renal biopsy


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renal biopsy

the removal of kidney tissue for microscopic examination. It is conducted to establish the diagnosis of a renal disorder and to aid in determining the stage of the disease, the appropriate therapy, and the prognosis. An open biopsy involves an incision, permits better visualization of the kidney, and carries a lower risk of hemorrhage. A closed or percutaneous biopsy performed by aspirating a specimen of tissue with a needle requires a shorter period of recovery and is less likely to cause infection. Contraindications to percutaneous biopsy include bleeding disorders, uncontrolled hypertension, and presence of a single kidney.
method Before biopsy, the procedure is explained and the patient is medically evaluated and tested for bleeding or coagulation time. Aspirin or coumadin therapy is discontinued for a period of time determined by the physician. Informed consent is obtained. The patient's blood is usually typed and crossmatched with two units of donor blood that are held for a possible transfusion until there is no threat of bleeding after the procedure. An open biopsy is generally carried out in the operating room, but the percutaneous procedure may be performed in the radiology department or the patient's room. The location of the kidney, determined by a plain x-ray film, dye contrast study, or fluoroscopic or ultrasound examination, is marked on the patient's skin in ink for a needle biopsy. The patient is then placed prone over a sandbag and soft pillow with the body bent at the level of the diaphragm, the shoulders on the bed, and the spine in straight alignment. A local anesthetic is injected, and the physician inserts the biopsy needle in the lower pole of the kidney, because this area contains the smallest number of large renal vessels. The needle is quickly withdrawn, and, after pressure is applied to the site for 30 to 60 minutes, a pressure bandage is applied. The patient is turned and kept supine and motionless for the next 4 hours. The dressing, blood pressure, and pulse are checked every 5 to 10 minutes for the first hour, then at frequency determined by institutional protocols. Excessive drainage, decreased blood pressure, tachycardia, or elevated temperature is reported to the physician. Fluids are forced to the maximum allotted for the patient's condition. The amount and character of urinary output are noted, and the physician is informed if hematuria occurs. The patient is kept in bed for at least 24 hours and is cautioned not to lift any heavy objects for 10 days or to take any anticoagulants until the physician gives permission.
interventions The nurse offers an explanation of the procedure, prepares and positions the patient for the percutaneous procedure, and, on its completion, provides care and emotional support.
outcome criteria A biopsy is the most accurate measure for determining the nature and stage of a renal pathological condition.

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

renal biopsy

Kidney biopsy A Bx guided by ultrasonography of a core of renal tissue to be examined by LM, immunofluorescence, EM Indications Nephrotic syndrome, idiopathic proteinuria, proteinuria with 'glomerular' hematuria, acute renal failure, lupus nephritis, rapidly progressive glomerulonephritis, transplant rejection, renal vasculitis Complications Microscopic hematuria–which occurs with most renal biopsies, and thus is regarded by some authors as normal, perineal hematoma, pain, worsened HTN, AV fistula formation, renal laceration, puncture or laceration of aorta or arteries, pancreas, spleen, liver, GI tract, and death, which occurs in 1:3000 Pts

Biopsy, Kidney

Synonym/acronym: Renal biopsy.

Common use

To assist in diagnosing cancer and other renal disorders.

Specimen

Kidney tissue or cells.

Normal findings

(Method: Macroscopic and microscopic examination of tissue) No abnormal cells or tissue.

Description

Kidney or renal biopsy is the excision of a tissue sample from the kidney for microscopic analysis to determine cell morphology and the presence of tissue abnormalities. This test assists in confirming a diagnosis of cancer found on x-ray or ultrasound or to diagnose certain inflammatory or immunological conditions. Biopsy specimen is usually obtained either percutaneously or after surgical incision.

This procedure is contraindicated for

  • high alertPatients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site), advanced renal disease, uncontrolled hypertension, or solitary kidney (except transplanted kidney as the biopsy may be required to determine whether rejection or other damage is occurring).

Indications

  • Assist in confirming suspected renal malignancy
  • Assist in the diagnosis of the cause of renal disease
  • Determine extent of involvement in systemic lupus erythematosus or other immunological disorders
  • Monitor progression of nephrotic syndrome
  • Monitor renal function after transplantation

Potential diagnosis

Positive findings in:

  • Acute and chronic poststreptococcal glomerulonephritis
  • Amyloidosis infiltration
  • Cancer
  • Disseminated lupus erythematosus
  • Goodpasture’s syndrome
  • Immunological rejection of transplanted kidney
  • Nephrotic syndrome
  • Pyelonephritis
  • Renal venous thrombosis

Critical findings

  • Assessment of clear margins after tissue excision
  • Classification or grading of tumor
  • Identification of malignancy
  • It is essential that critical findings be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. The notification processes will vary among facilities. Upon receipt of the critical finding the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical finding, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Obesity and severe spinal deformity can make percutaneous biopsy impossible.
  • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in establishing a diagnosis of kidney disease.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex or anesthetics.
  • Obtain a history of the patient’s genitourinary and immune systems, especially any bleeding disorders or other symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Note any recent procedures that can interfere with test results.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure.
  • Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Instruct the patient that prophylactic antibiotics may be administered before the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered before the percutaneous biopsy to promote relaxation and reduce discomfort; general anesthesia will be administered before the open biopsy. Explain to the patient that no pain will be experienced during the test when general anesthesia is used but that any discomfort with a needle biopsy will be minimized with local anesthetics and systemic analgesics. Inform the patient that the biopsy is performed under sterile conditions by an HCP specializing in this procedure. The surgical procedure usually takes about 60 min to complete, and sutures may be necessary to close the site. A needle biopsy usually takes about 40 min to complete.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line will be inserted to allow infusion of IV fluids, antibiotics, anesthetics, analgesics, or IV sedation.
  • Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:
  • Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners) or seeding of the biopsy tract with tumor cells

  • Ensure that the patient has complied with dietary restrictions.
  • Ensure that anticoagulant therapy has been withheld for the appropriate number of days prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Notify the HCP if patient anticoagulant therapy has not been withheld. Ensure that patients on beta-blocker therapy have continued their medication regimen as ordered.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Have the patient void before the procedure.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen containers with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location, especially right or left kidney.
  • Assist the patient to the desired position depending on the test site to be used, and direct the patient to breathe normally during the beginning of the general anesthetic. Instruct the patient to cooperate fully and to follow directions. Direct the patient to avoid unnecessary movement.
  • Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
  • After the administration of general or local anesthesia, use clippers to remove hair from the surgical site if appropriate, cleanse the site with an antiseptic solution, and drape the area with sterile towels.
  • Open Biopsy

  • Adhere to Surgical Care Improvement Project (SCIP) quality measures. Administer ordered prophylactic antibiotics 1 hr before incision, and use antibiotics that are consistent with current guidelines specific to the procedure.
  • After administration of general anesthesia and surgical preparation are completed, an incision is made, suspicious area(s) are located, and tissue samples are collected.
  • Needle Biopsy

  • A sandbag may be placed under the abdomen to aid in moving the kidneys to the desired position. Direct the patient to take slow deep breaths when the local anesthetic is injected. Protect the site with sterile drapes. Instruct the patient to take a deep breath, exhale forcefully, and hold the breath while the biopsy needle is inserted and rotated to obtain a core of renal tissue. Once the needle is removed, the patient may breathe. Pressure is applied to the site for 5 to 20 min, then a sterile pressure dressing is applied.
  • General

  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
  • Place tissue samples in formalin solution. Label the specimen, indicating site location, and promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume preoperative diet, as directed by the HCP. Assess the patient’s ability to swallow before allowing the patient to attempt liquids or solid foods.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Discontinue prophylactic antibiotics within 24 hr after the conclusion of the procedure. Protocols may vary among facilities.
  • Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
  • Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
  • Instruct the patient in the care and assessment of the site.
  • Instruct the patient to report any redness, edema, bleeding, or pain at the biopsy site. Instruct the patient to immediately report chills or fever.
  • Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
  • Inform the patient that blood may be seen in the urine after the first or second postprocedural voiding.
  • Monitor fluid intake and output for 24 hr. Instruct the patient on intake and output recording and provide appropriate measuring containers.
  • Instruct the patient to report any changes in urinary pattern or volume or any unusual appearance of the urine. If urinary volume is less than 200 mL in the first 8 hr, encourage the patient to increase fluid intake unless contraindicated by another medical condition.
  • Assess for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
  • Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
  • Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Inform the patient of a follow-up appointment for removal of sutures, if indicated. Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him or her to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include albumin, aldosterone, angiography renal, antibodies antiglomerular basement membrane, β2-microglobulin, BUN, CT renal, creatinine, creatinine clearance, cytology urine, cystoscopy, IVP, KUB studies, osmolality, PTH, potassium, protein, renin, renogram, sodium, US kidney, and UA.
  • Refer to the Genitourinary and Immune systems tables at the end of the book for related tests by body system.

renal

pertaining to the kidney. See also kidney.

renal abscess
results from infected emboli and infarcts. Usually without localizing signs unless they are very large and palpable, or when they extend into the renal pelvis and cause pyelonephritis.
renal adenoma
rare, incidental necropsy finding.
renal agenesis
failure of the renal tissue to develop; unilateral agenesis causes compensatory hypertrophy in the single kidney; bilateral is fatal. Commonly accompanies genital tract malformation.
renal artery
see Table 9.
avian renal hemorrhage
sporadic unexplained disease of turkeys; sudden death is common.
renal biopsy
is conducted usually with a biopsy needle introduced percutaneously through the flank. In food animals it is possible to fix the left kidney via a rectal manipulation, but the right kidney can be impossible to reach.
renal calculus
renal capsular cyst
see feline perirenal cysts.
renal carcinoma
commonest in old male dogs. They are very large, spread locally and metastasize widely.
renal casts
see urinary cast.
renal clearance tests
laboratory tests that determine the ability of the kidney to remove certain substances from the blood. See also phenolsulfonphthalein clearance test, inulin clearance.
renal cortical fissures
external fissures created by the lobar structure of the large ruminant kidney.
renal cortical hypoplasia
see renal dysplasia (below).
renal cortical necrosis
results from patchy or complete renal ischemia and is part of the terminal state of many diseases, e.g. severe metritis, grain overload in cattle, azoturia in horses.
renal countercurrent system
renal cyst
incidental necropsy finding except for polycystic kidney disease. See also feline perirenal cysts.
renal cystadenoma
inherited as an autosomal dominant trait in middle-aged German shepherd bitches with generalized nodular dermatofibrosis.
renal diabetes insipidus
see nephrogenic diabetes insipidus.
renal dialysis
the application of the principles of dialysis for treatment of renal failure (below). See also hemodialysis and peritoneal dialysis.
renal diverticuli
diverticuli of the renal pelvis.
renal dysfunction
reduced capacity to excrete metabolic products which accumulate systemically and are detectable clinicopathologically by renal function tests. The early stage of uremia.
renal dysplasia
small, misshapen kidneys at birth. May be caused by intrauterine infection of the fetus by virus, but numerous inherited renal dysplasias occur in dogs. They occur in several breeds and are manifested by signs of chronic renal insufficiency, e.g. polyuria, polydypsia, poor growth and weight gain, pale mucous membranes, and renal secondary osteodystrophia fibrosa, from an early age.
renal ectopia
see pelvic kidney, horseshoe kidney.
renal erythropoietic factor
erythropoietin.
renal failure
inability of the kidney to maintain normal function. Impairment of kidney function affects most of the body's systems because of its important role in maintaining fluid balance, regulating the electrochemical composition of body fluids, providing constant protection against acid-base imbalance, and controlling blood pressure. See also kidney.
renal function tests
include blood urea nitrogen and serum creatinine estimations, tests of concentrating ability, tests of ability to excrete test substances, e.g. phenolsulfonphthalein (PSP) clearance test. Of the urine tests, only specific gravity (SG) has any significance in terms of a function test but abnormalities of urine should lead to a function test being conducted.
renal hilus
a fissure on the medial border of the kidney through which arteries, veins and ureter enter.
renal hypophosphatemic rickets
inherited as an X-linked dominant trait in children and mice; characterized by hypophosphatemia and normocalcemia due to failure of phosphate resorption in renal tubules, and skeletal deformities. Called also vitamin-resistant rickets.
renal infarct
results from embolic or thrombotic occlusion of renal arteries or branches. Clinical signs are those of renal colic initially followed by toxemia if the infarct is infected.
renal insufficiency
see renal dysfunction (above).
renal ischemia
a significant cause of renal dysfunction and cortical and medullary necrosis. Is usually part of a general state of shock, dehydration and severe toxemia.
renal lobe
a large mass of a kidney, comprising the tissue contributing to each pyramid; kidneys may be unilobar (unipyramidal), e.g. cats, dogs, small ruminants, horses, or multilobar (multipyramidal), e.g. cattle, pigs.
renal lobule
small masses of kidney tissue comprising a medullary ray and its associated nephrons.
renal medullary necrosis
necrosis of the renal medulla due to restriction of blood flow in medullary vessels, usually due to venous occlusion.
renal medullary washout
see medullary solute washout.
renal mineralization
renal osteodystrophy, renal osteitis fibrosa, renal osteitis fibrosa cystica
see renal secondary hyperparathyroidism.
renal oxalosis
deposition of oxalate crystals in renal tubules of patients poisoned by dietary oxalate, usually in poisonous plants.
renal papillae
see renal papilla.
renal papillary necrosis
necrosis of renal papillae due usually to obstruction to urinary flow or poisoning or dehydration.
renal pelvis
the chamber in the kidney into which the collecting tubules discharge urine and from which urine is voided into the ureter.
renal plasma flow
the effective rate of blood flow through the kidneys; the determining factor relative to the rate of glomerular filtration.
renal portal system
a system unique to birds; half to two thirds of the blood supply to the kidney comes from the hindlimbs via veins and terminates in peritubular capillaries where it is mixed with arteriolar blood coming from the glomeruli.
renal rickets
see renal secondary hyperparathyroidism.
renal shutdown
cessation of the excretory function of the kidney; oliguria.
renal spongiform encephalopathy
spongiform encephalopathy associated with renal failure.
renal tubular casts
see urinary cast.
renal vein thrombosis
commonly associated with renal amyloidosis in dogs.
References in periodicals archive ?
Renal biopsy in renal transplant recipients: Nursing care and complications
On day 0, after blood sampling and renal biopsy, and once recovered from general anesthesia, parrots were treated for 2 weeks with meloxicam (0.
The guidelines dictating follow-up and screening for serum or urine free light chains should include renal biopsy for certain patients who show signs of renal dysfunction, even in the absence of free light chain deposition.
This non-invasively acquired molecular fingerprint of NS patients might aid in the diagnosis, elucidation of potential therapeutic response, and risk stratification of NS patients, thereby precluding the need for a renal biopsy and its associated potential for complications.
The most frequently performed institutional procedures that may cause iatrogenic renal injury are renal biopsy, percutaneous nephrostomy placement, laparoscopic or open partial nephrectomy and PNL.
Patients were interviewed and their medical records were abstracted to collect race/ethnicity, clinical laboratory tests, renal imaging studies, renal biopsy results, history of diabetes mellitus, hypertension, hepatitis B and C, syphilis, injection drug use, dialysis, and macrolide antibiotic and tetracycline use prior to the diagnosis of renal disease.
In a renal biopsy there was always a risk of bleeding, although in most cases the bleeding healed itself.
On day 16, less than 24 hours after renal biopsy, our patient developed pain and swelling in his left calf.
Compared with renal biopsy, which typically is performed about 10 days posttransplant if there is suspicion of rejection, measurement of soluble CD30 levels predicted the early onset of rejection several days earlier-3 to 5 days after transplantation.
In addition to providing RenalVysion[TM], Nephrocor[TM] offers renal biopsy and chemistry profiles for the diagnosis, treatment and management of kidney diseases.
13 Dogan and colleagues concluded that renal biopsy can be safely performed in patients with suspected renal malignancy that have a solitary kidney or are considered high-risk for treatment.
Although renal biopsy was not obtained, the results of other investigations pointed toward ATN as the cause of AKI.