http://www.utdol.com/patients/content/topic.do?

topicKey=~fUTHEZAispiA_M
INTRODUCTION
A renal biopsy, also called a kidney biopsy, is a test that may be done to diagnose and determine the
severity of a kidney disorder. The procedure is generally safe and can provide valuable information
about your kidney disease.
This article discusses why you might need a renal biopsy, how to prepare for it, and what
complications might occur. More detailed information about renal biopsy is available by
subscription. (See "Indications for and complications of renal biopsy".)
REASONS FOR RENAL BIOPSY
A renal biopsy is recommended for certain people with kidney disease. It may be performed when
other blood and urine tests cannot give enough information. The following are the most common
reasons for kidney biopsy. You may have one or more of these problems, but not everyone with
these problems needs a renal biopsy.

Blood in the urine (called hematuria). (See "Patient information: Blood in the urine
(hematuria) in adults".)

Protein in the urine (called proteinuria) occurs in many people with kidney problems. A
renal biopsy may be recommended if you have high or increasing levels of protein in the
urine or if you have proteinuria along with other signs of kidney disease. (See "Patient
information: Protein in the urine (proteinuria)".)

Problems with kidney function If your kidneys suddenly or slowly stop functioning
normally, a renal biopsy may be recommended, especially if the cause of your kidney
problem is unclear.

RENAL BIOPSY PROCEDURE

Preparation Before your biopsy, you may need testing to see if you have a blood clotting
abnormality or infection. To decrease the risk of bleeding, you should stop taking medicines that
increase the risk of bleeding (such as aspirin, ibuprofen, or naproxen) for one to two weeks before
the biopsy. Review your medicines with your healthcare provider to determine which ones are safe
to continue.
If you take warfarin (Coumadin), heparin, clopidogrel (Plavix) or other medicines that prevent
blood clots, ask your physician when to take these medications before your biopsy.
Biopsy procedure Renal biopsy is usually performed you are awake, after you are given local
anesthesia (numbing medicine) to minimize pain. The most common way to perform a biopsy is to
use a needle, which is inserted through the skin and into the kidney.
In most cases, you will have an ultrasound or x-ray so that the physician knows exactly where to
insert the needle. Once the needle is in the right position, the physician will take a sample of tissue
from the kidney with the needle.
In some cases, a different approach is used to perform the biopsy. An open renal biopsy involves
sedating you, injecting local anesthetic to prevent pain, and making a small cut in your skin, which
is opened to obtain the kidney tissue.
After the biopsy, the kidney tissue will be sent to a laboratory and examined with a microscope.
This microscopic examination is looking for scarring, infection, or abnormal deposits in the kidney
tissue. The results of the microscopic exam are usually available within one to two weeks after the
biopsy. In urgent situations, the results can be available within a few hours.
After an open or needle biopsy, you will be kept in a recovery unit for several hours to monitor for

potential complications, including pain and bleeding. Most people can go home after a few hours of
monitoring. Less commonly, you may need to stay in the hospital overnight.
RENAL BIOPSY COMPLICATIONS
Serious complications of renal biopsy are rare. Less serious complications can occur, and can
include bleeding, pain, and development of an abnormal connection between two blood vessels (a
fistula).
Bleeding Bleeding is the most common complication of renal biopsy. Most people will notice
blood in their urine for several days after a renal biopsy. If your urine is bright red or brown for
longer than one week after your biopsy, call your healthcare provider.
Pain Pain is a common problem after a renal biopsy. You will be given medications to reduce
pain after the procedure, and the pain usually resolves within a few hours. If you have severe or
prolonged pain, call your healthcare provider immediately.
Arteriovenous fistula The biopsy needle can accidentally injure the walls of a nearby artery and
vein, and this can lead to the development of a fistula (a connection between the two blood vessels).
Fistulas generally do not cause problems and usually close on their own over time.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2545528/
The Biopty cut procedure for renal biopsies
J C Mackenzie, I G Mackay, N D Millar, A G MacIver, and J B Penry
Br Med J (Clin Res Ed). 1988 April 16; 296(6629): 11281129.

http://www.nature.com/ki/journal/v22/n2/abs/ki1982153a.html
Kidney International (1982) 22, 198201; doi:10.1038/ki.1982.153

A rapid ultrastructural embedding procedure for renal biopsy

tissue
Robert P Swain1, Patricia A Pilia1 and Sterling K Ainsworth1
1Department

of Pathology (Immunopathology), Medical University of South Carolina, Charleston,

South Carolina
Correspondence: Dr S K Ainsworth, Department of Pathology, Medical University of South
Carolina, 171 Ashley Avenue, Charleston, South Carolina 29425, USA
Received 9 December 1981; Revised 12 February 1982.

Abstract
The increasing reliance of pathologists on ultrastructural morphology for the diagnosis of human
biopsy material has created a need for rapid ultrastructural embedding procedures (RUEP) to
accelerate the preparation of material. The reduction of technical time required for complete (wet
tissue to stained grid) processing of a biopsy specimen, from the several days [35] of conventional
tissue processing to less than 1 day, greatly aids the physician in patient management, particularly in
renal pathology. Differentiation between lipoid nephrosis, dense deposit disease, membranous

glomerulonephritis, and amyloidosis is accomplished easily at the ultrastructural level, and in some
cases, can best be diagnosed by electron microscopy. The extent and pattern of distribution of
immune complexes in systemic lupus erythematosus determine both the aggressiveness of treatment
and the prognosis.

http://kidney.niddk.nih.gov/kudiseases/pubs/biopsy/

What is a kidney biopsy?

A biopsy is a diagnostic test that involves collecting small pieces of tissue, usually through a needle,
for examination with a microscope. A kidney biopsy can help in forming a diagnosis and in
choosing the best course of treatment. A kidney biopsy may be recommended for any of the
following conditions:

hematuria, which is blood in the urine

proteinuria, which is excessive protein in the urine
impaired kidney function, which causes excessive waste products in the blood

A pathologist will look at the kidney tissue samples to check for unusual deposits, scarring, or
infecting organisms that would explain a persons condition. The doctor may find a condition that
can be treated and cured. If a person has progressive kidney failure, the biopsy may show how
quickly the disease is advancing. A biopsy can also help explain why a transplanted kidney is not
working properly.
Patients should talk with their doctors about what information might be learned from the biopsy and
the risks involved so the patients can help make a decision about whether a biopsy is worthwhile.
[Top]

What are the preparations for a kidney biopsy?

Patients must sign a consent form saying they understand the risks involved in this procedure. The
risks are slight, but patients should discuss these risks in detail with their doctors before signing the
form.
Doctors should be aware of all the medicines a patient takes and any drug allergies that patient
might have. The patient should avoid aspirin and other blood-thinning medicines for 1 to 2 weeks
before the procedure. Some doctors advise their patients to avoid food and fluids before the test,
while others tell patients to eat a light meal. Shortly before the biopsy, blood and urine samples are
taken to make sure the patient doesnt have a condition that would make doing a biopsy risky.
[Top]

What are the procedures for a kidney biopsy?

Kidney biopsies are usually done in a hospital. The patient is fully awake with light sedation. A
local anesthetic is given before the needle is inserted.
Patients lie on their stomachs to position the kidneys near the surface of their backs. Patients who
have a transplanted kidney lie on their backs. The doctor marks the entry site, cleans the area, and
injects a local painkiller. For a biopsy using a needle inserted through the skin, the doctor uses a
locating needle and x-ray or ultrasound equipment to find the kidney and then a collecting needle to
gather the tissue. Patients are asked to hold their breath as the doctor uses a spring-loaded
instrument to insert the biopsy needle and collect the tissue, usually for about 30 seconds or a little
longer for each insertion. The spring-loaded instrument makes a sharp clicking noise that can be

startling to patients. The doctor may need to insert the needle three or four times to collect the
needed samples.

The kidneys filter wastes and extra fluid from the blood and direct them to the bladder as urine.
The entire procedure usually takes about an hour, including time to locate the kidney, clean the
biopsy site, inject the local painkiller, and collect the tissue samples.
Patients who are prone to bleeding problems should not have a biopsy through the skin. These
patients may still undergo a kidney biopsy through an open operation in which the surgeon makes
an incision and can see the kidney to collect tissue samples.
[Top]

What happens after a kidney biopsy?

After the test, patients lie on their backs in the hospital for a few hours. Patients who have a
transplanted kidney lie on their stomachs. During this time, the staff will monitor blood pressure
and pulse and take blood samples to assess for blood loss. On rare occasions when bleeding does
not stop on its own, a transfusion may be necessary to replace lost blood. Most patients leave the
hospital the same day. Patients may notice some blood in their urine for 24 hours after the test.
A rare complication is infection from the biopsy.
Patients should tell their doctors or nurses if they have any of these problems:

bloody urine more than 24 hours after the test

inability to urinate
fever
worsening pain in the biopsy site
faintness or dizziness

[Top]

How are kidney biopsy results reported?

After the biopsy, the doctor will inspect the tissue samples in the laboratory using one or more
microscopes, perhaps using dyes to identify different substances that may be settled in the tissue.
Electron microscopes may be used to see small details. Getting the complete biopsy results usually
takes a few days. In urgent cases, a preliminary report may be given within a few hours.
[Top]

Points to Remember

A biopsy is a diagnostic test that involves collecting small pieces of tissue, usually through a
needle, for examination with a microscope.

A kidney biopsy can help in forming a diagnosis and in choosing the best course of
treatment.

Before the kidney biopsy, patients should

talk with their doctors to make sure they understand the need for a biopsy
sign a consent form
tell their doctors about any allergies they have and medicines they take
follow their doctors orders for food restrictions

After the kidney biopsy, patients should

lie on their backsor stomachs if they have a transplanted kid-neyfor a few hours
report any problems, such as

bloody urine more than 24 hours after the test

inability to urinate
fever
worsening pain
faintness or dizziness

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31801999000200003

Sao Paulo Medical Journal

Print version ISSN 1516-3180
Sao Paulo Med. J. vol.117 n.2 So Paulo Mar. 1999
doi: 10.1590/S1516-31801999000200003

Original Article
Marilda Mazzali
Maria Almerinda Vieira Fernandes Ribeiro-Alves
Gentil Alves Filho

Percutaneous renal graft biopsy: a clinical, laboratory and

pathological analysis
Disciplina de Nefrologia, Departamento de Clnica Mdica, Faculdade de Cincias MdicasUniversidade Estadual de Campinas, Campinas, Brazil

ABSTRACT
CONTEXT: Renal allograft biopsies have been used as a good method for monitoring the
evolution of kidney transplants for at least 20 years.1 Histological analysis permits differential
diagnosis of the causes of allograft dysfunction to be made.
OBJECTIVES: To correlate the data of urinalysis and serum creatinine with histological diagnosis
of renal graft in a group of renal transplant patients.
DESIGN: Accuracy study, retrospective analysis.
SETTING: A university terciary referral center.
SAMPLE: 339 percutaneous allograft biopsies obtained from 153 patients. Blood and urine
samples were obtained before the graft biopsy.
MAIN MEASUREMENTS: Laboratory evaluation and hystological analysis (light microscopy,
imunofluorescent eletronic microscopy).
RESULTS: Most of the biopsies (58.9%) were performed during the first month post-transplant. An
increase in serum creatinine was associated with acute tubular and/or cortical necrosis. Proteinuria
and normal serum creatinine were associated with glomerular lesions. Non-nephrotic range
proteinuria and an increase in serum creatinine were associated with chronic rejection.
CONCLUSIONS: Evaluation of serum creatinine and urinalysis can be useful in suggesting the
histological graft diagnosis.
KEY WORDS: Kidney transplantation. Renal biopsy. Acute rejection. Acute tubular necrosis.
Glomerulonephritis.

INTRODUCTION
Renal allograft biopsies have been used as a good method for monitoring the evolution of kidney
transplants for at least 20 years.1 Histological analysis permits differential diagnosis of the causes of
allograft dysfunction to be made. Such an evaluation can lead to the avoidance of the use of
additional immunosuppressive drugs, thereby reducing the incidence of complications.1,2 The usual
position of an allograft in the iliac fossa renders it easily palpable and accessible to safe needle
biopsy.1 However, the risk of accidents leading to loss of the allografts is still around 1%.3
Sufficient material for histological evaluation is generally obtained in about 90% of the cases.3
In the present study, we analyzed 339 percutaneous needle allograft biopsies from 135 patients and
compared these results with the clinical presentation and laboratory data obtained before the biopsy
as well as with the incidence of complications.
METHODS
From November 1986 to December 1991, 339 percutaneous biopsies were obtained from 135 renal
transplant patients.
The usual immunosuppressive protocol included azathioprine (2 mg/kg/day) and prednisone (2
mg/kg/day) for recipients of a transplant from a living related HLA-identical sibling donor, and
cyclosporine (7 mg/kg/day) for recipients of a transplant from a living related non-identical or
cadaver donor. Prednisone was progressively reduced to 10 mg/day at the third month posttransplant, and the cyclosporine dose was adjusted to maintain blood levels around 100 to 200 ng/dl
as determined by a monoclonal antibody radioimmunoassay.
Acute rejection episodes were treated with a pulse of methylprednisolone (500 mg/day, IV), for
three days.
Laboratory evaluation. Blood and urine samples were collected before renal biopsy. The urinary

analysis involved sediment and biochemical tests. When proteinuria was positive, 24 hour urine
samples were collected for the quantification of protein. The blood samples were analyzed for their
creatinine (Jaff method) and cyclosporine levels as well as their ability to coagulate.
Indications for percutaneous needle allograft biopsy. Percutaneous needle allograft biopsy was
indicated when at least one of the following criteria was present:
1. An increase in the serum creatinine level to more than 25% above basal.
2. Signs and symptoms of acute rejection, including fever, edema, arterial hypertension, renal pain,
body weight gain, eosinphilia, oliguria and elevation of serum creatinine levels.
3. Cadaver kidney recipients with oliguria or anuria and/or stable serum creatinine levels above
normal values (> 2 mg%).
4. Unsuccessful treatment of the acute rejection with methylprednisolone.
5. Abnormal urinalysis with glomerular hematuria, proteinuria in isolated samples and/or hematic or
leukocytic casts.
6. Twenty-four hour proteinuria above 1 g/day.
Biopsy Procedure. Prior to renal biopsy, the patients had their blood pressure controlled and their
blood coagulation parameters determined. In addition, the allografts were evaluated by renal
ultrasound. If other causes of renal dysfunction such as vascular or ureteral obstruction were
conclusively discarded, the renal biopsy was performed. Vin-Silverman-Franklin or discardable
Tru-Cut Travenol needles were used. Usually the needle was positioned in the convex lateral
border in the superior pole and, after local anesthesia, was introduced in a perpendicular position,
followed by the removal of one or two tissue fragments. Post-biopsy hematuria was monitored by
the visual inspection of urine samples on three separate occasions.
Histological Analysis. Renal biopsy fragments were considered adequate if they contained cortical
or cortical/medullar junction tissue. Samples containing only medullar tissue were inadequate for
diagnosis, and another biopsy was performed. The biopsy material was processed in the University
Department of Pathological Anatomy. Fragments were examined by light microscopy following
HE, PAS and Masson staining. Immunofluorescent staining was done with antiserum to IgM, IgG,
IgA, C3, C1q, kappa and lambda. Some samples were examined by electron microscopy.
Statistical Methods. Statistical analysis was carried out using the chi-square test and unpaired
Students t test.
RESULTS
From November 1986 to December 1991, 339 needle allograft biopsies were obtained from 135
renal transplant patients (95M, 40F), out of a total of 247 such transplants performed during this
period. The number of biopsies per patient (Table 1) was significantly greater in individuals
receiving a kidney from cadaver donors (p < 0.05). In 64 such recipients, 194 biopsies were done,
compared to 145 biopsies in 71 patients receiving a kidney from related living donors (14 HLAidentical and 57 non-identical).

The indications for renal biopsy were graft dysfunction in 272 instances (80.2%), anuria in 34
(10.0%) and abnormal urinalysis in 33 (9.8%). Graft dysfunction (n = 272) was associated with
oliguria in 74 instances (27.2%) and no response to rejection treatment in 15 (5.5%). In the patients
for whom allograft biopsy was indicated by abnormal urinalysis, the most frequent abnormality
observed was isolated proteinuria (in 20 biopsies) followed by proteinuria in association with
glomerular hematuria in six biopsies. Isolated glomerular hematuria was the cause of renal biopsy
on seven occasions (Table 2). One hundred and eighty-three biopsies (53.9%) were done during the
first month post-transplant, with a gradual reduction in the number thereafter. In the first year after
the renal transplant, 302 biopsies (89%) were performed (Table 3). Adequate material for analysis
was obtained in 306 fragments (91.1%). Severe hemorragic complications occurred in four cases,
and led to graft loss in two.

ACR = acute cellular rejection, AVR = acute vascular rejection, ATN = acute tubular necrosis, CR =
chronic rejection, GN = glomerulonephritis. *other: medullar (n=33), cortical necrosis (n=13), hemolytic
uremic syndrome (n=3), Cyclosporine nephrotoxicity (n=2), chronic pyelonephritis (n=2), normal (n=1),
granulomatosis (n=1), nephrosclerosis (n=1).

Acute rejection was observed in 136 fragments (40.1%), 106 of them during the first two months
post-transplant and four after the first year. In this group, renal dysfunction was the main indicator
of renal biopsy in 127 instances, followed by anuria in seven and abnormal urinalysis in two. Acute
cellular rejection (ACR) without a vascular component or acute tubular necrosis was observed in 57
biopsies. ACR associated with acute tubular necrosis was seen in 47 instances and was associated
with vascular rejection in 32 fragments. No difference in the incidence of ACR was observed
between recipients of cadaver or living-related donor organs.
Acute tubular necrosis (ATN) was the second most frequent diagnosis (66 biopsies, 19.4%). As with
ACR, acute tubular necrosis was observed mainly during the first two months post-transplant (62
cases). The histological diagnosis of ATN was more frequent in cadaver donor recipients. In
individuals with ATN, the indication for biopsy was renal dysfunction in 52 instances, anuria in 12
and abnormal urinalysis in two.
Chronic rejection was observed in 40 fragments (11.7%). This diagnosis became more frequent
after the sixth month post-transplant (Table 3). Renal dysfunction was again the major indicator of
the need for a biopsy. In 26 fragments, a glomerular lesion was detected.
Glomerulonephritis (GN) was diagnosed in 27 biopsies (7.9%). Focal and segmental
glomerulosclerosis was the most frequent diagnosis, occurring in ten biopsies from eight patients.
Mesangiocapillary type I GN was observed in seven biopsies from four patients, and type III in two
biopsies from two patients. Membranous GN occurred in two fragments from two patients. In one
patient, the diagnosis was mesangial proliferative GN. In this group, proteinuria (7.71g, SD 8.82)
was greater than in others, while serum creatinine (2.36mg/dl, SD 1.99) was the lowest among the
various groups. In living donor recipients, the diagnosis of GN was more frequent than in cadaver
ones.
Acute vascular rejection was observed in 14 fragments (4.1%) from 11 patients. Graft loss occurred
in all patients within two months after diagnosis. All biopsy indications were based on renal
dysfunction. The urinalysis (proteinuria below 1 g/l, hematuria < 50 RBC per high power field) and
serum creatinine levels (6.45 mg/dl) were similar to ACR group.
Cortical necrosis was the diagnosis in 13 fragments (3.8%), and in 12 of them the indication for
renal biopsy was anuria. All biopsies were done in the first month post-transplant. A total of seven
patients were included in this group and all the grafts were removed.
DISCUSSION
Percutaneous needle allograft biopsy may be performed in order to evaluate the renal function of
kidney transplant patients. The position of the allograft in the iliac fossa permits easy access for the
biopsy procedure. The kidney can be localized by bimanual palpation and hemostasis is facilitated
by the use of a compressive technique.3 Adequate material for histological analysis, containing
cortical and cortical/medullar junction material is obtained in 80% to 100% of renal biopsies. Renal
biopsy accidents that result in kidney loss are rare, occurring in about 1% of the cases. In the
present study, the incidence of allograft loss after percutaneous needle biopsy was 1.5% (2 graft
losses for 135 patients).
The major indication for kidney transplant biopsy was the differential diagnosis of acute rejection
and renal dysfunction. This indication was based on the increase in serum creatinine levels.

Probable differential diagnoses included acute vascular rejection, chronic rejection, acute tubular
necrosis and cyclosporine nephrotoxicity. Matas1 suggested that 40% of renal transplant patients
presented no changes in their immunosuppressive therapy after renal allograft biopsy. In the present
study, unchanged immunosuppression was observed in 38% of the cases.
The usefulness of urinalysis as an indicator for allograft biopsy is controversial. Hematuria has no
value either as an indicator for renal biopsy or in the prognosis of renal function. Proteinuria is an
important marker and has been extensively studied.4,5,6,7 Massive proteinuria after transplant is
frequent during the first three months, with spontaneous remission during evolution.4 Persistent
proteinuria occurs in about 30% of transplants, and is positively correlated with the presence of
glomerular lesions, which is indicative of chronic rejection or glomerulonephritis. Persistent
proteinuria is one of the most frequent indicators for renal biopsy. In the present study, proteinuria
was used as an indicator for allograft biopsy in 7.6% of the cases, and was present in 21.6% of the
renal biopsies.
Abnormal urinalysis was indicative of allograft biopsy in 10% of the cases, especially after the third
month post-transplant. The histological diagnoses were chronic rejection and glomerular disease.
Acute tubular necrosis (ATN) occurs in about 30 to 60% of cadaver kidney recipients and in about
10% of recipients from living donors.8 The former incidence may be associated with extended
periods of cold organ storage that can promote tissue ischemia and acute tubular necrosis. The
hemodynamic status of the donor can also influence the onset of acute tubular necrosis.8,9 In our
study, ATN occurred in 29.3% of the patients (74.3% received a kidney from a cadaver donor and
25.6% from a living donor). Urinalysis was not important in this group, since the presence of nonglomerular hematuria and leukocyturia could have been secondary to the post-operatory period or to
the presence of a bladder catheter.
Acute rejection is considered to be the most frequent cause of allograft dysfunction and usually
occurs during the first three months post-transplant.1,2 In the present study, we observed acute
rejection in 40.1% of the biopsies. The incidence of acute rejection was similar between recipients
from cadaver or living related donors. Acute rejection associated with ATN was a frequent
histological observation in our patients. This association may reflect antigen presentation by
necrotic tubule cells which results in a rejection process.8
Acute vascular rejection can be secondary to the presence of humoral factors.10 Vascular rejection is
considered a poor prognostic indicator, because the intimal infiltrate can lead to occlusive
arteriolopathy and tissue ischemia.11 Individuals in this group had short survival since the
aggressive immunosuppressive therapy can promote infectious complications and death of the
patient. In our series, acute vascular rejection was associated with long-term graft loss in 100% of
the cases. The histological analysis showed renal cortical ischemia and obliterative arteriolopathy,
secondary to intimal growth, suggestive of endothelial disease.
Chronic rejection occurs frequently after the sixth month post-transplant and progresses to chronic
renal failure.12 The condition occurs in about 17% of renal transplants, although in our series the
incidence of chronic rejection was 11.8% (40 histological diagnoses in 21 patients). The clinical
diagnosis was based on an increase in serum creatinine levels, usually in the presence of normal
urinalysis. The average level of isolated proteinuria was about 1.31 g. Histological evaluation
showed tubular atrophy, interstitial fibrosis and thickening of vascular walls, all of which suggest
ischemic disease. Varying degrees of glomerular sclerosis were also present. The differential
diagnosis between transplant glomerulopathy, chronic rejection and segmental glomerulosclerosis
can be difficult. Immunofluorescence and electron microscopy can be helpful in such cases.
Post-transplant glomerulonephritis is frequent, but classification as de novo, recurrent or
indeterminate is difficult since the primary renal disease is rarely diagnosed. Such

glomerulonephritis can be due to persistent systemic factors,13 donor glomerular disease,14

ischemic lesions, hypertension or secondary to acute rejection episodes.8 Following its introduction,
cyclosporine has been found to be a further factor causing glomerular lesions15,16
Histologically, glomerular lesions can be superposed since, as with ischemia, hypertension and
immunological or toxic factors, the pathogenic mechanisms can lead to endothelial injury17 which
in turn produces focal and segmental glomerulosclerosis, usually in the vascular pole of the
glomerulus. These mechanisms can promote thickening of the basal membrane. In short, the
histological analysis of biopsy fragments by optical microscopy alone, along with imprecise
diagnosis of the primary renal disease, does not permit correct diagnosis of post-transplant
glomerular disease.
The differential diagnosis of chronic rejection, cyclosporine-mediated nephrotoxicity and focal and
segmental glomerulosclerosis requires immunofluorescence and electron microscopy. The serum
levels of cyclosporine may also be useful in such diagnoses.17,18
In summary, percutaneous needle allograft biopsy is an useful procedure in the follow-up of kidney
transplants. Since such biopsies permit a differentiation between rejection and any other causes of
allograft dysfunction, they should prove to be useful in determining adequate immunosuppressive
therapy and in reducing the risk of complications.
The only laboratory data that generally correlated with the histological diagnosis was the elevation
in serum creatinine levels associated with ATN or cortical necrosis. Proteinuria with normal
creatinine levels was associated with glomerular lesions, usually after the sixth month posttransplant. Late proteinuria in the non-nephrotic range associated with increased creatinine levels
may be indicative of chronic rejection.

http://www.nlm.nih.gov/medlineplus/ency/article/003907.htm
Renal biopsy

MedlinePlus Topics
Kidney Diseases
Images
Kidney anatomy
Kidney - blood and urine flow

Renal biopsy

Read More
Acute nephritic syndrome
Acute tubular necrosis
Alport syndrome
Atheroembolic renal disease
Diabetic nephropathy
Focal segmental glomerulosclerosis
Goodpasture syndrome
IgA nephropathy
Interstitial nephritis
Lupus nephritis
Medullary cystic kidney disease
Membranoproliferative GN
Membranous nephropathy
Minimal change disease
Nephrotic syndrome
Post-streptococcal GN
Protein - urine
Systemic lupus erythematosus
Transplant rejection
Urine - bloody
A renal biopsy is the removal of a small piece of kidney tissue for laboratory examination.
How the Test is Performed
There are many ways to perform a kidney biopsy. The most common uses ultrasound guidance.
This means the doctor uses an ultrasound image to locate the proper area in your kidney. The biopsy
is done in the hospital, usually in the radiology suite. Your doctor will go over the procedure,
benefits, and risks in great detail.
You will lie face down for at least 20 - 30 minutes. A towel may be placed under your upper
abdomen so you remain in the correct position. Ultrasound will be used to find the proper biopsy
site. The health care provider will then apply local numbing medicine (anesthetic) to the skin near
the area.
The health care provider makes a tiny cut in the skin and inserts a biopsy needle into the area and to
the surface of the kidney. You will be asked to take and hold a deep breath as the needle is
introduced into the kidney. If the health care provider is not using direct ultrasound guidance, you
may be asked to take deep breaths to verify the needle is in place.
The biopsy needle is then withdrawn, and pressure is applied to the biopsy site to stop the bleeding.
The needle may need to be inserted again (possibly several times) before enough tissue is collected.
After the procedure, a bandage is applied to the biopsy site.
You will need to stay in bed for 6 - 8 hours after the procedure and will remain in the hospital for a
day. The health care team will give you pain medicines and fluids by mouth or a vein. Your urine
will be checked for excessive bleeding. (A little bleeding usually occurs.) Blood counts and vital
signs are monitored.
Kidney biopsies may also be done using CT scan guidance. Under some circumstances, the biopsy
may be performed by running the biopsy catheter through one of the neck veins -- this is called a
transjugular biopsy.

How to Prepare for the Test

Tell your doctor if you are pregnant or if you have any drug allergies or bleeding problems. Make
sure the health care team knows what medications you are taking.
You may be told to avoid foods or fluids before the test.
How the Test Will Feel
The amount of pain during and after the procedure depends on the patient. Because a local
anesthetic is used, discomfort during the procedure is usually minimal. The anesthetic may burn or
sting when first injected. After the procedure, the area may feel tender or sore for a few days.
You may see bright, red blood in the urine the first 24 hours after the test. If the bleeding lasts
longer, tell your health care provider.
Why the Test is Performed
Your doctor may order a kidney biopsy if you have an unexplained drop in kidney function,
persistent blood in the urine, or protein in the urine. The test is sometimes used to evaluate a
transplanted kidney.
Normal Results
A normal value is when the kidney tissue shows normal structure.
What Abnormal Results Mean
An abnormal result means there are changes in the kidney tissue. This may be due to infection, poor
blood flow through the kidney, connective tissue diseases such as systemic lupus erythematosus, or
other diseases that may be affecting the kidney.
For transplant patients, an abnormal kidney biopsy may be a sign of transplant rejection.
Additional conditions under which the test may be performed:

Acute nephritic syndrome

Acute tubular necrosis
Alport syndrome
Atheroembolic renal disease
Chronic glomerulonephritis
Complicated urinary tract infection
Diabetic nephropathy
Focal segmental glomerulosclerosis
Goodpasture syndrome
IgA nephropathy (Berger's disease)
Interstitial nephritis
Lupus nephritis
Medullary cystic kidney disease
Membranoproliferative GN I
Membranoproliferative GN II
Membranous nephropathy
Minimal change disease
Nephrotic syndrome
Post-streptococcal GN
Rapidly progressive glomerulonephritis

Risks
Risks include:

Bleeding from the kidney (in rare cases, may require a blood transfusion)
Bleeding into the muscle, which might cause soreness
Infection (small risk)

Considerations
Avoid strenuous activities and lifting heavy objects for 2 weeks after the test. Sometimes a repeat
biopsy is needed.
Alternative Names
Kidney biopsy; Biopsy - kidney
Update Date: 10/22/2007
Updated by: Robert Mushnick, M.D., Clinical Assistant Professor, Department of Nephrology,
SUNY Downstate Health Center, Brooklyn, NY. Review provided by VeriMed Healthcare Network.
http://www.sprun.scot.nhs.uk/Documents/Renal%20Guidelines/Renal%20Biopsy.pdf

Contraindications
Renal biopsy remains a relatively a blind procedure and bleeding may be difficulty to detect.
However, unlike the liver, kidneys are contained

in a firm fascial compartment. Perirenal

hematomas usually are well walled off and become organized and reabsorbed. Nevertheless, we
avoid biopsy wherever there is any significant deviation in the bleeding or coagulation work-up.
Patients with rapidly advancing uremia are likely to bleed even when the coagulation work-up is
normal. Most of such patients will come to post mortem and we see little justification for biopsy. It
is unwise to biopsy a unilateral kidney since bleeding necessitating operating removal would have
obvious tragic complications. Total anuria is a contraindication unless a ureteral catheter is in place.
We have hesitated to enter a renal abscess or perinephritis because of the fear of spreading infection.
The same consideration might be applied to malignant cells. Two of the most serious instances of
bleeding have been encountered in malignant hypertension. We have oral reports of several
fatalities in this type of patient and have therefore included it in the contraindications.

Transjugular renal biopsy in high-risk patients: an

American case series
Kevin C Abbott1 , Franco M Musio1
and Christina M Yuan1

, Ellen M Chung2

, Nick N Lomis2

, John D Lane2

Nephrology Service, Walter Reed Army Medical Center, Washington, DC

Interventional Radiology Service, Walter Reed Army Medical Center, Washington, DC

author email

corresponding author email

BMC Nephrology 2002, 3:5doi:10.1186/1471-2369-3-5

The electronic version of this article is the complete one and can be found online at:
http://www.biomedcentral.com/1471-2369/3/5
Received: 2 April 2002
Accepted: 11 July 2002
Published:11 July 2002
2002 Abbott et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying
and redistribution of this article are permitted in all media for any purpose, provided this notice is
preserved along with the article's original URL.
Keywords: transjugular renal biopsy, kidney, liver, anticoagulation, horseshoe kidney, renal failure

Abstract
Background
In the United States, transjugular renal biopsies using the Quickcore side cut needle system have
previously been described primarily for transjugular renal biopsy in patients with concurrent liver
and kidney disease.
Methods
We describe transjugular renal biopsy with the Quickcore system in 9 patients with nephrotic
syndrome and contraindications to percutaneous renal biopsy, who underwent biopsy between 23
October 1996 and 12 April 2001. The most common contraindication was oral anticoagulation with
coumadin (40%). Other contraindications included horseshoe kidney, severe renal failure, and
spontaneous coagulopathy. A 62 cm straight catheter and 60 cm side-cut Quickcore biopsy needle
were used to obtain cortical tissue. Packing of the biopsy tract with Gelfoam was used for
venographically identified capsular perforation.
Results
Ten procedures were performed on 9 patients with one requiring re-biopsy (5% of all renal biopsies
performed at our institution). There were 9 transjugular renal biopsy and one combined liver-kidney
biopsy. A mean of 4 2 passes were made, with a mean of 3 1 cores obtained per procedure.
Histologic diagnosis was made in 90% of biopsies and in 100% of patients. Two patients developed
transient hydronephrosis associated with gross hematuria; both required transfusion. Capsular
perforation occurred in 90%. One patient died of bacterial sepsis, unrelated to the biopsy, several
days after the procedure.

Conclusions
Transjugular renal biopsy appears to be efficacious in high-risk patients, for whom the percutaneous
approach is contraindicated, including patients on oral anticoagulation. The transfusion rate in the
present study was similar to other American reports using this technique.

Background
The number of patients who are not suitable candidates for percutaneous renal biopsy (PRB) may
increase in the future because of increasing prevalence of bleeding diatheses, both spontaneous and
due to wider use of anticoagulation for thrombotic disorders and dysrythmias. [1] The most
common indication for renal biopsy in the United States is the nephrotic syndrome. [2] This
condition has been associated with an increased risk of thromboembolism, particularly in patients
with membranous nephropathy [3] or systemic lupus erythematosus, [4] and such patients may thus
also require anticoagulation. Several alternative techniques have developed over the last decade for
those who have contraindications to PRB. Of these, the most widely used are the various methods
of endovascular biopsy. The current status of transjugular renal biopsy (TJRB) has been reviewed
recently. [1] Most reports and the largest series, in a broad array of settings, have come from
Europe. [5-7] In the United States, the only reports of experience with TJRB have been in patients
with concurrent liver and kidney disease. [8]
Since the seminal report of Mal, et al [5], an even larger TJRB series has been reported by Cluzel, et
al [6]. Four hundred patients undergoing TJRB were compared to 400 patients undergoing PRB,
using the modified Colapinto aspiration needle system. Diagnostic tissue adequacy was 95.8%,
with a major complication rate of 1%. Although excellent results were obtained, this technique
appears to require a steep "learning curve," according to the authors. The endovascular automated
side-cut core biopsy sets such as the Quick-Core (Cook, Bloomington, IN) may allow even
higher yields of diagnostic tissue with possibly less operator-dependence. In addition, biopsy tract
embolization to reduce bleeding risk post-biopsy is possible using this system. So far no American
center has reported results on the use of the Quick-Core biopsy set in patients with
contraindications to PRB (other than combined liver and kidney disease) referred for TJRB. We
report our experience with this technique at our institution from October 1996April 2001.

Materials and Methods

Data on 9 of 10 patients undergoing TJRB at Walter Reed Army Medical Center (WRAMC) from
23 October 1996 to 30 April 2001, including demographics, indications, technical details, and
complications, were recorded and analyzed. The starting date reflects the time at which all TJRB
began to be tracked by both Nephrology and Interventional Radiology at WRAMC. The protocol
(WU # 1186) was submitted to the WRAMC institutional review board and approved in May 1997.
Seven patients with biopsies performed between October 1996 and May 1997 were analyzed
retrospectively. Data on 3 of 4 subsequent biopsies were obtained prospectively. (One patient
declined consent, and thus no clinical data is available regarding the biopsy). Six different
interventional radiologists performed the biopsies over the course of the study.
All biopsies were performed in the interventional radiology suite with biplane or single-plane
anteroposterior and lateral fluoroscopic capabilities. Biopsy was performed only if patient blood
pressure was <140/90 mm Hg. In most patients, a previous abdominal sonogram was available.
Prothrombin time, partial thromboplastin time, INR (where indicated), platelet count, and serum
creatinine level were obtained before each procedure. No patient had significant thrombocytopenia.
Management of patients on anticoagulation was per the recommendations of Kearon, et al [9]. No
patient was given fresh frozen plasma or cryoprecipitate, before or after the procedure. No bleeding
times were performed. Patients were given pre-biopsy DDAVP or estrogen if the serum creatinine

was 3 mg/dl or the creatinine clearance by the Cockcroft-Gault formula was 30 cc/min, as
previously described (N = 5) [10]. No patients were dialysis-dependent, either acutely or
chronically.
All biopsies were performed with the transjugular Quick-Core needle biopsy system (Cook,
Bloomington, IN), which consists of a 7 F, 50.5-cm transjugular sheath with a 14 G inner-stiffening
cannula; a 5 F, 80-cm multipurpose curved catheter; and a 60-cm biopsy needle with a 2-cm throw
length. Biopsy was performed preferentially on the right kidney because the right renal vein is
shorter than the left, and provides a better angle for access to the kidney. Biopsy specimens were
obtained with the 60-cm biopsy needle oriented in a posterolateral direction to avoid inadvertent
puncture of the colon.
The right neck was prepared and draped in sterile fashion. A guide wire was advanced through the
distal lumen of 9F catheter into the inferior vena cava and the 9F catheter removed. This was
replaced with a 14F short vascular sheath.
For the one patient who underwent a combined liver and kidney biopsy, a 5F angled multipurpose
catheter was advanced through this sheath, over a wire, to the inferior vena cava and used to
selectively cannulate the right hepatic vein. The catheter was passed distally into the hepatic vein.
Hepatic wedge venography with carbon dioxide (because of the patient's renal insufficiency) was
performed. An Amplatz (Cook, Bloomington, IN) wire was then placed and the catheter removed.
Over the Amplatz wire the Cook Quick-Core biopsy sheath was advanced without difficulty
into the proximal hepatic vein. The wire was removed and a 20-gauge Quick-Core biopsy needle
used to obtain core biopsy specimens. The sheath was then removed over a wire.
For patients undergoing renal biopsy (either combined or separate), after cannulation of the right
internal jugular vein, the multipurpose catheter was advanced and used to engage the right renal
vein. Over a hydrophilic wire, the catheter was advanced until it wedged within the right lower pole
of the kidney. This was verified by injection of 3 cc of contrast material. The guiding sheath was
then angled posteriorly (to avoid inadvertent colonic puncture) and biopsy specimens obtained with
the 18-gauge Quick Core needle as described for liver biopsy. Extravasation of contrast post
venography through the sheath was taken as evidence of capsular perforation. If extravasation of
contrast was seen, the tract was selected using a Terumo wire and the small catheter included in the
liver access set. A Gelfoam (Pharmacia, Upjohn Inc., Peapack, New Jersey) pledget was then
placed at the far aspect of this tract near the capsule until no further extravasation of contrast was
demonstrated. The collecting system was assessed for free drainage of contrast or development of
caliectasis. No further filling of the tract was demonstrated after the embolization. All biopsy
devices were then removed. The catheter, its stiffeners, and sheath were all removed and hemostasis
obtained with manual compression. For patients previously on oral coumadin, depending on the
indication (as per Kearon, et al [9]), intravenous heparin was restarted in as soon as two hours (no
bolus, maintenance infusion only). Oral coumadin was generally started the same night.
For the patient with the horseshoe kidney, access to the right internal jugular vein and inferior vena
cava was as above. A wedged venogram with a very small amount of contrast material demonstrated
some cortical staining. The Rosen guide wire was reintroduced and the catheter was exchanged for
the 8-French vascular sheath with a stiffener. The guide wire was removed, and a small amount of
contrast material again demonstrated intravascular placement of the sheath.
There was transgression of the collecting system with the first biopsy specimen; however, there was
no filling of the collecting system following the introduction of a single pledget of GelfoamTM.
After completion of the procedure, there was no evidence of intraluminal filling defect within the
right renal collecting system (i.e., no significant thrombus within the collecting system). The
extracapsular contrast collection was approximately 2 cm 2 cm and was not observed to expand
over the final 10 minutes of the procedure.

The length of core samples obtained was generally 1014 mm, maximally 1820 mm. Tissue for
hematoxylin and eosin, periodic acid-Schiff and other special stains, as well as electron microscopy
was fixed in 2% glutaraldehyde solution. Tissue for immunofluorescence was preserved in Michel's
Fixative (Poly Scientific, Bay Shore, NY). Paraffin sections were used for light microscopy.
Specimens were processed for immunofluorescence and electron microscopy in standard fashion.
All specimens were examined by a single nephropathologist at the Armed Forces Institute of
Pathology.
After biopsy, outpatients were admitted to a 23-hour recovery unit, and remained in bed for at least
12 hours, with frequent observation of vital signs. Hematocrit was assessed 46 hours post biopsy.
Serial urines were collected to assess for hematuria. All but two of the patients in whom TJRB was
performed as an outpatient procedure were discharged the next day. The patient found to have
systemic amyloidosis was already an inpatient for clinical reasons.

Results
Patient characteristics, contraindications to conventional PRB, and outcomes are shown in Table 1
(see additional file 1). Ten biopsies were performed in 9 patients (1 patient had a successful repeat
TJRB one month after the first attempt yielded inadequate tissue). No patient required open surgical
biopsy. Mean age was 58 21 years. Six were Caucasian; 2 African-American, and 1 AsianAmerican. There were 4 males and 5 females.
Four of 9 patients had substantial renal failure, i.e., serum creatinine 3 mg%, which constituted a
relative contraindication. No patient was referred for morbid obesity. The most common
contraindication to PRB was bleeding diathesis (5/9), either due to coumadin anticoagulation (2
with history of deep vein thrombosis, 1 with history of pulmonary embolus, and 1 with anticardiolipin antibody syndrome with associated deep vein thrombosis) or spontaneous coagulopathy.
No patient had a platelet count < 100,000 cells/mm3. Mean INR (international normalized ratio) at
the time of biopsy in these 5 patients was 1.4 0.3. Two patients proved to have membranous
glomerulonephritis, and were on coumadin prior to biopsy. Proteinuria had preceded
thromboembolic events in these patients.
Tissue was adequate for diagnosis in 9/10 biopsies, and in all patients (due to successful re-biopsy).
The mean number of passes was 4 2, yielding 3 1 biopsy cores, with a mean glomerular number
of 9 8. Capsular perforation occurred in 9/10 biopsies, but gross hematuria occurred in 6/10
biopsies-1 of which occurred in the only patient without capsular perforation. The biopsy that
produced inadequate tissue was the only one in which capsular perforation did not occur. The
hematocrit declined 4 % after biopsy in 3/10 biopsies. Transfusion was needed in only 2 patients;
these two also developed hydronephrosis due to collecting system bleeding, which resolved without
further intervention. One had horseshoe kidney, and the other was on coumadin for anti-cardiolipin
antibody syndrome. She resumed intravenous heparin and coumadin the day of the biopsy due to
high thrombosis risk. Only one other of the 4 patients on oral anticoagulants had intravenous
heparin restarted the same day; the other two began oral coumadin that night. One patient died of
bacterial sepsis (presumed due to line infection) several days after biopsy (an 88-year-old man with
liver and renal amyloidosis). No patient developed significant renal failure after the procedure
(defined as a serum creatinine level elevation 1.5 mg/dl or requirement for dialysis).
Additional File 1. Table1
Format: DOC Size: 44KB Download file
This file can be viewed with: Microsoft Word Viewer

Discussion
Recent series have shown that tissue adequacy with TJRB is excellent (>95%) 5,7 and comparable
to PRB [5]. The tissue adequacy of 90% for procedures and 100% for patients in our study is
comparable to that in other reports. The mean number of glomeruli obtained by Sam, et al [8] was
higher than in our series. This may be due to their routine use of pathology review during biopsy,
which was not feasible at our institution.
Biopsy influenced management in all cases, except for Patient 9, who was diagnosed with
amyloidosis, and who died from sepsis. Subsequent to biopsy, patients 1 and 2 were treated with
chlorambucil and methylprednisolone [11]. Patient 7, who presented with heavy proteinuria and
nephritic urinary sediment, proved to have mesangial lupus nephritis. Without renal biopsy, which
excluded diffuse proliferative lupus nephritis, she might have been reasonably treated empirically
with cyclophosphamide [12]. Patient 8 had minimal change nephropathy. While this 22-year-old
patient might have been treated empirically with prednisone, his presentation was also consistent
with focal segmental glomerulosclerosis, which would have been treated differently [13].
Although large series of TJRB using the modified Colapinto aspiration needle system have been
reported [5-7], the largest series on the use of 18-g automated biopsy needle is that of Sam, et al, [8]
which reported on 29 TJRB. In the series reported by Cluzel, et al [6], 8 of 400 TJRB were done
with Quick Core automated systems. They commented that the stiffness of the Quick Core
system virtually precludes a left jugular approach, but because of its thinness, allows deeper
placement in the renal parenchyma. The Colapinto device appears to require more training to
deploy properly, because of its flexibility and the requirement for manual aspiration of samples. In a
randomized, unblinded study of liver biopsies, the time required for training, procedure time, and
tissue adequacy were superior for automated biopsies vs. aspiration biopsies, with similar
complication rates [14]. No such comparisons exist for TJRB.
During the same time period as this series, we performed 192 native PRB. There were no
laparoscopic or open surgical biopsies. Thus, only 5% of biopsies at WRAMC were deemed
"contraindicated" by the percutaneous approach, and all were able to be done using TJRB.
Therefore, TJRB, at least in our practice setting, is unlikely to become a "high-volume" procedure,
but despite this, is able to be effectively and safely done by interventional radiologists with
transjugular liver biopsy experience and equipment, i.e., the Quick Core automated system.
Transjugular liver biopsy is generally a more common procedure, and was performed 1214 times a
year at our institution during the time of the study.
In our series, 5/9 patients had a coagulopathy, either spontaneous or due to coumadin. Two (22%)
had an INR > 1.5 at the time of biopsy, in comparison to 39% in the series of Sam, et al [8], whose
patients had advanced chronic liver disease. They attempted to correct coagulopathy in all patients,
although the details of correction were not specified. In contrast, because of the different etiology of
coagulopathy in most of our patients, we performed TJRB through a heparin window as per Kearon,
et al [9]. Theoretically, the same could be done for PRB, although bleeding risk would typically
persist for six weeks, and the percutaneous tract would be associated with a greater bleeding risk
than with TJRB, even given capsular perforation.
The issue of capsular perforation is also relevant to tissue adequacy. In animal models, better
specimens with more glomeruli were obtained after unintentional capsular perforation, presumably
due to more distal positioning of the biopsy needle [15]. The high rate of capsular perforation in our
study was not associated with a high complication rate, given the high risk of the population. The
transfusion rate of 20% is lower than the 29% rate of Sam, et al [8]. The use of a side-cut needle
with a shorter (1 cm) throw and a blunt-tipped end to reduce the risk of capsular perforation and
other organ damage 16 has been successful in animal models, but has not been reported in humans.

Cluzel, et al [6] reported low transfusion rates (about 1%) after TJRB. However, the population
studied is not comparable to ours or that of Sam, et al [8]. Possibly the most common indication for
TJRB in the Cluzel study was an elevated bleeding time, even with a normal creatinine or absent
bleeding history. It was largely on this basis that 76% of the patients in the study were said to have
had a "bleeding abnormality." In many centers, particularly in the United States, such patients are
likely to be treated with DDAVP or conjugated estrogen before PRB [1]. In our study, only one
patient with a "coagulopathy" required transfusion. The other transfusion was required by the
patient with a horseshoe kidney, who had no other risk factors for bleeding, and is, to our
knowledge, the first such patient to undergo TJRB.
The two cases of bleeding-associated hydronephrosis, one of which was in the patient with
horseshoe kidney, were the result of a communication with the urinary tract. In the horseshoe
kidney, this could have been due to aberrant location of the collecting system. In fact, contrast
extravasation into the collecting system was observed during the procedure. In the other case,
caliectasis was noted during the procedure, which was initially attributed to the pressure of
injection. This patient had been on coumadin anticoagulation, although the INR at the time of
biopsy was 1.2. She was restarted on heparin and coumadin the day of the biopsy because of high
risk of thrombosis. The use of Gelfoam embolization did not prevent significant bleeding in these
two patients, possibly because the tracts could not be exactly approximated, or the Gelfoam
pledget became displaced. It is noteworthy that both transfusion and Gelfoam failure were
associated with urinary tract perforation, because Gelfoam embolization is less likely to be
successful in preventing bleeding in this setting. Gross hematuria, without the need for transfusion,
has not been reported specifically as a complication after TJRB. Therefore, our gross hematuria rate
of 60% cannot be compared with other studies. However, we speculate that in the process of
obtaining a core specimen, adjacent vessels were disrupted and could have led to introduction of
blood into the renal tubules, especially in patients with disturbed hemostasis.
The one death in our series was due to sepsis in a patient with systemic amyloidosis, unrelated to
the biopsy. The patient's hematocrit declined only 1.4% post-procedure, despite a spontaneous
coagulopathy.
The generalizability of our series is limited by its small size. Because none of the patients were
obese, no conclusions about the safety of TJRB in obese patients can be drawn. As technology
improves, the cost and complexity of TJRB is likely to decrease. In fact, the cost of TJRB at
"experienced" institutions is less than twice that of PRB, and the technique is particularly
advantageous in combined liver-kidney biopsy [5-8]. Given the "user-friendly" characteristics of the
Quick Core transjugular biopsy set, interventional radiologists throughout the world with
transjugular liver biopsy experience can reasonably apply this technique. The most common
contraindications to PRB are likely to be maintenance anticoagulation or bleeding diathesis (due in
some cases to acute or chronic renal failure), perhaps followed by congenital abnormalities. The
present study shows that the transjugular technique can obtain diagnostic renal tissue in these
circumstances. The safety of this procedure in high-risk populations is still uncertain due to the
small numbers of patients studied with the equipment used in the present study. Due to the low
volume of procedures, it is unusual to find institutions with experience in multiple methods of highrisk renal biopsy (ie, both TJRB and Laparoscopic renal biopsy). Because TJRB is considered only
when conventional PRB is contraindicated, comparison with PRB is not possible. Future studies are
suggested to determine the best method of embolizing the biopsy tract in TJRB, given the results of
the present study.

Competing Interests
None declared.

Author's contributions
Dr. Abbott assumed the role of primary investigator for the research protocol after the departure of
Dr. Musio, and was responsible for data collection, analysis, and manuscript preparation.
Dr. Musio originally submitted the research protocol, and as the first primary investigator, was
responsible for submission of the initial abstract, which was presented a poster at the 1997
American Society of Nephrology meeting and published in the Journal of the American Society of
Nephrology in 1997.
Dr. Chung was responsible for performance of the transjugular renal biopsy in the patient with the
horseshoe kidney and was responsible for the diagnostic and therapeutic planning and description of
the case, as part of the overall manuscript.
Dr. Lomis was responsible for the performance of the combined transjugular renal and hepatic
biopsy, the first performed at Walter Reed Army Medical center, and was responsible for the
diagnostic and therapeutic planning and description of the case, as part of the overall manuscript.
Dr. Lane was responsible for two of the transjugular renal biopsies and contributed to the
development and description of the technique, as well as provided comparisons with other
techniques of transjugular biopsies in the literature. Dr. Lane assisted in all aspects of manuscript
preparation and data analysis.
Dr. Yuan was an associate investigator on the original protocol and assisted in all aspects of
manuscript preparation and data analysis.
All authors read and approved the final manuscript.

Acknowledgements
We would like to acknowledge Dr. Alan Meglin and Dr. Mark Lukens for their participation in this
study and their contribution to previous work, without which this study would not have been
possible.
http://www.biomedcentral.com/1471-2369/3/5
http://radiology.rsna.org/content/215/3/689.abstract

Transjugular versus Percutaneous Renal Biopsy for

the Diagnosis of Parenchymal Disease: Comparison
of Sampling Effectiveness and Complications1
1. Philippe Cluzel, MD,
2. Frank Martinez, MD,
3. Marie France Bellin, MD,
4. Yann Michalik, MD,
5. Hlne Beaufils, MD,
6. Chantal Jouanneau, BS,
7. Olivier Lucidarme, MD,

8. Gilbert Deray, MD and

9. Philippe A. Grenier, MD
+ Author Affiliations
1.

From the Diagnostic and Interventional Polyvalent Radiology Service (P.C., M.F.B., Y.M.,
O.L., P.A.G.) and the Nephrology Service (F.M., G.D.), Universit Pierre et Marie Curie,
Hpital Piti-Salptrire, 43-87 boulevard de l'Hpital, 75651 Paris cedex 13, France;
Unit Institut National de la Sant et de la Recherche Mdicale (INSERM) 423, Paris,
France (H.B., C.J.); and Unit INSERM 494, Paris, France (P.A.G.). Received May 7,
1999; revision requested July 16; revision received August 31; accepted September 24.
Address correspondence to P.C. (e-mail: philippe .cluzel@psl.ap-hop-paris.fr).
2. June 2000 Radiology, 215, 689-693.

Abstract
PURPOSE: To compare the effectiveness and safety of transjugular renal biopsy with those of
percutaneous renal biopsy for diagnosis of renal parenchymal disease.
MATERIALS AND METHODS: Results and complications of 400 consecutive transjugular renal
biopsies performed between 1993 and 1998 with a modified Colapinto transjugular hepatic biopsy
system were compared retrospectively with those of 400 percutaneous renal biopsies performed
during the same period. Transjugular renal biopsy was associated with 14 cardiac and 35 hepatic
biopsies. Number of glomeruli per tissue core, adequacy of tissue core for histopathologic
diagnosis, and rate and severity of complications were analyzed.
RESULTS: Renal tissue was obtained with percutaneous renal biopsy in 382 (95.5%) of 400
patients and with transjugular renal biopsy in 383 (95.8%) of 400 patients. The mean numbers of
intact glomeruli per tissue core with optical microscopy were 11.2 7.7 (SD) and 9.8 7.6 for
percutaneous renal biopsy and transjugular renal biopsy, respectively. With immunofluorescent
microscopy, the mean numbers were 6.4 5.3 and 4.6 4.6 for percutaneous renal biopsy and
transjugular renal biopsy, respectively. Tissue cores were adequate for histopathologic diagnosis in
98.2% with both techniques. Major complications occurred with transjugular renal biopsy in four
patients and with percutaneous renal biopsy in three patients.
CONCLUSION: Use of transjugular renal biopsy provides diagnostic yield and safety similar to
those of percutaneous renal biopsy and allows multiorgan biopsy during the same procedure. It can
be recommended in patients with percutaneous renal biopsy contraindication or failure.

Percutaneous Kidney Biopsy

Original Date of Publication: 01 May 2001
Reviewed by: Stanley J. Swierzewski, III, M.D.
Last Reviewed: 01 Dec 2007
Original Source: http://www.nephrologychannel.com/biopsy/index.shtml

Physician-developed
-monitored.

Original Date of Publ

May 2001
Reviewed by: Stanley
Swierzewski, III, M.D
Last Reviewed: 01 D

Overview, Preparation, Procedure, Post Biopsy Care,

Other Types

Original Source: http://www.nephrologychannel.com/biopsy/

Home Percutaneous Kidney Biopsy Overview, Preparation,
Procedure, Post Biopsy Care, Other Types

Overview
Percutaneous kidney biopsy (through the skin) the removal of a sample of kidney tissue for
diagnosis or to evaluate the function of a transplanted kidney. A nephrologist performs the
procedure on an outpatient basis, usually in the radiology department of the hospital. Preparation,
biopsy, and recovery take several hours.

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Preparation
The following medications must be discontinued before biopsy to reduce bleeding:

Aspirin (10 days before)

Coumadin, Heparin, and other anticoagulants

Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen)

Typically, blood platelet count is evaluated to ensure that the blood will clot properly after the
procedure. A low blood platelet count may indicate that the patient has a disorder that makes a
biopsy inadvisable.
Procedure

Biopsy is performed on one kidney. The person lies on the stomach on a firm table with cushioning
under the abdomen for support and must not move during the procedure. Once the kidney is located
with ultrasound or CT scan, the biopsy site is marked over the right kidney and a local anesthetic is
injected. Once the area is numb, the nephrologist uses ultrasound to view the kidneys in real time
and guides a spring-loaded biopsy needle into the kidney. The needle removes about 5 to 15
glomeruli. Two or three samples are usually required, each the size and shape of one-half inch of
string. After the core tissue samples are extracted, pressure is applied to the incision to slow
bleeding, and a bandage is placed on the wound.
Post Biopsy Care
The patient must lie on his or her back for 8 to 24 hours. Some nephrologists advocate a 24-hour
recovery in the hospital, where the patient can be observed for complications.
The kidney contains many blood vessels and bleeds as a result of the biopsy. Bright red (arterial)
blood in the urine (hematuria) may be seen for the first 24 hours. If blood is seen in the urine after
24 hours, further care may be required to stop the bleeding. Many people experience muscle aches
and general soreness during recovery.
Complications
The following complications may occur:

Acute blood loss (in as many as 10%)

Bleeding requiring surgery, transfusion, or kidney removal (less than 1%)

Death (less than 1%)

Pain lasting longer than 12 hours (in 4%)

Contraindications
The most common contraindication to kidney biopsy is disease:

Bleeding disorder (e.g., inability to coagulate, platelet abnormality)

Hypertension

Pyelonephritis (disease of the pelvis of the kidney)

Shrunken kidney (i.e., as a result of disease)

Tumor

Nephrologists generally consider it safe for people with only one kidney (solitary kidney) to
undergo open biopsy, unless their individual case warrants closed biopsy, which is done under
general anesthesia. The risks of general anesthesia usually outweigh the risks of a closed biopsy.

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Other Types of Biopsy
Other types of biopsy, such as transjugular and laparoscopic, are performed on patients with
bleeding disorders, tumor, obesity, or a solitary kidney. These are done as outpatient procedures,
under general anesthesia.

Transjugular biopsy, also called transvenous, involves inserting a small tube through the jugular
vein in the neck and guiding it to the kidney using ultrasound. A biopsy needle is passed through the
tube to the kidney to obtain a tissue sample. Laparoscopy involves using an endoscope (thin,
lighted telescopic instrument) to explore the abdomen. Gas is introduced into the abdomen to
separate the organs and to allow the laparoscope to pass. The needle is then inserted through the
laparoscope and guided to the kidney with ultrasound.
Percutaneous biopsy generally allows for quicker recovery, causes less pain, and has fewer risks; it
is used more frequently.