Transjugular renal biopsy: our experience and technical considerations.

The purpose of this study was to describe the indications for and technique of transjugular renal biopsy (TJRB) and evaluate the efficacy and complications of this method. We performed a retrospective review of 59 patients who underwent TJRB using the Quick-core needle biopsy system (Cook, Letchworth, UK) over a 4-year period. The indications for obtaining renal biopsy included acute renal failure, chronic renal failure, nephrotic syndrome, and proteinuria with or without other associated disease. Indications for the transjugular approach included coagulopathy, biopsy of a solitary kidney or essentially single functioning kidney, simultaneous renal and hepatic biopsy, morbid obesity, and failed percutaneous biopsy. All but four cases were performed via the right internal jugular vein. The right, left, or both renal veins were cannulated in 41, 14, and 4 cases, respectively. Combined liver and renal biopsies were obtained in seven cases. Diagnostic biopsy specimens were obtained in 56 of 59 patients (95%). The number and size of tissue cores ranged from 1 to 9 mm and from 1 to 20 mm, respectively. The mean numbers of glomeruli per procedure on light microscopy and electron microscopy were 10.3 and 2.6, respectively. Specimens for immunohistology were acquired in 49 cases, of which 40 were adequate. Of the 56 successful TJRB procedures, 34 (61%) were associated with isolated capsular perforation (19), contained subcapsular leak (10), isolated collecting system puncture (1), and concurrent collecting system and capsular perforation (4). There was a significant increase in capsular perforation with six or more needle passes, although no significant correlation was seen between number of needle passes and complication. Six patients had minor complications defined as hematuria or loin pain. Seven patients developed major complications, of whom five received blood transfusion alone. Two required intervention: in one an arteriocalyceal fistula was embolized and the patient was temporarily dialyzed; the remaining patient required ureteric stenting. In conclusion, TJRB provides an adequate yield for diagnosis. Complication rates are relatively high, but patients are also at high risk from the conventional percutaneous approach. Patient selection and optimization are critical to avoid major complications.

Natural history of hepatic sarcoidosis and its response to treatment.

BACKGROUND: Liver involvement in sarcoidosis is variable and can occur in the absence of pulmonary disease. Data on the natural history of hepatic sarcoid and response to therapy are lacking. This study investigates hepatic dysfunction complicating lung disease and significant liver involvement presenting independent of pulmonary sarcoid. PATIENTS AND METHODS: One hundred and eighty patients were included in the study. The minimum follow-up was 2 years. RESULTS: Fifty per cent of the study population had derangement of liver function attributable to hepatic sarcoid. Twenty-three patients (13%) had liver involvement without lung disease. Sixty-three patients were administered corticosteroids; approximately one-third had a complete clinical response, one-third a partial response and one-third showed no response. Fourteen patients (8%) were cirrhotic at presentation, and two progressed to cirrhosis despite steroid therapy. Sixteen patients received a second-line immunosuppressive agent; one-half of these showed a response to treatment augmentation (four patients azathioprine, three patients methotrexate, one patient both drugs). Six patients required liver transplantation, with disease recurrence in one recipient. In four patients, sarcoid as the aetiology of end-stage liver disease was diagnosed only on examination of the explanted liver. CONCLUSION: Sarcoidosis can cause end-stage chronic liver disease, which is often unrecognized until examination of the explanted liver. Response to conventional immunosuppression is variable and unpredictable. Transplantation is feasible and safe in this population but recurrence is possible.