KIDNEY BIOPSY:

INDICATIONS AND TECHNIQUE

Belen Ponte

Cheffe de clinique scientifique

Service de Néphrologie - HUG

PLAN

History

Indications and contraindications

Percutanerous Technique: preparationand step by step

Complications

Other techniques

Some history

1924: Jungmann report 1st pathological result of a biopsy

taken during an abdominal operation

1943: Castelman report large series of surgical biopsies

taken during lumbar sympathectomy for hypertension

1944: Alwall did 13 percutaneous biopsies but stop after 1

patient died

1949: Iversen used systematically percutaneous biopsy,

but with patient sitted

Before biopsy:

Urine culture,

coagulation study

Nitrogen products

Blood type + Xmatch

IV pyelogram

Phenolsufonphtalein

Indications: native kidney

Diagnosis Glomerular hematuria and/or proteinuria

Nephritic or nephrotic syndrome

Acute kidney injury of unknown origin

Rapidly progressive glomerulonephritis

Chronic kidney disease

Immunological or paraneoplasic diseases with kidenyinvolvement

Control response to therapy

Primary graft non-function

Proteinuria or glomerular hematuria of unknown origin

Acute kidney injury of unknown origin

Decrease in renal function of unknown origin

No response to antirejection therapy

Protocol biopies (no clear recommandation)

Indications: transplant kidney

Ahmad. Sem Interv Radiol 2004

Racusen et al. CJASN 2006

Contraindications

Relative:

Small kidneys, solitary kidney

Multiple cysts, Renal mass

Hydronephrosis, infection

Uncontrolled hypertension

Pregnancy

Absolute:

Bleeding diathesis

Patient not collaborative

Preparation and control….

Previous us showing 2 kidneys of normal size

BP controlled <140/90. Medication taken as usual.

Hb >100g/l. Blood type and crossmatch (in some centers).

Coagulation and platelets normals

Stop anticoagulation. No anti-aggregants or AINS >5 days

Sterile urine

Signed inform consent

Peripheric venous access. Temesta.

Surveillance 4-6h (transplant) or 12h-overnight (native): BP, FC

every 30min for 2h, then 1x/h for 4h. Check color of urine.

Technique: percutaneous

For native kidneys: Patient lying face down

Localise lower inferior pole of the left kidney with us

Stop breathing when punction (inspirium)

For transplant kidneys: Patient lying back

Localise upper pole of transplant kidney with us

Check with doppler the position of ureter and arteries!

Technique : position

Step by step

16-18 Gauge

1. 2. 3.

With guiding device

Transport in NaCl

3 fragments

4.

Images pbr: mo, immuno, me

Biopsy sampling

95% CI

Madaio. Kint 1990

Complications

Microhematuria 90-100%

Pain 12-18%

Macrohematuria 2-10%

Relevant hematoma 2-7.8%

Need of transfusion 0.4-6%

AV fistula 5-10%

Other tissue lesion <5%

Surgical Intervention

Nephrectomy

<0.2%

1/2000-1/5000

Death 0.1%

Whitthier. JASN 2012.

Tondel. CJASN 2012

Chung. BMC Nephrology 2014

Simard. Nephron Extra 2014

Tondel. CJASN 2012

Risk factors

Simard. Nephron Extra 2014

Tondel. CJASN 2012

Other techniques

Stiles et al. AJKD 2000

Thompson et al. .AJKD 2004

Right kidney more suitable

Transjugular route

Techniques and complications

Stiles et al. AJKD 2000

CONCLUSIONS

Is the biopsy indicated?

Are they any contraindications?

If yes, which is the safest way for diagnosis?

Minimise the risks

Be careful, Be careful, Be careful…