Kidney Biopsy

Kidney Biopsy

 

Definition

Kidney biopsy is a medical procedure in which a small piece of tissue is removed from the kidney for microscopic examination.

Purpose

The test is usually done to diagnose kidney disease and to evaluate the extent of damage to the kidney. A biopsy is also frequently ordered to detect the reason for acute renal failure when normal office procedures and tests fail to establish the cause. In addition, information regarding the progression of the disease and how it is responding to medical treatment can be obtained from a biopsy. Occasionally a biopsy may be done to confirm a diagnosis of kidney cancer, to determine its aggressiveness, and decide on the mode of treatment.

Precautions

The biopsy is not recommended for patients who have any uncontrollable bleeding disorders. Platelets are blood cells that play an important role in the blood clotting process. If the bleeding disorder is caused by a low platelet count (less than 50,000 per cubic millimeter of blood), then a platelet transfusion can be done just before performing the biopsy.

Description

The kidneys, a pair of organs that are shaped like beans, lie on either side of the backbone, just above the waist. The periphery (parenchyma) of the kidney is made up of tiny tubes. These tubes filter and clean the blood by taking out the waste products and making urine. The urine is collected in the central portion of the kidney. Tubes called ureters drain the urine from the kidney into the bladder, where it is held until it is voided from the body.
A kidney specialist (nephrologist) performs the biopsy. It can be done either in the doctor's office or in a local hospital. The patient may be given a calming drug before the procedure to help him relax. The skin and muscles on the back overlying the site that is to be biopsied may be numbed with local anesthesia.
The patient will be asked to lie face down and a pad or a rolled towel may be placed under the stomach. Either the left or the right kidney may be biopsied depending on the results of the imaging tests: x rays, computed tomography scans (CT scans), magnetic resonance imaging (MRI), and ultrasound. The area that will be biopsied is cleaned with an antiseptic solution and sterile drapes are placed on it. The skin is numbed with local anesthesia. A small incision is made on the skin with a scalpel blade. Using a long needle, the physician injects local anesthesia into the incision so that it infiltrates down to the kidney. The biopsy needle is then advanced slowly through the incision. The patient is asked to hold his or her breath each time the needle is pushed forward. Once the wall (capsule) of the kidney has been penetrated, the patient can breathe normally. The tissue is collected for examination and the needle is withdrawn. The needle may be re-inserted into another part of the kidney so that tissue is collected from at least three different areas. The tissue samples are sent to the laboratory for examination. The entire procedure may last about an hour.

Preparation

Before performing the biopsy, the doctor should be made aware of all the medications that the patient is taking. The doctor should also be told whether the patient is allergic to any medications. The procedure and the risks of the procedure are explained to the patient and the necessary consent forms are obtained. The patient should be told that a kidney biopsy requires a 24-hour stay in the hospital after the biopsy.
Some doctors order blood tests to check for clotting problems before performing the biopsy. The patient's blood type may also be determined in case a transfusion becomes necessary.

Aftercare

Immediately after the biopsy, pulse, respiration, and temperature (vital signs) are measured. If they are stable, the patient is instructed to lie flat in bed for at least 12 hours. The pulse and blood pressure are checked at regular intervals by the nursing staff. All urine voided by the patient in the first 12-24 hours is examined in the laboratory for blood cells.
If bleeding is severe, iron levels in the blood drop significantly, or the patient complains of severe pain at the biopsy site, the physician should be contacted immediately. After the patient goes home, he should avoid heavy lifting, vigorous exercise, and contact sports for at least one or two weeks.

Risks

The risks of a kidney biopsy are very small. Severe bleeding may occur after the procedure. There is also a slight chance that an infection or a lump of blood under the skin that looks black and blue (hematoma) may develop. In most cases, the hematoma disappears by itself and does not cause any pain. However, severe pain or a drop in blood pressure and iron levels in the blood indicates that the hematoma is expanding. This condition could lead to complications and should be reported immediately to the doctor.
Very rarely, the patient may develop high blood pressure (hypertension), and the bleeding may be severe enough to require a transfusion. In extremely rare circumstances, the kidney may rupture, or the surrounding organs (pancreas, bowel, spleen, and liver) may be punctured. Death occurs in about one in 3000 cases.

Normal results

The results are normal if no abnormalities can be seen in the tissue samples with the naked eye, with an electron microscope or through staining with a fluorescent dye (immunofluorescence).

Abnormal results

Any abnormalities in the size, color, and consistency of the sample will be reported as an abnormal result. In addition, any change in the structure of the renal tubules, the presence of red blood cells, or abnormalities in the cells are considered an abnormal result. If cancerous changes are detected in the kidney cells, they are further characterized in order to determine the stage of the tumor and decide on the appropriate mode of treatment.

Resources

Organizations

National Kidney Cancer Association. 1234 Sherman Ave., Suite 203, Evanston, IL 60202-1375. (800) 850-9132.
National Kidney Foundation. 30 East 33rd St., New York, NY 10016. (800) 622-9010. http://www.kidney.org.

Key terms

Biopsy — The surgical removal and microscopic examination of living tissue for diagnostic purposes.
Computed tomography (CT) scan — A medical procedure in which a series of x rays are taken and put together by a computer in order to form detailed pictures of areas inside the body.
Magnetic resonance imaging (MRI) — A medical procedure used for diagnostic purposes in which pictures of areas inside the body can be created using a magnet linked to a computer.
Nephrologist — A doctor who specializes in the diseases and disorders of the kidneys.
Renal ultrasound — A painless and non-invasive procedure in which sound waves are bounced off the kidneys. These sound waves produce a pattern of echoes that are then used by the computer to create pictures of areas inside the kidney (sonograms).

renal biopsy

Nephrology
A ultrasonography-guided biopsy of a core of renal tissue to be examined by light microscopy, immunofluorescence, and electron microscopy. 

Indications
Nephrotic syndrome, idiopathic proteinuria, proteinuria with “glomerular” haematuria, acute renal failure, lupus nephritis, rapidly progressive glomerulonephritis, transplant rejection, renal vasculitis.
 
Complications
Microscopic haematuria (which occurs with most renal biopsies), perirenal haematoma, pain, worsened hypertension, AV fistula formation, renal laceration, puncture or laceration of aorta or arteries, pancreas, spleen, liver, GI tract, and death (which occurs in 1:3000 patients).

Contraindications
Severe coagulopathy, single kidney, renal artery aneurysm, perinephric abscess.

Renal Biopsy 
Glomerulus
• Distribution of changes, if any:
     – Focal/diffuse
     – Segmental/global
• Proliferation
Mesangial, endocapillary, extracapillary.
• Sclerosis
Mesangial, nodular, segmental, global.
• Capillary wall
Membrane spikes, reduplication.
• Capillary lumen
Collapse, inflammation, thrombosis.

Tubules
• Casts
Red cell, protein, crystals, calcification.
• Epithelium
Necrosis, regeneration, vacuolation, reabsorbed material.
• Inflammation
Neutrophils, lymphocytes, giant cells.
• Atrophy

Interstitium
• Inflammation
Acute, chronic, granulomatous, eosinophils.
• Deposits
Crystals, amyloid.
• Fibrosis
Early, late.
• Pattern
Striped, segmental, subcapsular, diffuse peritubular.

Arteries, arterioles
Amyloid, fibrinoid necrosis, intramural hyalinosis, accelerated and/or chronic hypertensive changes, lumen has thrombosis and cholesterol emboli.

Diagnostic utility, renal biopsy
 • Identify aetiology of proteinuria
• Assess multicystic disease
• Focal segmental glomerulosclerosis
• Membranous glomerulonephritis
• Lupus nephritis
• Diabetes
• Light chain disease
• Amyloid
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