1.Overview
Renal biopsy is often called renal puncture. Due to the wide variety of kidney diseases, complex etiology and pathogenesis, the clinical manifestations of many kidney diseases are not completely consistent with the histological changes of the kidney. In order to clarify the etiology of the disease and further confirm the specific type of disease the patient is suffering from, it is necessary to do a kidney puncture biopsy! In recent years, with the development of science and technology, the update of imaging equipment and the improvement of operational skills, percutaneous renal biopsy technique has been carried out more widely, which can directly observe the morphological changes of the kidney in kidney disease and allow for a series of observations.
The quality of its diagnosis has also been greatly improved due to the improvement of puncture techniques, immunohistochemistry techniques and the application of electron microscopy. It has become an important tool for diagnosis, guiding treatment and prognosis determination of renal diseases. It has also contributed to the etiology and development trend of many glomerular diseases.
1.Nephrotic syndrome: When the etiology of nephrotic syndrome is unknown, consider whether it is secondary to systemic diseases;
2, glomerulonephritis with rapid renal decompensation, kidney biopsy is required to determine the pathological type of its renal damage.
3. In acute nephritis syndrome, renal biopsy can reveal the morphology of inflammation and immune deposits and their extent, which is important for the early diagnosis and treatment of acute nephritis. Primary acute nephritis with atypical clinical manifestations or acute nephritis that does not heal after several months or decreased renal function.
4, primary nephrotic syndrome seen in adults is best to do a kidney biopsy to determine its tissue type before using hormones to avoid side effects caused by the blind use of hormones, especially for those who are ineffective in treatment.
5, patients with hematuria can be considered for renal biopsy after various examinations to exclude non-glomerular hematuria, and those who fail to establish the diagnosis can be considered for renal biopsy, and those with persistent hematuria without clinical manifestations and hematuria with proteinuria and 24-hour urine protein quantification greater than 1 gram should have renal biopsy.
6.For those who have proteinuria for a long time without any symptoms, kidney biopsy can clarify the pathological type to facilitate the use of drugs and prognosis.
7. Lupus nephritis, renal hypertension, acute renal failure and chronic renal failure of unknown origin can be diagnosed by kidney biopsy to help diagnosis.
When the above conditions occur, patients had better go to the hospital for kidney biopsy to make a clear diagnosis.
It is mainly used to diagnose lupus nephritis in rheumatic immune system diseases and is an important tool to understand the pathological type of lupus nephritis. In recent years, due to the improvement of renal biopsy technology, trans-B ultrasound-guided renal biopsy has been gradually carried out more widely. Renal biopsy is the main basis for determining the diagnosis, adjusting the treatment plan and judging the prognosis. One of the main roles of renal biopsy in lupus nephritis is to determine the activity and chronicity of the lesion in order to understand the prognosis and guide the treatment.
Active lesions in lupus nephritis have been recognized as an indicator to guide aggressive and intensive treatment. It is an important indicator for aggressive administration of corticosteroids and cytotoxic drugs. For example
① segmental glomerular necrosis;
(ii) marked glomerular cell hyperplasia;
(iii) wire-ring-like changes in the basement membrane;
④Electron microscopy revealed more electron-dense deposits in the subendothelial and thylakoid areas, more nuclear fragments and hematoxylin vesicles;
(⑤) Crescentic cells;
(6) Small renal vascular lesions;
(vii) extensive interstitial edema and mononuclear cell infiltration.
However, if lupus nephritis is dominated by chronic lesions, the outcome is poor. Evidence of chronic lesions are.
(i) glomerulosclerosis ;
(ii) Fibrous crescent;
(iii) tubular atrophy;
④Interstitial fibrosis;
⑤ Renal capsule adhesions;
(6) tubular sclerosis. The 5-year survival rate of the kidney is significantly lower in those with the predominance of the above chronicity indicators.
2.The significance of kidney biopsy
Understanding the histomorphological changes of the kidney provides an important basis for clinicians to judge the condition, treat the disease and estimate the prognosis. It can be said that the development of renal pathology examination is a leap in the development of nephrology. At present, the results of renal pathology examination have become the golden indicator for the diagnosis of kidney diseases. To summarize, the clinical significance of renal puncture examination mainly includes the following points.
(1) Clear diagnosis: The clinical diagnosis of more than one-third of patients can be revised through renal puncture biopsy.
(2) Guidance of treatment: The clinical treatment plan of nearly one third of patients can be modified by renal puncture biopsy.
(3) Estimation of prognosis: The prognosis of patients with kidney disease can be more accurately evaluated by renal puncture biopsy.
In addition, repeat renal pathology is sometimes required to understand the effect of treatment or to understand the progression of pathology (e.g., crescentic nephritis, lupus nephritis and IgA nephropathy).
In order to clarify the diagnosis, guide the treatment or judge the prognosis, and when there is no contraindication to puncture, renal puncture can be performed in various primary, secondary and hereditary renal parenchymal diseases (especially diffuse lesions) in internal medicine.
(1) Primary renal diseases.
①Acute nephritis syndrome, when renal function is rapidly deteriorating and acute nephritis is suspected, renal puncture should be done as early as possible; renal puncture should be done when the condition does not improve according to the treatment of acute nephritis for 2 to 3 months.
② primary nephrotic syndrome, first treatment, hormone rule treatment for 8 weeks when invalid kidney puncture; or first puncture, according to the type of pathology differentiated treatment.
③ asymptomatic hematuria, deformed red blood cell hematuria when the clinical diagnosis is unclear, asymptomatic proteinuria, proteinuria persist >1g/d when the diagnosis is unclear should do renal puncture.
(2) Secondary or hereditary renal disease: renal puncture should be done when the clinical suspicion is undiagnosed, when the clinical diagnosis has been confirmed, but the renal pathological information is important for guiding the treatment or judging the prognosis.
(3) Acute renal failure: prompt puncture should be performed when the cause cannot be determined by clinical and laboratory tests (including chronic kidney patients with rapid deterioration of renal function).
(4) Transplanted kidney.
①When the cause of significant renal function decompensation is unclear
② serious rejection reaction to decide whether to remove the transplanted kidney;
③Suspected recurrence of the original kidney disease in the transplanted kidney.
3. Contraindications to renal biopsy
Renal biopsy is an invasive test, so when selecting a biopsy case, it is necessary not only to master the indications, but also to carefully exclude the contraindications.
(1) Absolute contraindications.
① obvious bleeding tendency.
②Severe hypertension.
③Psychiatric or uncooperative patients.
④ isolated kidney.
⑤ small kidney.
(2) Relative contraindications.
①Active pyelonephritis, renal tuberculosis, hydronephrosis or pus accumulation in the renal pelvis, renal abscess or perirenal abscess.
② Renal tumor or renal aneurysm.
③Polycystic kidney or large cyst in the kidney.
④Kidney position is too high (the lower pole of the kidney does not reach below the twelfth rib even with deep inspiration) or wandering kidney.
⑤ chronic renal failure.
(6) Excessive obesity.
⑦Severe ascites.
(8) Heart failure, severe anemia, hypovolemia, pregnancy or old age.
4.Pre-operative kidney biopsy education
1. Diet. Eat semi-liquid on the day of surgery, such as: meat loaf porridge, soup noodles, wontons, minced meat, vegetable puree, small soup buns, etc., but do not eat too much, and do not fast.
2.Position training. Practice the intraoperative position, i.e. prone position, and put a small pillow on the abdomen.
3.Breathing exercises. Practice inhalation followed by breath-holding action.
4.Strengthen bed feeding training. Prepare supplies for feeding in bed, such as: straws, spoons, etc. Train to eat in bed 3 to 5 times.
5.Strengthen the training of urination and defecation in bed. Practice using the commode 3 to 5 times.
6. Female patients cannot undergo renal biopsy during menstruation.
7.Notify family members to come to the hospital to accompany the patient on the day of surgery before the operation.
5.What should be prepared before doing renal puncture
A. The doctor should introduce the basic knowledge of kidney puncture to the patient before he/she does it.
Second, the patient should understand the kidney function before doing the procedure, check the isotope renal chart to understand the fractional kidney function, and make ultrasound to understand the kidney size, location and right kidney mobility.
Third, check the patient’s blood type and whether there is serious anemia.
Four, two days before doing renal puncture surgery to take or intramuscular injection of vitamin K, a week before doing renal puncture surgery can not use anticoagulant drugs.
V. Patients suffering from acute renal failure should have their prothrombin time measured in addition to their prothrombin time, and platelet function should be checked from time to time in addition to the platelet count, and if abnormalities are found, they should be corrected before surgery. Abnormal platelet count and function can be corrected by preoperative transfusion of fresh platelets on the day of puncture. Prolonged bleeding time can be corrected by transfusion of cold precipitates rich in clotting factors.
Patients should be checked for complications after the kidney puncture, and if there are any complications, they should be treated in time.
6.Intraoperative cooperation
1. The patient should be placed in a prone position. The abdomen should be padded with a small pillow (about 10 cm thick) to fully expose the lumbar back puncture site.
2.Patients cooperate with the surgeon during the operation and pay attention to breath-holding.
3.Patients try to relax and avoid tension during the operation.
4.When crossing the bed after puncture, patients pay attention to avoid exertion and try to relax the whole body.
7.Postoperative care of renal biopsy
(1) General care
①After the patient’s kidney biopsy, local wound pressure is applied for several minutes and then pushed into the ward on a flat cart.
②Measure blood pressure and pulse every half hour, and stop measuring after 4 hours when blood pressure is stable. If the patient’s blood pressure fluctuates or is low, it should be measured until it is stable and symptomatic treatment should be given.
③After 24 hours of lying down, if the condition is stable and there is no sarcoid hematuria, you can go down to the floor. If the patient develops sarcoid hematuria, bed rest should be extended until the sarcoid hematuria disappears or is significantly reduced. Give intravenous hemostatic drugs or blood transfusion if necessary.
④After surgery, the patient should be advised to drink more water to expel a small amount of clot as soon as possible. At the same time, urine specimens should be taken 3 times for routine examination. Postoperatively, patients can eat normally without any special conditions.
⑤ During bed rest, the patient should be asked to rest quietly and reduce the movement of the body to avoid wound bleeding, and at the same time, the patient should be carefully observed to see if there is any bleeding from the wound and to enhance life care.
⑥Patients should be closely observed for changes in vital signs, asked if there are complaints of discomfort, and abnormalities should be handled in a timely manner.
(2) Care of complications
In order to make a small amount of bleeding discharged from the kidney as soon as possible, in addition to absolute bed rest, the patient should be asked to drink a lot of water, and the change of urine color should be observed each time to determine whether the hematuria is gradually aggravated or reduced. In case of obvious hematuria, bed rest should be prolonged, and hemostatic drugs should be given intravenously in time, and blood transfusion should be given if necessary.
② Perirenal hematoma: absolute bed rest should be provided within 24 hours after renal biopsy. If the patient cannot tolerate it, the importance of absolute bed rest and the possible complications of strenuous activities should be explained to the patient in a timely manner. To obtain the patient’s cooperation. After 24 hours of bed rest without visual hematuria, the patient should start to move gradually and should not increase the activity suddenly to avoid rebleeding of the wound that has not completely healed. At this time, the patient’s activities should be restricted and appropriate care should be given. Patients with perirenal hematoma detected by postoperative ultrasound should be kept in bed for a longer period of time.
③Lumbar pain and lumbar discomfort: Most patients have mild ipsilateral lumbar pain or lumbar discomfort, which usually lasts about 1 week. Most patients can reduce pain by taking general painkillers, but patients with combined perirenal hematoma have severe back pain and can be given narcotic painkillers for pain relief.
④ Abdominal pain and distension: abdominal pain occurs in individual patients after renal biopsy and lasts from 1 to 7 days, and a few patients may have pressure pain and rebound pain. Due to the change of living habits plus the compression of the lap band, the patient drinks a lot of water or may have abdominal distension, which generally does not require special treatment, and lactase and antispasmodics can be given to those with obvious abdominal distension and abdominal pain to relieve the symptoms.
⑤ Fever: Patients with perirenal hematoma may have moderate fever due to the absorption of the hematoma, and should be cared for as febrile patients and given appropriate medication.