Open renal biopsy: comorbidities and complications in a contemporary series

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To report the indications and outcomes of a contemporary series of patients with contraindications to percutaneous renal biopsies (PRBs) who had an operative RB (ORB), as although ORB is a relatively infrequent procedure, it remains an important and underreported operation.

PATIENTS AND METHODS

In a retrospective review of patients who had an ORB we examined comorbidities, indications, and 30‐day morbidity and mortality. Preoperative comorbidities were stratified according to the Charlson comorbidity index.

RESULTS

In all, 115 patients had ORB between 1991 and 2006 (mean age 48 years, range 18–83); 60% of the patients were American Society of Anesthesiologists class ≥3. The median Charlson comorbidity index score was 3, with a score of 0 in 20.9%, 1–2 in 27.8%, 3–4 in 30.4% and ≥5 in 20.9% of patients. Indications for an ORB included morbid obesity, failed PRB, coagulopathy, and solitary kidney. In all, 47.8% of patients had a serum creatinine level of <3.0 mg/dL, 34.8% of >3.0 mg/dL and 17.4% were dialysis‐dependent. There were 43 complications in 36 patients. The mortality rate after surgery was 0.8%. There were eight major complications in seven patients (6.1%) including cardiac arrest, stroke, sepsis, reoperation and re‐intubation. There were minor complications 34 times in 31 patients (27%), the most common being wound infection, pneumonia, intraoperative transfusion of >2 units, arrhythmia, postoperative retroperitoneal bleed, and seep vein thrombosis.

CONCLUSIONS

This study shows that there are significant comorbidities in patients referred to urologists for an ORB. With a mortality rate of 0.8% and major and minor complication rates of 6.1% and 27%, respectively, the ORB, while infrequent, carries a significant risk in this population that should be included in preoperative decision making and used for patient counselling.     

经皮肾穿刺活检术中的临床应用

经皮肾穿刺活检术是较为安全、准确的肾肿瘤诊断方法。良性肾肿瘤通常无需手术治疗,穿刺活检术可以用于良性肾肿瘤的诊断,使患者避免不必要的外科治疗。经皮肾穿刺活检能明确肿瘤性质,为临床医师选择合理的治疗方案提供重要依据。目前经皮肾穿刺活检也应用于射频消融治疗肾肿瘤术后病灶残留或复发的评估与确诊。本文就经皮肾穿刺活检的诊断效果、适应证及风险作一综述。     

Utility of percutaneous renal biopsy in chronic kidney disease

Background: We tested the hypothesis that patterns of serum creatinine concentrations (S‐cr) prior to percutaneous renal biopsy (PRB) predict the utility of PRB in safely making renal diagnoses, revealing treatable disease, and altering therapy in chronic kidney disease patients. Methods: PRB specimens (170 patients) were assigned to 1 of 5 groups: S‐cr never greater than 0.11 mM for at least 6 months prior to PRB (Group 1); S‐cr greater than 0.11 mM but less than 0.18 mM during the 6 months prior to PRB (Groups 2); S‐cr less than 0.18 mM during the 6 months prior to PRB but greater than 0.18 mM prior to these 6 months (Group 3); S‐cr greater than 0.18 mM for less than 6 months prior to PRB (Group 4); S‐cr greater than 0.18 mM for more than 6 months prior to PRB (Group 5). Results: Histopathology chronicity score (0–9) increased with increasing group number: 2.1 (Group 1); 4.4 (Group 2); 4.5 (Group 3); 5.4 (Group 4); 7.0 (Group 5). Post‐PRB bleeding was more common with increasing group number. New therapy was instituted after PRB most frequently in Group 4 (62%) and least frequently in Group 5 (24%). Conclusion: After more prolonged elevations of S‐cr, PRB may be less safe and less likely to reveal treatable disease and opportunities for therapy.     

经皮肾穿刺活检出血血管造影表现及介入治疗效果

正经皮肾穿刺活检是诊断肾脏疾病的重要手段,可分为靶目标活检和非靶目标活检,一般情况下前者用于肾脏局灶性病变如肾占位,后者用于肾脏内科疾病等无特定穿刺目标时,如慢性肾脏疾病。出血是经皮肾穿刺活检的并发症之一~([1]),发生率5%～7%,多可通过保守治疗缓解,但仍有约0.5%的患者经保守治疗效果不佳,出现失血性休克及压迫等症状,需外科手术或介入治疗止血~([2-4])。本研究观察经皮肾穿刺活检出血的血管造影表现及介入治疗效果。     

Safety and cost effectiveness of pediatric percutaneous renal biopsy

Because of the rising cost of health care, more patients are undergoing procedures as outpatients rather than inpatients. The purpose of this study was to compare safety and cost of outpatient versus inpatient, overnight stay, for children undergoing percutaneous renal biopsy. Charts of all such patients between January 1989 through January 1995 were reviewed for the following: age of patient, native versus allograft biopsy and preparation costs (in 1995 U.S. dollars), and complications. Of the 75 biopsies reviewed, 58 were native and 17 allograft with 35 (47%) of the biopsies being outpatient and 40 (53%) inpatient. There were four complications (11.4%) in 2 patients for the outpatient group and seven complications (17.5%) in 6 patients in the inpatient group (X² = 0.1003, P = 0.75). The median cost for an outpatient biopsy was U.S. $ 1,968 while an inpatient biopsy was U.S. $ 3,178. We conclude that outpatient percutaneous renal biopsy in children is as safe as inpatient and more economic, with a saving of greater than U.S. $ 1,000 per biopsy. Received October 2, 1995; received in revised form and accepted February 7, 1996     

Diagnosis of renal lymphoma by percutaneous image guided biopsy: experience with 11 cases

PURPOSE: We reviewed an institutional experience with image guided percutaneous biopsy of focal renal masses that yielded a diagnosis of lymphoma. MATERIALS AND METHODS: We retrospectively reviewed the hospital records of patients undergoing percutaneous renal biopsy between September 1997 and February 2005. RESULTS: A total of 407 image guided focal renal lesion biopsies were identified. A diagnosis of lymphoma was made in 11 patients (3%). Biopsies were performed under computerized tomography guidance in 9 cases (82%) and under ultrasound guidance in 2 (18%). Core biopsies were performed in 11 cases, while fine needle aspiration was done in 10 (91%). Fine needle aspirations underwent cytological analysis in 10 cases and flow cytometry analysis in 9. The final combined pathological diagnoses were B-cell lymphoma in 10 cases and lymphomatoid granulomatosis in 1. Analysis of core biopsies yielded a diagnosis of B-cell lymphoma in 10 cases (91%) and lymphomatoid granulomatosis in 1. Analysis of fine needle aspirations yielded a diagnosis of B-cell lymphoma in 3 cases (30%), lymphoma in 4 (40%), suspicion of lymphoma in 1 (10%), atypical cells in 1 (10%) and a nondiagnostic sample in 1 (10%). Flow cytometry concurred with cytology in the diagnosis of B-cell lymphoma in 2 cases, allowed the identification of lymphoma subtype, which was not made on cytology, in 4, was insufficient in 2 and identified no abnormality in 1. No patients underwent surgery or an ablative procedure. CONCLUSIONS: Core biopsy has a higher diagnostic yield than fine needle aspiration for diagnosing renal lymphoma. Flow cytometry analysis adds additional diagnostic information to cytological examination of fine needle aspiration samples. Accurate diagnosis of lymphoma in these cases allowed proper treatment without unnecessary surgery or other procedures.     

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.     

右美托咪定复合氯胺酮用于患儿经皮肾穿刺活检术的效果

目的探讨右美托咪定复合氯胺酮用于患儿经皮肾穿刺活检术的效果。方法选择拟行经皮肾穿刺活检术的患儿60例,男32例,女28例,年龄1～12岁,体重9～36 kg,ASAⅡ或Ⅲ级。采用随机数字表法随机分为两组:右美托咪定复合氯胺酮组(DK组)和丙泊酚复合氯胺酮组(PK组),每组30例。入室后DK组先予右美托咪定1μg/kg负荷量,10 min泵完,后予氯胺酮1 mg/kg静注诱导,右美托咪定0.5μg·kg~(-1)·h~(-1)泵注维持;PK组缓慢静注丙泊酚中长链脂肪乳2～2.5 mg/kg、氯胺酮1 mg/kg诱导,丙泊酚中长链脂肪乳6 mg·kg~(-1)·h~(-1)泵注维持。术中出现体动反应时静脉追加氯胺酮0.5 mg/kg。观察并记录两组术中体动反应、氧饱和度下降(SpO_295%)的发生情况,记录追加氯胺酮情况、术后苏醒时间和苏醒期躁动的发生情况。结果 DK组术中体动反应和SpO_2下降发生率明显低于PK组(P0.05)。DK组追加氯胺酮比例明显少于PK组(P0.05),苏醒时间明显长于PK组(P0.05),苏醒期躁动发生率明显低于PK组(P0.05)。结论右美托咪定复合氯胺酮全麻用于患儿经皮肾穿刺活检术,可有效降低患儿术中体动反应和SpO_2下降发生率,降低追加氯胺酮比例,减少苏醒期躁动,但延长了苏醒时间。     

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.     

Laparoscopic renal biopsy: a 9-year experience

OBJECTIVES: To present our experience and outcome of consecutive laparoscopic renal biopsy over a 9-year period, as renal biopsy remains an important diagnostic procedure for evaluating proteinuria, haematuria and renal failure, but when percutaneous biopsy is contraindicated, a laparoscopic biopsy is an attractive option because it is minimally invasive. PATIENTS AND METHODS: Seventy-four patients (29 male, 45 female, mean age 45 years, range 3-79) had a laparoscopic renal biopsy taken for various indications, e.g. morbid obesity, solitary kidney, coagulopathy, failed percutaneous biopsy, high location of the kidney and poor visualization with ultrasonography. The kidney was approached via a laparoscopic retroperitoneal route using a two-port technique, with the patient in the flank position. After identifying the kidney, one to five cortical biopsies were obtained with cup-biopsy forceps. RESULTS: Adequate tissue was obtained in 96% of the patients; the mean (range) operative duration was 123 (9-261) min and the estimated blood loss 67 (5-2000) mL. Forty-three patients were discharged within 24 h. Complications occurred in 10 patients, with significant bleeding in three. One patient died after surgery, secondary to a perforated peptic ulcer while on high-dose steroid therapy. CONCLUSION: Laparoscopic renal biopsy is a safe and effective alternative to open renal biopsy for patients in whom percutaneous biopsy is not feasible. It offers the advantage of obtaining cortical biopsies and achieving haemostasis under direct vision. Adequate renal tissue is obtained in most cases. Recovery and convalescence are short for most patients.     

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.     

Importance of renal biopsy*

Renal biopsy remains an essential requirement for the accurate diagnosis and treatment of several forms of renal disease. Recent advances in technique have improved the safety of the procedure. However, its use in certain categories of patients remains controversial. These include patients with diabetes or chronic renal failure and patients over the age of 60 years. This brief review addresses some of the advances in the biopsy procedure and its application to diseases of the native kidney.     

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     

Epidemiology of renal disease in Romania: a 10 year review of two regional renal biopsy databases.

BACKGROUND: Epidemiological data of renal disease are available from large national renal biopsy registries from Central and Western European countries; in contrast, detailed epidemiological data from Eastern European countries are missing. This report is the first review of histological data, over a period of 10 years (1995-2004), covering a population of over 6 million inhabitants and two distinct regions from an East European country - Romania. METHODS: 635 eco-guided kidney biopsies from the Moldova (North-Eastern Romania, 8 counties, 4 754 048 inhabitants) and Banat (Western Romania, 3 counties, 1 454 747 inhabitants) regions were analysed. Data on serum creatinine concentration (sCr), 24 h proteinuria, haematuria, clinical diagnosis, histological diagnosis and complications after renal biopsy were collected. RESULTS: The number of biopsies performed varied between 10.9 p.m.p./year in 1995 and 11.3 p.m.p./year in 2004. The most common clinical syndromes - as indication for performing the renal biopsy - were: nephrotic syndrome (52.3%), followed by nephritic syndrome (21.9%), acute renal failure (ARF) (12.4%), chronic kidney disease (CKD) (10.2%) and asymptomatic urinary abnormalities (AUA) (3.3% of the cases). The major histological groups identified were: primary glomerulonephritis (GN) (66.2%), secondary GN (26.4%), vascular nephropathies (2.3%), and tubulointerstitial nephropathies (TIN) (1.5%) of the cases. Among primary GN's, the most frequent diagnoses were: membranoproliferative GN (MPGN) (29.4%, incidence in 2004 - 9.3 p.m.p./year), mesangioproliferative GN (MesGN) (28.9%, incidence - 10 p.m.p./year), membranous GN (MGN) (11.2%, incidence - 5.3 p.m.p./year), minimal change disease (MCD) (8.5%, incidence - 7.3 p.m.p./year), focal and segmental glomerulosclerosis (FSGS) (11.5%, incidence - 3.3 p.m.p./year) and crescentic GN (CGN) (7.9%, incidence - 3.3 p.m.p./year). The prevalence of membranoproliferative GN significantly decreased from 1995 to 2004. The prevalence of different types of secondary GN was similar to Western and Central European countries, with the particular difference of higher infectious diseases associated GN. CONCLUSION: The present data are an important contribution to the epidemiology of renal diseases in Europe, highlighting not only numerous similarities but also significant epidemiological differences in Western and Central European countries, particularly a higher, albeit declining, incidence and prevalence of membranoproliferative GN. This report represents the basis for the future of Romanian Registry of Renal Biopsies and is intended to serve as a source of information for nephrologists concerned with East European renal pathology.