06 May 2015
valid until Jul 2016
08 Oct 2015
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RenalMed is a website written and maintained by a group of senior nephrology (UK and non-UK based) health professionals.
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(06 May 2015) - Link
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(07 Jul 2015) - Link
Lisa Crowley, Kieron Donovan, Peter Topham - Review Date Jan 2016 (Senior Editor Pete Topham)
Since its introduction to clinical medicine in the 1950s, percutaneous renal biopsy has become a routine investigation in the evaluation of patients with kidney dysfunction. It provides a tissue diagnosis in more than 95% of cases, and is a relatively safe procedure with a life-threatening complication rate of less than 0.1%. However, the decision to proceed to biopsy should not be taken lightly and must be made by a consultant. It is important that trainees discuss the need for a biopsy with a consultant before booking it.
Aim of Renal Biopsy
Patients with renal disease often present with a syndrome' such as nephrotic syndrome, AKI, or CKD. In themselves, these are not diagnoses'. They are merely patterns of kidney disease that can have many causes.To aid the management of such patients, the histological analysis of a renal biopsy sample should therefore aim to:
identify a specific diagnosis
reflect the level of disease activity
provide information to allow informed decisions about treatment.
Is the Biopsy Necessary?
This is a vital question to ask oneself at all stages of the process; as it is always a judgement of the balance of risk vs useful information. A renal biopsy is not without risk therefore before undertaking a biopsy, think carefully about whether the biopsy result is likely to alter management. Given the complexity of renal pathology, a discussion between the pathologist and the nephrologist is required, in order for the result to interpreted correctly within the clinical context.
The information gained subsequently affects management in approximately 30-40% of cases, and 85% of patients with nephrotic syndrome and unexplained AKI (Richards 1994, Stratta 2007). Nonetheless, at times, the role of renal biopsy has been debated (Madaio 1990, Adu 1996).
Most nephrologists would agree that renal biopsy is more likely to change management in symptomatic kidney disease (proteinuria, nephrotic syndrome), unexplained AKI or sudden changes in eGFR in CKD. It can also be useful for prognostic purposes, as well as helping to direct or change treatment.
In nephrotic syndrome and AKI, the biopsy may make the difference between giving immunosuppression or not, withdrawal of drugs or not etc. The role of renal biopsy in determining the quantity and intensity of treatment is widely but not universally accepted, particularly in lupus nephritis.
There are four common indications for renal biopsy:
Significant proteinuria/nephrotic syndrome (>1g/L, or PCR > 100mg/mmol) with two normal sized, non-obstructed, kidneys and no obvious cause (usually considering the diagnosis of a glomerulo- or interstitial nephritis)
Acute Kidney Injury (AKI) with two normal sized, non-obstructed, kidneys and no obvious cause
Chronic Kidney Disease (CKD) with two normal sized, non-obstructed, kidneys and no obvious cause
Renal transplant dysfunction
Other, less common (and more controversial) indications. Many of these patients may have normal renal function:
Renal dysfunction in systemic disease (eg diabetes, myeloma, amyloidosis, SLE)
Familial renal disease (where diagnosis in this patient, benefits them and their family)
Biopsies are absolutely contraindicated in the following situation:
Uncontrolled bleeding diathesis
Biopsies are relatively contraindicated when:
Uncontrolled hypertension (>160/95)
Patient unable to consent
Solitary kidney. This is a 'big decision' and should be carefully made by a consultant and the patient
Small kidneys (less than 10 cm; less than 9 cm in a small patient)
Anatomical abnormalities (eg vascular lesion)
Renal neoplasm, multiple cysts, abscess or pyelonephritis
Note: when considering a diagnosis of amyloid, it may be advisable to biopsy other less vascular tissues (fat, rectum) first, since this may establish the diagnosis and avoid the inherent risk of the renal biopsy. Patients with amyloid (particularly those with blood vessel deposition) may be more likely to bleed. This view has been challenged by Fish in 2010.
Diabetes and Renal Biopsy
If the clinical presentation is consistent with diabetic nephropathy (ie signficant proteinuria [often nephrotic range], CKD3b-4, diabetes of over 10 years duration, normal soluble immunology, presence of other microvascular complications [eg retinopathy and neuropathy]), renal biopsy is not necessary and it can be assumed that the patient has diabetic nephropathy.
If however the presentation is atypical (haematuria, haematoproteinuria, diabetes of less than 5 years duration, abnormal soluble immunology, no microvascular complications, rapid fall in GFR), renal biopsy should then be considered. Patients with diabetes may develop a glomerulonephritis or another form of intrinsic renal disease. A higher than average risk of glomerulonephritis has been described in patients with diabetes (Soni, 2006) although this has not been universally seen (Waldherr, 1992).
Age, Race and Renal Biopsy
Moutzouris (2009) has published a series of biopsies in the elderly (> 80 years) suggesting this is still a useful technique with results that affect management in a significant number of patients.
There are racial differences between biopsy appearances. For example, Hoy (2012) has described a wide range of atypical findings in Australian aborginal people.
This talk by Vishal Golay (on 28.10.10) is a very good, especially regarding the practicalities of renal biopsy.
(06 May 2015) - Link
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