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renal biopsy and platelets.
Any rads want to weigh in on renal biopsies?
SIR states 50k minimum for platelets. Uptodate 100k. National kidney foundation 120k.
transfuse platelets if less than 80k?
Blood pressure? less than 140 systolic? 170 systolic upper limit?
18 or 16 gauge needle?
3 good cores enough?
Strict bed rest 4 hours? 6 hours? 8 hours? -
35 Replies
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Renal mass or renal parenchymal for entities such as autoimmune disease, glomerulonephritis ?
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Random.
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– 50K PLT
– SBP < 180 (lower the better w/in reason)
– 18 G
– 2 passes of renal cortex
– bed rest 3 hours min, usually home same day
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In my limited experience, 2 x 18g are never enough. They need a certain number of glomeruli to make a diagnosis and our bedside pathologists could barely count above 10 (with 2, sometimes even 3 passes through the cortex). I ended up throwing 4 passes, most of the time. No bleeding complication. The rest is similar to what TurboEcho mentioned.
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Quote from Hubcap
In my limited experience, 2 x 18g are never enough. They need a certain number of glomeruli to make a diagnosis and our bedside pathologists could barely count above 10 (with 2, sometimes even 3 passes through the cortex). I ended up throwing 4 passes, most of the time. No bleeding complication. The rest is similar to what TurboEcho mentioned.
We send ours out to a special lab. Have only done 2 my entire career and we have general guys and IR guys mixed in. We are well above the quoted threshold numbers. Lower pole cortex, tangential approach.
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Quote from Hubcap
In my limited experience, 2 x 18g are never enough. They need a certain number of glomeruli to make a diagnosis and our bedside pathologists could barely count above 10 (with 2, sometimes even 3 passes through the cortex). I ended up throwing 4 passes, most of the time. No bleeding complication. The rest is similar to what TurboEcho mentioned.
A recent path report said I got 35 glomeruli with 3 18G cores. Key in my experience is really making sure you’re in the cortex and only putting the outer needle through the cortex once.-
Quote from Pedrad2017
Quote from Hubcap
In my limited experience, 2 x 18g are never enough. They need a certain number of glomeruli to make a diagnosis and our bedside pathologists could barely count above 10 (with 2, sometimes even 3 passes through the cortex). I ended up throwing 4 passes, most of the time. No bleeding complication. The rest is similar to what TurboEcho mentioned.
A recent path report said I got 35 glomeruli with 3 18G cores. Key in my experience is really making sure you’re in the cortex and only putting the outer needle through the cortex once.
how do you find a new tract? angle the gun in different directions?
How far in do you park the introducer needle?
If the introducer is barely in the kidney it can come out with respiration or tear the capsule. If it is in too far you get medulla.
I have parked the introducer outside the capsule on some cases.-
Firing while outside the kidney multiple times is more dangerous in my opinion than leaving the outer needle less than 1 cm embedded into the cortex and angling the needle with each fire of the biopsy gun. If you’re aiming along the curvature of the lower pole of the kidney obliquely (cortical tangential approach) you’ll get more cortex.
[link=https://pubs.rsna.org/doi/pdf/10.1148/radiol.2016160912]https://pubs.rsna.org/doi…1148/radiol.2016160912[/link]-
I go tangential and minimally advance the coax through the capsule. Rotate the tray and angle the coax each time to sample different areas. My pathologist demands 6 x 18g which seems like overkill to me.
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6 cores is outrageous. Might as well open up the retroperitoneum and do a partial nephrectomy.
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Quote from Pedrad2017
6 cores is outrageous. Might as well open up the retroperitoneum and do a partial nephrectomy.
Local pathologist doesn’t read them anyway. At most determines specimen adequacy. -unless you are in a big institution that has electron microscopy.
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Quote from Pedrad2017
Quote from Hubcap
In my limited experience, 2 x 18g are never enough. They need a certain number of glomeruli to make a diagnosis and our bedside pathologists could barely count above 10 (with 2, sometimes even 3 passes through the cortex). I ended up throwing 4 passes, most of the time. No bleeding complication. The rest is similar to what TurboEcho mentioned.
A recent path report said I got 35 glomeruli with 3 18G cores. Key in my experience is really making sure you’re in the cortex and only putting the outer needle through the cortex once.
Agree, key is cortical tissue. Try to puncture renal capsule/cortex only once and have good trajectory for throws, whether you’re using CT or U/S. I use 18 gauge end core bx gun x 3, generally bigger and better samples than side-notch devices. Checked my last path report, and that netted 31 glomeruli. Also, have a nurse available for monitoring BP and giving sedation. Recover patient 2-4 hours depending on comfort level and how procedure went, then d/c home.
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Quote from TurboEcho
– 50K PLT
– SBP < 180 (lower the better w/in reason)
– 18 G
– 2 passes of renal cortex
– bed rest 3 hours min, usually home same dayThose are pretty aggressive numbers. Thanks for the feedback.
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50K
SBP <160
3 18ga cores
3 hours bedrest-
I remember the days of admission for 23 hours observation under the nephrologist. LOL
Times have changed.-
US or CT?
I imagine the die hard IRs will like ultrasound because it is faster or requires more skill.
I do both but lean to CT.-
I do 100% US since I want to be certain that my needle trajectory is entirely within the cortex and also US can accommodate the obliquity.
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Would be insane to transfuse blood products for an elective procedure IMO
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Quote from IR27
Would be insane to transfuse blood products for an elective procedure IMO
So what do you do?
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They could see someone to be medically optimized before you do an elective procedure for a chronic disease process.
Obviously it also depends on the context, its laughable that at 49k we lose our minds and say no can do but 51k is good, like there is any significant physiologic difference between those two
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Quote from IR27
They could see someone to be medically optimized before you do an elective procedure for a chronic disease process.
Obviously it also depends on the context, its laughable that at 49k we lose our minds and say no can do but 51k is good, like there is any significant physiologic difference between those two
Isn’t transfusing a patient with thrombocytopenia medical optimization? Do you even do renal biopsies?
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I guess but someone should probably look into why they are so low instead of just giving them blood products and hoping it fixes the issue . They can do other things medically without shoving my platelets into their blood and let their marrow do its job naturally .
Its like saying I have a tire thats leaking but I can get to work ok if its 20 psi even though its supposed to be 40. Well why dont we figure out why the tire is leaking. And putting more air in the tire doesnt result in harmful reactions sometimes like transfusions do.
This is one of the reasons we have shortages bc people misuse products like this.
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Shoving platelets* typo
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49k we lose our minds and say no can do but 51k is good
Nice point.
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In my neck of the woods the biopsy specimens get sent to dedicated renal pathologists – the reports are incredibly detailed. Take a look at the reports. I can’t imagine doing this for a living!
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Quote from Badabing
In my neck of the woods the biopsy specimens get sent to dedicated renal pathologists – the reports are incredibly detailed. Take a look at the reports. I can’t imagine doing this for a living!
I think this is the case everywhere. Not many hospitals have electron microscopy.
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so are people generally doing 18 gauge? how many cores?
When I first got to this job they were doing 14 g cores (breast biopsy needle) with lots of hematomas being induced. Keeping all patients overnight. -
Quote from MD20/20
so are people generally doing 18 gauge? how many cores?
When I first got to this job they were doing 14 g cores (breast biopsy needle) with lots of hematomas being induced. Keeping all patients overnight.I use 17 gauge introducer and 18 gauge core. Try to penetrate the cortex only once if possible. If I get three good cores on the first three passes I stop. No pathologist present to verify specimen adequacy. I would say most cases get some perinephric hemorrhage on post biopsy CT. US probably bleed just as much but perinephric hemorrhage harder to see.
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This is similar to what I now do. Prefer CT to US as nearly all the patients I encounter are morbid – super morbid obese.
Are most people discharging (and if so how long after) or admitting for observation after the procedure? -
Your local pathologist should be present to evaluate your cores to make sure you have enough glomeruli. They use a light microscope, low power. The number of cores needed will depend on the patients pathology – some have plenty of glomeruli. Just about every community hospital can do this. The cores then get sent out for electron microscopy.
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Quote from IRdoc16
Your local pathologist should be present to evaluate your cores to make sure you have enough glomeruli. They use a light microscope, low power. The number of cores needed will depend on the patients pathology – some have plenty of glomeruli. Just about every community hospital can do this. The cores then get sent out for electron microscopy.
Your local pathologist “should” be present. My current pathologist refuses.
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Hmm.. I use a coaxial system with one cortical puncture but use big needles. 15G introducer and 16G BARD biopsy gun(my younger colleague calls it the harpoon). 2 cores only.
I always use ultrasound as I can place the needle into the cortex. BUT.. mainly slim patients in my neck of the woods(affluent part of UK). Also are cooperative. Haven’t had a big bleeder yet. Good results.
Perhaps luck but I also do many nephrostomies/PCNL’s with US guidance so have a lot of experience with kidneys.
The more I practice the luckier I get(apologies to Gary Player) -
Quote from NLynch
Hmm.. I use a coaxial system with one cortical puncture but use big needles. 15G introducer and 16G BARD biopsy gun(my younger colleague calls it the harpoon). 2 cores only.
I always use ultrasound as I can place the needle into the cortex. BUT.. mainly slim patients in my neck of the woods(affluent part of UK). Also are cooperative. Haven’t had a big bleeder yet. Good results.
Perhaps luck but I also do many nephrostomies/PCNL’s with US guidance so have a lot of experience with kidneys.
The more I practice the luckier I get(apologies to Gary Player)What is your cut off for platelets and blood pressure?
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I honestly think luck/randomness has 90% to do with a post-renal bleed. Perhaps some truth to uremia (Cr > 2) and thrombocytopenia. Don’t stick the needle in the renal pelvis. About the best one can hope for
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I have used the bard Maxcore biopsy gun on livers. It gets good cores. I should try the bard on my next renal.
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