Renal biopsy – indications, safety and complications
Farida Hussain
EMEESY Education Day – 14th Oct 2016
Identify a specific diagnosis
Reflect the level of disease activity
Provide information to allow informed decisions about treatment
Aims of renal biopsy
HSP MCNS FSGS IgA SLE
PSGN normal TIN MPGN membranous
TBM CKD Alports other
Renal biopsies - diagnoses
Case study - 1
5yr old boy
2 week history of puffy eyes
Initially treated with antihistamines by GP
Urine dip 3+ protein 1+ blood
BP 86/40
Case study - 1
Would you biopsy?
A yes
B no
0 A B
15 yr old girl
Presented with 9 day history of abdo pain & diarrhoea
Increasing puffiness (eyes and ankle oedema)
Urine: protein 4+, blood 3+
BP 90
Creatinine 83µmol/l, Albumin 13g/L
Case study - 2
Would you biopsy?
A yes
B no
Case study - 2
0 A B
5yr old – transfer from DGH
Completed 4 weeks of 60mg/m2 prednisolone for new diagnosis of nephrotic syndrome – not in remission
PMHx – intermittant swelling over past 6 months
Urine dip at initial presentation: protein 3+ blood 4+
Case study - 3
Would you biopsy?
A yes
B no
Case study - 3
0 A B
Biopsy
RaDaR/NephroS
Steroid resistant nephrotic syndrome
Case study - 4
GP refers an 8yr old girl found to have microscopic haematuria on screening
Otherwise well
No family history
Urine dip: blood 2+
Persisted for 2 years
Case study - 4
Would you biopsy?
A yes
B no
0 A B
Nottingham – 12 years, 59 biopsies
42 – thin basement membrane
6 – IgA nephropathy
6 – Alports
4 - normal
BAPN : 9.1% biopsies (2005) to 3.7% (2012)
Richards et al: Bx changed management in 1 of 36 pts
Genetics
Isolated haematuria
A Any
B >50mg/mmol
C 50-100mg/mmol
D >100mg/mmol
Proteinuria – what level?
0 A B C D
Proteinuria – what level?
BAPN audit 2012
>50mg/mmol 1 centre
50-100mg/mmol 4 centres
>100mg/mmol 3 centres
No defined level 3 centres
Haematuria & proteinuria
AKI
Drugs
CKD
Transplants >10% rise in creat
Delayed graft function
Disease recurrence
De novo disease
Protocol biopsies
Other indications
Renal biopsy - safety
operator
Who has the lowest complication rate?
A paediatric consultant
B paediatric trainee
C interventional radiologist
operator
0 A B C
54% nephrologist alone
18% radiologist alone
27% combination
No significant difference in complications between operators
operator
Which is associated with the highest complication rate?
A iv sedation
B entonox®
C General anaesthetic
sedation
0 A B C
GA – 56% cases
IV sedation – 24% cases
Entonox – 5% cases
No significant difference in complication rate
sedation
sedation
70/1014 biopsies - 7%
Age range 8.1-19.8yrs (mean =16.1yrs)
Wt range 27.4 -112.4kg (mean=52.3kg)
2 patients had minor complications (1.4%)
Which size needle has the highest complication rate?
A 14 gauge needles
B 16 gauge needles
C 18 gauge needles
Biopsy needles
0 A B C
Renal biopsy - complications
complications
Delay in patient discharge as a result of post-biopsy complications or requirement for further investigations, intervention or monitoring as a result of biopsy
Audit standard <5%
Complications - major
Indications
Safety
Complications
Summary
Any Questions?