Renal Biopsy in the Pediatric Patient

Renal biopsy in children can be performed either by percutaneous, laparoscopic, or open surgical approaches. As reported in a recent large pediatric series (Hussain et al., 2010), the percutaneous approach is by far the most commonly utilized, with the open approach typically reserved for situations in which percutaneous biopsy may be relatively contraindicated or there is the need for a large wedge of tissue. Increasingly, more centers are reporting successful experience with laparoscopic approaches as an alternative to open surgical biopsies (Caione et al., 2000; Luque Mialdea et al., 2006; Mukhtar et al., 2005). Native renal biopsy should be performed in a child when kidney disease is suspected and treatment decisions require confirmation, when staging or characterization of a known kidney disease is warranted, or when the disease diagnosis is known but the utility of further treatment is questioned. In contrast to adults, renal insufficiency in children is more often secondary to sequelae from congenital or structural anomalies rather than acquired diseases. As a result, loss of renal function is not unexpected and tends to progress more slowly. Typically, children with such well-defined renal anomalies do not undergo biopsy even as renal function declines, unless a new entity is thought to be present. On the other hand, children presenting with an acquired kidney condition, especially with rapidly changing renal function or lack of response to empiric therapy, do require renal biopsy to allow for accurate diagnosis and tailoring of therapeutic intervention. Moreover, while relatively common medical conditions such as hypertension and diabetes mediate much of the chronic kidney disease seen in adults, these conditions are rarer in children and less likely to impact renal health in the pediatric patient, leading to a need for clinicians to actually identify why kidney disease has arisen in the child. In contrast to many adults, children and adolescents typically require significant conscious sedation or even general anesthesia for successful renal biopsy. Consequently, the risks of both the procedure and sedation/anesthesia must be considered when determining whether to do the biopsy. There are several medical conditions that often preclude biopsy. Although each case must be individually considered and there may be an occasion when the information garnered at biopsy outweighs the potential risk, the following situations are often considered contraindications or relative contraindications for pediatric biopsy: