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Clinical and quality aspects of native and transplant kidney biopsies in Sweden
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Percutaneous kidney biopsies have been performed since 1944 to establish diagnoses and treatment. Risk factors based on a limited amount of data have shown age, blood pressure, kidney function and needle size as some risk factors for biopsy complications. Although the techniques of biopsy have improved over the years, it is still an invasive procedure and serious complications can occur.

The overall aim of this thesis was to obtain a large series of data from biopsy procedures and to use these to bring further light on risk factors to help minimize the risk for patients and to optimize diagnostics. Specific aims were to clarify if different factors, such as gender, diagnoses, localization of biopsies, needle types and sizes, could be useful to help minimize complication risks in native kidney biopsies (Nkb) and transplant kidney biopsies (Txb). Another point to investigate was the value of the Resistive Index (RI) obtained at ultrasound before performing Txb.

Materials and methods: A protocol for prospective multicentre registration of various factors and complications associated with Nkb and Txb was designed. Consecutive data were obtained from seven hospitals. All biopsies, except one computer tomography-guided Nkb, were performed using real-time ultrasound guidance and an automated spring-loaded biopsy device. For the biopsies 14- to 20- Gauge (G) needles were used. The kidney function level, i.e. estimated glomerular filtration rate (eGFR), was calculated using the Modification of Diet in Renal Disease (MDRD) formula (GFR in mL/min per 1.73m2). For statistical analyses the IBM SPSS Statistic 22 (Armonk, NY, USA) and OpenEpi (Open Source Epidemiologic Statistics for Public Health, www.OpenEpi.com) were used. Data were presented as Odds Ratio (OR), Risk Ratio (RR) and Confidence Intervals (CI). A two sided p-value of <0.05 was considered significant. In total 1299 consecutive biopsies (1039 native and 260 transplant kidneys) in 1178 patients (456 women and 722 men) were used for investigation. The median age of patients was 55 years (range 16 to 90 years). Major (require an intervention) and minor biopsy complications (no need of intervention) were registered.

Results: The overall frequency of biopsy complications for Nkb was 8.8% (major 6.7%, minor 2.1%) and for Txb was 6.5% (major 3.8%, minor 2.7%); no death. Women had a higher risk for development of major (10.7% versus 4.7%, OR 2.4, CI 1.4-4.2) and overall biopsy complications (13.2% versus 6.5%, OR 2.2, CI 1.4-3.5) compared to men in Nkb. In Nkb, major complications were more common after biopsies from the right kidney in women versus men (10.8% vs 3.1%, OR 3.7, CI 1.5–9.5), in patients with lower versus higher BMI (25.5 vs 27.3, p=0.016) and for younger versus older age (44.8 vs 52.3 years, p=0.002). Lower (90 mmHg) compared to higher (98 mmHg) mean arterial pressure in Txb indicated a risk of major complications (p=0.039). Factors such as number of passes and kidney function did not influence complication rates. Biopsy needles of 16 G compared to 18 G showed more glomeruli per pass in Nkb (11 vs 8, p<0.001) and in Txb (12 vs 8, p<0.001). Sub-analysis revealed that 18 G 19 mm side-notch needles in Nkb resulted in more major (11.3% vs 3%, OR 4.1, CI 1.4-12.3) and overall complications (12.4% vs 4.8%, OR 2.8, CI 1.1-7.1) in women than in men. If the physician had performed less compared to more than four Nkb per year, minor (3.5% vs 1.4%, OR 2.6, CI 1.1-6.2) and overall complications (11.5% vs 7.4%, OR 1.6, CI 1.1-2.5) were more common. The localization of biopsy within the kidney (Nkb and Txb) was not a risk factor for complications. Patients with IgA-nephritis compared to patients with other diseases had a higher risk of major complications (11.7% vs 6.4 %, OR 1.8, CI 1.1–3.2). More major complications were found in Nkb if they had higher versus lower degree of glomerulosclerosis (31% vs 20 %, p=0.008) and in Txb if there was a higher versus lower degree of interstitial fibrosis (82% vs 33%, p<0.001). Re-biopsies (Nkb) were more common in patients with IgA-nephritis than those with other diseases (4.7% vs 1.3 %, OR 4, CI 1.5–11), in younger versus older age (42.6 vs 52.3 years, p=0.031), and in those with a higher versus lower degree of interstitial fibrosis (63% vs 34 %, p=0.046). In Txb, a RI≥0.8 compared to RI<0.8 predicted major (13.3% vs 3.2%, RR 4.2, CI 1.3-14.1) and overall biopsy complications (16.7% vs 5.3%, RR 3.2, CI 1.2-8.6). In the group <0.8, RI correlated with age (rs=0.28, p<0.001) and systolic blood pressure (rs=0.18, p=0.02). In the group ≥0.8, RI correlated with degree of interstitial fibrosis (rs=0.65, p=0.006) and systolic blood pressure (rs=0.40, p=0.03). The multiple regression analysis showed that the <0.8 RI group correlated only with age (p<0.001), whereas the ≥0.8 RI group correlated only with the degree of interstitial fibrosis (p=0.003).

Conclusions: The present results motivate greater attention to be paid to the possibility of major side-effects after Nkb in women and biopsies from their right side, but as well in younger patients, and in those with lower BMI. This also applies for patients with presumptive IgA-nephritis and higher degree of glomerulosclerosis. In Txb, patients with higher degree of interstitial fibrosis had a greater risk of major complications. Moreover, the present data indicate that Nkb and Txb should be preferably taken with 16 G needles with 20 mm sample size. This results in better histological quality and there is a lower risk for major complications as compared to 18 G needles. The localization of biopsy within the kidney (Nkb and Txb) does not alter complication rates. For Nkb there were fewer complications if the physician had performed at least four biopsies per year. A RI≥0.8 in Txb indicates a greater risk for major and overall complications.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2016. , 58 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1786
Keyword [en]
Native and transplant kidney biopsies, biopsy complications, risk factors, patients’ safety, biopsy needles, Resistive Index, IgA-nephritis.
National Category
Urology and Nephrology
Research subject
Internal Medicine
Identifiers
URN: urn:nbn:se:umu:diva-124615ISBN: 978-91-7601-428-8OAI: oai:DiVA.org:umu-124615DiVA: diva2:953492
Public defence
2016-09-28, Sal E04, Målpunkt R-1 (by 6E), Biomedicin, NUS, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-09-07 Created: 2016-08-17 Last updated: 2016-09-09Bibliographically approved
List of papers
1. A study of clinical complications and risk factors in 1001 native and transplant kidney biopsies in Sweden
Open this publication in new window or tab >>A study of clinical complications and risk factors in 1001 native and transplant kidney biopsies in Sweden
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2014 (English)In: Acta Radiologica, ISSN 0284-1851, E-ISSN 1600-0455, Vol. 55, no 7, 890-896 p.Article in journal (Refereed) Published
Abstract [en]

Background: In Sweden, native and transplant kidney biopsies are usually performed in major renal medical centers. Purpose: To clarify risk factors in native and transplant kidney biopsies to improve patient safety. Material and Methods: A total of 1001 biopsies (in 352 women and 565 men) were included. The median age was 54 years (range, 16-90 years). Data were derived from 826 native kidney biopsies (640 prospective and 186 retrospective) and 175 transplant kidney biopsies (170 prospective and 5 retrospective). Various factors and complications were registered while performing native and transplant kidney biopsies, focusing on major (e. g. blood transfusions, invasive procedures) and minor complications. The prospective protocol was used at six centers and at one center data were obtained retrospectively. Results: Women were at greater risk of overall complications than men (12.2% vs. 6.5%; P = 0.003; odds ratio [OR], 2.0; confidence interval [CI], 1.3-3.1) as well as of major complications (9.6% vs. 4.5%; P = 0.002; OR, 2.2, CI 1.3-3.7). Major complications occurred more commonly after biopsies from the right kidney, in women than in men (10.8% vs. 3.1%; P = 0.005; OR, 3.7; CI, 1.5-9.5), and in patients with lower BMI (25.5 vs. 27.3, P = 0.016) and of younger age (45 years vs. 52.5 years; P = 0.001). Lower mean arterial pressure in transplant kidney biopsies indicated a risk of major complications (90 mmHg vs. 98 mmHg; P = 0.039). Factors such as needle size, number of passes, serum creatinine, and eGFR did not influence complication rates. Conclusion: The present findings motivate greater attention being paid to the risk of major side-effects after right-side biopsies from women's kidneys, as well as after biopsies from younger patients and patients with lower BMI.

Keyword
Urinary, interventional, ultrasound, biopsy, complications, kidney
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:umu:diva-104162 (URN)10.1177/0284185113506190 (DOI)000342575300016 ()24068748 (PubMedID)
Available from: 2015-06-17 Created: 2015-06-08 Last updated: 2016-09-06Bibliographically approved
2. Sixteen Gauge biopsy needles are better and safer than 18 Gauge in native and transplant kidney biopsies
Open this publication in new window or tab >>Sixteen Gauge biopsy needles are better and safer than 18 Gauge in native and transplant kidney biopsies
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2016 (English)In: Acta Radiologica, ISSN 0284-1851, E-ISSN 1600-0455Article in journal (Refereed) Epub ahead of print
Abstract [en]

BACKGROUND: Kidney biopsies are essential for optimal diagnosis and treatment.

PURPOSE: To examine if quality and safety aspects differ between types and sizes of biopsy needles in native and transplant kidneys.

MATERIAL AND METHODS: A total of 1299 consecutive biopsies (1039 native and 260 transplant kidneys) were included. Diagnostic quality, needle size and type, clinical data and complications were registered. Eight-three percent of the data were prospective.

RESULTS: In native kidney biopsies, 16 Gauge (G) needles compared to 18 G showed more glomeruli per pass (11 vs. 8, P < 0.001) with less complications. Sub-analysis in native kidney biopsies revealed that 18 G 19-mm side-notch needles resulted in more major (11.3% vs. 3%; odds ratio [OR], 4.1; 95% confidence interval [CI], 1.4-12.3) and overall complications (12.4% vs. 4.8%; OR, 2.8; 95% CI, 1.1-7.1) in women than in men. If the physician had performed less compared to more than four native kidney biopsies per year, minor (3.5% vs. 1.4%; OR, 2.6; 95% CI, 1.1-6.2) and overall complications (11.5% vs. 7.4%; OR, 1.6; 95% CI, 1.1-2.5) were more common. In transplant kidney biopsies, 16 G needles compared to 18 G resulted in more glomeruli per pass (12 vs. 8, P < 0.001). No differences existed in frequency of biopsy complications. The localization of performing biopsies was not a risk factor to develop complications.

CONCLUSION: Kidney biopsies taken by 16 G needles result in better histological quality and lower frequency of complications compared to 18 G. For native kidney biopsies the performer of the biopsy should do at least four biopsies per year.

Keyword
Urinary, interventional, biopsy, percutaneous, kidney, complications
National Category
Urology and Nephrology
Identifiers
urn:nbn:se:umu:diva-124611 (URN)10.1177/0284185116641349 (DOI)27055922 (PubMedID)
External cooperation:
Available from: 2016-08-17 Created: 2016-08-17 Last updated: 2016-09-06
3. Increased risk of renal biopsy complications in patients with IgA-nephritis
Open this publication in new window or tab >>Increased risk of renal biopsy complications in patients with IgA-nephritis
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2015 (English)In: Clinical and Experimental Nephrology, ISSN 1342-1751, E-ISSN 1437-7799, Vol. 19, no 6, 1135-1141 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The aim of this study was to investigate if specific clinical and histological findings can be related to biopsy complications to enable more closely monitoring patients at high risk.

METHODS: Results from 1081 biopsies (994 patients, median age 54.5 years; 896 native and 185 transplant kidney biopsies) were included. Diagnostic quality, morphology, clinical data and complications were prospectively registered.

RESULTS: In native kidney biopsies, the most common diagnosis was IgA-nephritis, while in transplant kidney biopsies it was rejection. Patients with IgA-nephritis had a higher risk of major complications (11.7 versus 6.4 %, Odds Ratio (OR) 1.8, Confidence Interval (CI) 1.1-3.2) when compared to patients with other diseases. In native kidney biopsies, patients who experienced major complications had higher degrees of glomerulosclerosis (31 versus 20 %, p = 0.008), whereas in transplant kidney biopsies, patients had higher degrees of interstitial fibrosis (82 versus 33 %, p < 0.001) when compared to patients without major complications. IgA-nephritis-patients had a higher risk of re-biopsies (4.7 versus 1.3 %, OR 4, CI 1.5-11) than patients with other diseases. Patients with native kidneys who needed re-biopsies were younger (42.6 versus 52.3 years, p = 0.031) and had a higher degree of interstitial fibrosis (63 versus 34 %, p = 0.046).

CONCLUSIONS: Patients with IgA-nephritis have an increased risk of major biopsy complications. The risk of re-biopsies was higher in younger individuals and in patients with IgA-nephritis.

Keyword
Biopsy complications, Glomerulosclerosis, IgA-nephritis, Interstitial fibrosis, Kidney biopsy
National Category
Urology and Nephrology
Identifiers
urn:nbn:se:umu:diva-107321 (URN)10.1007/s10157-015-1121-3 (DOI)000366626000018 ()25951807 (PubMedID)2-s2.0-84951905338 (ScopusID)
External cooperation:
Available from: 2015-08-21 Created: 2015-08-21 Last updated: 2016-09-06Bibliographically approved
4. High Resistive Index in transplant kidneys is a possible predictor for biopsy complications
Open this publication in new window or tab >>High Resistive Index in transplant kidneys is a possible predictor for biopsy complications
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(English)Manuscript (preprint) (Other academic)
National Category
Urology and Nephrology
Identifiers
urn:nbn:se:umu:diva-124612 (URN)
Available from: 2016-08-17 Created: 2016-08-17 Last updated: 2016-09-06

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