Sedation with intravenous benzodiazepine and ketamine for renal biopsies

“Lytic cocktail” is the customary sedation before percutaneous renal biopsy. Owing to deficient sedation and respiratory depression, this approach is no longer advised. The intravenous combination of a benzodiazepine plus ketamine, which has been found to be effective and safe in several conditions, was therefore used for 60 pediatric biopsies. In addition to pulse oximetry, a physician trained in airway management monitored the patient. The quality of sedation was acceptable (n = 7) or optimal (n = 53) in all cases. None of the patients required ventilation or intubation. A mild oxygen desaturation lasting 4 min or less was detected in 6 patients. None of the patients experienced major change in respiratory rate or blood pressure. The administration of ketamine and, in some cases, the biopsy puncture were associated with a mildly increased heart rate. In conclusion, a benzodiazepine plus ketamine provides effective deep sedation for renal biopsy in childhood. Received May 7, 1997; received in revised form September 3, 1997; accepted September 4, 1997     

Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy

Background

Percutaneous needle core biopsy has become established in the management of small renal masses ≤4 cm (SRMs). Recent series have reported success rates of ≥80%. Nondiagnostic results continue to be problematic.

Objective

To determine the results of SRM biopsy and the outcomes of nondiagnostic biopsy and repeat biopsy.

Design, setting, and participants

Patients undergoing renal tumor biopsy (RTB) for suspected renal cell carcinoma (RCC) were included in a prospectively maintained database.

Measurements

The database was analyzed retrospectively to determine the pathology and outcomes of SRM biopsy. Outcomes of patients with nondiagnostic biopsy were determined. Patients undergoing repeat biopsy were identified and their outcomes analyzed.

Results and limitations

Three hundred forty-five biopsies were performed (mean diameter: 2.5 cm). Biopsy was diagnostic in 278 cases (80.6%) and nondiagnostic in 67 cases (19.4%). Among diagnostic biopsies, 221 (79.4%) were malignant, 94.1% of which were RCC. Histologic subtyping and grading of RCC was possible in 88.0% and 63.5% of cases, respectively. Repeat biopsy was performed in 12 of the 67 nondiagnostic cases, and a diagnosis was possible in 10 (83.3%). Eight lesions were malignant and two were oncocytic neoplasms. Pathology was available for 15 masses after initial nondiagnostic biopsy; 11 (73%) were malignant. Larger tumor size and a solid nature on imaging predicted a successful biopsy on multivariate analysis. Grade 1 complications were experienced in 10.1% of cases, with no major bleeding and no seeding of the biopsy tract. There was one grade 3a complication (0.3%).This is a retrospective study and some data are unavailable on factors that may affect biopsy success rates. Repeat biopsy was not standard practice prior to this analysis.

Conclusions

RTB can be performed safely and accurately in the investigation of renal masses ≤4 cm. A nondiagnostic biopsy should not be considered a surrogate for the absence of malignancy. Repeat biopsy can be performed with similar accuracy, providing a diagnosis for most patients.     

Pediatric renal biopsy in the ambulatory care environment

The use of pediatric ambulatory care facilities to perform invasive procedures that have low morbidity is increasingly popular. Over a 2-year period, 46 pediatric renal biopsies were performed in an ambulatory care setting at the Winnipeg Children's Hospital, with the patient discharged the same day. There were no serious complications and adequate tissue was obtained in 45 cases. Renal biopsy may be safely performed on an outpatient basis on carefully selected patients by experienced operators in properly equipped facilities.     

Laparoscopic renal biopsy in obese children

Percutaneous kidney biopsy is routinely used to obtain renal tissue for histological examination. It is usually successful and has very few contraindications. We describe two children with clinical obesity in whom the percutaneous approach failed to yield renal tissue for histology. They underwent successful laparoscopic kidney biopsies that yielded adequate renal tissue for diagnosis, although the first attempt in one patient yielded renal medulla necessitating a repeat biopsy. We recommend that laparoscopic kidney biopsies should be considered in obese children when percutaneous kidney biopsies are considered impossible.     

Evaluation of complications due to percutaneous renal biopsy: a clinical and angiographic study

Complications due to 173 percutaneous biopsies in 158 patients were evaluated. In 57 of the patients the biopsies were guided by renal angiography, and in this group hematomas were found in 23% of the biopsies, arteriovenous fistulae in 8%, and renal infarction in 6%. No predisposing factors leading to complications were found. A transient increase in serum creatinine concentration was recorded with a maximal value about the fourth to sixth day after the biopsy. Thirteen percent of the biopsies controlled by angiography resulted in permanent kidney lesions, but none of them seemed to be of clinical importance.     

Pediatric renal biopsy: should this procedure be performed in an outpatient setting?

Although several retrospective reports suggest that pediatric outpatient renal biopsies may be done in a safe and cost-effective manner, risk factors and the natural history of major complications following this procedure have not been clearly delineated. In an effort to determine the minimal observation period required to detect major post-renal biopsy complications in children and to establish clinical parameters predictive of these complications, a retrospective review of 177 percutaneous renal biopsies was performed. The overall major complication rate was 3.4%, while the minor complication rate was 14.1%. The mean percentage change in hemoglobin 4 – 10 h postbiopsy in patients with major bleeding complications was significantly greater than patients with minor bleeding complications. Using a 16% drop in hemoglobin 4 – 10 h postbiopsy, the sensitivity and specificity of identifying a major bleeding complication was 100% and 98%, respectively, while the positive and negative predictive value was 68% and 100%, respectively. All patients with major complications due to excess sedation or immediate bleeding were diagnosed within 11 h of the biopsy. Automated renal biopsies offered several safety and efficiency advantages compared with non-automated methods. Our results suggest that outpatient pediatric renal biopsies should be encouraged provided certain precautions are taken to reduce the risk of developing major complications. Received July 1, 1997; received in revised form October 9, 1997; accepted October 10, 1997     

Renal mass biopsy for the small renal mass

Opponents of premanagement biopsy of small renal masses are not difficult to find. Many urologists contend that the benefits of biopsy do not outweigh the risks, arguing that the results do not influence management substantially and that the most useful information from renal mass biopsy can be attained with advanced imaging. In this article, we develop the counter arguments and demonstrate that renal mass biopsy should be implemented into the small renal mass management algorithm.     

TNF staining of graft biopsy in renal transplantation

Tumour Necrosis Factor (TNF) is a cytokine which may be found in patients' plasma and urine in association with acute rejection in renal transplantation [1]. TNF is produced mainly by macrophage/monocytes and activated lymphocytes and its release in acute rejection may damage the nephron leading to renal dysfunction. However localization of TNF in renal grafts has not yet been demonstrated. We investigated TNF localization in renal graft tissue and the association with acute rejection compared with non-immunological events (cyclosporine toxicity and acute tubular necrosis) in graft biopsy.     

四川地区肾活检2330例临床病理分析

目的：探讨四川地区肾穿刺活检病理类型的分布特点以及疾病谱的变迁。方法回顾性分析2330例肾活检患者的临床病理资料,分析本地区肾脏疾病的临床病理特征。结果2330例肾活检患者中,男女比例为1∶1.15,发病高峰年龄为20~40岁。2330例患者中,原发性肾小球疾病1896例（占81.37%）,常见的病理类型依次为 IgA 肾病820例（占35.19%）、系膜增生性肾小球肾炎372例（占15.97%）、膜性肾病298例（占12.79%）、微小病变肾病200例（占8.58%）和局灶节段性肾小球硬化症78例（占3.35%）;继发性肾小球疾病367例（占15.75%）,以狼疮性肾炎最常见（134例,占5.88%）,其次为紫癜性肾炎127例（占5.45%）、糖尿病肾脏疾病35例（占1.5%）和淀粉样变性肾病20例（占0.86%）;肾小管间质疾病50例（占2.15%）;遗传性肾病17例（占0.73%）。2330例肾脏疾病患者的临床表现依次为肾病综合征1015例（占43.56%）、慢性肾炎综合征681例（占29.22%）、急性肾炎综合征392例（占16.82%）、隐匿性肾小球肾炎121例（占5.29%）、慢性肾衰竭72例（占3.09%）、急性肾衰竭47例（占2.02%）。近年来,膜性肾病构成比呈逐渐增加趋势。结论本地区肾脏疾病多见于青壮年,以原发性肾小球疾病最常见,其中 IgA 肾病和系膜增生性肾小球肾炎是最多见的病理类型,膜性肾病的检出率有增高趋势。继发性肾小球疾病以狼疮肾炎和紫癜性肾炎最常见。     

Experience of renal biopsy in children with nephrotic syndrome

Percutaneous renal biopsy (PRB) is useful in childhood renal diseases. This study was done to determine the indications for renal biopsy in nephrotic children, to correlate the indications with histology and to document the complications of PRB. This study included 250 nephrotic children younger than 18 years old who had renal biopsy from January 1988 to December 2002. Ultrasonographic guidance was used in the latter part of the study. Coagulation profile and renal function assessment and blood group testing were done prior to biopsy. Children were monitored clinically during and after the procedure. All children had local anesthesia and 202 children also had short-acting general anesthesia. All biopsies were done on the left kidneys. The specimens were studied under light and immunofluorescent microscopy. All had a post-biopsy ultrasonography at 24 h. Biopsy was diagnostic in 95.2% of children, with a failure rate of 4.8%. The most common indication for biopsy was steroid-resistant nephrotic syndrome (65.2%), and minimal change disease (52.1%) was the most common histology, irrespective of the indications for renal biopsy. Mild (16.0%) and gross (16.8%) hematuria and subcapsular hematoma (6.0%) were the common complications. Fifty-five percent of the children had no complications. Only two children (0.8%) had biopsy site infection.     

Comparison of two core biopsy techniques before and after laparoscopic cryoablation of small renal cortical neoplasms

Introduction:

Cryoablation is an acceptable treatment option for small renal cortical neoplasms (RCN). Unlike extirpative interventions, intraoperative needle biopsy is the only pathologic data for ablated tumors. It is imperative that sampled tissue accurately captures pathology. We studied the optimal intraoperative needle core biopsy protocol for small RCN during laparoscopic renal cryoablation (LCA).

Methods:

Patients with RCN<4cm underwent intraoperative biopsy during LCA. Four biopsy cores were taken per tumor, 2 before and 2 after LCA by using both a standard and modified technique. Standard technique: needle biopsy device was deployed after insertion into the renal tissue at a depth of 5mm. Modified technique: needle biopsy device was deployed 1mm outside of the renal tissue. Biopsies were examined and compared with reference standard pathology. Percentage agreement was calculated across biopsy types (standard vs. modified) and time points (pre- vs. postcryoablation). Logistic regression was used to identify factors impacting biopsy accuracy.

Results:

Thirty patients with 33 RCNs underwent LCA. The mean patient age was 69.1±8.0yrs, and mean tumor size was 2.3±0.7cm. No significant bleeding resulted from biopsies. A definitive diagnosis was made in 31/33 RCNs (94.0%). Ten tumors (30.3%) were benign, 21 (63.7%) were malignant, and 2 (6.0%) were nondiagnostic. Biopsy length was significantly longer using the standard vs. modified technique with mean lengths of 9.3mm vs. 7.0mm, respectively (P=.02). Highest agreement was seen in preablation biopsies (90.3%). A significant association with agreement was seen for younger age (P=.05) and larger tumor size (P=.02).

Conclusions:

Younger age and larger tumor size were associated with improved accuracy. Preoperative sampling resulted in superior accuracy and the standard technique resulted in significantly longer cores. Use of preablation standard biopsy technique may result in the most accurate pathologic diagnosis for patients undergoing cryoablation for small RCNs.     

A new percutaneous renal biopsy device for pediatric patients

A new automated biopsy technique is described for performing percutaneous renal biopsies in pediatric patients. The biopsy device (Bard Biopty Instrument) employs a relatively small needle (18 gauge). We believe this procedure offers a safer and more effective means of obtaining adequate renal tissue for pathological assessment in pediatric patients.     

Renal biopsy diagnosis in children presenting with haematuria

We reviewed the clinical and renal biopsy findings in 322 children presenting during the years 1975–1996 with recurrent macro- or continuous microscopic haematuria persisting for ≥6 months, in whom non-glomerular causes were excluded. Family involvement was documented for first-degree relatives. All biopsies were examined by light microscopy, 317 by electron microscopy and 315 by immunofluorescence. Biopsies were classified as IgA nephropathy (78), Alport nephropathy (86), thin basement membrane nephropathy (TMN) (50), miscellaneous glomerulonephritis (32), hilar vasculopathy (28) and normal glomeruli (48). Although microscopic haematuria alone was more frequent in Alport nephropathy and TMN, the pattern of haematuria in individual patients did not predict histology. Of patients with familial haematuria, 79% of biopsies showed either Alport nephropathy or TMN. Hilar vasculopathy was observed both in isolation and in all abnormal histological categories. Received August 10, 1997; received in revised form December 3, 1997; accepted December 4, 1997     

Day care renal biopsy

Over the 6 years 1989–1994, 384 percutaneous renal biopsies were performed, 329 on native and 55 on transplanted kidneys. Biopsy was undertaken on a day care basis in 304 instances (79.2%). Failure to obtain 5 or more glomeruli was experienced in 23 (6.0%) of the 304 day care biopsies. There were no significant differences in technical failure rates between day care patients and inpatients, local analgesia and general anaesthetic, or native and transplanted kidneys, but a higher rate was observed in biopsies performed unaided by trainees than by experienced operators (P = 0.002). Six patients were detained overnight for minor complications and a seventh for unrelated reasons. Two patients discharged on the day of biopsy despite gross haematuria were readmitted 8–10 days later with secondary haemorrhage. The complication rate of 2.6% compares favourably with published data. Few paediatric renal units currently perform day care renal biopsy, and we recommend its wider acceptance. Received August 4, 1995; received in revised form November 6, 1995; accepted November 17, 1995     

Ultrasonography as a predictor of overt bleeding after renal biopsy

Background  Renal biopsy is essential for the diagnosis of kidney diseases, but complications, particularly bleeding incidents, remain problematic. Methods  To evaluate the frequency of renal biopsy complications, and to reveal clinical and laboratory factors associated with overt bleeding complications, focusing on those available at hospital ward, we conducted a retrospective observational study for the period between 2001 and 2005 at Mie University Hospital in patients who underwent percutaneous renal biopsy of a native kidney. Of a total of 323 patients, 317 met the inclusion criteria. Results  Only one patient (0.3%) required blood transfusion or intervention to stop bleeding. The mean decrease in hemoglobin (Hb) after biopsy was 0.43 ± 0.7 g/dL. Hb decreased ≥1.0 g/dL in 66 patients (20.8%) and ≥10% in 32 patients (10.1%). On ultrasonography, perirenal hematoma was detected immediately after biopsy in 273 patients (86.1%), and 41 patients (12.9%) showed hematoma ≥2 cm in width. Analgesics were required for back pain in 67 patients (21.1%). Vasovagal response developed in 31 patients (9.8%). Macrohematuria occurred in 12 patients (3.8%). Urinary catheter was used in 161 patients (50.8%). For Hb decrease ≥10% after biopsy, multivariate analysis revealed perirenal hematoma (≥2 cm) as a significant factor. Other significant factors were prolonged international normalized ratio of prothrombin time, elevated blood pressure on hospital admission, older age, increased serum creatinine level, and steroid use. Conclusion  Perirenal hematoma ≥2 cm on ultrasonography immediately after biopsy might well represent a predictive factor for bleeding complications.     

Rationale for percutaneous biopsy and histologic characterisation of renal tumours

Context

The use of percutaneous biopsy of renal tumours has been traditionally reserved for selected cases because of uncertainties regarding its safety, accuracy, and clinical utility. With the adoption of modern biopsy techniques and increasing expertise in interpreting biopsy specimens, renal tumour biopsy today has limited morbidity and allows histologic diagnosis in the majority of cases in centres with expertise.

Objective

To review the current rationale, indications, and outcomes of percutaneous biopsies and histologic characterisation of renal tumours.

Evidence acquisition

We conducted a systematic review of English-language articles on percutaneous biopsies of renal tumours published between January 1999 and December 2011 using the Medline, Embase, and Web of Science databases. One hundred twelve articles were selected with the consensus of all authors and analysed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria.

Evidence synthesis

In recent years, the increasing incidence of incidental small renal masses (SRMs), the development of conservative and minimally invasive treatments for low-risk renal cell carcinoma (RCC), and the discovery of novel targeted treatments for metastatic disease have provided the rationale for expanding the indications for renal tumour biopsy. Percutaneous biopsy for diagnostic assessment of SRMs can avoid unnecessary surgeries and support treatment decisions, especially in patients at high surgical risk. Biopsies can confirm histologic success after thermal ablation of SRMs and support the selection of the appropriate systemic therapy for metastatic RCC. There is increasing evidence that further diagnostic and prognostic information can be obtained from renal tumour biopsies with the use of immunohistochemistry, cytogenetic and molecular analysis, and high-throughput gene expression profiling.

Conclusions

Percutaneous biopsies have increasing indications and can significantly contribute to clinical management of renal tumours but are still underutilised in clinical practice. Further research is needed to define optimal and standardised patterns of biopsy and improve the accuracy of biopsies to determine tumour histology. Molecular and genetic analysis of biopsy specimens can provide additional information to support patient counselling and treatment decision making.     

移植肾功能恢复延迟受者供肾及移植肾活检的意义

目的 分析移植肾功能恢复延迟(DGF)受者进行供肾及移植肾活检对其病因诊断的价值及对治疗的指导意义.方法 回顾性分析144例DGF受者的临床表现、实验室检查特点.获取供肾进行修肾时行供肾活检,在B型超声引导下行经皮肾活检术检查移植肾,分别行组织学、免疫病理和超微病理检查.结果 (1)1994-1997年间DGF的发生率为10.16%,1998-2001年间为7.83%,2002-2005年间为7.48%,2006-2009年降至5.35%;(2)DGF受者的临床表现包括无尿(16.67%)、少尿(16.67%)和高血压(47.22%).123例行移植肾B型超声检查者中肾脏体积增大者占79.67%,血管阻力增高者占45.53%;(3)全部DGF受者均存在血肌酐(SCr)不降或下降缓慢,80例SCr为451～707μmol/L,23例SCr持续＞707μmol/L.70.83%的DGF受者尿N-乙酰-BD-氨基葡萄糖苷酶升高,54.86%的DGF受者尿蛋白定性阳性,53.47%的DGF受者尿沉渣镜检红细胞计数＞50万/ml.(4)144例中,发生急性排斥反应者占45.83%,发生钙调磷酸酶抑制剂肾毒性者占15.28%,IgA肾病者占12.50%,缺血再灌注损伤者占7.64%,移植肾组织学形态正常者占7.64%,急性肾小管坏死者占5.56%,急性间质性肾炎3.47%,移植后复发性疾病占1.39%,肾小球毛细血管内增生性病变占0.69%.(5)60.55%的受者除变更免疫抑制方案外,还进行了肾脏替代治疗.结论 尽管[GF的原因复杂,但供肾质量及移植肾早期病理改变与DGF有直接关系;移植肾活检有助临床更改治疗方案.     

零点活检对活体肾移植术后受体肾功能的预测价值

目的探讨活体肾移植供肾零点活检对受体术后1年内移植肾功能的预测价值。方法 149例活体肾移植受者,根据是否同意活检和活检是否发现异常分为3组：未活检组（63例）,活检正常组（58例）和活检异常组（28例）。受体术后平均随访8个月,比较3组间受体术后移植肾功能恢复情况。结果供肾零点活检异常率为33%,其中肾小管炎7例,肾小管萎缩5例,肾小球硬化8例,肾小球钙化3例,肾小球玻璃样变3例,肾间质炎7例,肾间质纤维化1例,系膜增生2例以及小动脉玻璃样变2例（部分病例有一种以上病理改变）。供者年龄与移植前零点活检异常相关（P〈0.05）。从术后1个月之后至术后1年内,活检异常组各时间点受体血清肌酐均高于未活检组和活检正常组（均为P〈0.05）;术后3个月,活检异常组各时间点受体肾小球滤过率均低于未活检组和活检正常组（P〈0.05）,但术后1年内3组各随访时间点的血尿素氮比较差异无统计学意义（P〉0.05）。术后6个月内重复测量趋势分析显示,与活检正常组比较,活检异常组的血清肌酐和肾小球滤过率的变化趋势差异有统计学意义（均为P〈0.05）,活检异常组的血清肌酐与未活检组比较差异亦有统计学意义（P〈0.05）。结论活体供肾零点活检结果对术后1年内特别是术后6个月内移植肾功能有预测价值,具有临床实用性。     

糖尿病合并肾脏损害患者肾活检的临床意义

糖尿病肾脏疾病(DKD)是导致慢性肾衰竭的主要原因,其中2型糖尿病所致的肾脏病变占绝大多数。肾活检病理检查是诊断的"金标准",对患者治疗方案的选择及预后判断具有重要价值,对新药的开发具有重要意义,也是DKD流行病学调查、确定临床病理联系和开发无创诊断方法的重要依据。因此,对糖尿病尤其是2型糖尿病合并肾脏损害的患者积极开展肾活检病理检查具有重要的临床意义。