biopsy Ultrasound is the preferred imaging technique to mark the position of the kidney It is particularly preferred

Microscopic and macroscopic hematuria with or without proteinuria - Patients with distorted red cells in urine (which suggests a glomerular lesion) often have IgA nephropathy. or thin membrane nephropathy. Other glomerular lesions e. g. lupus glomerulonephritis may be present Biopsy should be witheld if GFR is normal. 4. Impaired renal function, proteinuria and hematuria - Biopsy is mandatory. 5. Systemic disorders associated with hematuria, proteinuria or impaired renal function - Biopsy important for determining diagnosis and prognosis Severity of renal lesion may influence nature of therapy e. g. in SLE, serial biopsies may be useful in judging response to treatment. 6. Acute renal failure - if obstruction, hypovolemia, low cardiac output and septicemia have been excluded as primary causative factors. Early biopsy may reveal treatable form of rapidly progressive glomerulonephritis, such as polyarteritis or antiglomerular basement disease. 7. Chronic and end-stage renal failure - provided kidneys are not small and shrunken, biopsy is useful in determining the cause and prognosis Certain forms of nephritis (e g focal glomerulosclerosis and mesangiocapillary glomerulonephritis) recur in transplants, and it is helpful to know this for future management. 8. Special situations - (a) Uncontrolled hypertension may lead to renal impairment, hematuria and proteinuria, and this may occasionally result in nephrotic syndrome. Once hypertension is controlled, renal biopsy may be the sole criterion for determining whether the problem is due to pure hypertension or underlying nephritis. (b) In 10-20% of patients with diabetes mellitus, proteinuria and impaired renal function may be due to causes other than diabetic nephrosclerosis, particularly in those with no other evidence of microvascular disease e g diabetic retinopathy. 9. Renal allograft dysfunction - (a) It provides only reliable method of distinguishing rejection from cyclosporin nephrotoxicity (b) It helps in deciding the scale of antirejection therapy and differentiating allograft nephropathy form recurrent or de novo nephritis Contraindications - 1. Single kidney or severe malfunction of one kidney 2 Uncontrollable bleeding diathesis. 3. Small, shrunken kidneys (difficult to locate and information obtained usually nonspecific) 4 Presence of cystic disease, nephrolithiasis, reflux nephropathy or obstruction or hemangioma Technique - Localization of the kidney- Lateral border of lower pole of kidney is the safest part to biopsy Ultrasound is the preferred imaging technique to mark the position of the kidney It is particularly preferred in patients with impaired function as it avoids use of contrast media (as in IVU). Attachments are available for ultrasound probes which can precisely direct the needle to the kidney. Biopsy needle -.(a) Franklin-modified Vim Silverman needle. (b) Tru-Cut needles are disposable needles and not composed of different parts (c) Biopsy gun is a spring-loaded device which shoots' a variant of tru-cut needle into the organ (d) Biopsy needles with tips which are easily seen by ultrasound They are smaller but adequate tissue can usually be obtained Biopsy of the native kidney - (a) Pre-medication to allay anxiety and pain. (b) 'Fixing1 the kidney - so that it does not move significantly with patient's respirations Patient's upper abdomen and lower chest should be supported by pillows so adjusted that patient's diaphragm is well splinted. (c) Sedation - with IV diazepam to produce deep sleep. (d) Position of lower pole of the kidney as determined by ultrasound is marked on the skin and depth of the kidney measured. (e) Biopsy is then performed Enough tissue must be taken for light microscopy, electron microscopy, immuno-fluorescence or immunoperoxidase techniques and, if appropriate for culture Biopsy of transplanted kidney - The allograft may be easily palpable in the iliac fossa but it should be localised by ultrasound aiming for the lateral border of upper pole Since transplanted kidney often becomes encased in fibrous tissue, this must be penetrated before biopsy is taken If it is not, cutting prongs of a modified Vim Silverman needle or cutting tip of a Tru-Cut disposable needle may 'bounce' off the kidney and lacerate it, causing hemorrhage Fine-needle aspiration biopsy (FNAB) - is used in diagnosis of renal transplant dysfunction It is less traumatic and analgesia and sedation are normally unnecessary. FNAB can diagnose acute cellular reaction, but not early vascular rejection. Also it is not possible to judge severity of allograft damage in order to determine the nature and dose of anti-rejection therapy. Complications - COMMON - (a) Bleeding is most common complication. (b) Arterio-venous fistula within the kidney. It can cause bleeding Treatment - Bleeding can be controlled with bed rest and transfusion. If necessary identification and control of bleeding point of A-V fistula by transdermal percutaneous arteriography followed by embolization UNCOMMON - (a) Pneumothorax. (b) Ileus. (c) Laceration of liver, spleen, mesenteric artery and bowel.2. HEMATURIA Causes - .1. In the urinary tract - Kidney - 1. Congenital anomalies Polycystic disease, angioma .2. Calculus .3. Mobile kidney 4 Infections - Pyelonephritis, tuberculosis, glomerulonephritis 5. Neoplasms -Renal carcinoma, Wilm's tumour .6. Drugs - Sulphonamides, anticoagulants. 7. Trauma - Ruptured kidney. 8. Oxaluria. 9. Post-