Pediatric Radiology

, Volume 47, Issue 12, pp 1572–1579 | Cite as

Pediatric renal transplant biopsy with ultrasound guidance: the ‘core’ essentials

  • Aris Oates
  • Saveen Ahuja
  • Marsha M. Lee
  • Andrew S. Phelps
  • John D. Mackenzie
  • Jesse L. Courtier


This review provides a comprehensive and practical approach to pediatric percutaneous renal transplant biopsies, highlighting techniques and strategies to optimize adequate sample yield and ensure patient safety. In children with end-stage renal disease, transplantation is the preferred choice of therapy, providing for overall lower long-term morbidity and mortality compared with dialysis. In the ongoing management of renal transplant patients, core tissue sampling via a percutaneous renal biopsy remains the gold standard when transplant dysfunction is suspected. Indications for renal transplant biopsy and techniques/tools for adequate sample yield are discussed. Strategies for common challenges such as poor visualization and renal transplant mobility are addressed. We discuss the clinical signs, techniques and imaging findings for common complications including hematomas, arteriovenous fistulas and pseudoaneurysms. Although the percutaneous renal transplant biopsy procedure is generally safe with rare complications, care must be taken to ensure major complications are promptly recognized and treated. Adequate tissue samples obtained via renal biopsy are imperative to promptly identify transplant rejection to provide valuable information for patient diagnosis, treatment and outcomes. Radiologist and nephrologist attention to proper ultrasound techniques and optimal biopsy tools are critical to ensure tissue adequacy and minimize complications.


Biopsy Children Kidney Percutaneous biopsy Transplant Ultrasound 



The authors wish to thank Jeffery Yang for his assistance with the biopsy core photo.

Compliance with ethical standards

Conflicts of interest

Dr. Mackenzie has received research support from General Electric Healthcare. Drs. Oates, Ahuja, Lee, Phelps and Courtier report no conflicts of interest.


  1. 1.
    National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2012) U.S. renal data system. USRDS 2012 annual data report: Atlas of chronic kidney disease & end-stage renal disease in the United StatesGoogle Scholar
  2. 2.
    National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2015) U.S. renal data system. 2015 USRDS annual data report: Epidemiology of kidney disease in the United StatesGoogle Scholar
  3. 3.
    Seikaly MG, Ho PL, Emmett L et al (2003) Chronic renal insufficiency in children: the 2001 annual report of the NAPRTCS. Pediatr Nephrol 18:796–804CrossRefPubMedGoogle Scholar
  4. 4.
    Baumgarten M, Gehr T (2011) Chronic kidney disease: detection and evaluation. Am Fam Physician 84:1138–1148PubMedGoogle Scholar
  5. 5.
    McDonald SP, Craig JC, Australian and New Zealand Paediatric Nephrology Association (2004) Long-term survival of children with end-stage renal disease. N Engl J Med 350:2654–2662Google Scholar
  6. 6.
    Lai WM (2009) Quality of life in children with end-stage renal disease: does treatment modality matter? Perit Dial Int 29(Suppl 2):S190–S191Google Scholar
  7. 7.
    Saini T, Murtagh FE, Dupont PJ et al (2006) Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliat Med 20:631–636CrossRefPubMedGoogle Scholar
  8. 8.
    Liem YS, Bosch JL, Arends LR et al (2007) Quality of life assessed with the Medical Outcomes Study Short Form 36-Item Health Survey of patients on renal replacement therapy: a systematic review and meta-analysis. Value Health 10:390–397CrossRefPubMedGoogle Scholar
  9. 9.
    Liem YS, Weimar W (2009) Early living-donor kidney transplantation: a review of the associated survival benefit. Transplantation 87:317–318CrossRefPubMedGoogle Scholar
  10. 10.
    Chavers BM, Molony JT, Solid CA et al (2015) One-year mortality rates in US children with end-stage renal disease. Am J Nephrol 41:121–128CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Ferris ME, Gipson DS, Kimmel PL, Eggers PW (2006) Trends in treatment and outcomes of survival of adolescents initiating end-stage renal disease care in the United States of America. Pediatr Nephrol 21:1020–1026CrossRefPubMedGoogle Scholar
  12. 12.
    Matas AJ, Smith JM, Skeans MA et al (2015) OPTN/SRTR 2013 Annual Data Report: kidney. Am J Transplant 15(Suppl 2):1–34CrossRefPubMedGoogle Scholar
  13. 13.
    Casey MJ, Meier-Kriesche HU (2011) Calcineurin inhibitors in kidney transplantation: friend or foe? Curr Opin Nephrol Hypertens 20:610–615CrossRefPubMedGoogle Scholar
  14. 14.
    Offermann G (2004) Immunosuppression for long-term maintenance of renal allograft function. Drugs 64:1325–1338CrossRefPubMedGoogle Scholar
  15. 15.
    Al-Awwa IA, Hariharan S, First MR (1998) Importance of allograft biopsy in renal transplant recipients: correlation between clinical and histological diagnosis. Am J Kidney Dis 31:S15–S18CrossRefPubMedGoogle Scholar
  16. 16.
    Silva DM, Garcia JP, Ribeiro AR et al (2007) Utility of biopsy in kidney transplants with delayed graft function and acute dysfunction. Transplant Proc 39:376–377CrossRefPubMedGoogle Scholar
  17. 17.
    Broecker V, Mengel M (2015) The significance of histological diagnosis in renal allograft biopsies in 2014. Transpl Int 28:136–143CrossRefPubMedGoogle Scholar
  18. 18.
    Schwarz A, Mengel M, Gwinner W et al (2002) Protocol biopsy program after renal transplantation: structure and first results. Transplant Proc 34:2238–2239CrossRefPubMedGoogle Scholar
  19. 19.
    Birk PE (2012) Surveillance biopsies in children post-kidney transplant. Pediatr Nephrol 27:753–760CrossRefPubMedGoogle Scholar
  20. 20.
    Matas AJ, Sibley R, Mauer M et al (1983) The value of needle renal allograft biopsy. I. A retrospective study of biopsies performed during putative rejection episodes. Ann Surg 197:226–237CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Solez K, Axelsen RA, Benediktsson H et al (1993) International standardization of criteria for the histologic diagnosis of renal allograft rejection: the Banff working classification of kidney transplant pathology. Kidney Int 44:411–422CrossRefPubMedGoogle Scholar
  22. 22.
    Bates WD, Davies DR, Welsh K et al (1999) An evaluation of the Banff classification of early renal allograft biopsies and correlation with outcome. Nephrol Dial Transplant 14:2364–2369CrossRefPubMedGoogle Scholar
  23. 23.
    Tanaka T, Kyo M, Kokado Y et al (2004) Correlation between the Banff 97 classification of renal allograft biopsies and clinical outcome. Transpl Int 17:59–64CrossRefPubMedGoogle Scholar
  24. 24.
    Solez K, Racusen LC (2013) The Banff classification revisited. Kidney Int 83:201–206CrossRefPubMedGoogle Scholar
  25. 25.
    Ahmad I (2004) Biopsy of the transplanted kidney. Semin Interv Radiol 21:275–281CrossRefGoogle Scholar
  26. 26.
    Iversen P, Brun C (1951) Aspiration biopsy of the kidney. Am J Med 11:324–330CrossRefPubMedGoogle Scholar
  27. 27.
    Kim D, Kim H, Shin G et al (1998) A randomized, prospective, comparative study of manual and automated renal biopsies. Am J Kidney Dis 32:426–431CrossRefPubMedGoogle Scholar
  28. 28.
    Whittier WL, Korbet SM (2004) Renal biopsy: update. Curr Opin Nephrol Hypertens 13:661–665CrossRefPubMedGoogle Scholar
  29. 29.
    Maya ID, Maddela P, Barker J, Allon M (2007) Percutaneous renal biopsy: comparison of blind and real-time ultrasound-guided technique. Semin Dial 20:355–358CrossRefPubMedGoogle Scholar
  30. 30.
    Patel MD, Phillips CJ, Young SW et al (2010) US-guided renal transplant biopsy: efficacy of a cortical tangential approach. Radiology 256:290–296CrossRefPubMedGoogle Scholar
  31. 31.
    Kudryk BT, Martinez CR, Gunasekeran S, Ramirez G (1995) CT-guided renal biopsy using a coaxial technique and an automated biopsy gun. South Med J 88:543–546CrossRefPubMedGoogle Scholar
  32. 32.
    Donati-Bourne J, Roberts HW, Coleman RA (2014) Donor-recipient size mismatch in paediatric renal transplantation. J Transp Secur 2014:317574Google Scholar
  33. 33.
    Nicholson ML, Wheatley TJ, Doughman TM et al (2000) A prospective randomized trial of three different sizes of core-cutting needle for renal transplant biopsy. Kidney Int 58:390–395CrossRefPubMedGoogle Scholar
  34. 34.
    Gupta RK, Balogun RA (2005) Native renal biopsies: complications and glomerular yield between radiologists and nephrologists. J Nephrol 18:553–558PubMedGoogle Scholar
  35. 35.
    Chung S, Koh ES, Kim SJ et al (2014) Safety and tissue yield for percutaneous native kidney biopsy according to practitioner and ultrasound technique. BMC Nephrol 15:96CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Yesudas SS, Georgy NK, Manickam S et al (2010) Percutaneous real-time ultrasound-guided renal biopsy performed solely by nephrologists: A case series. Indian J Nephrol 20:137–141CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Durkan AM, Beattie TJ, Howatson A et al (2006) Renal transplant biopsy specimen adequacy in a paediatric population. Pediatr Nephrol 21:265–269CrossRefPubMedGoogle Scholar
  38. 38.
    Hussain F, Mallik M, Marks SD et al (2010) Renal biopsies in children: current practice and audit of outcomes. Nephrol Dial Transplant 25:485–489CrossRefPubMedGoogle Scholar
  39. 39.
    Tøndel C, Vikse BE, Bostad L, Svarstad E (2012) Safety and complications of percutaneous kidney biopsies in 715 children and 8573 adults in Norway 1988-2010. Clin J Am Soc Nephrol 7:1591–1597CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Colvin RB, Cohen AH, Saiontz C et al (1997) Evaluation of pathologic criteria for acute renal allograft rejection: reproducibility, sensitivity, and clinical correlation. J Am Soc Nephrol 8:1930–1941PubMedGoogle Scholar
  41. 41.
    Racusen LC, Solez K, Colvin RB et al (1999) The Banff 97 working classification of renal allograft pathology. Kidney Int 55:713–723CrossRefPubMedGoogle Scholar
  42. 42.
    Riehl J, Maigatter S, Kierdorf H et al (1994) Percutaneous renal biopsy: comparison of manual and automated puncture techniques with native and transplanted kidneys. Nephrol Dial Transplant 9:1568–1574PubMedGoogle Scholar
  43. 43.
    Morgan TA, Chandran S, Burger IM et al (2016) Complications of ultrasound-guided renal transplant biopsies. Am J Transplant 16:1298–1305CrossRefPubMedGoogle Scholar
  44. 44.
    Marwah DS, Korbet SM (1996) Timing of complications in percutaneous renal biopsy: what is the optimal period of observation? Am J Kidney Dis 28:47–52CrossRefPubMedGoogle Scholar
  45. 45.
    Whittier WL, Korbet SM (2004) Timing of complications in percutaneous renal biopsy. J Am Soc Nephrol 15:142–147CrossRefPubMedGoogle Scholar
  46. 46.
    Redfield RR, McCune KR, Rao A et al (2016) Nature, timing, and severity of complications from ultrasound-guided percutaneous renal transplant biopsy. Transpl Int 29:167–172CrossRefPubMedGoogle Scholar
  47. 47.
    Korbet SM (2012) Nephrology and the percutaneous renal biopsy: a procedure in jeopardy of being lost along the way. Clin J Am Soc Nephrol 7:1545–1547CrossRefPubMedGoogle Scholar
  48. 48.
    Schwarz A, Hiss M, Gwinner W et al (2008) Course and relevance of arteriovenous fistulas after renal transplant biopsies. Am J Transplant 8:826–831CrossRefPubMedGoogle Scholar
  49. 49.
    Schwarz A, Gwinner W, Hiss M et al (2005) Safety and adequacy of renal transplant protocol biopsies. Am J Transplant 5:1992–1996CrossRefPubMedGoogle Scholar
  50. 50.
    Güneyli S, Gök M, Bozkaya H et al (2015) Endovascular management of iatrogenic renal arterial lesions and clinical outcomes. Diagn Interv Radiol 21:229–234CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Sharma AK, Sunil S, Rowlands P, Bakran A (2002) Pseudoaneurysm with severe haematuria in renal allograft after renal biopsy treated by percutaneous embolization. Nephrol Dial Transplant 17:934–935CrossRefPubMedGoogle Scholar
  52. 52.
    Simckes AM, Blowey DL, Gyves KM, Alon US (2000) Success and safety of same-day kidney biopsy in children and adolescents. Pediatr Nephrol 14:946–952CrossRefPubMedGoogle Scholar
  53. 53.
    Patel IJ, Davidson JC, Nikolic B et al (2012) Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 23:727–736CrossRefPubMedGoogle Scholar
  54. 54.
    Visconti L, Cernaro V, Ricciardi CA et al (2016) Renal biopsy: Still a landmark for the nephrologist. World J Nephrol 5:321–327CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Sethi I, Brier M, Dwyer A (2013) Predicting post renal biopsy complications. Semin Dial 26:633–635CrossRefPubMedGoogle Scholar
  56. 56.
    Cavuoto KM, Rodriguez LI, Tutiven J, Chang TC (2014) General anesthesia in the pediatric population. Curr Opin Ophthalmol 25:411–416CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Aris Oates
    • 1
  • Saveen Ahuja
    • 2
  • Marsha M. Lee
    • 1
  • Andrew S. Phelps
    • 2
  • John D. Mackenzie
    • 2
  • Jesse L. Courtier
    • 2
  1. 1.Division of Nephrology, Department of PediatricsUniversity of CaliforniaSan FranciscoUSA
  2. 2.Department of Radiology and Biomedical ImagingUniversity of CaliforniaSan FranciscoUSA

Personalised recommendations