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Current Procedures: Pediatrics

Chapter 67. Percutaneous Kidney Biopsy

Jerome C. Lane, MD

• Persistent or recurrent gross hematuria of glomerular origin (ie, not related to urinary infection or bladder abnormalities).
• Persistent, nonorthostatic proteinuria.
• Nephrotic syndrome.
- • Younger than 18 months or older than 8 years.
  • As a result of systemic disease (eg, systemic lupus erythematosus or other collagen vascular disease, vasculitis).
  • As a result of glomerulonephritis (low C3, hypertension, hematuria, or decreased renal function).
  • Corticosteroid-resistant nephrotic syndrome.
• Acute nephritis.
- • As a result of systemic disease (systemic lupus erythematosus, vasculitis).
  • Normal C3.
  • Low C3 for > 8 weeks (unlikely to be postinfectious nephritis).
  • With nephrotic syndrome.
  • With deteriorating kidney function.
• When the cause of acute kidney insufficiency is not apparent, consider obtaining a biopsy in selected cases:
- • Nephrotic syndrome.
  • Glomerulonephritis.
  • Vasculitis.
  • Systemic lupus erythematosus or other systemic disease.
• Obtain biopsy in selected cases of chronic kidney insufficiency to establish diagnosis, prognosis, and risk of recurrence.
• Follow up on prior biopsy in chronic kidney disease to establish disease progression, severity, and prognosis.
• Kidney transplant with rise in creatinine.

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• In many cases of kidney disease, laboratory evaluation of the blood and urine fails to yield a specific diagnosis.

• Occasionally, a clinical syndrome or constellation of laboratory findings might narrow the differential diagnosis; examples include the following:

• Post-streptococcal glomerulonephritis (acute onset, transient hypocomplementemia, recent streptococcal infection).

• Systemic lupus erythematosus (positive antinuclear antibody and anti-ds-DNA antibodies, hypocomplementemia, joint pains, and rashes).

• Minimal change nephrotic syndrome (nephrosis in a school-age child without azotemia, hypocomplementemia, or other complications).

• In these instances, a kidney biopsy might not be required.

• However, in most cases, a tissue specimen is required to establish a specific etiology.

Absolute

• Solitary, ectopic, or horseshoe kidney.
• Bleeding diathesis.
• Uncontrolled hypertension.
• Abnormal kidney vascular supply or arteriovenous malformation.
• Kidney tumor.
• Large kidney cysts.
• Kidney abscess.
• Pyelonephritis.
• Patient who is unwilling or unable to cooperate (insufficient sedation when indicated).

Relative

• Severe obesity.
• Hydronephrosis.
• Small kidney (as seen in end-stage kidney disease, for example).

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• Consider open biopsy in cases in which relative contraindications are present.

Equipment

• Ultrasound.
• Biopsy needle (in general, automated, spring-loaded system preferred).
• Biopsy tray (sterile drapes, scalpel, syringes and needles for injecting local anesthetic, gauze).
• Specimen container with saline, on ice.

• Before the procedure obtain following tests:
- • Complete blood count.
  • Prothrombin time.
  • Partial thromboplastin time.
• Patient should have nothing by mouth as indicated by sedation protocol.
• No nonsteroidal anti-inflammatory drugs for 1–2 weeks prior to procedure.
• Obtain informed consent prior to procedure.
• Review indications, procedure, and risks with patient and ...

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