renal biopsy indications, safety and complications€¦ · aims of renal biopsy . hsp mcns fsgs iga...
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Renal biopsy – indications, safety and complications
Farida Hussain
EMEESY Education Day – 14th Oct 2016
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Identify a specific diagnosis
Reflect the level of disease activity
Provide information to allow informed decisions about treatment
Aims of renal biopsy
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HSP MCNS FSGS IgA SLE
PSGN normal TIN MPGN membranous
TBM CKD Alports other
Renal biopsies - diagnoses
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Case study - 1
5yr old boy
2 week history of puffy eyes
Initially treated with antihistamines by GP
Urine dip 3+ protein 1+ blood
BP 86/40
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Case study - 1
Would you biopsy?
A yes
B no
0 A B
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15 yr old girl
Presented with 9 day history of abdo pain & diarrhoea
Increasing puffiness (eyes and ankle oedema)
Urine: protein 4+, blood 3+
BP 90
Creatinine 83µmol/l, Albumin 13g/L
Case study - 2
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Would you biopsy?
A yes
B no
Case study - 2
0 A B
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5yr old – transfer from DGH
Completed 4 weeks of 60mg/m2 prednisolone for new diagnosis of nephrotic syndrome – not in remission
PMHx – intermittant swelling over past 6 months
Urine dip at initial presentation: protein 3+ blood 4+
Case study - 3
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Would you biopsy?
A yes
B no
Case study - 3
0 A B
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Biopsy
RaDaR/NephroS
Steroid resistant nephrotic syndrome
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Case study - 4
GP refers an 8yr old girl found to have microscopic haematuria on screening
Otherwise well
No family history
Urine dip: blood 2+
Persisted for 2 years
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Case study - 4
Would you biopsy?
A yes
B no
0 A B
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Nottingham – 12 years, 59 biopsies
42 – thin basement membrane
6 – IgA nephropathy
6 – Alports
4 - normal
BAPN : 9.1% biopsies (2005) to 3.7% (2012)
Richards et al: Bx changed management in 1 of 36 pts
Genetics
Isolated haematuria
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A Any
B >50mg/mmol
C 50-100mg/mmol
D >100mg/mmol
Proteinuria – what level?
0 A B C D
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Proteinuria – what level?
BAPN audit 2012
>50mg/mmol 1 centre
50-100mg/mmol 4 centres
>100mg/mmol 3 centres
No defined level 3 centres
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Haematuria & proteinuria
AKI
Drugs
CKD
Transplants >10% rise in creat
Delayed graft function
Disease recurrence
De novo disease
Protocol biopsies
Other indications
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Renal biopsy - safety
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operator
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Who has the lowest complication rate?
A paediatric consultant
B paediatric trainee
C interventional radiologist
operator
0 A B C
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54% nephrologist alone
18% radiologist alone
27% combination
No significant difference in complications between operators
operator
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Which is associated with the highest complication rate?
A iv sedation
B entonox®
C General anaesthetic
sedation
0 A B C
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GA – 56% cases
IV sedation – 24% cases
Entonox – 5% cases
No significant difference in complication rate
sedation
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sedation
70/1014 biopsies - 7%
Age range 8.1-19.8yrs (mean =16.1yrs)
Wt range 27.4 -112.4kg (mean=52.3kg)
2 patients had minor complications (1.4%)
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Which size needle has the highest complication rate?
A 14 gauge needles
B 16 gauge needles
C 18 gauge needles
Biopsy needles
0 A B C
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Renal biopsy - complications
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complications
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Delay in patient discharge as a result of post-biopsy complications or requirement for further investigations, intervention or monitoring as a result of biopsy
Audit standard <5%
Complications - major
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Indications
Safety
Complications
Summary
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Any Questions?