Pediatric Kidney Biopsy: Clinical Perspectives Based on Survey of Pediatric Nephrologists and Interventional Radiologists

Many significant renal conditions present with unspecific clinical symptoms such as hematuria, proteinuria and/or anuria and require percutaneous ultrasound-guided kidney biopsy for definitive diagnosis and management. Kidney Biopsy adequacy is defined by the quality and quantity of glomeruli able to be collected per pass1Moledina D. G. Luciano R. L. Kukova L. Chan L. Saha A. Nadkarni G. Alfano S. Wilson F. P. Perazella M. A. Parikh C. R. Kidney Biopsy-Related Complications in Hospitalized Patients with Acute Kidney Disease. Clin J Am Soc Nephrol. 2018 Nov 7; 13 (Epub 2018 Oct 22. PMID: 30348813; PMCID: PMC6237071): 1633-1640https: //doi. org/10. 2215/CJN. 04910418Crossref PubMed Scopus (67) Google Scholar. While this procedure has traditionally been performed by nephrologists, the growth and diversification of Interventional Radiology (IR) has led to a shift in who performs this procedure, with no agreed upon standard for who should perform these procedures2Emelianova D. Prikis M. Morris C. S. Gibson P. C. Solomon R. Scriver G. Smith Z. T. Bhave A. Shields J. DeSarno M. Kumar A. The evolution of performing a kidney biopsy: a single center experience comparing native and transplant kidney biopsies performed by interventional radiologists and nephrologists. BMC Nephrol. 2022 Jun 25; 23 (PMID: 35752759; PMCID: PMC9233823): 226https: //doi. org/10. 1186/s12882-022-02860-1Crossref Scopus (4) Google Scholar. Almost 70% of recently graduating adult nephrology fellows no longer think they should be required to demonstrate competence in kidney biopsies as 65-83% of practicing adult nephrologists don't perform this procedure3Kurtis A. Pivert, Anna M. Burgner, Lili Chan, Susan Halbach, Koyal Jain, Benjamin Ko, Hitesh H. Shah, Stephen M. Sozio, Joshua Waitzman, and Suzanne M. Boyle. 2022. "On Deck: Results from the 2022 ASN Nephrology Fellow Survey. " October 21, 2022. https: //data. asn-online. org/posts/2022fellowₛurvey. Google Scholar, 4Yuan C. M. Nee R. Little D. J. Narayan R. Childs J. M. Prince L. K. Raghavan R. Oliver 3rd, J. D. Survey of Kidney Biopsy Clinical Practice and Training in the United States. Clin J Am Soc Nephrol. 2018 May 7; 13 (Nephrology Education Research and Development Consortium (NERDC) ) (Epub 2018 Apr 18. PMID: 29669819; PMCID: PMC5968891): 718-725https: //doi. org/10. 2215/CJN. 13471217Crossref PubMed Scopus (26) Google Scholar. To gauge the thoughts of each specialty, a survey was created to investigate comfort, efficacy, and thoughts on performing kidney biopsies. The survey was created by the authors representing both specialties to capture relevant feelings and data on the experience being trained kidney biopsy. All three questionnaires were created to ensure face validity and a strong quality of questions without leading or confusing questions. The final questionnaires were sent out to large pediatric nephrology (pedneph and pccrt) and pediatric interventional radiology (SPIR) listservs. A total of 280 respondents Pediatric Interventional Radiologist: 29; Pediatric Nephrologist: 202 and Pediatric Nephrology – Fellow: 49 participated in the survey. A statistically significant difference was observed for the performance related attributes such as confidence about adequately performing a native renal biopsy strongly agree - IR: 100% vs. PN 51. 3% vs. PNF: 40%; p=0. 023; adequately perform a renal transplant biopsy strongly agree – IR: 100% vs. PN: 51. 3% vs. PNF: 46. 7%; p=0. 012; requirement of assistance while performing a renal biopsy [Never – IR: 88. 9% vs. PN: 28. 7% vs. PNF: 3. 3%; p153 (27. 3%) 72 (51. 8%) 75 (50%) Number of native renal biopsies performed per year00 (0%) 13 (11%) 0 (0%) 13 (8. 3%) 0. 0181-203 (33. 3%) 73 (61. 9%) 22 (73. 3%) 98 (62. 4%) 21-302 (22. 2%) 14 (11. 9%) 5 (16. 7%) 21 (13. 4%) 31-502 (22. 2%) 12 (10. 2%) 0 (0%) 14 (8. 9%) >502 (22. 2%) 6 (5. 1%) 3 (10%) 11 (7%) Number of renal transplant biopsies performed per year00 (0%) 31 (26. 3%) 2 (6. 7%) 33 (21%) 0. 0321-207 (77. 8%) 70 (59. 3%) 24 (80%) 101 (64. 3%) 21-301 (11. 1%) 13 (11%) 3 (10%) 17 (10. 8%) 31-500 (0%) 4 (3. 4%) 1 (3. 3%) 5 (3. 2%) >501 (11. 1%) 0 (0%) 0 (0%) 1 (0. 6%) Type of renal biopsy performed most frequentlyUSHB10 (83. 3%) 136 (93. 2%) 27 (90%) 173 (92%) 0. 207Percutaneous based1 (8. 3%) 7 (4. 8%) 2 (6. 7%) 10 (5. 3%) USOB0 (0%) 0 (0%) 1 (3. 3%) 1 (0. 5%) CTHB0 (0%) 1 (0. 7%) 0 (0%) 1 (0. 5%) Others1 (8. 3%) 2 (1. 4%) 0 (0%) 3 (1. 6%) Type of renal biopsy performed most frequently by your institutionUSHB10 (83. 3%) Not Asked29 (96. 7%) 39 (92. 9%) 0. 192USOB0 (0%) 1 (3. 3%) 1 (2. 4%) Percutaneous based1 (8. 3%) 0 (0%) 1 (2. 4%) Others1 (8. 3%) 0 (0%) 1 (2. 4%) Believe that renal biopsies should be performed by pediatric nephrologyYes0 (0%) 95 (81. 9%) Not Asked95 (76%) 122 (22. 2%) 54 (47%) 13 (44. 8%) 69 (45. 1%) Performed a repeat biopsy on a patient due to an error while collecting or analyzing the sample the first timeYes1 (11. 1%) 30 (26. 3%) 2 (6. 9%) 33 (21. 7%) 0. 044No8 (88. 9%) 84 (73. 7%) 27 (93. 1%) 119 (78. 3%) Open table in a new tab Abbreviations: USHB - Ultrasound guided-hospital based; USOB: Ultrasound guided-office based A ASPN/AAP survey in 2013 of pediatric nephrologists surveyed found that 72% conduct renal biopsies and 81% reporting that pediatric nephrologists performed most pediatric kidney biopsies at their respective hospitals 6Primack W. A. Meyers K. E. Kirkwood S. J. Ruch-Ross H. S. Radabaugh C. L. Greenbaum L. A. The US pediatric nephrology workforce: a report commissioned by the American Academy of Pediatrics. Am J Kidney Dis. 2015 Jul; 66: 33-39Abstract Full Text Full Text PDF Scopus (34) Google Scholar. Those who did not report performing renal biopsies unanimously reported that IRs performed these procedures. 10 years later that number has risen to 79% of practicing nephrologists and 100% of IRs. IRs were more likely to report feeling comfortable with the procedure and required less assistance compared to nephrologists. As primarily proceduralists, IRs are more comfortable with all procedures overall, whereas for pediatric nephrologists, this may be the only procedure they perform. Concerning training, the specialized procedural aspect of IR residency, allows them to be better able to handle complicated cases and management of severe complications7. In most institutions, pediatric IRs perform biopsies considered "more complicated, " where patients are coagulopathic, obese, and/or have difficult transplanted anatomy7Naur T. M. H. Nilsson P. M. Pietersen P. I. Clementsen P. F. Konge L. Simulation-Based Training in Flexible Bronchoscopy and Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA): A Systematic Review. Respiration. 2017; 93 (Epub 2017 Mar 25. PMID: 28343219): 355-362https: //doi. org/10. 1159/000464331Crossref PubMed Scopus (40) Google Scholar. Currently for pediatric nephrologists, there is no requirement or minimum number of biopsies that need to be performed during pediatric fellowship, with expectations varying widely across training programs8Accreditation Council for Graduate Medical Education: Common Program Requirements. ACGME Program Requirements for Graduate Medical Education in Nephrology, 2020. Available at: https: //www. acgme. org/globalassets/PFAssets/ ProgramRequirements/148Nephrology₂020. pdf? ver=2020- 06-29-162357-583 Nephrology Policies, 2021. Available at: https: //www. abim. org/certification/policies/Google Scholar. Although it can be argued that an IR may be better trained or more comfortable to perform the biopsy procedure, in theory having the biopsy performed by a nephrologist would allow for the real-time decision-making with regards to tissue adequacy depending on the disease being evaluated7. For either practitioner practicing in low volume settings, avenues for improved/additional training might include attending workshops and simulations. Procedural simulation trainings for kidney biopsies can improve trainee confidence with recent studies finding upwards of 94% of fellows being able to procure an adequate yield with post training10Dawoud D. Lyndon W. Mrug S. Bissler J. J. Mrug M. Impact of ultrasound-guided kidney biopsy simulation on trainee confidence and biopsy outcomes. Am J Nephrol. 2012; 36 (Epub 2012 Dec 5. PMID: 23221146; PMCID: PMC3918883): 570-574https: //doi. org/10. 1159/000345305Crossref PubMed Scopus (22) Google Scholar. With advances in virtual reality technology, more realistic recreation of ultrasound-guided biopsies and allow for practice of a multitude of techniques. In any given center, the issue of who performs a kidney biopsy should be decided by local factors and expertise with results recorded and audited in a collaborative manner by all the specialists involved. If the pediatric nephrology field decides that this is an important procedure for the nephrologist to perform, then it will be imperative to gather all stakeholders responsible for pediatric nephrology training to develop clear guidelines and training metrics for kidney biopsies. There may be an opportunity for high quality and effective advanced simulation/virtual reality training, which is becoming more common in medical training to address this gap. Further prospective studies are needed to compare technical success and complication rates amongst these specialties. NN, RR, and CV came up with the project idea and conceptualization. CV, RR, and MP worked on survey delivery and data procurement. JV worked on data analysis and presentation. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. None. The authors declare that they have no relevant financial interests. Received September 24, 2023. Evaluated by 2 external peer reviewers, with direct editorial input from an Associate Editor and the Editor-in-Chief. Accepted in revised form February 26, 2024.