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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 62-66

Nationwide pediatric renal biopsy audit by the Indian Society of Pediatric Nephrology


1 Department of Pediatric Nephrology, Institute of Child Health, Kolkata, West Bengal, India
2 Division of Pediatric Nephrology, Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, Bengaluru, Karnataka, India
3 Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, Bengaluru, Karnataka, India
4 Department of Pediatric Nephrology, St John's Medical College and Hospital, Bengaluru, Karnataka, India
5 Division of Pediatric Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication27-Dec-2018

Correspondence Address:
Dr Abhijeet Saha
Department of Pediatrics, Division of Pediatric Nephrology, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, Room No. 102, New Delhi - 110001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJPN.AJPN_25_18

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  Abstract 


Objective: The survey was conducted to identify current renal biopsy practices in India and compare them with the British Association of Pediatric Nephrology (BAPN, 2015) standards. Methods: A 53-question survey questionnaire was sent to 48 centers across the country by electronic mail. Questions included were related to the number of biopsies performed, indications, prerequisites and procedure of biopsy, monitoring, and complications. The results were compared against the BAPN 2015 standards. Results: Thirty (62.5%) out of 48 centers responded to the questionnaire. Real-time ultrasound was the favored method at 24 (80%) centers. Most (80%) of the biopsies were performed by nephrologists alone. The biopsy was usually (80%) an inpatient procedure with overnight hospitalization; 20% of the centers performed it as a day-care procedure. The 18-gauge needle was preferred by 60% of the centers. Biopsy was achieved with three or fewer passes in 93% of the centers. Almost half (47%) of the centers considered 10 or more glomeruli on light microscopy as adequate to reach a diagnosis. The rates of gross hematuria were <5% in 80% of the centers surveyed. Death following biopsy was reported by two centers. Conclusion: Majority of the centers surveyed across India achieve BAPN standards in most parameters. Such audit of practices against the standards for kidney biopsy enables comparison between units as well as for monitoring of individual center's performance over time.

Keywords: Children, kidney, histology, ultrasound


How to cite this article:
Sinha R, Arora N, Kaur M, Iyengar A, Hari P, Saha A. Nationwide pediatric renal biopsy audit by the Indian Society of Pediatric Nephrology. Asian J Pediatr Nephrol 2018;1:62-6

How to cite this URL:
Sinha R, Arora N, Kaur M, Iyengar A, Hari P, Saha A. Nationwide pediatric renal biopsy audit by the Indian Society of Pediatric Nephrology. Asian J Pediatr Nephrol [serial online] 2018 [cited 2019 Jul 23];1:62-6. Available from: http://www.ajpn-online.org/text.asp?2018/1/2/62/248638


  Introduction Top


Percutaneous renal biopsy (PRB) is an indispensable tool for the diagnosis and prognostication of various kidney disorders. The methods and instruments used to perform the procedure have changed markedly since its introduction in the 1950s. PRB guided by real-time ultrasonography and using automated spring-loaded biopsy device is the current standard of practice.[1] The British Association of Pediatric Nephrology (BAPN) first published guidelines for standards related to PRB in 2003.[2] In 2010 and 2015, PRB practices were audited and BAPN standards were revised.[3],[4] In this nationwide survey, we explored the current PRB practices in India and compared the results with the BAPN standards [Table S1 [Additional file 1]].


  Methods Top


An electronic survey to understand practices of PRB was circulated among pediatric nephrologists across India on behalf of the Indian Society of Pediatric Nephrology (ISPN). A 53-item questionnaire was developed using SurveyMonkey®, an open source survey application, and was transmitted as a link in e-mail to 48 centers across India in October 2015. Questions were related to the number of biopsies performed, indications and prerequisites for biopsy, biopsy procedure, and complications and monitoring after biopsy [Supplementary Annexure 1 [Additional file 2]]. Most questions pertained to the results over a period of 1 year except a few that asked about changes in practice over the past 5 years and significant complications over the past 10 years. Each center was represented by one respondent. The results were compared against the BAPN 2015 PRB standards [Table 1].[4]
Table 1: Comparison of results of kidney biopsy audit of the Indian Society of Pediatric Nephrology with the standards for kidney biopsy proposed by the British Association of Pediatric Nephrology in 2015

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  Results Top


Thirty (62.5%) of 48 centers responded to the questionnaire. [Table 1] compares the results of this ISPN survey with BAPN 2015 standards. Biopsies were usually performed in radiology area (40% of centers), nephrology ward (34%), or the pediatric intensive care unit (26%). Four (13%) centers performed more than 100 biopsies annually, whereas 40% of the centers performed less than 20 biopsies annually; 47% performed 20–100 biopsies per year. However, the rates of complications did not differ between these groups of centers. Real-time ultrasound was the favored method for guiding biopsy in 24 (80%) centers. Two centers reported the use of open renal biopsy to obtain tissue. PRB was performed using percutaneous real-time ultrasound-guided puncture by the nephrologist alone at 20 (67%) centers, by nephrologist along with the radiologist at 4 (13%) centers, and by both nephrologist and radiologist at 6 (20%) centers.

Biopsy was performed as an inpatient procedure with overnight hospitalization at 24 (80%) centers and as a day-care procedure at 6 (20%) centers. At the latter group of centers, patients were observed after procedure for a minimum of 6 hr. Prothrombin time and complete blood count were routinely performed at all centers before performing biopsy. Further, 57% of the centers also ensured normal bleeding time and 40% of the centers performed clotting time. At 67% of the centers, crossmatching and typing for one or more blood units was performed before the procedure.

PRB was considered risky in patients with Stage 4 and 5 chronic kidney disease (CKD) by 67% and 93% of the survey respondents, respectively. Two-thirds of the respondents reported performing biopsy in patients on hemodialysis, if it was indicated. PRB was avoided by 96% of the respondents if the patient was on antiplatelet drugs; such agents were withheld for at least a week before procedure at 56% of the centers and 22% and 18% centers reporting withholding such therapy for a minimum of 3 days or 2 weeks, respectively. Around 43% of the centers used desmopressin before biopsy to reduce the risk of bleeding in patients with CKD or acute kidney injury with uremia.

While biopsy in patients with steroid-resistant nephrotic syndrome was routine, 97% of the respondents also performed biopsy in patients with steroid-dependent nephrotic syndrome planned for therapy with calcineurin inhibitor. Isolated microscopic hematuria (>20 red blood cells/high-power field) persisting for 6 months was an indication for biopsy at around 30% of the centers.

The procedure was performed in the prone position at all the centers. While 90% of the centers used local anesthesia with sedation for performing biopsy, general anesthesia was also used at 27% of the centers, chiefly in children younger than 10 years of age. Automatic kidney biopsy needle was used at 83% of the centers; the rest used semi-automatic biopsy needles. The 18-gauge needle was preferred by 60% of the respondents; 33% used 16-gauge needles, whereas 7% of the centers used 22-gauge needle. In 93% of the centers, fewer than three passes were required in more than 80% biopsies, a requirement of the BAPN standards. Ten percent of the centers used bedside microscopy to assess the adequacy of the sample. Fourteen (47%) respondents considered having 10 or more glomeruli in light microscopy as an adequate sample for making the diagnosis. While immunofluorescence was performed in native kidney biopsy at all centers, electron microscopy was available at only 13% of the centers.

After the biopsy, vital signs were monitored frequently at all the centers for at least 4 hr. Postprocedure ultrasound to look for hematoma was routinely performed at 60% of the centers, usually (86.6% of the cases) within 30–60 min of the procedure. The reported rate for macroscopic hematuria in the prior year was <5% for 80% of the centers [Figure 1]. Less than one percent of the patients required blood transfusion after biopsy in the prior year in all centers. Two (7%) centers each reported death and need for intervention, such as angiographic embolization or nephrectomy, following kidney biopsy.
Figure 1: Percentage of patients that developed gross hematuria after kidney biopsy in the preceding year across centers

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  Discussion Top


In this multicenter audit, we collected data on renal biopsy procedure from centers spread all across the country and compared the practices against the BAPN standards. Real-time ultrasonographic guidance allows nephrologists to perform the procedure bedside with continuous visualization of the kidney and the needle and avoids radiation exposure and nephrotoxic contrast media administration involved undertaking biopsy under fluoroscopic control.[5] Additional advantages of superior yield and fewer complications in comparison to the blind procedure[6],[7],[8] are reasons why majority of the centers in our country now undertake renal biopsy under ultrasound guidance. With the use of real-time ultrasonography, radiologists rather than nephrologists now perform most PRB, particularly in the Western world,[9] as indicated by surveys from Europe,[10] Norway,[11] the USA,[12] and Australia.[9] Some studies suggest that nephrologists alone without the assistance of radiologists can perform renal biopsies with better yield and fewer complications as compared to radiologists.[13],[14] Nephrologists have a better understanding of the patient's clinical status and kidney disease and can answer the patient's queries in a more comprehensive manner.[8],[15],[16]

With real-time ultrasound guidance, procedure-related complications have decreased, making its performance in a day-care setting feasible,[17],[18] leading to reduced costs of care.[2] Since most complications occur within the first 8 hr after the procedure, performing biopsy in a day-care setting does not significantly alter the complication rate or the chance of missing complications.[19],[20],[21] An audit of pediatric renal biopsy practices in the UK reinforced safety of performing PRB in day-care setting.[4] However, occasionally, complications are delayed and, unfortunately, there are no factors predicting these.[22] In a case series of 750 biopsies of native kidneys, 67% of major complications were observed within the first 8 hr, suggesting that 33% of the complications may be missed if the child is not observed for 24 hr.[23] Majority of the respondents in our survey preferred to keep the patient overnight for observation in contrast to 82% of the centers in the UK performing PRB on a day-care basis.[4]

Before performing a renal biopsy, it is a universal practice to check the blood counts and prothrombin and partial thromboplastin time.[24] As PRB has a high risk of bleeding, the antiplatelet drugs should be withheld 7 days before the procedure and should be resumed 2–3 days after the biopsy. Platelet count below 50,000/mm3 is the standard threshold for transfusion before surgical intervention, but most nephrologists are uncomfortable performing kidney biopsy at platelet count <100,000/mm3, since platelet dysfunction may accompany uremia and direct hemostasis cannot be provided.[25] The use of desmopressin is shown to reduce the risk of bleeding in patients with uremia and advanced renal failure.[26] The European Society of Pediatric Radiology (ESPR) recommends ultrasound before biopsy to localize the kidney and to assess for structural factors that may increase the risk of bleeding, for example, duplex or solitary kidney and aberrant renal vessels.[27] All centers in the ISPN survey performed PRB in the prone position and 60% of the centers used an 18-gauge needle, as is recommended by ESPR.[27] However, results from the Norwegian registry,[11] a recent single-center Indian study,[28] a randomized controlled trial,[29] and the BAPN re-audit[4] indicate that 16-gauge needles provide better yield and, paradoxically, carry lower risk of gross hematuria as compared to 18-gauge needles. The higher risk of complications with 18-gauge needles is attributed to increased number of passes needed to obtain adequate tissue[4] and the tendency of thinner needles to deviate from the lower pole proximally toward the pelvis.[11]

The BAPN standards state that adequate biopsy of native or allograft kidneys should be obtained using <3 passes on at least 80% of occasions. In our survey, 93% of the centers claim to achieve this standard. Similarly, two reports from India[28],[30] have previously documented achieving such standard in 97%–100% biopsies. In contrast, the target was not achieved by 3 of 11 centers surveyed in the BAPN audit. Routine bedside microscopy to assess the adequacy of the biopsied sample could further reduce the required number of passes; however, only 10% of our respondents had the facility.

An adequate biopsy specimen was defined by the BAPN audit as one containing 10 or more glomeruli; if the histopathologist could reach a diagnosis with fewer glomeruli, the specimen was considered adequate. In the BAPN audit, this was achieved in 97.9% of the cases. Likewise, in the two prior reports from India, 10 or more glomeruli were found in 78%–96.5% of the cases, and a diagnosis based on light microscopy was reached in 100% of the cases.[28],[30] While this retrospective recall-based survey could not determine the proportion of cases with 10 or more glomeruli or with a satisfactory diagnosis, only 47% of the respondents considered 10 or more glomeruli as essential in an adequate specimen; 35% of the respondents felt that 7 or more glomeruli were sufficient, whereas 18% of the centers were satisfied if 5 or more glomeruli were sampled.

Various studies reporting PRB in large numbers of adult patients indicate that the rates of major complications following biopsy vary from 0.8% to 6.4%.[23],[31],[32],[33],[34],[35] Factors that increase the risk of complications include renal insufficiency, poorly controlled hypertension, and prolonged bleeding time.[36],[37] The reported rate of gross hematuria in the present survey was <5% at 80% of the centers, thus meeting the BAPN standard. Most centers reported blood transfusion requirement in <1% of the patients, comparable to recent meta-analysis of studies in adults that reports macroscopic hematuria in 3.5% of the cases with blood transfusion requirement in 0.9% of the cases.[38] Other significant complications, although not included in the BAPN audit, are perinephric hematomas >2 cm in size and formation of arteriovenous fistulae.[38] Only 2 (6.6%) respondents in our survey reported death or need for angiographic embolization after the biopsy procedure, during the past decade. Finally, while 44% centers appear to be conducting periodic audit of their biopsy practices, only two centers have published their findings.[28],[30]


  Conclusion Top


This nationwide multicenter survey for auditing the PRB practices being followed in India highlights the fact that even in resource-limited setting like ours, it is possible to achieve the standards for PRB in line with BAPN recommendations. However, the study is limited by its retrospective design based on recall from memory by individual respondents from each center. A prospective audit is strongly recommended for better understanding the results of the current PRB practices. Periodic audits and re-audits involving more centers and gathering more detailed information may help formulate local standards for practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

We thank and acknowledge the following doctors and centers for participating in this survey. Abhijeet Saha, Dr. RML Hospital, New Delhi; Amarjeet Mehta, SMS Medical College, Jaipur; Amit Agarwal, Batra Hospital and Medical Research Center, New Delhi; Amish Udani, L.T.M.M.C and L.T.M.G Hospital, Sion; Anil Vasudevan, St. John's Medical College Hospital, Bengaluru; Arvind Bagga, All India Institute of Medical Sciences (AIIMS), New Delhi; Girish Bhatt, AIIMS, Bhopal; Indira Agarwal, Christian Medical College, Vellore; Janaki Menon, Government Medical College, Trissur; Kamran Afzal, Jawaharlal Nehru Medical College, Aligarh; Kanav Anand, Sir Ganga Ram Hospital, New Delhi; Kishore Phadke, Rainbow Children Hospital, Bangalore; Manoj Matnani, KEM Hospital, Pune; Mukta Mantan, Maulana Azad Medical College, Delhi; Narendra Rai, Hind Institute of Medical Sciences, Lucknow; OP Mishra, Institute of Medical Sciences, Varanasi; Pankaj Deshpande, Hinduja Hospital Mahim and Yewale hospital, Vashi; Prabha Senguttuvan, Mehta Children Hospital, Chennai; Prashant Prabhu, Goa Medical College, Bambolim; Rajiv Sinha, AMRI Mukundpur; Siddharth Sethi, Medanta the Medicity, Gurugram; Sonia Sharma, Max Hospitals, New Delhi; Srinivasu Achanta, Care Hospital, Nagpur; Tathagata Bose, Command Hospital, Kolkata; Varsha Phadke, K.J. Somaiya Medical College and Hospital, Mumbai; SK Patnaik, Research and Referral Hospital, New Delhi; Sushmita Banerjee, CMRI Hospital, Kolkata; Shubham, Karoti Hospital, Kohlapur; Manasa, Kidney Foundation, Tirupati; and Bharati Hospital, Pune.

 
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