REVIEW Renal Biopsy for Medical Renal Disease: Indications and Contraindications Jathin Bandari, MD, Thomas W
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REVIEW Renal biopsy for medical renal disease: indications and contraindications Jathin Bandari, MD, Thomas W. Fuller, MD, Robert M. Turner II, MD, Louis A. D’Agostino, MD Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA BANDARI J, FULLER TW, TURNER II RM, nephrolithotomy (PCNL) and biopsy of transplant kidneys D’AGOSTINO LA. Renal biopsy for medical renal were queried. Summaries of the data were compiled and disease: indications and contraindications. Can J Urol synthesized in the body of the text. 2016;23(1):8121-8126. Results: Percutaneous renal biopsy is safe and effective in the majority of kidney units for the evaluation of medical Introduction: Percutaneous renal biopsy (PRB) is a renal disease. Rates of bleeding range from 0.3%-7.4%, safe and effective modality for sampling kidney tissue. and nephrectomy rates are exceedingly low (0.1%-0.5%). In limited circumstances, alternative methods for kidney Bleeding rates in open and laparoscopic approaches biopsy may be indicated. Historical contraindications are comparable and range from 0%-7.0%, with major for PRB such as bleeding diathesis, morbid obesity and complications ranging from 0%-6.1%. solitary kidney have been called into question in the Conclusions: The successes of percutaneous methods have literature. We present a review of the literature on PRB called into question traditional contraindications such as and the risks and benefits associated with alternatives. solitary kidney, bleeding diathesis, and morbid obesity. In Materials and methods: A review of the literature was limited cases, alternative methods may be appropriate. We performed through MEDLINE and PubMed. A total of 726 present a review of the literature for the various approaches articles exist under the query, “percutaneous renal biopsy.” and their associated complication rates. Large series describing indications, contraindications, procedural methods, and complications were extracted. Key Words: percutaneous renal biopsy, open renal To further investigate the risks of percutaneous renal biopsy, laparoscopic renal biopsy, transjugular renal biopsy on solitary kidneys, the literature on percutaneous biopsy Introduction challenged with improvements in the technique and safety of percutaneous biopsy. We review biopsy Since its introduction in 1951, percutaneous techniques including open and laparoscopic surgical renal biopsy has become an integral part of the approaches and modern relative and absolute clinical practice in nephrology and subsequently contraindications. revolutionized the management of kidney disease.1 Information garnered from histologic examination Indications for renal biopsy of renal tissue may be useful in the diagnosis, prognostic assessment, and therapy guidance of Indications for renal biopsy vary amongst nephrologists. renal disease. Despite the value of tissue diagnosis, Common precipitants for renal biopsy include idiopathic not all patients are candidates for percutaneous nephritic and nephrotic syndromes, diagnosis of biopsy. Historically, absolute contraindications unknown primary lesions, and the evaluation of small have included solitary kidney or bleeding diathesis, renal masses.2 In contrast to the variation in indications, prompting referral to urologists for consideration there is consensus regarding clinical scenarios in which of alternative means of renal biopsy. Classically renal biopsy is not indicated, including the evaluation described contraindications are increasingly being of non-nephrotic proteinuria and isolated glomerular hematuria. Renal biopsy is also unnecessary in cases of Accepted for publication October 2015 slowly progressive renal failure with a known etiology such as diabetes mellitus, hypertension or acute renal Address correspondence to Dr. Jathin Bandari, 3471 Fifth failure with an obvious antecedent event such as Avenue, Suite 700, Pittsburgh, PA 15213 USA hypotension.3 © The Canadian Journal of Urology™; 23(1); February 2016 8121 Renal biopsy for medical renal disease: indications and contraindications Widespread use of renal biopsy for small renal threatening hemorrhage. In the same study only 0.9% masses has been limited by the perception that there of patients required blood transfusion.11 is a high risk of tumor seeding in the percutaneous Urologic experience with percutaneous tract, bleeding complications when biopsying a nephrolithotomy (PCNL) suggests that percutaneous hypervascular tumor, and a historically low diagnostic access and even subsequent dilation are safe in patients certainty with low negative predictive value. Multiple with a solitary kidney.12-14 The Clinical Research Office series of percutaneous renal mass biopsies have of Endourological Studies (CROES) database evaluated recently been published providing growing clinical 5803 patients undergoing PCNL, of whom 189 (3.3%) experience to more accurately define the usefulness, had solitary kidneys.15 Though bleeding rates were yield, and clinical utility of small renal mass biopsies.4-7 similar in the solitary kidney group versus those with two kidneys (10.2% versus 7.7%), patients with solitary Contraindications kidneys received twice as many transfusions. This may be due to physician variability in management Absolute contraindications to percutaneous renal of patients with solitary kidneys undergoing PCNL biopsy have historically included uncontrolled severe or compensatory hypertrophy of the solitary kidney hypertension, inability to cooperate with biopsy, resulting in increased severity of bleeding.16 solitary kidney, and uncontrollable bleeding diathesis. Long term functional outcomes after PCNL in Relative contraindications include severe azotemia, solitary kidneys have been excellent. At 3 year follow renal anatomical abnormalities, anticoagulation, up, a study of 200 patients with solitary kidneys pregnancy, and urinary tract infections.8 It is rare that undergoing PCNL showed an improvement in hypertension cannot be controlled to an extent where creatinine to 1.83 from baseline of 2.0.17 Thirty-one biopsy cannot be pursued, and a patient unable to percent of patients showed improved eGFR, 53.5% comply can have biopsy performed under sedation had stationary eGFR, and 15.5% showed deterioration. or general anesthesia. Only one patient developed end-stage renal disease requiring hemodialysis. Importantly, nephrostomy Solitary kidney tracts do not appear to have an effect on long term Traditionally, biopsy of a solitary kidney has been function of kidneys on 99mTc-Dimercaptosuccinic Acid avoided out of concern that post-biopsy hemorrhage (DMSA) scans in either single-functioning or double- could result in the need for nephrectomy. Studies functioning kidney systems after PCNL.18,19 performed on patients with solitary kidneys are Percutaneous renal biopsy is routinely performed limited; however, those performed on carefully in transplanted allografts for evaluation of graft selected cohorts have been successful.9 In this study, dysfunction. Wilczek published a series of 1129 nine patients were deemed “low risk” for hemorrhage, biopsy specimens between 1974 and 1988. Only 0.7% meeting the criteria of adequate control of blood of patients required transfusion.20 Biopsies within pressure (< 170/90 mm Hg), normal platelet count, the medulla were associated with an increased risk prothrombin time, partial thromboplastin time, of bleeding. This study was performed without hematocrit greater than 30%, and a normal-sized radiographic aid, and modern techniques have served solitary kidney. Eight of the nine biopsies retrieved to mitigate this risk. A recent series evaluating 282 renal adequate tissue sampling, and only one patient transplant surveillance biopsies similarly reported no developed transient gross hematuria. There were major complications, including hemorrhage or need no other complications reported. While open renal for allograft nephrectomy.21 biopsy has been advocated in solitary kidneys due to Despite these reassuring data, undertaking a solitary the purported benefit of direct hemostasis, the low rate kidney biopsy remains an important decision that of bleeding complications and nephrectomy in patients should be made only after carefully thinking about with bilateral kidneys undergoing percutaneous whether the renal biopsy is likely to have important biopsy suggests that this concern is overstated. In therapeutic implications. In the cohort of patients a review of 19,459 percutaneous renal biopsies from that do have complications, management can be 1951-1990 an overall complication rate of 2.1% to 10.8% considerably more difficult than in those with two was reported.10 Nephrectomy was only required on native kidneys.22 For example, arterial complications 13 occasions (0.06%). In a more recent meta-analysis such as arteriovenous fistula, arteriocalyceal fistula, of 34 studies, including 8941 biopsies performed in aneurysm, pseudoaneurysm or perinephric hematoma the era of ultrasound-guidance and automated biopsy may require contrasted CT scan in the early arterial phase devices, only one nephrectomy was required for life- for diagnosis. Superselective renal angiography remains 8122 © The Canadian Journal of Urology™; 23(1); February 2016 BANDARI ET AL. the gold standard for treatment of uncontrolled bleeding the procedure but this decision must be balanced and the physician should consider the effects of contrast against the risk of cessation especially in the setting on a solitary kidney when these complications