Renal+Biopsy

This document outlines the processes around performance of renal biopsies within the CRGH Renal Unit.
 * 1) **Medical Appointment Pre Biopsy**
 * 2) Procedure must be explained to patient with interpreter if needed.
 * 3) Patient should be consented and provided with information sheet.
 * 4) Ensure patient has made arrangements for transport to and from hospital as the patient should not drive following the biopsy.
 * 5) Ensure patient is given a pathology form for FBC and coagulation studies (INR & APTT) to be done prior to planned biopsy. In stable patients these can be performed within 1 month of the biopsy. In unstable or acutely unwell patients they should be done within 3 days of the biopsy.
 * 6) Confirm negative urine culture within 1 month of the biopsy.
 * 7) Review medications, in particular looking for anticoagulants that need to be withheld prior to the biopsy or may even preclude the biopsy altogether. Examples include: aspirin, clopidogrel, warfarin/heparin, NSAIDs, dabigratran, rivaroxaban, apixaban, ticagrelor. All NSAIDs should be withheld for at least 1 week prior to biopsy.
 * 8) Consider risk/benefit of anti-platelet/anticoagulation medications. If appropriate withhold for one week prior to biopsy. If not appropriate to withhold then consider outpatient haematology consultation prior to biopsy or admission to hospital prior to biopsy to decide upon safest method.
 * 9) **Booking the biopsy**
 * 10) Call CRGH Radiology Dept on 9767 6501 to book the time of biopsy
 * 11) Fax the completed Radiology Dept request form to 9767 7765
 * 12) Put the completed request form along with signed consent and Recommendation for Admission Form (RFA) in an envelope and mail to CRGH Radiology Dept with a note on the request form of the date for the procedure.
 * 13) **Prior to the biopsy**
 * 14) There is no need to fast the patient and a light breakfast is permitted
 * 15) Patient should have planned transport home after the biopsy.
 * 16) **Day of Biopsy:**The patient does not need to fast and can have a light breakfast. The person performing the biopsy must:
 * 17) Ensure that the patient has been consented.
 * 18) Ensure patient can comply with the procedure.
 * 19) Verify that patient has arranged appropriate transport home.
 * 20) Confirm the indication for the biopsy (ie: the investigation is clinically justified) and complete the Pathology Request Form (see 4.10 below).
 * 21) Review medications and ensure appropriate medications have been withheld.
 * 22) Check that FBC and coagulation studies prior to biopsy are normal.
 * 23) Blood pressure should be taken and checked by person performing the biopsy. Hypertension is a relative contra-indication for biopsy, with systolic values >=160 and diastolic values >=95 being a threshold for concern. If the blood pressure values are of concern discussion must be had with the supervising specialist to decide upon proceding with the biopsy or not.
 * 24) A 14G (or 16G) needle should be used preferentially for native biopsies and a 16G (or 18G) needle should be used for transplant biopsies.
 * 25) Once 4 passes have been made by one operator and adequate tissue has not been obtained, the procedure should be abandoned and re-booked on a case by case basis.
 * 26) **Pathology Request Form:** this should outline the reasons for the kidney biopsy and ideally include details of the patient's renal function, presence and amount of proteinuria (eg: nephrotic range), presence of haematuria, history of hypertension, any immune serology results and important medical history (eg: diabetic status, multiple myeloma). For transplant biopsies there should be information (additional to the above) regarding the reasons for the biopsy along with any history of rejection, changes in immune suppression and native kidney disease. The better the clinical information, the more likely it is that pathology will be able to provide valuable information from the biopsy specimen.
 * 27) **Post Biopsy**
 * 28) Patient should lie still and supine for 4 hours. If transplant biopsy, apply sandbag to biopsy site.
 * 29) BP and pulse should be monitored every 15 minutes during the first hour and then every 30 minutes for the total observation time.
 * 30) Oral fluids should be encouraged unless there is a contra-indication to this (fluid overload or fasting for example).
 * 31) All urine should be checked for evidence of **macroscopic** **haematuria,** with a small sample of each specimen kept for review by the medical staff. If macroscopic haematuria is present, the renal registrar should review the patient as soon as possible.
 * 32) **Significant pain or discomfort** requiring more than paracetamol should be notified to the renal registrar.
 * 33) **Hypotension** (a fall in BP of 30mmHg or sBP<100) should be immediately notified to the renal registrar.
 * 34) Any patient who experiences **significant pain or discomfort, macroscopic haematuria or hypotension** should not be discharged.
 * 35) A patient must pass urine and ambulate prior to discharge.
 * 36) All patients must be reviewed by a member of the Renal Unit medical staff (either consultant or registrar/RMO) prior to discharge and should ensure that appropriate follow up is organised. Note that the results of the biopsy will usually take around 1 week for routine biopsies (shorter for urgent biopsies), so appointments should usually be made for 2-3 weeks following the biopsy to discuss the results.
 * 37) Patients should be be advised not to lift items greater than 5kg, or strain for the next 2 weeks and to avoid contact sports for the next month. The patient should be advised to re-present if there is macroscopic haematuria, significant pain, if they feel unwell or if concerned in any way.
 * 38) Any anticoagulation that has been stopped will usually be restarted around 72 hours after the biopsy (if there is no evidence of bleeding) but this should be tailored to the risk of the individual patient.