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Uses of kidney biopsy in undiagnosed kidney disease
In which clinical settings is a kidney biopsy most useful as an aid in the evaluation and management of a patient with undiagnosed kidney disease?
Acute Kidney Injury (AKI)
A kidney biopsy is recommended when a patient has unexplained AKI that does not improve with supportive therapy.
Prerenal disease, acute tubular necrosis, and obstruction must be ruled out, as these can be diagnosed based on clinical history.
Nephrotic Syndrome
Adults with evidence of nephrotic syndrome with no apparent underlying cause should undergo a kidney biopsy.
Children with nephrotic syndrome are presumed to have minimal change disease and are treated empirically with steroids.
A kidney biopsy is reserved for children with atypical features, including steroid resistance, hematuria, or kidney impairment.
Systemic Disease
Patients with vasculitis, systemic lupus erythematous, and viral infection-related nephropathy often require a kidney biopsy.
Information is important in not only confirming a diagnosis but also in dictating further therapy based on the extent of active or chronic changes.
In patients diagnosed with diabetes mellitus with kidney dysfunction, a kidney biopsy is sometimes suggested in the presence of features inconsistent with diabetic nephropathy, such as rapid progression or persistent hematuria.
Additionally, a kidney biopsy is often recommended in the setting of various dysproteinemias when information would change the management strategy.
Hematuria
In patients with isolated microscopic hematuria, urologic causes must first be excluded.
Patients with persistent non-urologic microscopic hematuria with proteinuria and/or kidney insufficiency often require a kidney biopsy for diagnostic and therapeutic purposes.
In contrast, a kidney biopsy is usually not required in isolated microscopic non-urologic hematuria without kidney insufficiency, hypertension, or proteinuria.
One may consider a kidney biopsy with microscopic hematuria and unique circumstances, such as in the evaluation of potential living kidney donors, life insurance, or employment purposes.
Transplant Allograft
Kidney biopsy is used in transplant kidney recipients who develop hematuria, proteinuria, or kidney transplant dysfunction to differentiate between the various forms of rejection versus other causes of kidney failure.
Chronic Kidney Disease
A kidney biopsy may be useful in prognostication for patients with unexplained chronic kidney disease and normal-sized kidneys on imaging.
