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NDT Advance Access originally published online on September 21, 2007
Nephrology Dialysis Transplantation 2007 22(12):3516-3520; doi:10.1093/ndt/gfm272
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© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org


Theoretical calculation of optimal depth in the percutaneous native kidney biopsy to drastically reduce bleeding complications and sample inadequacy for histopathological diagnosis

Antonio Pasquariello1, Maurizio Innocenti1, Valentina Batini1, Giovanna Pasquariello1, Sara Beati2, Stefano Rindi1, Sabrina Paoletti2 and Vincenzo Panichi2

1Nephrology Division, Hospital of Pisa and 2U.O. Internal Medicine Department, University of Pisa, Italy

Correspondence and offprint requests to: Antonio Pasquariello, MD, Divisione Nefrologica, Ospedale S.Chiara, Via Roma 55, 56100 PISA, Italy. Email: a.pasquariello{at}ao-pisa.toscana.it



   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 
Background. In recent years percutaneous native kidney biopsy (PNKB) has become of very common use and safe enough for the patient if performed by skilled physicians; nevertheless, haemorrhagic complications or inadequate tissue sample for the diagnosis may occur. We report here the type and the adequacy rate of specimens for diagnosis and complication rate associated with PNKB performed in a single centre from May 2003 to December 2005 using a mathematical formula to determine the depth in centimetre where pushing the trigger.

Methods. In this prospective study we analysed data from 126 consecutive PNKB performed by the same two skilled nephrologists with the free hand technique using the 14-gauge automated biopsy gun under continuous sonographic control (Group I). The trigger was pushed exactly at the depth previously calculated by a mathematical formula: BW/H (body weight expressed in hectograms divided by patient height expressed in centimetres) less 0.5 (BW/H – 0.5). The type and the adequacy rate of specimens for diagnosis and the associated complication rate were retrospectively compared with data obtained from 123 consecutive PNKB performed from January 2001 to April 2003 by the same operators before using the mathematical formula described earlier (Group II).

Results. Of our series of 126 consecutive PNKD using the mathematical formula (Group I), only four subjects presented post-biopsy gross haematuria (3.2%) and three experienced symptomatic small subcapsular haematoma (2.4%). All biopsy specimens proved to be adequate for diagnosis (100%) with a mean of 22 glomeruli (range 5–60) per specimen.

The previous series of 123 consecutive PNKB (Group II) showed gross haematuria (8.4%; P < 0.01 vs Group I) and symptomatic subcapsular haematoma (3.7%) with an adequate sampling of 94.8% (P < 0.01 vs Group I) and a mean glomerular count of 17 (range 4–47) per specimen (P < 0.01 vs Group I).

Conclusions. PNKB is an invasive procedure that in spite of progress made in safety, diagnostic adequacy and performing techniques, still involves minor or major risks. The results obtained show that our method is extremely useful to reduce significantly the incidence of bleeding complications and permits us to take enough renal tissue for diagnostic evaluation in all cases.

Keywords: complications; theoretical depth calculation; mathematical formula; percutaneous native kidney biopsy; tissue adequacy



   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 
In 1951, Iversen and Brun [1] first described the technique of percutaneous native kidney biopsy (PNKB) using an aspiration needle in acute renal failure, with the patient in the sitting position, and with no direct instrumental guidance. A few years later, Kark and Muehrcke [2] published a new technique, with the patient in the prone position, and utilizing the Franklin-modified Vim–Silverman cutting needle instead of aspiration needle. Afterwards, the disposable needles took the place of the Franklin-modified Vim–Silverman needle in percutaneous renal biopsy [3–5]. Some years later, semiautomatic and automatic spring-loaded needles were available and utilized [6,7]. The needle tip was directed toward the lower pole of the left or right kidney. Previous techniques used to locate the lower pole of the left or right kidney utilized intravenous pyelography [8] or fluoroscopy [9]. From the eighties, ultrasound guidance has been used worldwide to locate the lower pole of the kidney [6,10]. In the nineties, Mal et al. [11] published a new renal biopsy method utilizing the transjugular system in patients with contraindications or with other anomalies precluding PNKB (unwillingness to cooperate, psychiatric or very obese patients, subjects with solitary kidney or uncontrolled hypertension, etc.). The safety and the sample effectiveness of transjugular renal biopsy in 400 consecutive patients compared with those of 400 PNKB produced identical results: tissue adequacy and complication rate were the same [12]. A further option to perform the kidney biopsy in high risk patients is the laparoscopic renal biopsy in alternative to open renal biopsy, a safe and effective technique developed worldwide in the nineties [13,14]. In recent years PNKB has become, in clinical nephrology, a very useful tool and indispensable for diagnosis, therapy and research; moreover, utilizing automated gun biopsy needle devices under continuous ultrasound control, it is now performed in almost all centres, and in the hands of experienced operators is safe enough for the patient. In spite of the advances in security, simplicity and handiness this invasive procedure is not free from risks [15]. The percentage of post-bioptical complications on ultrasound-guided PNKB is still considerable and depends in part on the skill of the operators, in part on the good or poor visibility of the needle-tip's path in the screen. Here we report our experience using a mathematical formula method aimed to reduce the post-biopsy complication rate and to ensure the adequacy of specimens. These data have been compared with our previous experience of 123 PNKB performed from January 2001 since April 2003.



   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results
 Discussion
 Acknowledgements
 References
 
Patients
The demographic characteristics of our cohort are shown in Table 1. All patients who underwent renal biopsy were normotensive and none received anticoagulants such as heparin preparations or vitamin K antagonists, fibrinolytic agents, antiplatelet drugs such as aspirin or other platelet aggregation inhibitors and anti-inflammatory drugs in the days previous to the biopsy. A complete blood count and clotting tests were performed in all patient. [16,17]. Patients with severe clotting disorders were excluded. Renal failure was not considered an exclusion factor if not associated with aberrant renal anatomy or with evident renal size reduction (longitudinal diameter <9 cm). Serum creatinine values ranged from 0.6 to 12 mg/dl with a mean creatinine of 1.7 mg/dl in Group I and 1.6 in Group II. The indications for PNKB are depicted in Table 2.


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  		Table 1. Demographic data

 

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  		Table 2. Indications for percutaneous native kidney biopsy

 
Methods
All 249 consecutive biopsies of Groups I and II were performed in a single nephrology unit using the 14-gauge x 150 mm, mm spring-loaded automated gun device type of two different brands, namely ACHIEVE (Allegiance Healthcare Corporation, McGaw Park, IL, USA) or ACECUT (TSK Laboratory, Dublin, Ireland), with a single needle insertion [18].

All patients underwent an abdominal ultrasound and renal colour-Doppler sonography examination before the biopsy procedure, to exclude marked renal size reduction with a longitudinal diameter of <9 cm, the presence of one or more cysts in the lower pole of the left or right kidney, or the possible presence of an accessory renal artery of the lower pole. After localizing the lower pole of the left or right kidney under ultrasound guidance, the entry point position on the lumbar skin was marked with a felt pen; under continuous ultrasound control, the needle tip was gradually introduced into the lumbar wall and directed towards the back surface of the lower pole of the kidney. All biopsies were carried out using real-time ultrasonography control with the free-hand technique without fixed mechanical guidance applied to the probe (3.75-MHz convex probe, AU 570; ESAOTE, Italy).

In Group I patients, from May 2003 to December 2005, to obtain homogenous and reliable results, we carefully checked the body weight of patients expressed in hectograms and the height of subjects expressed in centimetres. The following mathematical formula: BW/H (body weight expressed in hectograms divided by patient height expressed in centimetres) less 0.5 (BW/H – 0.5) was used to calculate the depth in centimetres where pushing the trigger.

The progression of the biopsy needle was checked under ultrasonography control; as soon as the distance calculated by the formula was reached, the patient was asked to hold his breath while expiring so the renal specimen was carried out in a few seconds. A few minutes later, an ultrasonography control was made and the patient transferred to his room and instructed to lay in bed in the supine position for a 24-h observation period.

PNKD performed using more than one pass or attempt were excluded from this study, in order to check the real complication rate occurring effectively after a single needle insertion.

Statistics
Statistical analysis was performed using the Mantel–Haenszel chi-square test and Student's t-test when appropriate; P-values <0.05 were considered statistically significant.



   Results
Top
 Abstract
 Introduction
 Subjects and methods
 Results
Discussion
 Acknowledgements
 References
 
Adequacy of sampling
No sample revealed medullary tissue alone, and all specimens (100%) were adequate for diagnosis, with a mean of 22 glomeruli (range 5–60) per specimen. The histopathological analysis revealed that there were 116 (92%) optimum samples with a mean of 29 glomeruli (range 10–60) and of these, 102 specimens showed cortical tissue alone and of these 97 with renal capsule, 5 without capsule, and 14 samples presented corticomedullary tissue including renal capsule; 10 cylinders (8%) showed corticomedullary tissue without renal capsule and with a mean of 12 glomeruli (range 5–23). All data regarding adequacy of sampling are summarized in Table 3. Group II resulted in an adequate sampling of 94.8% (P < 0.01 vs Group I) and a mean glomerular count of 17 (range 4–47) per specimen. (P < 0.01 vs Group I). Eighty-five specimen consisted of cortical tissue including renal capsule, 29 samples showed cortical tissue alone, 10 corticomedullary tissue and nine medullary tissue alone.


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  		Table 3. Tissue specimen characteristics of Group I

 
Complications
No major complications were observed during the study. Biopsy-related haemorrhagic complications (Table 4) occurred in seven patients (5.6%). Of the seven patients who experienced post-renal biopsy bleeding, four patients (3.2%) developed gross haematuria and three patients (2, 4%) manifested subcapsular perinephric haematoma. All samples of the three subjects with post-renal biopsy haematoma showed cortical tissue with renal capsule. None of the seven patients presenting haemorrhagic complications were obese, underweight or nephrotic. The previous series of 123 consecutive PNKB (Group II) showed gross haematuria (8.4%; P < 0.01 vs Group I) and symptomatic subcapsular haematoma (3.7%) (Table 4).


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  		Table 4. Biopsy-related complications

 
A more detailed analysis of Group I revealed no significant difference in age, gender, body mass index, presence or absence of nephrotic syndrome or renal failure comparing biopsy-related complication to non-complicated PNKB. (chi-square test). A strong association between post-renal macroscopic haematuria (P < 0.001) and the samples without renal capsule (4/15 specimens), and a slight significance (P < 0.05) between macroscopic haematuria and corticomedullary samples without capsule (4/10 samples) was shown. Another highly evident association was identified between biopsy-related gross haematuria and total corticomedullary specimens (4/24 specimens) (P < 0.001) (Table 5). No statistical correlation was found comparing perirenal haematomas with age, gender, BMI, presence or absence of acute or chronic renal failure or nephrosis.


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  		Table 5. Correlation between complication and sampling adequacy in Group I patients

 


   Discussion
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
Acknowledgements
 References
 
The results obtained show that the mathematical formula is extremely useful to reduce the incidence of bleeding complications and allows an adequate sampling for diagnostic evaluation in all cases.

We are completely aware that the major limitation of this study is the lack of a contemporary control group of kidney biopsies performed without this mathematical formula, but we believe that its use could be of clinical interest for the scientific community.

We experienced a very low incidence rate of biopsy-related haemorrhagic complications (5.6%) compared with the post-biopsy bleeding rate that ranges from 11.8 to 34.1% in recent large series [19–22].

Furthermore, the use of the mathematical formula was able to significantly reduce the rates of bleeding complication and improve the adequacy of sampling in respect of our previous experience.

Moreover, from 1994 to 2003 in our nephrology centre, all percutaneous native kidney biopsies (PNKB) have been performed under real-time ultrasound guidance by the same two skilled nephrologists: a significant percentage of specimen were inadequate for diagnosis and several patients showed gross haematuria or symptomatic subcapsular haematoma. In this article, we have reported adequacy and complication rates of biopsies performed in a very recent period, from 2001 to April 2003: in spite of long-standing experience 5.2% of specimen were inadequate for diagnosis and 8.4% of patients showed gross haematuria and 3.7% symptomatic subcapsular haematoma.

To improve our performance, from 2001 to 2003 we started to register, for each patient undergoing kidney biopsy, the depth at which the biopsy was performed; all specimens which were revealed to be cortical tissue with renal capsule were accurately evaluated. For example, in the case of a bioptical cortical renal sample consisting of a capsule obtained at a depth of 4.5 cm in a patient with a height of 1.80 mt, a body weight of 90 kg, we expressed the body weight value in hectograms and the height value in centimeters: 90/180=5, and subtracting 0.5, was exactly 4.5 cm.

After several attempts, the application of this empiric formula permits the calculation of the effective distance of the lower renal pole back surface from lumbar skin plane in the majority of the cases.

The decision to use a 14-gauge needle size instead of 16 or 18-gauge, resulted in more diagnostic value permitting to obtain more renal material and glomeruli, without the associated complications [23,24]. Currently most of the operators, performing PNKB under real-time sonography control, take two or three renal cylinders with two, three or more passes [19,25]. Although there are no reports in the literature that taking one renal specimen for histopathological examination rather than two or three cores, involves less risk for the patient; and a prospective study on 471 patients published in 2004 showed no association between haemorrhagic post-biopsy complications and number of passes [19]. However, it is indisputable that our solution to take one renal core, allows the operator to save time, while the patient spends less time in the uncomfortable prone position.

The results of our prospective controlled study prove that the formula, if used by operators, allows an adequate renal tissue sampling in 100% of cases, an optimal result considering the specimen adequacy rate published in recent articles in a series of renal biopsies performed using the percutaneous [22,26], transjugular [12] or laparoscopic technique [14]. In most controlled studies the majority of haemorrhagic complications occurred within 6–8 hours [27,28]; therefore, in the last two decades there has been an increasing use of PNKB in the ambulatory regimen to reduce the hospitalization costs and to better cope with a shortage or lack of beds [28, 29]. All biopsies of this study were performed on in-patients to closely control the 24-hour post-biopsy period for possible complications, especially bleeding, and to afford prompt treatment when required. We believe that the results from this mathematical formula represent the equivalent of an "off limits" point or a "no trespassing line" for the operators, and its application is a useful tool to reduce the length of hospital stay. Because the major haemorrhagic biopsy-related complications are identified in the first 8–12 hours of post-biopsy observation in 85–90% of cases [27,28], our method could be considered a small step forward in the safety and diffusion of PNKB as an outpatient procedure, which would reduce the hospital bills in developed countries, and could contribute to the development of the renal histopathological diagnosis in emerging countries or in countries with depressed economies (30,31).

In conclusion, PNKB is an invasive procedure that in spite of progress made in safety, diagnostic adequacy and performing techniques, still involves minor or major risks. The results obtained show that our method is extremely useful to reduce significantly the incidence of bleeding complications and permits us to take enough renal tissue for diagnostic evaluation in all cases.



   Acknowledgements
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
References
 
This work is dedicated to the memory of our sweet friend Luciana Pozzolini. We acknowledge Dr A. Cupisti for performing statistical analysis.

Conflict of interest statement. None declared.



   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 

  1. Iversen P, Brun C. Aspiration biopsy of the kidney. Am J Med (1951) 11:324–330.[CrossRef][Web of Science][Medline]
  2. Kark RM, Muehrcke RC. Biopsy of kidney in prone position. Lancet (1954) 1:1047–1049.[Web of Science]
  3. Lavastida MT, Hulet WH. A disposable needle for percutaneous renal biopsy. Clin Pediatr (1968) 7:170–173.[Free Full Text]
  4. Madaio MP. Nephrology Forum. Renal biopsy. Kidney Int (1990) 38:529–543.[Web of Science][Medline]
  5. Meola M, Barsotti G, Buoncristiani E, Giovannetti S. Free-hand ultrasound-guided renal biopsy: report of 650 consecutive cases. Nephron (1994) 67:425–430.[Web of Science][Medline]
  6. Wiseman DA, Hawkins R, Numerow LM, Taub KJ. Percutaneous renal biopsy utilizing real time ultrasonic guidance and a semiautomated biopsy device. Kidney Int (1990) 38:347–349.[Web of Science][Medline]
  7. Burstein DM, Kobert SM, Schwartz MM. The use of automatic core biopsy system in percutaneous renal biopsies: a comparative study. Am J Kidney Dis (1993) 22:545–552.[Web of Science][Medline]
  8. Ginsburg IW, Dinant JR, Mendez L. Percutaneous renal biopsy under direct radiology control. JAMA (1962) 181:211–213.[Abstract/Free Full Text]
  9. Almkuis RD, Buckalew VM Jr. Techniques of renal biopsy. Urol Clin North Am (1979) 6:503–517.[Web of Science][Medline]
  10. Yoshimoto M, Fujisawa S, Sudo M. Percutaneous renal biopsy well-visualized by orthogonal ultrasound application usin linear scannind. Cl Nephrol (1988) 30:106–110.
  11. Mal F, Meyrier A, Callard P, et al. The diagnostic yield of transjugular renal biopsy: experience in 200 cases. Kidney Int (1992) 41:445–449.[Web of Science][Medline]
  12. Cluzel Ph, Martinez F, Bellin MF, et al. Transjugular versus percutaneous renal biopsy for the diagnosis of parenchimal disease: comparison of sampling effectiveness and complications. Radiology (2000) 215:689–693.[Abstract/Free Full Text]
  13. Gimenez LF, Micali S, Chen RN, et al. Laparoscopic renal biopsy. Kidney Int (1998) 54:525–529.[CrossRef][Web of Science][Medline]
  14. Shetye KR, Kavoussi LR, Ramakumar S, et al. Laparoscopic renal biopsy: a 9-year experience. BJU Int (2003) 91:817–820.[CrossRef][Web of Science][Medline]
  15. Parrish AE. Complication of percutaneous renal biopsy: a review of 37 years experience. Clin Nephrol (1992) 38:135–141.[Web of Science][Medline]
  16. Channing RP, Levin JA. Critical Reappraisal of the Bleeding Time. Sem Thromb Hemostasis (1990) 16:1–20.[CrossRef]
  17. Stiles KP, Hill C, LeBrun CJ, et al. The impact of bleeding times on major complication rates after percutaneous real-time ultrasound-guided renal biopsies. J Nephrol (2001) 14:275–279.[Web of Science][Medline]
  18. Pasquariello A, Innocenti M, Batini V, Moriconi L. Routine immunofluorescence and light microscopy processing with a single renal biopsy specimen: 18 years’ experience in a single centre. J Nephrol (2000) 13:116–119.[Web of Science][Medline]
  19. Manno C, Strippoli FM, Arnesano L, et al. Predictors of bleeding complications in percutaneous ultrasound-guided renal biopsy. Kidney Int (2004) 4:1570.
  20. Korbet SM. Percutaneous renal biopsy. Sem Nephrol (2002) 22:254–267.[CrossRef][Web of Science][Medline]
  21. Whittier WL, Korbet SM. Timing of complications in percutaneous renal biopsy. J Am Soc Nephrol (2004) 15:142–147.[Abstract/Free Full Text]
  22. Gonzales-Michaca L, Chew-Wong A, Soltero L, et al. Percutaneous renal biopsy, a 26 years analysis: complications rate and risk factors. Rev Invest Clin (2001) 52:125–131.[Web of Science]
  23. Song JH, Cronan JJ. Percutaneous biopsy in diffuse renal disease: comparison of 18 and 14 gauge automated biopsy devices. JVIR (1988) 9:651–655.[CrossRef]
  24. Nicholson ML, Wheatley TJ, Doughman SA, et al. A prospective randomized trial of three different size of core-cutting needle for renal transplant biopsy. Kidney Int (2000) 1:390–395.
  25. Ballal SH, Nayak P, Dhanraj P, et al. Percutaneous renal biopsy: a single center experience with automated spring-loaded "gun" type device. Clin Nephrol (1995) 4:274–275.
  26. Jardine M, Gallagher M, Bundhari S, et al. Safety and adequacy of native renal biopsy. Nephrology (2000) 5:A109.
  27. Jones B, Puvaneswary P, Nanra R, et al. Reduced duration of bed rest after percutaneous renal biopsy. Clin Nephrol (1991) 35:44–45.[Web of Science][Medline]
  28. Marwah DS, Korbet SM. Timing of complications in percutaneous renal biopsy: what is optimal period of observation? Am J Kidney Dis (1996) 28:47–52.[Web of Science][Medline]
  29. Maddux FW, Maddux DW, Starling JF, et al. Outpatient renal biopsy is a safe procedure in the community setting. J Am Soc Nephrol (1992) 3:345.
  30. Oviasu E, Ugbodaga P. Evaluation of percutaneous renal biopsy as a day case procedure: experience from Nigeria. J Nephrol (1998) 11:246–248.[Web of Science][Medline]
  31. Alebiosu CO, Kadiri S. Percutaneous renal biopsy as an outpatient procedure. JAMA (2004) 96:1215–1218.
Received for publication: 5.12.06
Accepted in revised form: 10. 4.07


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[Abstract] [Full Text] [PDF]

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