Endoscopy 2022; 54(06): E285-E286
DOI: 10.1055/a-1519-6365
E-Videos

Endoscopic ultrasound-guided renal biopsy: an alternative to transjugular renal biopsy in high-risk patients

Sridhar Sundaram
1   Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
,
Prachi Patil
1   Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
,
Aadish Jain
1   Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
,
Utkarsh Chhanchure
1   Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
,
Suman Kumar Ankathi
1   Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
,
Shaila Khubchandani
2   Department of Pathology, Jaslok Hospital, Mumbai, India
,
Shaesta Mehta
1   Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
› Author Affiliations
 

A 32-year-old man with hepatocellular cancer who had undergone right hepatectomy 2 years previously presented with facial puffiness and abdominal distension. Ultrasound showed moderate ascites with normal kidneys. Serum albumin was 2.8 g/dL, hemoglobin 8.4 g/dL, platelet count 74 000/μL, and creatinine 1.7 mg/dL. Urine examination showed 3 + proteinuria and 3 + hematuria, while 24-hour urinary protein was 3030 mg/dL. Transjugular renal biopsy (TJRB) was advised after nephrology consultation, due to the ascites with thrombocytopenia, but the patient was not willing to undergo this procedure. Hence, endoscopic ultrasound (EUS)-guided biopsy with a linear echoendoscope (GIF UCT180; Olympus, Tokyo, Japan) was planned.

Examination revealed significant ascites with interbowel fluid ([Fig. 1]). The left kidney was sampled via a transgastric approach, as the patient’s surgically altered anatomy made scope positioning in the duodenal bulb precarious. A 22G Acquire needle (Boston Scientific, USA) was used to target the cortex of the lower pole of the left kidney, avoiding major medullary vessels. Two passes were made with three actuations each, with a slow-stylet pull-through ([Fig. 2]; [Video 1]). A 2.7 × 1.6 cm subcapsular hematoma was seen ([Fig. 3]). On visualization up to 10 minutes, no increase in the size of the hematoma could be seen. Ultrasound 12 hours after the procedure still revealed no increase in the hematoma. A 20-mm core was sent for histopathologic analysis and immunofluorescence studies ([Fig. 4]). The diagnosis of focal segmental glomerulosclerosis was confirmed ([Fig. 5]).

Zoom Image
Fig. 1 Endoscopic ultrasonography showing interbowel fluid.
Zoom Image
Fig. 2 Endoscopic ultrasound-guided fine-needle biopsy (FNB) taken from lower pole of left kidney.

Video 1 Endoscopic ultrasound-guided kidney biopsy from the lower pole of the left kidney for evaluation of nephrotic syndrome.


Quality:
Zoom Image
Fig. 3 Subcapsular hematoma in the lower pole of the left kidney, 27 × 17 mm in size.
Zoom Image
Fig. 4 Core specimen (arrow) obtained with a 22G FNB needle.
Zoom Image
Fig. 5 Histopathologic analysis revealed a sclerosed glomerulus with mesangial widening with fibrosis in the interstitium, suggestive of focal segmental glomerulosclerosis.

TJRB is the alternative to percutaneous biopsy in high-risk patients with ascites and thrombocytopenia [1]. EUS-guided fine-needle aspiration cytology of renal masses has been described in case series [2] [3], but sampling for primary diagnosis of nephrotic syndrome has not been described. Unlike in EUS liver biopsy, where a 19G needle is used [4], in our case a 22G needle was used to reduce risk of bleeding. We were able to achieve an optimal sample for diagnosis using EUS, while avoiding radiation exposure and the use of contrast in a patient with compromised renal function.

Endoscopy_UCTN_Code_CCL_1AF_2AF_3AD

Endoscopy E-Videos
https://eref.thieme.de/e-videos

Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos


#

Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Sridhar Sundaram, MD, DM
Department of Digestive Diseases and Clinical Nutrition
Tata Memorial Hospital
Dr. E. Borges Road
Parel
Mumbai
Maharashtra 400012
India   

Publication History

Article published online:
02 July 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Endoscopic ultrasonography showing interbowel fluid.
Zoom Image
Fig. 2 Endoscopic ultrasound-guided fine-needle biopsy (FNB) taken from lower pole of left kidney.
Zoom Image
Fig. 3 Subcapsular hematoma in the lower pole of the left kidney, 27 × 17 mm in size.
Zoom Image
Fig. 4 Core specimen (arrow) obtained with a 22G FNB needle.
Zoom Image
Fig. 5 Histopathologic analysis revealed a sclerosed glomerulus with mesangial widening with fibrosis in the interstitium, suggestive of focal segmental glomerulosclerosis.