Who performs a renal biopsy?

Who Performs Renal Biopsies

Renal biopsies are primarily performed by nephrologists, interventional radiologists, and surgeons, with specialized training being essential for proper specimen collection and interpretation. 1

Qualifications and Training Requirements

For Performing the Biopsy Procedure:

• Nephrologists: Traditionally perform renal biopsies and should receive specialized training

  • Require training beyond standard residency experience
  • Should have experience with ultrasound-guided techniques 1, 2

• Interventional Radiologists: Increasingly performing renal biopsies

  • Often achieve higher specimen adequacy rates
  • In one study, obtained significantly more glomeruli (19.17 vs 9.09) and cores (2.42 vs 1.57) compared to nephrologists/surgeons 3

• Surgeons: May perform biopsies, particularly in high-risk cases requiring:

  • Open surgical biopsies
  • Laparoscopic approaches
  • Specialized techniques for patients with contraindications to percutaneous approaches 4

For Interpreting Biopsy Results:

• Renal Pathologists: Specialized pathologists who interpret the biopsy specimens
  • No formal subspecialty certification exists from the American Board of Pathology
  • Should have received more extensive training than typical pathology residency provides
  • Fellowship training or concentrated exposure under an experienced nephropathologist is highly recommended 1
  • Must stay current with rapidly evolving field through continuing education 1

Procedural Considerations

Equipment and Techniques:

• Real-time ultrasound guidance is standard practice
• Automated spring-loaded biopsy devices with 14-18 gauge needles are commonly used 2
• Specimen handling requires careful technique to avoid artifacts:
  • Gentle handling with 18G needle or wooden stick (not forceps)
  • Proper fixation for light microscopy, immunohistochemistry, and electron microscopy 1

Special Circumstances:

• Transplant Biopsies: Often handled differently than native kidney biopsies

  • Minimum of two cores recommended (improves sensitivity from 91% to 99%)
  • May omit immunofluorescence and electron microscopy unless recurrent disease is suspected 1

• High-Risk Patients: May require alternative approaches

  • Transjugular (transvenous) biopsy for patients with coagulopathy
  • Laparoscopic approaches for obese patients
  • Open surgical biopsy in certain cases 4

Emerging Trends

There has been a shift in recent years from nephrologists to interventional radiologists performing renal biopsies 5. This trend raises concerns about nephrologists potentially losing proficiency in this core procedure of their specialty. Some medical centers have developed comprehensive Diagnostic and Interventional Nephrology (DIN) programs to ensure nephrologists maintain these skills 6.

Quality Considerations

The quality of renal biopsy interpretation depends on:

• Proper specimen collection and handling
• Complete workup including light microscopy, immunohistochemistry, and electron microscopy
• Integration of clinical information with pathological findings
• Communication between nephrologist and pathologist 1

Despite advances in molecular techniques, the renal biopsy remains an essential diagnostic tool in nephrology, requiring skilled professionals for both its performance and interpretation 2.