Blog
About

7
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      A retrospective analysis of the utility and safety of kidney transplant biopsies by nephrology trainees and consultants

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background and aims

          Dysfunction of a kidney transplant often requires histological sampling by percutaneous ultrasound-guided core needle biopsy. Transplant biopsy is more specialized than native kidney biopsy, the indications and complications are less well defined and in England are performed mainly by nephrologists. The aims of the study were to evaluate the adequacy and complication rate in living and deceased donor recipients according to training status of the nephrologist, assess the accuracy of physicians in predicting rejection, the threshold creatinine rise for biopsy, and the change in drug management post-biopsy.

          Materials and methods

          We performed a retrospective analysis of all adult patients undergoing a kidney transplant biopsy in 2015 at a major teaching hospital in the UK as part of a service evaluation program. The primary outcome measure was the rate of major complications and secondary measures included sample adequacy, seniority of operator, clinician-predicted diagnosis, biopsy diagnosis and change in drug management.

          Results

          One hundred and seven (n = 107) transplant biopsies were performed across 27 living donor (LD) recipients and 57 deceased donor (DD) recipients. LDs were statistically less likely to have diabetes, more likely to take azathioprine. Biopsies were performed by trainees rather than consultants at a ratio of 3:1. The complication rate was low with no major bleeding complications. Visible haematuria occurred in 4.7% and 2.8% of patients developed transplant pyelonephritis. 3.7% of biopsies contained no glomeruli. There was no effect attributed to training status. The pre-biopsy rise in creatinine was significantly less for LD compared to DD recipients (45% vs 70%). A clinician-suspected diagnosis of rejection was confirmed on biopsy in 42.9% of cases and overall about 47.9% of biopsies led to a change in drug management.

          Conclusions

          Kidney transplant biopsies were safe, performed adequately by trainee nephrologists and were often associated with a change in drug management.

          Highlights

          • Transplant biopsy is commonly performed with a risk of major bleeding complications.

          • In 107 consecutive kidney transplant biopsies in one calendar year there were no major complications.

          • Trainees performed more biopsies than consultants with no adverse effect on safety or biopsy quality.

          • Rejection was correctly predicted in 43% of cases and 48% of biopsies were associated with a change in drug management.

          • A significantly smaller rise in creatinine occurred before biopsy in living compared to deceased donors.

          Related collections

          Most cited references 14

          • Record: found
          • Abstract: found
          • Article: not found

          The Banff 97 working classification of renal allograft pathology.

          Standardization of renal allograft biopsy interpretation is necessary to guide therapy and to establish an objective end point for clinical trials. This manuscript describes a classification, Banff 97, developed by investigators using the Banff Schema and the Collaborative Clinical Trials in Transplantation (CCTT) modification for diagnosis of renal allograft pathology. Banff 97 grew from an international consensus discussion begun at Banff and continued via the Internet. This schema developed from (a) analysis of data using the Banff classification, (b) publication of and experience with the CCTT modification, (c) international conferences, and (d) data from recent studies on impact of vasculitis on transplant outcome. Semiquantitative lesion scoring continues to focus on tubulitis and arteritis but includes a minimum threshold for interstitial inflammation. Banff 97 defines "types" of acute/active rejection. Type I is tubulointerstitial rejection without arteritis. Type II is vascular rejection with intimal arteritis, and type III is severe rejection with transmural arterial changes. Biopsies with only mild inflammation are graded as "borderline/suspicious for rejection." Chronic/sclerosing allograft changes are graded based on severity of tubular atrophy and interstitial fibrosis. Antibody-mediated rejection, hyperacute or accelerated acute in presentation, is also categorized, as are other significant allograft findings. The Banff 97 working classification refines earlier schemas and represents input from two classifications most widely used in clinical rejection trials and in clinical practice worldwide. Major changes include the following: rejection with vasculitis is separated from tubulointerstitial rejection; severe rejection requires transmural changes in arteries; "borderline" rejection can only be interpreted in a clinical context; antibody-mediated rejection is further defined, and lesion scoring focuses on most severely involved structures. Criteria for specimen adequacy have also been modified. Banff 97 represents a significant refinement of allograft assessment, developed via international consensus discussions.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: found
            Is Open Access

            Risk factors for bleeding complications after nephrologist-performed native renal biopsy

            Abstract Background Bleeding is a recognized complication of native percutaneous renal biopsy. This study aimed to describe the incidence of major bleeding after biopsy in a single centre over a 15-year period and examine factors associated with major bleeding. Methods We identified consecutive adult patients undergoing ultrasound-guided native renal biopsy in the Glasgow Renal and Transplant Unit from 2000 to 2014. From the electronic patient record, we collected data pertaining to biopsy indication, pre- and post-biopsy laboratory measurements, prescribed medication and diagnosis. Aspirin was routinely continued. We defined major bleeding post-biopsy as the need for blood transfusion, surgical or radiological intervention or death. Binary logistic regression analysis was used to assess factors associated with increased risk of major bleeding. Results There were 2563 patients who underwent native renal biopsy (1499 elective, 1064 emergency). The average age of patients was 57 (SD 17) years and 57.4% were male. Overall, the rate of major bleeding was 2.2%. In all, 46 patients required transfusion (1.8%), 9 patients underwent embolization (0.4%), no patient required nephrectomy and 1 patient died as a result of a significant late retroperitoneal bleed. Major bleeding was more common in those undergoing emergency compared with elective renal biopsy (3.4 versus 1.1%; P  30). Conclusions The risk of major bleeding following native renal biopsy in the modern era is low. Complications are more common when biopsy is conducted as an emergency, which has implications for obtaining informed consent. Our data support the strategy of not stopping aspirin before renal biopsy.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              The significance of histological diagnosis in renal allograft biopsies in 2014.

              In 2014, the renal allograft biopsy still represents the best available diagnostic 'gold' standard to assess reasons for allograft dysfunction. However, it is well recognized that histological lesion observed in the biopsy is of limited diagnostic specificity and that the Banff classification as the international diagnostic standard represents mere expert consensus. Here, we review the role of the renal allograft biopsy in different clinical and diagnostic settings. To increase diagnostic accuracy and to compensate for lack of specificity, the interpretation of biopsy pathology needs to be within the clinical context, primarily defined by time post-transplantation and patient-specific risk profile. With this in mind, similar histopathological patterns will lead to different conclusions with regard to diagnosis, disease grading and staging and thus to patient-specific clinical decision-making. Consensus generation for such integrated diagnostic approach, preferably including new molecular tools, represents the next challenge to the transplant community on its way to precision medicine in transplantation.
                Bookmark

                Author and article information

                Contributors
                Journal
                Ann Med Surg (Lond)
                Ann Med Surg (Lond)
                Annals of Medicine and Surgery
                Elsevier
                2049-0801
                09 February 2018
                April 2018
                09 February 2018
                : 28
                : 6-10
                Affiliations
                Oxford Kidney Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Old Road, Oxford, OX3 7LE, United Kingdom
                Author notes
                []Corresponding author. Michael.reschen@ 123456ouh.nhs.uk
                Article
                S2049-0801(18)30015-3
                10.1016/j.amsu.2018.02.001
                5852268
                © 2018 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                Categories
                Original Research

                Comments

                Comment on this article