Renal biopsy seminar
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RENAL BIOPSY
DR. VISHAL GOLAY28-10-10
DM Seminar
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History of renal biopsy
Iverson and Brun (1951)- first renal biopsy description. Aspiration biopsy of kidney. Am J Med 11:324—330, 1951
Kark and Muehrcke (1954)-blind prone biopsy.
Biopsy of kidney in prone position. Lancet 1:1047—1049, 1954
New era - biopsy guns & imaging
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Vim-Silverman needle
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OVERVIEW
Indications & contraindications
The procedure
Tissue processing and staining
Brief introduction to microscopy
Some clinical examples
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Indications of renal biopsy
Nephrotic syndrome: Adult NS Children with atypical features
Acute renal failure: Undiagnosed Non resolving clinical ATN >3-4 weeks
Systemic diseases with renal dysfunction
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Indications of renal biopsy CONtd….
Sub-nephrotic proteinuria >2g/d in DM, early MGN, FSGS, IgAN <2g/d needs clinicians discretion
Hematuria Isolated (Q J Med 2004; 97:739–745)
Associated with proteinuria and abnormal urine sediment
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Indications of renal biopsy CONtd….
Post transplant
CKD- generally contraindicated
In moderate dysfunction-potential reversibility and basic disease
Diabetes Mellitus Microscopic hematuria Absence of retinopathy and neuropathy Onset of proteinuria <5years from diagnosis Acute worsening of renal function Systemic features
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Renal biopsy; a necessary evil?
276 native renal biopsies; management was altered in 42% of cases overall. Nephrol Dial Transplant. 1994;9(9):1255-9
3 year prospective study involving 80 patients; Pre-biopsy predicted histologic diagnosis was changed in 44% of the patients as a result of the biopsy. Prognosis changed in 57% of the patients. Therapy changed in 31% of the patients. Clin Nephrol. 1986 Nov;26(5):217-21
111 renal biopsies in childern; biopsy altered diagnosis in 24.5%. Post biopsy, treatment was changed in 22.6%. 18.9% had a change in both the diagnosis and treatment. Zhonghua Min Guo. 1998 Jan-Feb;39(1):43-7
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contraindications
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Preparation of the patient
Prerequisites Relevant history & examination USG KUB Hemogram and Hct PT/aPTT Urine RE/ME & culture
Bleeding time Current Opinion in Nephrology & Hypertension
1999;8: 715-718
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Biopsy gun
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Biopsy gun choice
14 G guns gives greater number of glomeruli per core than 18-G cores, but the rates of adequate biopsies were similar
Larger needle provided more tissue and glomeruli but were associated with more pain.
16-gauge needles are used as a compromise between the need of a sufficient size of tissue and the need of clinical safety.
Adequate quantity of tissue for diagnosis may be obtained with this needle size in 98.9 per cent of biopsies either in native or in transplanted kidneys.
OTCN
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Procedure
Informed consentPatient in prone position with wedge or pillow below
the abdomenLight sedationLocal anesthesia with 1-2% lignocaine from the skin
down to the capsuleStab incision can be given to ease biopsy gun entryAdvance the biopsy gun, when the capsule is reached,
instruct patient to take a deep breath and fire the gun2-3 cores can be taken from the lower pole of the left
kidneyPress on wound for 2-5 minutes
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Procedure
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Procedure
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USG guided vs blind biopsies
Worldwide the trend is towards USG guided biopsies
129 renal biopsies, USG guided Blind P
Mean number of glomeruli
18±9 11±9 0.0001
Repeat biopsy
0% 16% 0.0006
Hematoma requiring intervention
0% 11% 0.006
24 hour Hct 32±5% 30±4% 0.04Semin Dial. 2007 Jul-Aug;20(4):355-8
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USG guide to nephrologist
Safer and more efficient then blind biopsy
In one study of 101 biopsies nephrologists used a portable ultrasound machine for location and depth of the kidney. The results are similar to those of previous studies using automatic devices but under direct ultrasound guidance.
AJKD 1999;34:955-959
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Post procedure
Hand held lens/dissecting microscope can be used to check for the presence of cortical tissue
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Post procedure
Bed rest is instructed for 18-24 hours
BP and pulse are monitored in the following way- Every 15 mins for 1 hour f/b Every 30 mins for 1 hour f/b
Every hour for 4 hours f/b
4 hourly for next remaining 24 hours
Save aliquots of each voided urine sample in clear specimen jars
Hct monitored 6-8 hours and 18-24 hours after biopsy
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Complications of renal biopsy
•Complications of percutaneous renal biopsy: a review of 37 years experience. Clin Nephrol 1992;38:135-41.
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Complications of renal biopsy
Ateriovenous fistula-post biopsy
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Complications of renal biopsy
Page kidney: compression of kidney by a hematoma leads to high renin hypertension. It is believed to result from microvascular ischemia and alteration of small-vessel hemodynamics from external compression.
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Outpatient renal biopsy
750 biopsies; Complications were identified 42% patients by 4 h, in 67% patients by 8 h, in 85% patients by 12 h, and in 89% patients at 24 h. After
biopsy, an observation time of up to 24 h remains optimal.
J Am Soc Nephrol 15:142-147, 2004
Maya and Allon et al; 100 renal biopsies. 8 hour observation is safe.
Semin. Dial. 20, 355–358 (2007)
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Specimen processing
Specimen division >8mm - LM/IF/EM4-8mm - EM/IF<4mm - EM
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Specimen processing
Adequacy of the sample:
two biopsy cylinders with a minimal length of 1 cm and a diameter of at least 1.2 mm.
10–15 glomeruli are optimal; very often 6–10 glomeruli are sufficient
some cases even one glomerulus is enough
Nephrol Dial Transplant (2006)
21: 1157–1161
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Biopsy tissue examination
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Light microscopy
1. Fixative: Buffered, 10% aqueous formaldehyde solution
(formalin)-most commonly used Bouin’s Duboscq-Brasil Zenker’s
4% paraformaldehyde The material processed for LM can serve as reserve
material for IHC or EM if either of these other modalities is found lacking glomeruli.
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Light microscopy
2. Dehydration: done with a series of alcohols, say 70% to 95% to 100%.
3. Clearing: xylene, toluene, chloroform, limolene4. Embedding:
Paraffin Paraplast Plastics-methyl methacrylate, glycol methacrylate,
araldite, and epon.
5. Sectioning: manual/microtome. 2 µm sections are used
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Light microscopy
Routine stains (paraffin sections) Haematoxylin and eosin (HE) Periodic acid–Schiff’s (PAS) Fibrous tissue stain (i.e. Sirius red, Trichrome,
Ladewig, etc.) Silver stain Protein stain- acid fuchsin–Orange G stain (SFOG).
Optional stains Kossa stain (calcifications) Congo red stain (amyloid)
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Light microscopy
H&E: composition of the tissue (i.e. renal cortex vs medulla, number of glomeruli, cellular infiltration, etc.).
PAS:delineates in great detail glomerular cells, mesangial matrix and potential expansion, as well as potential
modifications of the composition of the matrix, changes of the GBM, i.e. thickening, irregularities, doubling,
rupture fibrinoid necrosis of the glomerular tuft alterations of the vessels, particularly arterial hyalinosis and
fibrinoid necrosis.
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Light microscopy
Protein stains: Immune deposits
Silver stain: permits the detection of changes of the GBM
Fibrous tissue stain: extent of fibrosis in the glomerulus or tubular interstitium
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Light microscopy-normal
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Immunohistochemistry-IF/IP
Preparation:
IF is best performed on unfixed, frozen sections. Tissues can be transported to the laboratory fresh on saline-soaked gauze or in Michel’s fixative. Serial sections are cut at 2–4 mm in a cryostat.
IP staining requires no special tissue preparation in that the same formalin-fixed, paraffin- embedded material used for LM is also used for IP.
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Immunohistochemistry-IF/IP
Staining: The antigens that should be routinely examined include: immunoglobulins (primarily IgG, IgM and IgA), complement components (primarily C3, C1q, and C4), fibrin, κ- and –λ light chains collagen IV alpha chains IgG subclasses, virus identification, lymphocyte phenotyping in allografts in suspected cases of PTLD, C4d in allograft biopsies
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Immunohistochemistry-IF/IP
Reported as: reaction is positive, pattern of staining, e.g. mesangial vs capillary
staining pattern, linear (or pseudolinear) vs granular staining. describe where the deposits are located, e.g. in a
subendothelial, intramembranous or subepithelial position
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Immunohistochemistry-IF/IP
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IgGIgA
Idiopathic MGN
IgA Nephropathy
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Electron Microscopy
Fixative: 2-3% glutaraldehyde, 1-4 % paraformaldehyde.
Processing: Instead of the clearing fluid, “transitional fluid”-1,2
Epoxypropane is used. Embedding done in epon. Sections must be less than 80 nm thick in order to allow at least
50% of the electron beam to penetrate the sample. Toluidine blue stained 1µm thick sections are used as an initial
guide
Stains: uranyl acetate (stains DNA), lead citrate, gold.
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Electron Microscopy
Electron microscopy permits assessment of the following: The presence and degree of cell proliferation (mesangial vs
endothelial cell proliferation) Changes in cell structure (i.e. podocyte foot process fusion
or podocyte vacuolization) Necrosis or apoptosis of cells Changes of glomerular basement membrane (i.e.
thickening, thinning, splicing, irregularities) Localization of immunoglobulin deposits (i.e. mesangial,
subendothelial or subepithelial) In some renal diseases, specific morphological changes
tubuloreticular structures.
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Electron Microscopy
Immunohistology is essential for diagnosis in 21% of cases and Electron Microscopy is essential in the diagnosis of 8% of cases OTCN
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Electron Microscopy
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Reporting a Renal Biopsy
The final report of a kidney biopsy should include information on: The adequacy of the specimen A description of the morphological changes in a systematic
fashion for each of the compartments of interest (glomeruli, tubules, interstititum, vessels
The results of immunofluorescence /immunohistochemical studies.
The results of the electron microscopy
It is useful to give two types of diagnosis:1.Descriptive2.Final
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Reporting a Renal Biopsy
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Reporting a Renal Biopsy
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Reporting a Renal Biopsy
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Reporting a Renal Biopsy
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Biopsy in special situations
Pediatric age group: Sedation is used (ketamine, midazolam, promethazine, BZDs) 18-G gun is used
Pregnancy: Indications of biopsy Sudden unexplained deterioration of renal function before 30-
32 weeks POG Symptomatic NS before 30-32 weeks POG Active urinary sediments, proteinuria and borderline renal
function
renal biopsy in pregnancy is safe before 30 weeks of pregnancy.
Acta Obstetricia Gynecologica Scandinavica 2001;80:888–893
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Biopsy in special situations
Allograft biopsy:Indications-
Failure of the graft to function in the first 7-10 days after surgery
Rapid deterioration of renal function of unknown cause after initial good function
Absence of response to antirejection therapy Unexplained nephrotic range proteinuria
Biopsy technique is the same Supine position USG guidance is necessary-for position and localisation, and
also to exclude presence of intestinal loops, fluid collections 2 cores of tissue is recommended-the sensitivity of a single
core for rejection is 91%; the addition of the second core improves the sensitivity to about 99%
Half the tissue is used for frozen section
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CLINICAL EXAMPLES
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SHEIKH ABDUL HALIM Kala Azar with Nephrotic
Syndrome
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Sushmita Das (SLE Class IV)
Wire loops
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Cellular crescent
Fibrinoid necrosis
Global proliferationwith neutrophilic infiltration
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Naima KhatoonLupus nephritis Class IV G( A/C)Activity index: 19/24Chronicity index: 4/12
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Kalpana Das (FSGS)
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Amal Panja (Crescentic GN)
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Sabita Majumdar (Pauci-immune CrGN)
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Sukumar Bodhak (IgA Nephropathy)
IgA
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THANK YOU