renal biopsy

Biopsy, Kidney

Common use

Specimen

Normal findings

Description

This procedure is contraindicated for

• high alertPatients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site), advanced renal disease, uncontrolled hypertension, or solitary kidney (except transplanted kidney as the biopsy may be required to determine whether rejection or other damage is occurring).

Indications

• Assist in confirming suspected renal malignancy
• Assist in the diagnosis of the cause of renal disease
• Determine extent of involvement in systemic lupus erythematosus or other immunological disorders
• Monitor progression of nephrotic syndrome
• Monitor renal function after transplantation

Potential diagnosis

Positive findings in:

• Acute and chronic poststreptococcal glomerulonephritis
• Amyloidosis infiltration
• Cancer
• Disseminated lupus erythematosus
• Goodpasture’s syndrome
• Immunological rejection of transplanted kidney
• Nephrotic syndrome
• Pyelonephritis
• Renal venous thrombosis

Critical findings

• Assessment of clear margins after tissue excision
• Classification or grading of tumor
• Identification of malignancy

• It is essential that critical findings be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

• Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. The notification processes will vary among facilities. Upon receipt of the critical finding the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical finding, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

• Obesity and severe spinal deformity can make percutaneous biopsy impossible.
• Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

• Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
• Patient Teaching: Inform the patient this procedure can assist in establishing a diagnosis of kidney disease.
• Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex or anesthetics.
• Obtain a history of the patient’s genitourinary and immune systems, especially any bleeding disorders or other symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
• Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
• Note any recent procedures that can interfere with test results.
• Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure.
• Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Instruct the patient that prophylactic antibiotics may be administered before the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered before the percutaneous biopsy to promote relaxation and reduce discomfort; general anesthesia will be administered before the open biopsy. Explain to the patient that no pain will be experienced during the test when general anesthesia is used but that any discomfort with a needle biopsy will be minimized with local anesthetics and systemic analgesics. Inform the patient that the biopsy is performed under sterile conditions by an HCP specializing in this procedure. The surgical procedure usually takes about 60 min to complete, and sutures may be necessary to close the site. A needle biopsy usually takes about 40 min to complete.
• Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
• Explain that an IV line will be inserted to allow infusion of IV fluids, antibiotics, anesthetics, analgesics, or IV sedation.
• Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
• Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

• Potential complications:

• Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners) or seeding of the biopsy tract with tumor cells

• Ensure that the patient has complied with dietary restrictions.
• Ensure that anticoagulant therapy has been withheld for the appropriate number of days prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Notify the HCP if patient anticoagulant therapy has not been withheld. Ensure that patients on beta-blocker therapy have continued their medication regimen as ordered.
• Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
• Have emergency equipment readily available.
• Have the patient void before the procedure.
• Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen containers with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location, especially right or left kidney.
• Assist the patient to the desired position depending on the test site to be used, and direct the patient to breathe normally during the beginning of the general anesthetic. Instruct the patient to cooperate fully and to follow directions. Direct the patient to avoid unnecessary movement.
• Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
• After the administration of general or local anesthesia, use clippers to remove hair from the surgical site if appropriate, cleanse the site with an antiseptic solution, and drape the area with sterile towels.

Open Biopsy

• Adhere to Surgical Care Improvement Project (SCIP) quality measures. Administer ordered prophylactic antibiotics 1 hr before incision, and use antibiotics that are consistent with current guidelines specific to the procedure.
• After administration of general anesthesia and surgical preparation are completed, an incision is made, suspicious area(s) are located, and tissue samples are collected.

Needle Biopsy

• A sandbag may be placed under the abdomen to aid in moving the kidneys to the desired position. Direct the patient to take slow deep breaths when the local anesthetic is injected. Protect the site with sterile drapes. Instruct the patient to take a deep breath, exhale forcefully, and hold the breath while the biopsy needle is inserted and rotated to obtain a core of renal tissue. Once the needle is removed, the patient may breathe. Pressure is applied to the site for 5 to 20 min, then a sterile pressure dressing is applied.

General

• Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
• Place tissue samples in formalin solution. Label the specimen, indicating site location, and promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

• Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
• Instruct the patient to resume preoperative diet, as directed by the HCP. Assess the patient’s ability to swallow before allowing the patient to attempt liquids or solid foods.
• Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Discontinue prophylactic antibiotics within 24 hr after the conclusion of the procedure. Protocols may vary among facilities.
• Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
• Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
• Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
• Instruct the patient in the care and assessment of the site.
• Instruct the patient to report any redness, edema, bleeding, or pain at the biopsy site. Instruct the patient to immediately report chills or fever.
• Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
• Inform the patient that blood may be seen in the urine after the first or second postprocedural voiding.
• Monitor fluid intake and output for 24 hr. Instruct the patient on intake and output recording and provide appropriate measuring containers.
• Instruct the patient to report any changes in urinary pattern or volume or any unusual appearance of the urine. If urinary volume is less than 200 mL in the first 8 hr, encourage the patient to increase fluid intake unless contraindicated by another medical condition.
• Assess for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
• Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
• Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
• Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Inform the patient of a follow-up appointment for removal of sutures, if indicated. Answer any questions or address any concerns voiced by the patient or family.
• Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him or her to review corresponding literature provided by a pharmacist.
• Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

• Related tests include albumin, aldosterone, angiography renal, antibodies antiglomerular basement membrane, β₂-microglobulin, BUN, CT renal, creatinine, creatinine clearance, cytology urine, cystoscopy, IVP, KUB studies, osmolality, PTH, potassium, protein, renin, renogram, sodium, US kidney, and UA.
• Refer to the Genitourinary and Immune systems tables at the end of the book for related tests by body system.