunofluorescent and electron microscopic examinations.


   Results Top


During a seven year period, 106 successful adequate renal biopsies were performed on 106 patients (57 males, 49 females) aged 1 month to 15 years (mean 79 months). The indications for biopsy along with the number of patients in each category are listed in [Table - 1]. Nephrotic syndrome (NS) (n = 63) was the most frequent indication for biopsy followed by chronic renal failure (n= 14), asymptomatic urinary abnormalities (n=12), acute renal failure (n = 7) and mixed nephritic-­nephrotic syndrome (n = 4). Additionally, there were six patients with systemic disease (4 with systemic lupus erythematosus and 2 with Henoch-Schonlein purpura nephritis).

The effect of renal biopsy findings on the accuracy of pre-biopsy diagnosis, alteration made in therapy and estimate of prognosis are depicted in [Table - 2]. In patients with steroid dependent or frequently relapsing NS, nine of the 28 patients (32.1%) had an inaccurate pre-biopsy diagnosis. The degree was much higher in the steroid resistant group; 14/21 being inaccurate (66.7%). In contrast, 6/7 patients (85.7%) with HBsAg associated nephropathy had accurate diagnosis and in those with systemic diseases all pre­biopsy diagnosis were accurate [Table - 2]. Overall, the pre-biopsy diagnosis was accurate in 56 of the 106 study patients (52.8%).

Based on the biopsy findings, therapy was altered in 35 of the 106 patients (33.0%). The groups with the largest number of patients in whom therapy was changed included steroid resistant NS (14/21; 66.7%), mixed nephritic-nephrotic syndrome (3/4; 75%) and systemic disease (6/6; 100%).

The impact on the estimate of prognosis was maximally evident in the group with steroid resistant NS where 14/21 patients (66.7%) had their prognostic estimate altered. Overall, the estimate of prognosis remained unaltered in 73/106 patients (68.9%).

The details of incorrect pre-biopsy diagnosis and their post-biopsy findings in each clinical category are outlined in [Table - 3].


   Discussion Top


The findings in this study suggest that renal biopsy frequently has an important impact on diagnosis, prediction of prognosis and therapy in children with renal disease. The diagnosis was changed in 50 patients (47%), therapy was changed in 35 (33%) and the physician's estimate of prognosis was altered in 33 patients (31%). These results are in general agreement with previous retrospective [8],[9] or prospective studies in adolescents or adults addressing the same issue [10],[11] .

In the group of patients with steroid responsive NS, the biopsy results had minimal impact on therapy or prognosis. Renal biopsy was performed in these patients to help in identifying those patients with certain pathological diagnoses, whose response to cytotoxic medications may be poor. Our findings confirm the previous observations and recommendation that renal biopsy is not necessary for these patients and their response to cytotoxic medication correlates better with initial corticosteroid response [12],[13] .

On the other hand, steroid resistant NS patients benefit from the renal biopsy results. This was clear in our series, where a correct diagnosis was not made in 66.7% of the cases all of whom required therapeutic and prognostic alterations after the biopsy. However, this issue is still controversial as indicated by a recent review wherein it was indicated that only 59% of the nephrologists opined that they would perform renal biopsy before starting cytotoxic therapy. An interesting observation was that less experi­enced nephrologists were more inclined towards biopsy [14] .

The other category of patients where renal biopsy was not found to be useful was in patients with chronic renal failure. The underlying pathology could be established only in two of the patients and only in one patient was there a need for therapeutic change. The low yield of renal biopsy result in such patients with the relative increased risk of complications of the procedure makes it unnecessary in the majority of patients [2] .

Another category where we found that renal biopsy was useful in arriving at a correct diagnosis was in patients with asymptomatic urinary abnormalities. Here again, the available reports give different opinions. Yoshikawa. et al have suggested that renal biopsy is indicated in a child with asymptomatic constant isolated proteinuria because 47% of such patients can have significant glome­rular lesions [15] . Lieu, et al have suggested that although renal biopsy might establish the diagnosis in patients with asymptomatic isolated microscopic hematuria, it seldom changes the treatment [16] . Feld, et al, in a review have stated that the vast majority of pediatric nephrologists in North America support a conservative approach to a child with asymptomatic hematuria or proteinuria [17] .

Although, in our study, the number of patients in each group is small and statistical signi­ficance was not achieved, the results certainly support a trend in favor of the biopsy in establishing diagnosis and guiding therapy. This is particularly so in patients with steroid resistant nephrotic syndrome and asymptomatic urinary abnormalities. The utility of renal biopsy seems least important in the clinical management of children with steroid sensitive nephrotic syndrome or chronic renal failure.


   Acknowledgment Top


I am grateful to Dr. M. Al-Mugeiren and Dr. A. Al-Salloum for allowing me to report some of their patients. I also thank Gemma S. Gemaol for her outstanding secretarial assistance in the preparation of this report.

 
   References Top

1.Carvajal HF, Travis LB, Srivastava RN, De Beukelaer MM, Dodge WF, Depree E. Percutaneous renal biopsy in children - an analysis of complications in 890 consecutive biopsies. Tex Rep Biol Med 1971;29:253-64.  Back to cited text no. 1    
2.Al-Rasheed SA, Al-Mugeiren MM, Abdurrahman MB, Elidrissy AT. The outcome of percutaneous renal biopsy in children: An analysis of 120 consecutive cases. Pediatr Nephrol 1990;4:600-3.  Back to cited text no. 2    
3.Gault MH, Muehicke RC. Renal biopsy: current views and controversies. Nephrol 1983;34:l-34.  Back to cited text no. 3    
4.Morel-Maroger L. The value of renal biopsy. Am J Kidney Dis 1982;l:244-8.  Back to cited text no. 4    
5.Striker GE. Controversy: the role of renal biopsy in modern medicine. Am J" Kidney Dis 1982;1:241-3.  Back to cited text no. 5    
6.Danovitch GM, Nissenson AR. The role of renal biopsy in determining therapy and prognosis in renal disease. Am J Nephrol 1982;2:179-84.  Back to cited text no. 6  [PUBMED]  
7.Hogg RJ. Diagnostic, prognostic and therapeutic implications of the renal biopsy in children with renal disease. Semin Nephrol 1985;5:240-54.  Back to cited text no. 7  [PUBMED]  
8.Paone DB, Meyer LE. The effect of biopsy on therapy in renal disease, Arch Intern Med 1981;141:1039-41.  Back to cited text no. 8    
9.Moxey Minis MM, Stapleton FB, Feld LG. Applying decision analysis to management of adolescent idiopathic nephrotic syndrome. Pediatr Nephrol 1994;8(6):660­-4.  Back to cited text no. 9    
10.Cohen AH, Nast CC, Adler SG, Kopple JD. Clinical utility of kidney biopsies in the diagnosis and management of renal disease. Am J Nephrol 1989;9:309-15.  Back to cited text no. 10  [PUBMED]  
11.Turner MW, Hutchinson TA, Barre PE, Prichard S, Jothy S. A prospective study on the impact of the renal biopsy in clinical management. Clin Nephrol 1986;217:21.  Back to cited text no. 11    
12.Schulman SL, Kaiser BA, Polinsky MS, Srinivasan R, Baluarte HJ. Predicting the response to cytotoxic therapy for childhood nephrotic syndrome: superiority of response to corticosteroid therapy over histopathologic patterns. J Pediatr 1988;113:996-1001.  Back to cited text no. 12  [PUBMED]  
13.Mattoo TK. Kidney biopsy prior to cyclophosphamide therapy in primary nephrotic syndrome. Pediatr Nephrol 1991;5:617-9.  Back to cited text no. 13  [PUBMED]  
14.Primach WA, Schulman SL, Kaplan BS. An analysis of the approach to management of childhood nephrotic syndrome by pediatric nephrologists. Am J Kidney Dis 1994;23(4):524-7.  Back to cited text no. 14    
15.Yoshikawa N, Kitagawa K, Ohta K, Tanaka R, Nakamura H. Asymptomatic constant isolated proteinuria in children. J Pediatr 1991;119(3):375-9.  Back to cited text no. 15    
16.Lieu TA, Grasmeder HM, Kaplan BS. An approach to the evaluation and treatment of microscopic hematuria. Pediatr Clin North Am 1991;3 5(3): 579-92.  Back to cited text no. 16    
17.Feld LG, Stapleton FB, Duffy L. Renal biopsy in children with asymptomatic hematuria or proteinuria survey of pediatric nephrologists. Pediatr Nephrol 1993)7(4):441-3.  Back to cited text no. 17    

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Correspondence Address:
Soud A Al-Rasheed
Department of Pediatrics, College of Medicine, King Khalid University, Riyadh
Saudi Arabia
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PMID: 18417778

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    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    Acknowledgment
    References
    Article Tables
 

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