Renal Biopsy

How to refer for a renal biopsy

• If urgent, please phone the Starship nephrologist on call

• If non-urgent, please email the nephrologist who covers your region, providing history and investigations to date

• Before a renal biopsy can be performed, a renal ultrasound is needed to demonstrate normal anatomy. If this has been done or can be done locally, please transfer to ADHB radiology via PACs. If you are unable to arrange please discuss at the time of referral.

• Please advise if child on aspirin or anticoagulants, there are known issues with thrombocytopenia, clotting or red cell antibodies that may delay a group and hold (bloods are checked on children with suspected SLE the day prior to the biopsy for this reason).

• You will be advised of the results as they become available

Who to refer for a renal biopsy

Nephrotic Syndrome

Consider renal biopsy in children with nephrotic syndrome:

• who have not responded to steroids after 4 weeks of therapy of 60mg/m2/day

• who are very young (under 1 yr old - all of these cases should be discussed at presentation)

• who become steroid resistant having previously been steroid sensitive

NB: Children with steroid dependent disease or frequently relapsing disease may not require a biopsy prior to treatment, however this should be discussed with nephrologist.

Children with minimal change disease can have hypertension and/or microscopic haematuria. These are not stand-alone indications for biopsy at initial presentation.

Vasculitis

Children with vasculitis can have significant disease on biopsy with minimal urinary findings. Please keep a low threshold for discussing the possibility of biopsy in these children.

In particular consider renal biopsy for children with

• Rapidly progressive decline in renal function over days or weeks

• Systemic lupus erythematosis (SLE) - any abnormal urine sediment including haematuria+/- proteinuria 

• Henoch Schonlein Purpura (HSP): 

  - Recurrent purpura with changes in urine sediment and degree of proteinuria

  - Impaired renal function

  - Nephrotic syndrome (oedema + albumin <25g/L + urine protein:creatinine ration >200mg/mmol)

  - Persistent or recurrent proteinuria (first am urine protein:creatinine ratio) according to the following:

  • uPCR >250mg/mmol for 4 weeks

  • uPCR>100mg/mmol for 3months

  • uPCR>50mg/mmol for 6months

Acute Glomerulonephritis

Consider renal biopsy in children who:

• Have rapidly progressive decline in renal function over days to weeks

• Have a history suggestive of a chronic illness

• Have an atypical history for post infectious glomerulonephritis, including

  - low C3 persisting 3 months after initial acute illness

  - "Recurrent" episodes of acute glomerulonephritis

• Ongoing renal impairment after the acute presentation, eg. persisting after 2 weeks

• Significant persistent proteinuria after 6 months (first am urine protein creatinine ratio > 50mg/mmol)

It is important to discuss these patients with either the on call nephrologist if the situation is rapidly changing or the outreach nephrologist to your region if not urgent.

Haematuria/Proteinuria

Please discuss the need for renal biopsy in children with:

• Persistent haematuria and proteinuria

• Recurrent macroscopic haematuria and negative haematuria work-up

• Family history of end stage renal failure and/or deafness with either of the above.

NB: Isolated microscopic haematuria is not an indication for biopsy.

Isolated proteinuria should be quantified via first morning urine protein:creatinine ratios (to exclude orthostatic proteinuria). These children should also have a renal ultrasound to exclude renal dysplasia as the cause for their proteinuria, and then referred for clinic review rather than a biopsy as first line investigation.

Post biopsy care

• Encourage fluids for the first 8 hours post-biopsy

• Use paracetamol regularly for pain control in the first 24 hours post-biopsy. If pain is not controlled by paracetamol then patient should be assessed and a renal ultrasound and full blood count performed

• If the child develops macroscopic haematuria after discharge they should have an ultrasound and a full blood count

• Avoid contact sports and heavy lifting for at least a fortnight

Please note further information also available at “Information for families” page link.