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?