Overview
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There is an indication for kidney biopsy beyond the above indication. The indication must be considered in every case. It is important that it does not limit the experience-rich institutional practice.
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Nephrologists, including young doctors with little experience in kidney biopsy, should recognize the safety procedures that are necessary to prevent the threshold to high-risk clinical conditions from lowering.
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Cases of serious complications such as bleeding can happen, and the appropriate security guidelines for treatment should be prepared before a kidney biopsy.
1. Glomerular hematuria with any degree of proteinuria |
2. Isolated proteinuria > 1 g/day(or g/gCr) |
3. Unexplained renal disease or intrinsic acute kidney injury |
4. Renal manifestation related to systemic disease |
Chapter 1: Indication for kidney biopsy (Table 2)
1. Isolated glomerular hematuria |
2. Isolated proteinuria |
3. Proteinuria and glomerular hematuria |
4. Rapidly progressive glomerulonephritis |
5. Intrinsic acute kidney injury |
6. Systemic disease with a urinalysis abnormality |
7. Systemic disease with renal dysfunction, and/or without urinalysis abnormality |
8. Diabetes mellitus |
9. Elderly renal disease |
10. Hereditary renal disease |
11. Repeated kidney biopsy |
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Systemic disease with renal dysfunction, but without a urinalysis abnormality, includes acute or chronic tubulointerstitial nephritis secondary to sarcoidosis, drug-related disease such as tyrosine kinase inhibitors and checkpoint inhibitors. IgG4-related nephritis, or hypercalcemic nephropathy by activated cholecalciferol. A high value of tubular impairment markers such as β2-microglobulin (β2MG), α1-microglobulin (α1MG), or N-acetyl-β-d-glucosaminidase (NAG) is characteristic.
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Systemic lupus erythematosus without urinary abnormality is called silent lupus nephritis. Light microscopy of kidney biopsy is reported to show mild glomerular change with class I or class II on 74% of silent lupus nephritis according to ISN-RPS lupus nephritis classification, but immunofluorescent microscopy shows IgG and C1q stain, and electron microscopy shows electron-dense deposits in the mesangium or subepithelium, which are characteristic to lupus nephritis.
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Systemic vasculitis, including MPA, GPA and EGPA, can be diagnosed by extrarenal complications such as fever, upper respiratory tract disease, lung disease, neuropathy, and positivity for ANCA, even though urinary abnormality is negative. For these patients, kidney biopsy is reported to show crescent formation or vasculitis of small arteries with a frequency of 69%, although extrarenal organ biopsy may not show any vasculitis [26‐29].
Chapter 2: Kidney biopsy for patients with a clinical condition of high risk for percutaneous native kidney biopsy
Overview
1. Solitary native kidney |
2. Contracted kidneys, small hyperechoic kidneys or end-stage kidneys |
3. Kidneys of anatomic abnormalities including horseshoe kidney, malrotation kidney and renal arterial aneurysm |
4. Polycystic kidney disease |
5. Hydronephrosis |
6. Malignant nephrosclerosis related to hypertensive emergency and scleroderma renal crisis |
7. Uncontrolled bleeding diathesis or severe thrombocytopenia |
8. Pregnancy |
9. Severe obesity |
10. Renal mass including malignant neoplasma |
11. Chronic anticoagulant therapy while taking antiplatelet or anticoagulant medication |
12. Active renal or perirenal infection, or skin infection over the biopsy site |
13. Inability to provide informed consent |
14. Uncooperative patient or inability to follow instructions during biopsy |
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For patients on chronic anticoagulation, kidney biopsy usually cannot be selected.
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Whether kidney biopsy is essential or necessary for diagnosis, prognosis, and/or management must be discussed in the conference conducted at the institute.
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If anticoagulation is temporarily stopped (e.g., mechanical heart valves), the risk of thrombosis must be judged in consideration of an individual situation, often in consultation with hematology and cardiology.
Drug | Drug holiday |
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Antiplatelet medication | |
Ticlopidine | ① 5–7 days, ② 10–14 days |
Clopidogrel | ① 5–7 days, ② 14 days |
Cilostazol | ① 1 day, ② 2–4 days |
Icosapentaenoic acid | 7–10 days |
Beraprost | 2–3 days |
Sarpogrelate | 1–2 days |
Aspirin | ① 3 days, ② 7–10 days |
Dipyridamole | 1–2 days |
Prasugrel | ① 5–7 days, ② 14 days |
Anticoagulant medication | |
Heparin | 1 day |
Dalteparin | 1 day |
Warfarin | 3–5 days (intravenous heparin) |
Dabigatran | 1–4 days |
Edoxaban | 1 day |
Rivaroxaban | 1 day |
Apixaban | 1–2 days (intravenous heparin) |
Vasodilator | |
Limaprost | 1 day |
Coronary vasodilator | |
Dilazep hydrochloride | 1 day |
Chapter 3: Informed consent and explanation document to the patients
Informed consent in kidney biopsy
Overview
Explanation document to the patients
Chapter 4: Pre-biopsy evaluation
Chapter 5. Method of kidney biopsy (technique)
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Setting the patient in lateral jack-knife position, through 3 cm of horizontal incision from 12 rib tip the muscles are divided in each layer to reach the inferior pole of the kidney covered by adipose tissue. Confirming not to damage the peritoneum, the circumrenal fat and Gerota fascia are cut to reach the surface of kidney. The biopsy gun for needle biopsy on the kidney or the wedge incision for block type specimen is used to take a piece of the kidney. After biopsy, hemostasis is securely performed by pressure with the forefinger for 10–15 min. The muscles and skin are closed in layers to finish the procedure. [144, 145].
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Because hemostasis pressure can be provided surely as compared with a native kidney biopsy, it is not necessary to discontinue the anticoagulant therapy. However, it is desirable to conduct an examination for coagulation system in advance.
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Under local anesthesia the biopsy needle is put into the kidney to take a piece of the kidney. This may be performed 2–3 times to obtain an adequate specimen.
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Just after the procedure, the physician presses the puncture area for 10–15 min for hemostasis. After that A 1 kg sandbag is put on the puncture area to maintain pressure for an hour. A small pillow is fixed with elastic tape on the area. Thereafter the patient must lie in bed for 6 h or until seen by the doctor. The patient must pay attention for blood in their urine after the biopsy.
Chapter 6: After care of the biopsy and post procedure observation
Chapter 7: Complications
Percutaneous native kidney biopsy | Percutaneous native kidney biopsy | Open biopsy | Transplanted kidney biopsy | |
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Adult | Children | |||
Total number of biopsies | 15,657 | 1685 | 1156 | 3808 |
Macroscopic hematuria with no treatment | 431 (2.8%) | 105 (6.2%) | 9 (0.78%) | 12 (0.31%) |
Erythrocyte transfusion | 121 (0.8%) | 0 (0%) | 4 (0.35%) | 2 (0.05%) |
Transcatheter arterial embolization | 31 (0.2%) | 1 (0.06%) | 2 (0.17%) | 4 (0.1%) |
Bladder lavage | 56 (0.4%) | 9 (0.5%) | 0 (0%) | 0 (0%) |
Nephrectomy | 0 (0%) | 0 (0%) | 0 | 1 (0.03%) |
Chapter 8: Histological evaluation of kidney biopsy specimen
Chapter 9: Kidney biopsy in children
Indication of kidney biopsy (Table 6)
1. Abnormal urinalysis | 1. Isolated proteinuria 0.5 g/gCr or more |
2. Proteinuria and glomerular hematuria | |
2. Nephrotic syndrome | 1. Steroid-resistant nephrotic syndrome |
2. Coexistence of hematuria, hypertension, renal dysfunction, and hypocomplementemia | |
3. Congenital nephrotic syndrome | |
3. Systemic disease with a urinalysis abnormality | 1. Systemic lupus erythematosus |
2. IgA vasculitis (Purpura nephritis) | |
3. Microscopic polyangiitis | |
4. Others | |
4. Intrinsic acute kidney injury | |
5. Others | 1. Drug-related disease |
2. Transplanted kidney |
Kidney biopsy for clinical condition with high risk
Pre-biopsy evaluation
Informed consent for kidney biopsy, explanation about kidney biopsy
Method of kidney biopsy (technique)
Sedation
After care of the biopsy and post procedure observation
Complications
Chapter 10: Biopsy of transplanted kidney
Chapter 11: Open (surgical) kidney biopsy and laparoscopic kidney biopsy
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As for the complications peculiar to laparoscopic kidney biopsy, nephric subcapsular hematoma, subcutaneous emphysema, peritoneal injury, and injury of the circumference organ are reported.
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An advantage of laparoscopic kidney biopsy in comparison with the percutaneous kidney biopsy includes certain sampling of renal tissue as well as confirmation and hemostasis of a bleeding point.
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An advantage of laparoscopic kidney biopsy in comparison to open kidney biopsy includes shortening of the hospital stay, pain reduction, and compatibility of the incised wound [4].