Puncture approaches for ultrasound-guided kidney biopsy specimens: a pediatric model study using piglet kidneys | Pediatric Research

Mar 05, 2025

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The optimal puncture approach for real-time ultrasound-guided native kidney needle biopsy in children remains undetermined due to insufficient evidence. This study evaluated various puncture approaches for glomeruli count and arterial injury in the small kidneys of piglets.

A total of 144 kidneys sourced from a slaughterhouse were examined. On each kidney, three puncture approaches were performed on the lower pole using a 16-gauge needle: Caudocranial, Craniocaudal, and Vertical. Blinded pediatric nephrologists assessed core length, glomeruli count, and arterial injury.

The kidneys had a mean vertical length of 9.31 ± 0.59 cm. Of 432 punctures, no punctures traversed the kidney. The Vertical approach yielded a significantly shorter core length than other methods (P < 0.001), but the glomeruli count was consistent across approaches (P = 0.41). Over 60% of the biopsies resulted in arterial injury, with the Caudocranial approach showing significantly higher injury rates (P < 0.03).

This study focused on puncture techniques in a pediatric model, suggesting that the Craniocaudal and Vertical approaches are advantageous for selective glomerular sampling without increasing the arterial injury risk. Although further research on smaller kidneys is necessary, these findings offer valuable guidance for biopsy approaches to small kidneys, particularly in pediatric patients.

Kidney biopsy is essential for establishing diagnosis and determining treatment strategies; however, there is no consensus on the puncture approach in children who have the additional risk factor of small-sized kidneys.

This study compared between biopsy specimens from piglet models of pediatric kidneys to clarify the best puncture approach based on pediatric characteristics.

Although the same number of glomeruli were sampled using all approaches, the Caudocranial approach exhibited a significantly higher incidence of arterial injury.

In kidney biopsy that considers the characteristics of children with small kidneys, the Craniocaudal or Vertical approaches may improve the safety and quality of biopsy specimens.

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Karam, A. R., Vijayaraghavan, G., Khan, A., Ustun, B. & Hussain, S. Renal Biopsy: Comparative Yield of Cranial Versus Caudal Needle Trajectory. Anal. Nephrol. 18, 304–306 (2013).

Article Google Scholar

Najafian, B., Lusco, M. A., Alpers, C. E. & Fogo, A. B. Approach to Kidney Biopsy: Core Curriculum 2022. Am. J. Kidney Dis. 80, 119–131 (2022).

Article CAS PubMed Google Scholar

Luciano, R. L. & Moeckel, G. W. Update on the Native Kidney Biopsy: Core Curriculum 2019. Am. J. Kidney Dis. 73, 404–415 (2019).

Article PubMed Google Scholar

Sekulic, M. & Crary, G. S. Kidney Biopsy Yield: An Examination of Influencing Factors. Am. J. Surg. Pathol. 41, 961–972 (2017).

Article PubMed Google Scholar

Varnell, C. D. Jr., Stone, H. K. & Welge, J. A. Bleeding Complications after Pediatric Kidney Biopsy: A Systematic Review and Meta-Analysis. Clin. J. Am. Soc. Nephrol. 14, 57–65 (2019).

Article PubMed Google Scholar

Andrulli, S. et al. The Risks Associated with Percutaneous Native Kidney Biopsies: A Prospective Study. Nephrol. Dial. Transpl. 38, 655–663 (2023).

Article Google Scholar

Pettit, C. et al. Kidney Biopsy Adequacy and Complications in Children - Does Technique Matter? Eur. J. Pediatr. 181, 2677–2684 (2022).

Article PubMed PubMed Central Google Scholar

Nishino, T. et al. Glomeruli Count and Arterial Injury in Real-Time Ultrasound-Guided Needle Kidney Biopsy Specimens: Adequacy of Three Approaches for Pig Kidneys. Am. J. Nephrol. 54, 528–535 (2023).

Rianthavorn, P., Kerr, S. J. & Chiengthong, K. Safety of Paediatric Percutaneous Native Kidney Biopsy and Factors Predicting Bleeding Complications. Nephrology 19, 143–148 (2014).

Article PubMed Google Scholar

Gupta, A. et al. Positive Trends in Paediatric Renal Biopsy Service Provision in the Uk: A National Survey and Re-Audit of Paediatric Renal Biopsy Practice. Pediatr. Nephrol. 31, 613–621 (2016).

Article PubMed Google Scholar

Kanzaki, G. et al. Distribution of Glomerular Density in Different Cortical Zones of the Human Kidney. Pathol. Int. 63, 169–175 (2013).

Article PubMed Google Scholar

Hoy, W. E. et al. A Stereological Study of Glomerular Number and Volume: Preliminary Findings in a Multiracial Study of Kidneys at Autopsy. Kidney Int. Suppl., 83, S31-S37 (2003).

Denic, A. et al. The Substantial Loss of Nephrons in Healthy Human Kidneys with Aging. J. Am. Soc. Nephrol. 28, 313–320 (2017).

Article PubMed Google Scholar

Samuel, T., Hoy, W. E., Douglas-Denton, R., Hughson, M. D. & Bertram, J. F. Determinants of Glomerular Volume in Different Cortical Zones of the Human Kidney. J. Am. Soc. Nephrol. 16, 3102–3109 (2005).

Article PubMed Google Scholar

Newbold, K. M., Sandison, A. & Howie, A. J. Comparison of Size of Juxtamedullary and Outer Cortical Glomeruli in Normal Adult Kidney. Virchows Arch. A Pathol. Anat. Histopathol. 420, 127–129 (1992).

Article CAS PubMed Google Scholar

Kremers, W. K. et al. Distinguishing Age-Related from Disease-Related Glomerulosclerosis on Kidney Biopsy: The Aging Kidney Anatomy Study. Nephrol. Dial. Transpl. 30, 2034–2039 (2015).

Article Google Scholar

Sawicka, K. et al. Direction of the Biopsy Needle in Ultrasound-Guided Renal Biopsy Impacts Specimen Adequacy and Risk of Bleeding. Can. Assoc. Radio. J. 70, 361–366 (2019).

Article Google Scholar

Corapi, K. M., Chen, J. L., Balk, E. M. & Gordon, C. E. Bleeding Complications of Native Kidney Biopsy: A Systematic Review and Meta-Analysis. Am. J. Kidney Dis. 60, 62–73 (2012).

Article PubMed Google Scholar

Montes, D., Beamish, C., Waheed, S., Osman, F. & Maursetter, L. What Happens after the Kidney Biopsy? The Findings Nephrologists Should Know. BMC Nephrol. 23, 265 (2022).

Article PubMed PubMed Central Google Scholar

Evan, A. P., Connors, B. A., Lingeman, J. E., Blomgren, P. & Willis, L. R. Branching Patterns of the Renal Artery of the Pig. Anat. Rec. 246, 217–223 (1996).

3.0.CO;2-Y" data-track-item_id="10.1002/(SICI)1097-0185(199610)246:23.0.CO;2-Y" data-track-value="article reference" data-track-action="article reference" href="https://doi.org/10.1002%2F%28SICI%291097-0185%28199610%29246%3A2%3C217%3A%3AAID-AR8%3E3.0.CO%3B2-Y" aria-label="Article reference 20" data-doi="10.1002/(SICI)1097-0185(199610)246:23.0.CO;2-Y">Article CAS PubMed Google Scholar

Prasad, N. et al. Comparison of Yield and Complications of Craniocaudal Versus Caudocranial Needle Trajectory for Kidney Biopsy. J. Vasc. Access 21, 73–78 (2020).

Article PubMed Google Scholar

Jaturapisanukul, S. et al. Cranial Versus Caudal Direction Technique of Native Percutaneous Kidney Biopsy: A Randomized Controlled Trial. Int J. Nephrol. Renovasc Dis. 16, 93–101 (2023).

Article CAS PubMed PubMed Central Google Scholar

Gjerstad, A. C. et al. Kidney Biopsy Diagnosis in Childhood in the Norwegian Kidney Biopsy Registry and the Long-Term Risk of Kidney Replacement Therapy: A 25-Year Follow-Up. Pediatr. Nephrol. 38, 1249–1256 (2023).

Article PubMed Google Scholar

Fujita, N. et al. Ultrasonographic Reference Values and a Simple yet Practical Formula for Estimating Average Kidney Length in Japanese Children. Clin. Exp. Nephrol. 26, 808–818 (2022).

Article PubMed PubMed Central Google Scholar

Ubara, Y. et al. Kidney Biopsy Guidebook 2020 in Japan. Clin. Exp. Nephrol. 25, 325–364 (2021).

Article PubMed PubMed Central Google Scholar

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This work was supported by a Japan Society for the Promotion of Science Grant-in-Aid for Scientific Research (C Grant Number JP 22K07875).

Department of Pediatrics, Teikyo University School of Medicine, Tokyo, Japan

Tomohiko Nishino, Sakurako Hirano, Shin Takemura, Shinya Tomori, Sayaka Ono, Kazuhiro Takahashi & Masakazu Mimaki

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All authors contributed to the conception and design of this study. Tomohiko Nishino: Drafted the manuscript and performed the data collection, statistical analysis, and material preparation. Sakurako Hirano, Shin Takemura, Shinya Tomori, Sayaka Ono, and Kazuhiro Takahashi collected the data and critically reviewed the manuscript. Masakazu Mimaki: Supervised this study. All the authors have read and approved the final manuscript.

Correspondence to Tomohiko Nishino.

The authors declare no competing interests.

This study did not require ethical approval from the Teikyo University School of Medicine Animal Ethics Committee due to the uniqueness of the specimens handled. Nevertheless, all authors respected the piglets, and all procedures were conducted following the ethical standards of the Institutional and/or National Research Committee, the International Guiding Principles for Biomedical Research Involving Animals (1985), The Protection of Animals Used for Experimental and Other Scientific Purposes (1986), and their subsequent amendments or comparable ethical standards.

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Nishino, T., Hirano, S., Takemura, S. et al. Puncture approaches for ultrasound-guided kidney biopsy specimens: a pediatric model study using piglet kidneys. Pediatr Res (2025). https://doi.org/10.1038/s41390-025-03956-8

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Received: 17 February 2024

Revised: 18 November 2024

Accepted: 16 February 2025

Published: 04 March 2025

DOI: https://doi.org/10.1038/s41390-025-03956-8

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