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Percutaneous Needle Biopsy of Human Renal Allotransplants
Vol 107, February Printed in U.S.A..
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
PERCUTANEOUS NEEDLE BIOPSY OF HUMAN RENAL ALLOTRANSPLANTS G. P. MURPHY From the Roswell Park Memorial Institute and New York State Department of Health, Buffalo, New York
Percutaneous biopsy of the kidney has been used with a variety of techniques and with a variable degree of hazard. 1- 5 Slotkin and Madsen reviewed 5,000 cases and reported on gross hematuria in 2 to 50 per cent of the cases, perirenal hematoma in 0.5 per cent and death in 0.1 per cent. 2 These figures seem representative. Ditscherlein recently reported a similar low mortality rate for man of 0.1 per cent, although he has observed none in a personal series of 1,000 cases. 5 Notwithstanding this apparent increased usage of needle biopsy, several modifications have evolved, including the use of prone position, 4 cine-radiography 3 and x-ray grid localization. 1 Although needle biopsy of the transplanted human kidney has been reported occasionally,1 we are unaware of any extensive use of this technique in human renal allotransplant recipients. Our experience for the past 3 years is described herein.
gloves were used. Location of the renal level was readily appreciated after a few biopsies were performed. The stylet was withdrawn and the component of the needle was introduced into kidney. The hub was extended over the needle and the entire apparatus was withdrawn swiftly (fig. l). Inspection of the needle revealed the size of the renal. material. If the specimen is grossly inadequate the procedure can be repeated but no more than twice. After a biopsy was taken, compression on the renal transplant area was continued for 5 minutes. The patient was then returned to his room where bed rest was maintained for 24 hours. Fluids were forced and urine specimens were collected in separate bottles for gross evaluation. The pre-biopsy and post-biopsy urine specimens could be compared microscopically. Concurrently with completion of the biopsy, attention was devoted to the ~f-""''""""''" TABLE 1.
MATERIALS AND METHODS
Patients. Sixteen renal allotransplant recipients (cadaveric or living donor kidney) underwent percutaneous needle biopsy of the kidney after transplantation during followup periods that varied from 1 to more than 15 months (table 1). Technique. A standard Vim-Silverman needle was used. No specific localizing techniques were considered warranted or proved to be necessary. All patients voided before examination and an aliquot was saved for microscopic examination and comparison. The patient was then examined on a firm mattress with some support in the lumbar sacral area (for example 2 towels folded). The pelvic kidney was readily identifiable in all instances, regardless of body size, degree of obesity and the like. The skin area was cleansed with betadine and draped with sterile towels. The skin and subcutaneous tissue were infiltrated with l per cent procaine. After 2 to 3 minutes the Vim-Silverman needle with stylet was placed in the previously selected area and introduced down to the renal surface. Sterile
Accepted for publication February 19, 1971. 1 Williams, A. V., Derrick, F. C., Jr. and Hargest, T. S.: A disposable radiopaque grid for percutaneous renal biopsy. J. Urol., 104: 646, 1970. 2 Slotkin, E. A. and Madsen, P. 0.: Complications of renal biopsy: incidence in 5000 reported cases. J. Urol., 87: 13, 1962. 3 Mertz, J. H. 0., Lang, E. and Klingerman, J. J.: Percutaneous renal biopsy utilizing cinefluoroscopic monitoring. J. Urol., 95: 618, 1966. 4 Muehrcke, R. C., Kark, R. M. and Pirani, C. L.: Technique of percutaneous renal biopsy in the prone position. J. Urol., 74: 267, 1955. 5 Ditscherlein, G.: Morphologische Folgen der Nierenpunktion; tierexperimentelle und humanpathologische Befunde. New York: Springer-Verlag, vol. 29, 1969.
Sex-Age (yrs.)
Percutaneous needle biopsy of human renal allotransplants Mos. Post-
Cadaveric kidney source M-42 2
3 4 5
M-37
F-34
13 4 14 8
12 13
F-29
4
M-39 2
Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Severe hemorrhage Suitable Suitable Suitable Suitable Suitable
Living donor source M-49 M-25
F-27
2
1 11
13 15 F-24
11 M-27
6
F-28 F-34 F-46 M-24
5 2
F-21 5
M-56
2
• Perigraft fluid aspirated.
193
Result
Transplant
Suitable Inadequate tissue, blood clots Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable No tissue* No tissue"' Suitable No tissueli' Suitable
194
MURPHY
Fm. 1. Techniques used for percutaneous needle biopsy of human renal allotransplants. A, patient in position for biopsy. B, palpation of transplant after preparation of skin. C, local skin infiltration. D, needle biopsy performed; stylet withdrawn.
Fm. 2. Typical needle biopsy specimen. Glomerulus shows thickened basement membrane and increased mesangial tissue. Proteinuria was present. H & E, reduced from X240.
195
PERCUTANEOUS NEEDLE BIOPSY OF HUMAN RENAL ALLOTRANSPLANTS
Biopsy specimen. The gross needle biopsy specimen should be handled with a fine needle point to avoid trauma or other artifact. Macroscopic inspection with a hand lens, if desired, will usually identify glomerular spots. If these spots are not seen, sufficient cortical tissue has not been obtained and a re-biopsy may be indicated. Fixation is then performed. The solution used depends on individual preference. Presently, freezing or other techniques using immunofluorescence are not suitable owing to the small size of the specimen. Several slides should be requested from the blocks prepared in order to give sufficient number of glomeruli and vascular structures for comparison with tubular cells and interstitial cellular infiltrate. Generally, 20 glomeruli should be available for individual evaluation (fig. 2). RESUL'rs
There were 17 needle biopsies obtained from 5 cadaveric renal allotransplant recipients. From 2 to 7 biopsies per patient were performed at different times and were suitable for diagnostic evaluation as described previously. In 1 case, although a suitable biopsy was obtained, severe hemorrhage ensued and transfusion and, ultimately, operative intervention were necessary. There were 16 biopsies obtained from 11 patients with renal allografts received from living donors, ranging from 1 to 3 biopsies per patient. Bleeding with bladder clots was encountered in 1 case and was resolved by cystoscopic evacuation without transfusion. Insufficient tissue was obtained in 1 instance. In 2 cases on 3 occasions no tissue was obtained. In these latter instances, perigraft fluid from local lymphatic collection was aspirated and no further attempt was made to obtain tissue. The fluid collection was further verified and followed by means of ultrasonic techniques. Generally satisfactory results were obtained in cadaveric sources in contrast to the living donor kidneys that were biopsied (table 2).
TABLE
2. Summary of results obtained with percutaneous biopsy of human renal allotransplants
Diagnostic Result
% of
% of
Total
Cadaveric Kidney
29 cases sufficient tissue
88.5
100
I case insufficient tissue 3 cases no tissue (fluid)
2. 7 8.8
0 0
% of Living Kidney 75
6.3 18. 7
Complications: Bladder clots, 1 case } 5 9% Severe hemorrhage, 1 case · 0
protection from the odd case of hemorrhage seems unlikely, especially in view of the previously described reports. 1- 5 Whether the risk is warranted in a transplant patient remains a decision made by the responsible surgeon. The present series has defined the apparent limitations. Sufficient tissue for diagnostic microscopic evaluation was obtained in 88.5 per cent; inadequate tissue or none at all was noted in 11.5 per cent of the attempts. Indication for attempted percutaneous needle biopsy may vary. Alternate diagnostic support undoubtedly serves to influence this decision. In our experience, despite all current available diagnostic support, differentiation of a chronic allograft rejection from other technical and ischemic factors remains a persistent problem. This problem is especially pronounced in cadaveric kidney transplant cases. The hazards of unnecessary immunosuppression with secondary infections are well appreciated by all transplant surgeons. On the other hand, the histological microscopic appearance may not differentiate an immunological cause for the renal deterioration although it may influence the degree of clinical therapeutic enthusiasm. Serial evaluation of a single case as shown in R current series may serve to shed more light on the sequence of significant histological changes. SUMMARY AND CONCLUSIONS
DISCUSSION
Needle biopsy of renal allografts has been satisfactory. However, if tissue is desired for immunofluorescent techniques this procedure will not suffice. Repeated biopsy under local or other anesthetic techniques may present a hazard of wound infection. However, bleeding from biopsy may be more directly controlled. In the needle biopsy series significant hemorrhage occurred in 5.9 per cent of the cases and necessitated transfusion and operative intervention in 1 case (2.9 per cent). Perhaps with more experience this could be decreased although
The results obtained by percutaneous needle biopsy of 16 human kidney allografts from cadaveric or living donor sources are described herein. Suitable tissue was obtained for diagnostic micro·scopic evaluation in 88.5 per cent of the cases insufficient tissue was obtained in 2.7 per cent case) and no tissue was obtained in 8.8 per cent cases). Significant hemorrhage occurred in 2 instances (5.9 per cent). In 1 instance (2.9 per cent) the bleeding required transfusion and operation. The clinical limitations and selected advantages of this technique are reviewed.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
PERCUTANEOUS NEEDLE BIOPSY OF HUMAN RENAL ALLOTRANSPLANTS G. P. MURPHY From the Roswell Park Memorial Institute and New York State Department of Health, Buffalo, New York
Percutaneous biopsy of the kidney has been used with a variety of techniques and with a variable degree of hazard. 1- 5 Slotkin and Madsen reviewed 5,000 cases and reported on gross hematuria in 2 to 50 per cent of the cases, perirenal hematoma in 0.5 per cent and death in 0.1 per cent. 2 These figures seem representative. Ditscherlein recently reported a similar low mortality rate for man of 0.1 per cent, although he has observed none in a personal series of 1,000 cases. 5 Notwithstanding this apparent increased usage of needle biopsy, several modifications have evolved, including the use of prone position, 4 cine-radiography 3 and x-ray grid localization. 1 Although needle biopsy of the transplanted human kidney has been reported occasionally,1 we are unaware of any extensive use of this technique in human renal allotransplant recipients. Our experience for the past 3 years is described herein.
gloves were used. Location of the renal level was readily appreciated after a few biopsies were performed. The stylet was withdrawn and the component of the needle was introduced into kidney. The hub was extended over the needle and the entire apparatus was withdrawn swiftly (fig. l). Inspection of the needle revealed the size of the renal. material. If the specimen is grossly inadequate the procedure can be repeated but no more than twice. After a biopsy was taken, compression on the renal transplant area was continued for 5 minutes. The patient was then returned to his room where bed rest was maintained for 24 hours. Fluids were forced and urine specimens were collected in separate bottles for gross evaluation. The pre-biopsy and post-biopsy urine specimens could be compared microscopically. Concurrently with completion of the biopsy, attention was devoted to the ~f-""''""""''" TABLE 1.
MATERIALS AND METHODS
Patients. Sixteen renal allotransplant recipients (cadaveric or living donor kidney) underwent percutaneous needle biopsy of the kidney after transplantation during followup periods that varied from 1 to more than 15 months (table 1). Technique. A standard Vim-Silverman needle was used. No specific localizing techniques were considered warranted or proved to be necessary. All patients voided before examination and an aliquot was saved for microscopic examination and comparison. The patient was then examined on a firm mattress with some support in the lumbar sacral area (for example 2 towels folded). The pelvic kidney was readily identifiable in all instances, regardless of body size, degree of obesity and the like. The skin area was cleansed with betadine and draped with sterile towels. The skin and subcutaneous tissue were infiltrated with l per cent procaine. After 2 to 3 minutes the Vim-Silverman needle with stylet was placed in the previously selected area and introduced down to the renal surface. Sterile
Accepted for publication February 19, 1971. 1 Williams, A. V., Derrick, F. C., Jr. and Hargest, T. S.: A disposable radiopaque grid for percutaneous renal biopsy. J. Urol., 104: 646, 1970. 2 Slotkin, E. A. and Madsen, P. 0.: Complications of renal biopsy: incidence in 5000 reported cases. J. Urol., 87: 13, 1962. 3 Mertz, J. H. 0., Lang, E. and Klingerman, J. J.: Percutaneous renal biopsy utilizing cinefluoroscopic monitoring. J. Urol., 95: 618, 1966. 4 Muehrcke, R. C., Kark, R. M. and Pirani, C. L.: Technique of percutaneous renal biopsy in the prone position. J. Urol., 74: 267, 1955. 5 Ditscherlein, G.: Morphologische Folgen der Nierenpunktion; tierexperimentelle und humanpathologische Befunde. New York: Springer-Verlag, vol. 29, 1969.
Sex-Age (yrs.)
Percutaneous needle biopsy of human renal allotransplants Mos. Post-
Cadaveric kidney source M-42 2
3 4 5
M-37
F-34
13 4 14 8
12 13
F-29
4
M-39 2
Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Severe hemorrhage Suitable Suitable Suitable Suitable Suitable
Living donor source M-49 M-25
F-27
2
1 11
13 15 F-24
11 M-27
6
F-28 F-34 F-46 M-24
5 2
F-21 5
M-56
2
• Perigraft fluid aspirated.
193
Result
Transplant
Suitable Inadequate tissue, blood clots Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable Suitable No tissue* No tissue"' Suitable No tissueli' Suitable
194
MURPHY
Fm. 1. Techniques used for percutaneous needle biopsy of human renal allotransplants. A, patient in position for biopsy. B, palpation of transplant after preparation of skin. C, local skin infiltration. D, needle biopsy performed; stylet withdrawn.
Fm. 2. Typical needle biopsy specimen. Glomerulus shows thickened basement membrane and increased mesangial tissue. Proteinuria was present. H & E, reduced from X240.
195
PERCUTANEOUS NEEDLE BIOPSY OF HUMAN RENAL ALLOTRANSPLANTS
Biopsy specimen. The gross needle biopsy specimen should be handled with a fine needle point to avoid trauma or other artifact. Macroscopic inspection with a hand lens, if desired, will usually identify glomerular spots. If these spots are not seen, sufficient cortical tissue has not been obtained and a re-biopsy may be indicated. Fixation is then performed. The solution used depends on individual preference. Presently, freezing or other techniques using immunofluorescence are not suitable owing to the small size of the specimen. Several slides should be requested from the blocks prepared in order to give sufficient number of glomeruli and vascular structures for comparison with tubular cells and interstitial cellular infiltrate. Generally, 20 glomeruli should be available for individual evaluation (fig. 2). RESUL'rs
There were 17 needle biopsies obtained from 5 cadaveric renal allotransplant recipients. From 2 to 7 biopsies per patient were performed at different times and were suitable for diagnostic evaluation as described previously. In 1 case, although a suitable biopsy was obtained, severe hemorrhage ensued and transfusion and, ultimately, operative intervention were necessary. There were 16 biopsies obtained from 11 patients with renal allografts received from living donors, ranging from 1 to 3 biopsies per patient. Bleeding with bladder clots was encountered in 1 case and was resolved by cystoscopic evacuation without transfusion. Insufficient tissue was obtained in 1 instance. In 2 cases on 3 occasions no tissue was obtained. In these latter instances, perigraft fluid from local lymphatic collection was aspirated and no further attempt was made to obtain tissue. The fluid collection was further verified and followed by means of ultrasonic techniques. Generally satisfactory results were obtained in cadaveric sources in contrast to the living donor kidneys that were biopsied (table 2).
TABLE
2. Summary of results obtained with percutaneous biopsy of human renal allotransplants
Diagnostic Result
% of
% of
Total
Cadaveric Kidney
29 cases sufficient tissue
88.5
100
I case insufficient tissue 3 cases no tissue (fluid)
2. 7 8.8
0 0
% of Living Kidney 75
6.3 18. 7
Complications: Bladder clots, 1 case } 5 9% Severe hemorrhage, 1 case · 0
protection from the odd case of hemorrhage seems unlikely, especially in view of the previously described reports. 1- 5 Whether the risk is warranted in a transplant patient remains a decision made by the responsible surgeon. The present series has defined the apparent limitations. Sufficient tissue for diagnostic microscopic evaluation was obtained in 88.5 per cent; inadequate tissue or none at all was noted in 11.5 per cent of the attempts. Indication for attempted percutaneous needle biopsy may vary. Alternate diagnostic support undoubtedly serves to influence this decision. In our experience, despite all current available diagnostic support, differentiation of a chronic allograft rejection from other technical and ischemic factors remains a persistent problem. This problem is especially pronounced in cadaveric kidney transplant cases. The hazards of unnecessary immunosuppression with secondary infections are well appreciated by all transplant surgeons. On the other hand, the histological microscopic appearance may not differentiate an immunological cause for the renal deterioration although it may influence the degree of clinical therapeutic enthusiasm. Serial evaluation of a single case as shown in R current series may serve to shed more light on the sequence of significant histological changes. SUMMARY AND CONCLUSIONS
DISCUSSION
Needle biopsy of renal allografts has been satisfactory. However, if tissue is desired for immunofluorescent techniques this procedure will not suffice. Repeated biopsy under local or other anesthetic techniques may present a hazard of wound infection. However, bleeding from biopsy may be more directly controlled. In the needle biopsy series significant hemorrhage occurred in 5.9 per cent of the cases and necessitated transfusion and operative intervention in 1 case (2.9 per cent). Perhaps with more experience this could be decreased although
The results obtained by percutaneous needle biopsy of 16 human kidney allografts from cadaveric or living donor sources are described herein. Suitable tissue was obtained for diagnostic micro·scopic evaluation in 88.5 per cent of the cases insufficient tissue was obtained in 2.7 per cent case) and no tissue was obtained in 8.8 per cent cases). Significant hemorrhage occurred in 2 instances (5.9 per cent). In 1 instance (2.9 per cent) the bleeding required transfusion and operation. The clinical limitations and selected advantages of this technique are reviewed.