Renal Biopsy of Dogs and Cats

Shelly L. Vaden, DVM, PhD, Diplomate ACVIM

Renal diseases are common in dogs and cats. Renal biopsy may be required during the evaluation of the patient to establish a denitive diagnosis, determine the severity of the lesion and formulate an optimal treatment plan. Renal biopsy specimens can be collected via several methods. Percutaneous techniques are performed with ultrasound guidance in both dogs and cats or blindly in cats. If ultrasound guidance is not available, the keyhole technique can be used in dogs. Biopsy can also be performed using laparoscopy or surgery. While complications can arise with any of these techniques, complications are less frequent when an experienced operator uses proper technique. Renal biopsy specimens must be processed and evaluated appropriately if consistent and accurate diagnoses are to be rendered. The article summarizes patient selection and evaluation, renal biopsy techniques, expected complications of renal biopsy, and appropriate processing and evaluation of the renal biopsy specimen. Clin Tech Small Anim Pract 20:11-22 2005 Elsevier Inc. All rights reserved. KEYWORDS renal biopsy, kidney biopsy, percutaneous kidney biopsy, laparoscopic kidney biopsy, surgical kidney biopsy, complications of renal biopsy, light microscopy, electron microscopy

enal diseases are common in dogs and cats. Historical information, physical examination and clinical laboratory data often allow for the differentiation of renal diseases into the general categories of acute renal failure, chronic renal failure, and glomerular disease. However, renal biopsy is often required to establish a denitive diagnosis and determine the severity of the lesion. A precise and accurate histologic diagnosis may also be needed to formulate an optimal treatment plan. Accurate assessment of response to therapy requires knowledge of both the type and severity of the disease being treated.1-4 There is often reluctance on the part of the practitioner to pursue renal biopsy in the clinical evaluation of their patients. Many concerns probably contribute to this reluctance, including the potential complications of renal biopsy, the expenses associated with procurement of the renal biopsy specimen, and adequate evaluation of the renal biopsy specimen as well as the belief that the rendered diagnoses may lack consistency. Studies have shown that the frequency of severe complications from renal biopsy is relatively low and that renal biopsy minimally affects renal function when proper technique is employed.1,2,5-11 The expense of the renal biopsy procedure can be minimized by correct patient selection and the use of proper technique. Consistent and accurate
Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina. Address reprint requests to Dr. Shelly L. Vaden, Professor, Internal Medicine, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, 4700 Hillsborough St., Raleigh, NC 27606. E-mail: shelly_vaden@ncsu.edu

diagnoses are more likely to be obtained when renal biopsy specimens are appropriately processed and evaluated. The purpose of this article is to discuss patient selection and evaluation, renal biopsy techniques, expected complications of renal biopsy, and appropriate processing and evaluation of the renal biopsy specimen.

Patient Selection
Renal biopsy is indicated only when the results are likely to alter patient management by providing an accurate histologic diagnosis or by facilitating prognostication. Patients whose management is most likely to be altered by results of a renal biopsy include those with glomerular disease (protein losing nephropathy) or acute renal failure (Table 1). Client factors that also need to be considered include the ability to incur the expense of the procedure and proper evaluation of the specimen as well as their desire to pursue additional treatment of their dog or cat, as may be indicated once an accurate histologic diagnosis is rendered. Renal biopsy provides a denitive diagnosis of glomerular disease but may not be needed if a potential underlying disease is identied and treatment of this disease leads to resolution of proteinuria. Likewise, a denitive diagnosis is unlikely to be of benet to the patient with glomerular disease if end stage renal disease is already present. In patients that do not have end stage renal disease, clinical decisions regarding diagnosis, therapy, and prognosis can be made from the information obtained through renal biopsy. In fact, obtaining an accurate histologic diagnosis may be one of the more 11

1096-2867/05/$-see front matter 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.ctsap.2004.12.003

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Table 1 Indications for Renal Biopsy Protein losing nephropathy

S.L. Vaden

Acute renal failure

Identify and treat potential underlying diseases before biopsy. Low yield in patients with end stage renal disease. Appropriate evaluation may require light and electron microscopy and immunology staining. Consider in patients with persistently severe uremia or oliguria. Consider in patients that deteriorate during appropriate medical management.

important factors in successful management of the dog or cat with glomerular disease. In most cases, appropriate evaluation of a renal biopsy specimen from a dog or cat with glomerular disease includes light, electron and immunouorescent microscopy. Renal biopsy is indicated in the dog or cat that has acute renal failure that is either persistently severe (ie, persistent oliguria or uremia) or has deteriorated despite appropriate medical management. In these patients, determining an etiologic diagnosis may lead to additional therapeutic measures that are specic for the primary disease. Renal biopsy can also facilitate prognostication in patients with acute renal failure through assessment of the overall appearance of the tissue as well as determination of the integrity of the tubular basement membrane. Light microscopy may be all that is required in the evaluation of a biopsy specimen from a patient with acute renal failure but renal tissue should also be collected for electron and immunouorescent microscopy in the event that a glomerular disease is causing the acute renal failure. Renal biopsy is unlikely to alter the prognosis, therapy or outcome of a patient with chronic renal failure. For patients with end stage renal disease, it is unlikely that the cause of the renal disease will be determined by renal biopsy. Furthermore, studies in people undergoing renal biopsy have demonstrated an increased risk of complication in patients with chronic renal failure.12 For these reasons, renal biopsy of patients with chronic renal failure is generally not indicated.

Considerations Before Renal Biopsy

Before renal biopsy, it is generally recommended that the patient be thoroughly evaluated by obtaining a current history, performing a complete physical examination, measuring systemic blood pressure, and analyzing results of a biochemical prole, complete blood count, urinalysis, and coagulation prole. These are performed not only to assess the current state of health and suitability of the patient to undergo renal biopsy but also to verify that there are no contraindications to biopsy. Contraindications to renal biopsy include the presence of an uncorrectable coagulopathy, severe anemia, hydronephrosis, uncontrolled hypertension, large or multiple renal cysts, perirenal abscess, extensive pyelonephritis, and end stage renal disease. Some authors have included a solitary kidney as a contraindication to biopsy; however, biopsy of a solitary kidney may be performed if proper technique is used and other contraindications are not present. To identify patients with bleeding tendencies, a coagulation prole is generally recommended before renal biopsy. However, studies in people have demonstrated that preoperative coagulation proles are not only unnecessary in patients

without an obvious tendency to bleed but abnormal results do not correlate with bleeding after percutaneous liver biopsy or general surgery.13,14 Contrary to these ndings, a recent report demonstrated that dogs and cats with moderate to severe thrombocytopenia (platelet counts 80,000/uL), dogs with prolonged one-stage prothrombin time (OSPT 1.5 normal) and cats with prolonged activated partial thromboplastin time (APTT 1.5 normal) had a greater risk of hemorrhage from ultrasound-guided biopsy procedures.15 Other patient factors that may be associated with an increased risk of hemorrhage include severe azotemia (serum creatinine 5 mg/dL), uncontrolled systemic hypertension or administration of a nonsteroidal anti-inammatory drugs within the previous 5 days.12,16-18 However, these patient abnormalities may not be absolute contraindications to renal biopsy. Rather, when renal biopsy is planned for patients with identied bleeding tendencies, the clinician should be prepared to monitor the patient for severe perirenal hemorrhage postbiopsy and have suitable blood products from a compatible donor available to administer to the patient if needed. Abdominal ultrasound is generally performed as part of the initial evaluation in patients with acute renal failure or protein losing nephropathy. In addition to assessing the size, shape, contour, and internal architecture of the kidney, abdominal ultrasound also allows for the identication of many of the previously listed contraindications to renal biopsy. Severe hydronephrosis is a contraindication to renal biopsy because of concern of penetrating the distended renal pelvis which is likely to be under increased pressure as well as the increased risk of transecting the larger arteries located in the corticomedullary junction and the medulla. Rupture of renal cysts and release of their contents into perirenal tissues is associated with pain in people. Although the risk of inducing infection through renal biopsy is low, cyst infections may be very difcult to treat because of poor antibiotic penetration into the cyst uid. Concern over inducing renal pain or infection via biopsy of renal cysts and the limited diagnostic yield of a biopsy specimen which contains large cysts has led to the recommendation that renal biopsy not be performed in kidneys that contain large or multiple cysts. Perirenal abscessation and extensive pyelonephritis are contraindications to renal biopsy because of the possibility that the abdomen could become seeded with bacteria or other infectious agents. Ideally, urinary tract infections should be eliminated before renal biopsy.

Procurement of the Renal Biopsy Specimen

Renal biopsies can be obtained using one of several techniques (Table 2). Regardless of the method selected, only

Renal biopsy of dogs and cats

Table 2 Methods used to Obtain Renal Biopsy Specimens Percutaneous Blind or palpation technique Laparoscopic biopsy Keyhole technique Ultrasound guidance Surgical Wedge biopsy Better suited for cats than dogs Requires specialized equipment and expertise Used in dogs if ultrasound guidance not available Preferred method for dogs >5 kg and all cats

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Preferred method for dogs <5 kg, animals with isolated areas of the kidney to avoid, or animals undergoing laparotomy for another reason.

cortical tissue should be obtained. Most diagnoses can be made through evaluation of cortical tissue alone. The risk of serious hemorrhage may increase as the kidney is penetrated more deeply because renal vessels progressively increase in size from the surface of the kidney toward the renal pelvis. Biopsy of the renal medulla may also be associated with an increased risk of creating large areas of infarction and brosis.19,20 Whenever possible, the biopsy is taken from either the cranial or caudal pole of the kidney because it is easier to stay in cortical tissue over a larger portion of the kidney within the poles. In the dog with generalized renal disease, the right kidney is often preferred over the left kidney for renal biopsy. The right kidney is more stable because the caudate lobe of the liver provides resistance to movement during the biopsy procedure. Conversely, the left kidney is more movable during the biopsy procedure but can be found in a more caudal position, providing easier access in some deep chested dogs. Feline kidneys are located more caudally in the abdomen when compared with canine kidneys. Both feline kidneys can be easily localized and immobilized making both equally suitable for renal biopsy.

by sedatives alone. Incomplete anesthesia of the peritoneum is a disadvantage of using only sedation and local anesthesia and can result in sudden abdominal movement during the biopsy procedure.5

Needle Selection
A variety of needles are available for percutaneous kidney biopsy. The Tru-cut biopsy needle was once the needle of choice, largely because other options were limited. However, these needles can be difcult to use. Improper technique can result in poor quality biopsy specimens and inadvertent trauma to the kidney. With the availability of spring-loaded needles and biopsy guns, the Tru-cut cannot be routinely recommended. Likewise, the Vim-Silverman needle is no longer routinely used for renal biopsy. We prefer disposable spring-loaded biopsy needles for renal biopsy (Fig. 1) (E-Z Core Single Action Biopsy Devise, Products group International, Inc., Lyons, CO). These needles can easily be operated using only 1 hand and are available in 14, 16, 18, and 20 gauge with lengths of 6, 9, or 15 cm. An advantage of this needle lies in the throw mechanism. During biopsy, the spring-loaded stylet is advanced rst and is visible by ultrasound. The cutting cannula is activated when the operator fully depresses the plunger with their thumb. The biopsy instrument does not move deeper into the tissue during activation of the cannula. The biopsy needle can then be removed from the animal and the specimen retrieved from the specimen notch. Alternatively, some institutions use automatic springloaded biopsy guns (Fig. 2) (eg, Bard Biopty, C. R. Bard, Inc., Murray Hill, NJ) that can be loaded with disposable needles of appropriate gauges and lengths that are available from a

Patient Sedation or Anesthesia

Proper biopsy technique requires patient immobilization. Failure to immobilize the patient may increase the likelihood that serious complications will develop after renal biopsy. In addition, providing general anesthesia to the patient during the biopsy procedure has been associated with procurement of a quality biopsy specimen.17 Although general anesthesia is most likely to produce complete immobilization of the patient, some patients who are very ill may be immobilized

Figure 1 Disposable spring-loaded biopsy instrument that can be used for renal biopsy (E-Z Core Single Action Biopsy Devise, Products group International, Inc., Lyons, CO).

Figure 2 Automatic spring-loaded biopsy gun and needle that can be used for renal biopsy (Bard Biopty, C. R. Bard, Inc., Murray Hill, NJ).

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S.L. Vaden
tectures and for selection of the biopsy site. Once the site of entry for the biopsy needle is determined, a small stab incision is made through the skin, allowing for the needle to stay sharp as it easily passes through the skin. The tip of the needle is guided to the renal capsule with 1 hand while the probe is held with the other (Figs. 3 and 4). The tip of the needle should be placed through the renal capsule before activation to prevent sliding of the needle along the capsule and avoid tearing the capsule. The biopsy is then taken using the method that is appropriate for the selected needle, making sure that the needles remains in the renal cortex (Fig. 5). When using a percutaneous method to obtain a renal biopsy from a patient with glomerular disease, at least 2 quality samples of renal cortex should be obtained using either a 16 or 18 g needle; 1 cortical biopsy may be all that is required from a patient with acute renal failure (see Evaluation the Renal Biopsy Specimen). Digital pressure should be applied to the kidney transabdominally for approximately 5 minutes after biopsy to minimize hemorrhage. Although needle guides are available for the ultrasound probe, we do not generally use these. The guides are probe specic and are not available for all probes. The requirement of specic computer software for operation of the guides makes their usage rather expensive. In addition, some operators nd that the guides are conning.

Figure 3 Schematic demonstrating the correct and incorrect method of directing the renal biopsy needle. Note that the needle should remain in the renal cortex, preferably in either the cranial or caudal pole. The needle should not cross the corticomedulary junction nor enter either the renal medulla or pelvis.

variety of manufacturers. We have found that the weight and size of the gun can render the use of these more difcult when compared with the spring-loaded biopsy needles. The operator needs to have large and strong hands to easily use the gun single handedly. These guns may be less suitable for obtaining kidney biopsies when compared with biopsy of other organs because of the limited control of the depth of biopsy. Activation of the needle causes the throw to go beyond where the tip of the needle is placed at the beginning of the procedure. This is a potential source of operator error and may be associated with an increased risk of penetration of the needle into the medulla. We use either a 16 or 18 gauge needle that is 9 cm in length for our kidney biopsies. In 1 study, use of a 14-gauge biopsy needle was associated with a greater likelihood that biopsy specimens contained medulla.17 Obtaining a good quality biopsy specimen with limited damage to the kidney requires the use of a sharp biopsy needle. Because needles become dull after several biopsies are taken and the needles are relatively inexpensive, reuse of these disposable needles is not generally recommended.

Keyhole Technique
The keyhole technique can be used in dogs if ultrasound guidance is not available.21,22 The dog is placed in left lateral recumbency for biopsy of the right kidney. The dogs back should be facing the surgeon. The hair in the lumbar fossa is clipped and the skin is aseptically prepared. An oblique, paralumbar 7.5 to 10 cm skin incision is made on a line that bisects the angle between the last rib and the edge of the lumbar musculature (Fig. 6). It may be impossible to palpate the kidney if the incision is made too far caudal or ventral. A large, vascular muscle mass will need to be dissected if the incision is made too far dorsal. Too cranial of an incision may lead to puncture of the intercostal artery. The muscle bers are separated along muscle planes and the peritoneum is

Percutaneous Biopsy using Ultrasound Guidance

Percutaneous renal biopsy using ultrasound guidance has become the renal biopsy method of choice for dogs that are larger than 5 kg and for all cats that do not have other contraindications for renal biopsy.7 With this technique, ultrasound is used to identify and examine the kidneys and subsequently guide correct placement of the needle. The normal renal cortex can easily be differentiated from the medulla because of the relative hyperechogenicity of the cortex; differentiation may be more difcult in diseased kidneys. The patient is placed in left lateral recumbency for biopsy of the right kidney or in right lateral recumbency for biopsy of the left kidney. The hair over the biopsy site is removed, the skin is aseptically prepared and sterile coupling gel is applied. A sterile sleeve is placed over the ultrasound probe. The kidneys are scanned for general examination of the renal archi-

Figure 4 Ultrasound guided renal biopsy in a dog. Note that the probe is held in 1 hand while the needle is held in the other hand.

Renal biopsy of dogs and cats

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Figure 5 The ultrasonographic image of the dog in Fig. 4. This image is used to guide the needle to the kidney and through the cortex.

Figure 7 Percutaneous kidney biopsy in the cat. The kidney is immobilized by 1 hand while the other manipulates the biopsy needle. (Courtesy of J. A. Barsanti, Athens, GA.)

incised. The peritoneal incision must be large enough to allow for easy insertion of the surgeons index nger over the caudal pole of the kidney. The index nger holds the kidney against the edge of the lumbar musculature. The other hand inserts the biopsy needle through a separate small stab incision in the lateral body wall. The biopsy needle is guided into the peritoneal cavity and the tip of the needle is positioned at the surface of the kidney or stabbed just through the capsule making sure the angle is such that the needle will pass only through renal cortex. Care should be taken not to penetrate too deeply beyond the renal capsule as this will reduce the amount of renal cortex in the biopsy specimen. Activate the needle cutting mechanism as appropriate for the selected needle. Additional biopsy specimens can be obtained, as required. After the needle is withdrawn, digital pressure should be placed for at least 5 minutes where the needle penetrated the kidney to minimize hemorrhage. Use of the keyhole technique has been associated with the creation of artifact in the biopsy sample, possibly because of the frequent need to displace the kidney a considerable distance before biopsy. Such artifact includes congestion of the peritubular and glomerular capillaries and extravasation of

erythrocytes into the tubular lumina and Bowmans space. However, in 1 study there were no differences in specimen quality between samples obtained with the keyhole technique compared with those obtained by laparoscopy.10

Blind or Palpation Technique

Performing renal biopsy with guidance by palpation is rarely done in dogs because of the more cranial location of the kidneys and the fact that canine kidneys can be difcult to immobilize by palpation. However, blind biopsy is more frequently performed in feline kidneys, which are relatively more caudal in position and can be more readily immobilized. Nonetheless, we prefer ultrasound guidance for renal biopsies in cats because ultrasound affords the ability to concurrently assess the renal architecture and establish that contraindications to renal biopsy are not present (eg, polycystic kidney disease) as well as guide the biopsy needle through the cortex. Blind renal biopsy in cats is performed with the cat in lateral recumbency. Either kidney is localized by palpation. The hair is clipped from the area over the kidney and the skin is aseptically prepared. A small stab incision is made in the skin with a scalpel blade. The kidney is immobilized with 1 hand. The other hand advances the needle through the stab incision and directs it toward the cranial or caudal pole of the kidney (Fig. 7). The tip of the needle is positioned at the surface of the kidney or stabbed just through the capsule making sure the angle is such that the needle will pass only through renal cortex. Penetrating too deeply beyond the renal capsule will reduce the amount of renal cortex in the biopsy specimen. The cutting mechanism of the needle is then activated. Additional biopsy specimens can be obtained, if needed. Digital pressure should be applied to the kidney for approximately 5 minutes after biopsy to minimize hemorrhage.

Laparoscopic Biopsy
Figure 6 Making the incision for insertion of a nger for percutaneous renal biopsy in the dog using the keyhole technique. (Courtesy of J. A. Barsanti, Athens, GA.)

Laparoscopy is an endoscopic procedure that is performed under sterile conditions and allows for visual examination of the peritoneal cavity after establishment of a pneumoperitoneum.1,23 Laparoscopy offers an advantage over the percuta-

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S.L. Vaden
trocar is removed from the cannula and replaced by the laparoscope. The abdominal organs can be systematically inspected. A biopsy needle can then be introduced into abdomen through a separate site. The renal biopsy is taken while observing the procedure through the laparoscope.

Surgical Biopsy
Surgical biopsy may be the preferred method in dogs that are small (5 kg) or in animals that either have isolated areas in the kidney (eg, large cysts) that need to be avoided during the biopsy procedure or are undergoing laparotomy for another reason. Likewise, surgical biopsy may be safer in some animals that have other listed contraindications to biopsy. A surgical wedge biopsy is preferred over a surgical needle biopsy. One has more control over the depth of biopsy and the volume of tissue collected when a wedge biopsy is obtained as compared with a needle biopsy. It is not surprising that surgical wedge biopsy were 5 times more likely to be of good quality than were surgical needle biopsies.17 The surgical biopsy can be obtained through a paracostal incision, if only 1 kidney is to be examined and biopsied, or a cranial midline abdominal incision if other intra-abdominal procedures are to be performed or both kidneys need to be examined before biopsy.21 The paracostal incision is made with the patient in lateral recumbency.24 The incision is parallel and 2 cm caudal to the last rib. The oblique muscles are divided between bers and retracted. The kidney is located after separating the transverse abdominal muscle. The kidney can be elevated through the incision by placing umbilical tape around both poles. In obese animals, exposure of the kidney may be difcult through the paracostal incision. Following exposure through either type of incision, the kidney is immobilized with thumb and forenger before biopsy. A wedge shaped incision is made through the capsule and into the cortex (Fig. 9). Tissue forceps are used to gently lift the biopsy wedge while the scalpel blade is used to sever any remaining attachments. Monolament, absorbable suture material (4-0) in a simple continuous pattern is used to close the renal capsule.

Figure 8 Close-up laparoscopic view of the right kidney in a dog. The tip of a biopsy needle is in the eld-of-view. Note that the biopsy needle is directed at a shallow angle to the capsule and away from the renal pelvis. From Grauer G, Laparoscopy of the urinary tract, in Tams TR (ed): Small Animal Endoscopy. St. Louis, Mosby, 1999, p 430.

neous biopsy techniques in that it allows for direct visualization and inspection of the kidneys through insertion of a rigid endoscope and permits visual control of the biopsy. Visualization of the kidneys before biopsy leads to a higher likelihood that diagnostic tissue will be obtained during biopsy, particularly if focal lesions are present. Because the abdominal incision is small, laparoscopy is less invasive and can be performed more quickly than surgery, allowing for comparatively less patient morbidity. Like surgery, other abdominal organs can be inspected and biopsy specimens collected, if necessary, during laparoscopy although complete abdominal exploration is not possible. As with surgery, postbiopsy hemorrhage can be monitored during laparoscopy; direct pressure can be applied with the laparoscope or laparoscopic tools if needed. Laparoscopy requires appropriate equipment and operator expertise. Contraindications to laparoscopy include peritonitis, extensive abdominal adhesions, hernias, obesity, coagulopathies, and operator inexperience.23 Potential complications of laparoscopy include the creation of air emboli, pneumothorax, or subcutaneous emphysema, the introduction of gas into a hollow viscus, damage to internal organs with the Verres needle or trocar, and cardiac arrest. Evacuation of the urinary bladder and colon before penetration into the abdomen will minimize the chance that these organs are punctured. Operator experience and attention to detail, as well as the use of a surgically placed port instead of the Verres needle, may reduce the likelihood of complications.23 In a study of laparoscopic renal biopsy performed in 37 dogs and 1 cat, none of these complications were encountered. Laparoscopy can be performed through a right lateral, left lateral, or midline incision. The right kidney is readily visible in dogs in left lateral recumbency (Fig. 8).1 To separate the abdominal wall from the organs, a pneumoperitoneum is created via injection of carbon dioxide through the Verres needle or a surgically placed trocar and cannula unit. If the Verres needle technique is used, the trocar and cannula units for the laparoscope are then inserted through a small (1 cm) skin incision. Once the assembly is in the abdomen, the

Postbiopsy Care of the Patient

Isotonic uids should be given liberally intravenously for several hours after renal biopsy in amounts needed to produce a diuresis. In theory, this will reduce the likelihood that obstructing clots will form in the renal pelvis or ureter. To reduce the risk of serious hemorrhage, the patient should be kept relatively quiet and in the hospital for 24 hours after biopsy. The patients packed cell volume should be evaluated 24 hours after biopsy or sooner if a concern arises that major bleeding is occurring. Dogs should be walked only on a leash for 72 hours after biopsy. The color of urine should be monitored for several days after renal biopsy. Gross hematuria is common after renal biopsy and usually resolves within 24 hours. Persistent gross hematuria warrants re-evaluation of the kidneys and biopsy site.

Complications Associated with Renal Biopsy

Results of clinical studies indicate that complications after renal biopsy are limited but vary in frequency from between

Renal biopsy of dogs and cats

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Figure 9 Surgical kidney biopsy. (A) The kidney is immobilized between thumb and forenger. A wedge shaped incision is made through the capsule and cortex. (B) Tissue forceps are used to gently lift the biopsy sample. Any remaining attachments are severed with the scalpel blade. (C) The capsule is closed with 4-0 monolament absorbable suture material. Pressure is applied with thumb and forenger to appose the edges during suturing. (Courtesy of E. A. Stone, Raleigh, NC).

1 and 18% (Table 3).1,2,5-10,17 This variation in complication rate is almost certainly because of biopsy technique as well as patient status at the time of biopsy. In 1 retrospective study, factors associated with the development of complications in dogs included patient age 4 years, body weight 5 kg, and presence of severe azotemia (serum creatinine 5 mg/dL).17 A hospital factor that appeared to be associated with the development of complications was having a radiologist or internist perform the biopsy. This association may have been a result of the use of percutaneous methods to collect the renal biopsy or the use of sedation or injectable anesthesia instead of general anesthesia. Microscopic hematuria is an expected nding after renal biopsy, developing in approximately 20 to 70% dogs and cats.2,17 Microscopic hematuria is self-limiting, generally resolving within 48 to 72 hours of biopsy. Macroscopic hematuria is less common, developing in approximately 1 to 4% of dogs and cats after renal biopsy. Small perirenal hematomas are also common following renal biopsy if the kidney is ex-

amined carefully by ultrasound. Severe hemorrhage, often severe enough to require blood transfusion, was the most common reported complication in 1 study, occurring in 9.9% of dogs and 16.9% of cats.17 In addition to the coagulation abnormalities previously discussed, uncontrolled hypertension, uremia, the administration of nonsteroidal antiinammatory drugs and the use of improper technique may increase the risk of serious hemorrhage.9,16,20 Hydronephrosis developing secondary to obstruction of the renal pelvis or ureter by a blood clot is an uncommon complication of renal biopsy. Death is also an uncommon complication, occurring in 3% or less of dogs and cats undergoing renal biopsy.9,17 Histologic changes in renal tissue after biopsy have been well documented. Linear infarcts representing needle tracts associated with varying amounts of atrophy and brosis appear to be common after renal biopsy.25 Retention cysts can also be found in association with the needle tract and probably form secondary to tubular obstruction.25 Studies have demonstrated correlations between severe renal parenchy-

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Table 3 Reported Complications of Renal Biopsy Arteriovenous stula formation Biopsy of non-renal tissue (eg, liver, adrenal gland, fat, muscle, connective tissue, spleen) Cyst formation Death Hemorrhage Microscopic hematuria Macroscopic hematuria Perirenal hematoma Intrarenal hematoma Lacerated renal artery or vein Intra-abdominal hemorrhage because of laceration of other organ or vessel Hydronephrosis Infarction and thrombosis Infection Scar formation and brosis

S.L. Vaden
ples should also be collected for electron and immunouorescent microscopy in the event that a glomerular disease is causing the acute renal failure. Thin sections (2-4 m) of parafn-embedded tissue should be used for light microscopy because standard sections of 5 to 6 m are too thick for adequate assessment of glomerular cellularity and capillary loop thickness.27,28 Hematoxylin and Eosin staining can be used for initial assessment of the general appearance of the specimen. However, periodic acid-Schiff (PAS), which stains glycoproteins, is the preferred stain of many nephropathologists and is particularly useful in the demonstration of interstitial and glomerular scarring and assessment of the glomerular basement membrane. Methenamine silver specically stains the basement membrane of the tubules, glomeruli and Bowmans capsule. Trichrome is useful for evaluation of the mesangium and is also the best light microscopic stain for visualization of immunoglobulins. Congo red can be used to demonstrate the presence of amyloid. Although electron microscopy of renal biopsy specimens has not been used frequently enough in dogs and cats to determine the diagnostic merit in groups of patients with varying presentations, it appears to be most helpful in the evaluation of people with renal hematuria, a familial history of renal disease, or proteinuria with normal renal excretory function. However, a sample should be collected for electron microscopy in nearly all dogs and cats undergoing renal biopsy because the exact diagnosis is most likely unknown. Immunouorescent microscopy or immunohistochemistry should include at a minimum stains for IgM, IgG, IgA, and C3. Immunologic studies are becoming more readily available at a variety of laboratories. However, the requirement that samples from patients with glomerular disease be evaluated by electron microscopy may necessitate that samples from such patients be submitted to, and perhaps even collected at, a veterinary teaching hospital.

mal changes of hemorrhage, thrombosis, infarction, and brosis and the presence of major renal vessels or medulla in the biopsy specimen.19,20 These ndings emphasize the need to direct the biopsy needle only through cortical tissue during the biopsy procedure, avoiding the corticomedullary junction and medulla. Despite histologic changes, renal biopsy appears to have minimal effect on renal function.9,11 However, one could imagine that inicting renal damage to an animal with preexisting renal disease could contribute to progressive loss of renal function. Obtaining multiple biopsies of the kidney does not appear to produce more damage than biopsy with only a single pass providing the biopsy needle remains in cortical tissue.26

Processing the Renal Biopsy Specimen

An adequate sample of cortex has a minimum of 5 glomeruli when examined by light microscopy, although 1 glomerulus may be all that is needed to make a denitive diagnosis in generalized glomerular diseases. Microscopic examination of each specimen using 10-fold magnication provides immediate verication that adequate biopsy samples have been obtained. Ideally this is performed with a transilluminating microscope but a standard light microscope can also be used. When 2 samples are obtained from a patient with glomerular disease, 1 sample should be placed in formalin and the other should be divided into 2 smaller pieces containing glomeruli. One of the pieces is put into a xative suitable for electron microscopy (eg, 4% formalin plus 1% glutaraldehyde in sodium phosphate buffer) and the other piece is frozen for immunouorescent microscopy. An alternative to freezing is to immerse the tissue in ammonium sulfate-N-ethylmaleimide xative (ie, Michels solution), which preserves tissue-xed immunoglobulins. Wedge biopsies should be divided in a similar fashion; tissue for electron microscopy should be minced appropriately. Although formalin xation may be all that is required for adequate histopathologic evaluation of specimens from patients with acute renal failure, sam-

Evaluating the Renal Biopsy Specimen

Whenever possible, specimens should be evaluated by a pathologist with expertise in nephropathology. Although renal biopsy specimens from dogs with acute renal failure may be adequately evaluated by light microscopy alone, specimens from proteinuric dogs and cats should be evaluated by light, electron, and immunouorescent microscopy. Limiting the evaluation in these patients to light microscopy alone often allows for only a subjective interpretation of the glomerular lesion with too much room for error. While there are many reports describing glomerular lesions in dogs and cats, the use of different nomenclature and different morphological criteria among pathologists sometimes makes interpretations and comparisons of the data difcult at best. A standard classication system for the characterization of glomerular lesions in dogs and cats needs to be embraced. The World Health Organization (WHO) criteria for the classication of human glomerulopathies have proven to be applicable to glomerular diseases in dogs.4 General acceptance of this system would lead to a better understanding of the natural his-

Renal biopsy of dogs and cats

19 when there is a thickened glomerular basement membrane and mesangial hypercellularity (3 nuclei per mesangial region) (Fig. 12). The glomerulus may become segmented or lobular in appearance. Type I membranoproliferative glomerulonephritis, also called mesangiocapillary glomerulonephritis, can have a railroad appearance to the glomerular basement membrane when evaluated by light microscopy, and is often induced by infectious diseases. Type II membranoproliferative glomerulonephritis is also called dense deposit disease and can be differentiated from type I via electron microscopy. In people, the dense deposits of type II membranoproliferative glomerulonephritis are not believed to be immune deposits; type II membranoproliferative glomerulonephritis is not associated with infectious diseases. Mesangioproliferative glomerulonephritis may have several subcategories (eg, IgA nephropathy) and is characterized by focal segmental to diffuse global mesangial cell hyperplasia. Lupus nephritis can be associated with any glomerular abnormality and, when active, often has an interstitial inltrate of mixed inammatory cells and acute damage to the tubules. Crescents can loosely be dened as 2 or more layers of cells in Bowmans space and are suggestive of severe pathological injury. Crescentic glomerulonephritis is diagnosed when crescents are present in 50% or more of the glomeruli. Focal segmental glomerulosclerosis is diagnosed when the patient has proteinuria and glomerulosclerosis of only a few lobules within affected glomeruli and another glomerular lesion is not present to explain the sclerosis (Fig. 13). Amyloidosis is easy to diagnose by expansion of the mesangium and glomerular basement membrane by acellular, eosinophilic staining material that stains red by Congo red (Fig. 14). Amyloid deposits are birefringent when viewed under polarized light. Tubular atrophy appears as irregular tubular basement

Figure 10 Normal glomerulus from a dog. Note the capillary lumens are widely patent and the capillary loops are thin, often appearing discontinuous. Hypercellularity is not present. Used with permission from Vaden SL, Glomerular disease, in Ettinger SJ, Feldman EC (eds): Textbook of Veterinary Internal Medicine (ed 6). Philadelphia, WB Saunders, 2005. 2005 Elsevier Inc.

tory, pathogenesis, and response to treatment of the various glomerular diseases in dogs and cats.

Evaluation of the Renal Biopsy Specimen by Light Microscopy

The normal kidney is composed of glomeruli, tubules, interstitium, and vasculature. The normal glomerulus contains 4 to 8 lobules; each lobule is composed of capillaries supported on a centrilobular core of mesangial matrix (Fig. 10).27,28 The glomerular basement membrane is thin, delicate, PAS-positive and argyrophilic (ie, capable of being impregnated with silver). The glomerular capillary lumen is normally widely patent and lined with eosinophilic endothelial cell cytoplasm. In any section, the glomeruli can appear of any size because the glomeruli have been cut in different planes. There should only be 1 to 2 nuclei per mesangial cell region. The tubules normally have a thick basement membrane and are separated from each other by a ne interstitial stroma that contains capillaries. The normal interstitium is relatively inconspicuous. The entire section should be evaluated under low power to exclude focal space occupying lesions (eg, granuloma, neoplasia) and to evaluate the distribution of other lesions. When glomerular lesions are present and nearly all glomeruli are affected, the disorder is generalized. If less than one-half of the glomeruli are affected, the disorder is focal. When evaluating individual glomeruli, the pattern is diffuse or global if the entire glomerulus is affected. The lesion is segmental or local if only a few lobules within affected glomeruli are involved. In membranous glomerulopathy, the glomerular basement membrane appears uniformly thickened and appears more rigid than normal (Fig. 11). Because the subepithelial immune deposits do not become impregnated with silver, spikes may be identied on the outside of the glomerular basement membrane when a silver stain is used. Membranoproliferative glomerulonephritis is diagnosed

Figure 11 Glomerulus from a dog with membranous nephropathy. Note the thickened, rigid appearing capillary loops and the lack of hypercellularity (Courtesy of JL Robertson).

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Figure 12 Glomerulus from a dog with membranoproliferative (mesangiocapillary) glomerulonephritis. Note the thickened capillary loops and the mesangial hypercellularity resulting in the segmented and lobular appearance. Used with permission from Vaden SL, Glomerular disease, in Ettinger SJ, Feldman EC (eds): Textbook of Veterinary Internal Medicine (ed 6). Philadelphia, WB Saunders, 2005. 2005 Elsevier Inc.

Figure 14 A glomerulus from a dog with segmental amyloid deposition. Note the homogenously staining, acellular material that is expanding the mesangium.

membrane thickening and luminal collapse and may suggest long-standing disease or a normal aging process. The tubules may be more widely separated than normal with brous tissue and lymphocytes present between the tubules. Hyaline droplets or protein reabsorption droplets can sometimes be seen in the renal tubular cells of patients with proteinuria. The tubules should be examined for presence of casts, and foci of degeneration, regeneration, and necrosis. The interstitium should be examined for edema, brosis, inammation, or combinations of these. Expansion of the interstitium may occur with tubular atrophy, edema, inammatory inltration, or brosis.

Evaluation of the Renal Biopsy Specimen by Electron Microscopy

Parietal epithelial cells, visceral epithelial cells, endothelial cells, and mesangial cells comprise the normal glomerulus and can easily be identied by electron microscopy. The parietal epithelial cells are attened cells that line the inner surface of Bowmans capsule. The visceral epithelial cells, or podocytes, line the outer surface of the capillary loops and rest on the glomerular basement membrane. The podocytes are characterized by foot processes and form the outermost layer of the capillary wall. The endothelial cells line the inner surface of the capillary loops with the nuclei disposed centrilobularly, toward the mesangium. The fenestrations of the endothelial cell cytoplasm can be visualized easily. The normal glomerular basement membrane should be approximately the same thickness as the base of a foot process turned 90. The mesangial matrix contains an interwoven network of microlaments. Minimal change disease is diagnosed when minimal changes are visualized via light microscopy (ie, slight hypercellularity as evident by 3-4 nuclei in the mesangial region) and marked foot process effacement is noted via electron microscopy (Fig. 15). Membranous glomerulopathy has 4 ultrastructural stages that correlate with temporal evolution of the disease and may predict therapeutic outcome; electron microscopy can be used to stage patients with membranous nephropathy (Fig. 16). Electron microscopy can also be used to identify the dense deposits in type II membranoproliferative glomerulonephritis and verify the presence of electron dense, presumably immune deposits in other patients with glomerulonephritis. Whereas veterinarians have classically been taught to look for these deposits within the glomerular basement membrane, in dogs with glomerulonephritis these deposits are located more frequently within the mesangium. The glomerular basement membrane varies in thickness and is

Figure 13 A glomerulus from a dog with a lesion resembling focal segmental glomerulosclerosis. Note the relatively normal appearance of the glomerular sections that are not sclerotic. Used with permission from Vaden SL, Glomerular disease, in Ettinger SJ, Feldman EC (eds): Textbook of Veterinary Internal Medicine (ed 6). Philadelphia, WB Saunders, 2005. 2005 Elsevier Inc.

Renal biopsy of dogs and cats

21 split into a number of layers in patients with hereditary nephritis.27

Evaluation of the Renal Biopsy Specimen by Immunouorescent Microscopy

The normal kidney should not have positive immunouorescent or immunohistochemical staining. However, staining is positive in animals with immune-mediated disease where there is either in situ immune complex formation, as is believed to occur with membranous glomerulopathy, or deposition of circulating complexes, as may occur with type I membranoproliferative glomerulonephritis. Because true antiglomerular basement membrane glomerulonephritis has not been documented in the dog, the expected staining pattern is discontinuous occurring either in the capillary loops, giving a circular appearance, or in the mesangium.

Figure 15 Electron micrograph of a glomerular capillary loop in a dog with minimal change disease. There is effacement of the foot processes. Used with permission from Vaden SL, Glomerular disease, in Ettinger SJ, Feldman EC (eds): Textbook of Veterinary Internal Medicine (ed 6). Philadelphia, WB Saunders, 2005. 2005 Elsevier Inc.

Figure 16 Ultrastructural stages in the progression of membranous nephropathy. (Courtesy of JC Jennette).

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10. Wise LA, Allen TA, Cartwright M: Comparison of renal biopsy techniques in dogs. J Am Vet Med Assoc 195:935-939, 1989 11. Drost WT, Henry GA, Meinkoth JH, et al: The effects of a unilateral ultrasound-guided renal biopsy on renal function in healthy sedated cats. Vet Radiol Ultrasound 41:57-62, 2000 12. Parrish AE: Complications of percutaneous renal biopsy: A review of 37 years experience. Clin Nephrol 38:135-141, 1992 13. McGill DB, Rakela J, Zinsmeister AR, et al: A 21-year experience with major hemorrhage after percutaneous liver biopsy. Gastroenterology 99:1396-1400, 1990 14. McVay PA, Toy PTCY: Lack of increased bleeding after liver biopsy in patients with mild hemostatic abnormalities. Am J Clin Pathol 94:747753, 1990 15. Bigge LA, Brown DJ, Pennick DG: Correlation between coagulation prole ndings and bleeding complications after ultrasound-guided biopsies: 434 cases (1993-1996). J Am Anim Hosp Assoc 37:228-233, 2001 16. Mezzano D, Tagle R, Pais E, et al: Endothelial cell markers in chronic uremia: Relationship with hemostatic defects and severity of renal failure. Thromb Res 88:465-472, 1997 17. Vaden SL: Renal biopsy. How and Why, in 2000 Scientic Proceedings, 18th Annual Veterinary Medical Forum, Seattle, WA, American College of Veterinary Internal Medicine, 2000, pp 675-676 18. Larrain C, Langdell TD: The hemostatic defect of uremia. II. Investigation of dogs with experimentally produced acute urinary retention. Blood 11:1067-1072, 1956 19. Osborne CA, Low DG, Jessen CR: Renal parenchymal response to needle biopsy. Invest Urol 9:463-469, 1972 20. Nash AS, Boyd JS, Minto W, et al: Renal biopsy in the normal cat: An examination of the effects of a single biopsy. Res Vet Sci 34:347-356, 1983 21. Stone EA, Barsanti JA: Diagnostic tests, in Stone EA, Barsanti JA (eds): Urologic Surgery of the Dog and Cat. Philadelphia, PA, Lea & Febiger, 1992, pp 37-52 22. Osborne CA, Bartges JW, Polzin DJ, et al: Percutaneous needle biopsy of the kidney. Indications, applications, technique and complications. Vet Clinics North Am 26:1461-1504, 1996 23. Patterson JM: Laparoscopy in small animal medicine, in Kirk RW (ed): Current Veterinary Therapy VII Small Animal Practice. Philadelphia, PA, WB Saunders, 1980, pp 969-973 24. Stone EA, Barsanti JA: General surgical approaches, in Stone EA, Barsanti JA (eds): Urologic Surgery of the Dog and Cat. Philadelphia, PA, Lea & Febiger, 1992, pp 100-106 25. Sweet EI, Davidson AJ, Hayslett JP: Complications of needle biopsy of the kidney in the dog. Radiology 92:849-854, 1969 26. Nash AS, Boyd JS, Minto AW, et al: Renal biopsy in the normal cat: An examination of the effects of repeated needle biopsy. Res Vet Sci 40: 112-117, 1986 27. Jennette JC, Olson JL, Schwartz MM, et al (eds): Heptinstalls Pathology of the Kidney (ed 5). Philadelphia, PA, Lippincott-Raven Publishers, 1998 28. Greenberg A, Cheung AK, Coffman TM, et al: Primer on Kidney Diseases (ed 3). San Diego, CA, Academic Press, 2001

Summary
Renal biopsy most often is indicated in the management of dogs and cats with glomerular disease or acute renal failure. Renal biopsy can readily be performed in dogs and cats via either percutaneous or surgical methods. Care should be taken to ensure that proper technique is used. When proper technique is employed and patient factors are properly addressed, renal biopsy is a relatively safe procedure that minimally affects renal function. Patients should be monitored during the postbiopsy period for severe hemorrhage, the most common complication. Accurate diagnosis of glomerular disease, and therefore accurate treatment planning, requires that the biopsy specimens not only be evaluated by light microscopy using special stains but also by electron and immunouorescent microscopy.

Acknowledgment
This manuscript was reproduced in part with permission from Vaden SL: Renal biopsy: Methods and interpretation. Vet Clin North Am (Small Anim Pract) 34:887-908, 2004.

References
1. Grauer GF, Twedt DC, Mero KN: Evaluation of laparoscopy for obtaining renal biopsy specimens from dogs and cats. J Am Vet Med Assoc 183:677-679, 1983 2. Minkus G, Reusch C, Hrauf A, et al: Evaluation of renal biopsies in cats and dogs histopathology in comparison with clinical data. J Small Anim Pract 35:465-472, 1994 3. Richards NT, Darby S, Howie AJ, et al: Knowledge of renal histology alters patient management in over 40% of cases. Nephrol Dial Transplant 9:1255-1259, 1994 4. Vilafranca M, Wohlsein P, Trautwein G, et al: Histological and immunohistological classication of canine glomerular disease. Zentralbl Veterinarmed A 41:599-610, 1994 5. Jeraj K, Osborne CA, Stevens JB: Evaluation of renal biopsy in 197 dogs and cats. J Am Vet Med Assoc 181:367-369, 1982 6. Lveill R, Partington BP, Biller DS, et al: Complications after ultrasound-guided biopsy of abdominal structures in dogs and cats: 246 cases (1984-1991). J Am Vet Med Assoc 203:413-415, 1993 7. Hager DA, Nyland T, Fisher P: Ultrasound-guided biopsy of the canine liver, kidney and prostate. Vet Radiology 26:82-88, 1985 8. Groman RP, Bahr A, Berridge BR, et al: Effect of serial ultrasoundguided renal biopsy on kidneys of healthy adolescent dogs. Vet Rad Ultrasound 451:62-69, 2004 9. Osborne CA: Clinical evaluation of needle biopsy of the kidney and its complications in the dog and cat. J Am Vet Med Assoc 158:1213-1228, 1971