Once hypertension is controlled, renal biopsy may be the sole criterion for datermining Afther the problem is due to pure hypertension

kldney are not small and shrunken, biopsy e useful In detarmining the cause and prognosis. Certain forms of nephritis (e.g. focal glomerulosclerosis and mesangocapillary glomerulonaphritis) recur in transplant, and it is helpful to know this or futures management 8. Special situations - (a) Uncontrolled hypertension may lead to renal impairment, hematuria and protainuria. and this may occasionaly result in nephrotic syndrome. Once hypertension is controlled, renal biopsy may be the sole criterion for datermining Afther the problem is due to pure hypertension or underlying nephritis, (b) In 1O-20% of patients with diabetes melltue. proteinuria and impaired renal function may be due to causes other man diabetic nephrosclerosis, particularly In Those with no other evidence of microvascular disease e.g. diabetic raimopathy. 9 .Renal allograft dysfunction - (a) it provides only reliable method of distinguishing rejection from cyclosporin nephrotoxicity. (b). it helps in daciding the scale of antirejection therapy and differinting allograft nephropathy form recurrent or de novo nephritis. Contraindications - 1 Single kidney or severe malfunction of one kidney. 2. Urgent reliable bleedng diathasis. 3. Small, shrunken kidneys (dificult to locate and information obialned usually nonspecitic). 4 .Presence of cystic diseaes. nephrolathiasis, reflux nephropathy or obstruction or hemangloma. Technique - Localization of the kidney- Lateral border of lower pale ol kidney &the sales part to biopsy. Ultrasound is the preferred imaging technique to mark, tne posltion of the kidney. it is particularly preferred in paitens with impaired function as it avoid use of contrast media (as inIVU) Attachments are available for ultrasound probes which can precisely dlract the needle tothe kidney Biopsy needle - (a) Franklin-modified Vim Sllverman needle (b) Tru-Cut needle are diposable needing and not composed of diffrent parts. (c) .Biopsy gun is a spring-loaded device which Shoots' a variant at 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) 'Fixing' the kidney - so that It does not move significantiy with patient respirations Patient upper abdomen and lower chest should be aupportedd by pillows so adjusted that patients daphragm welI splinted. (c) Sedation -with IV dazepam to produce deep sleep (d) Position ot lower pole of the kidney as determined by ultrasound is marked on the skin and depth of tne kidney measured (e) Biopsy then perfomed Enough Tissue must be taken for light microacopy, elactron microscopy, Imimuno-fluoregcance or imrrxirtopercxidaae tschnlquBS and, IE appropriate for cutlure Biopsy of transplanted kidney - The allograft may be easily palpable in tht iliac fosaa but it should be localised by ultrasound alrring for the lateral border of upper pole Since transplanted kidhey often becomes encased in fibrous issue, this must be penatrated before biopsy is taken If it is not, cutting prongs of a modfied Vim Silverman needs or cutting tip of a Tru-Cut disposable needle may 'bounce' off tne kidney and lacerate it, causing hemorrhage Fine-neede aspiration biopsy (FNAB) - is used in daignosis of renal transplant dysfunction It is less traumatic and analigesa and sedation are normally unnecessary FNAB can diagnose acute cellular reaction, but not early vascular rejaction Also it is not poasibfe to judge aeverfly of allograft damage in order to determine the nature and dose of antirajection therapy Complilcation COMMON -(a)Bleeding is most common complication (b) Artero-venous fistula with in the kidney It can cause bleeding Treatment - Bleeding can be controled with bed rest and transfusion if necessary Identification and control of bleeding point ol A-V llstula by transdermal percutaneous arteriography followed by embolization UNCOMMON -(a) Pneurrcthnra- (b) llaus (c)Lacertion of liver, spleen, mesenteruic artery and bowel. 2. HEMATURIA Causes - 1. In the urinary tract - Kidney - 1. Congenital anomalies. Polycystic disease, anglorna .2. Calculus .3. Mobile kidney .4. Infections - Pyelonephritis. tuberculasis, glomerulonephrltis. 5. neoplasme -Renal carcinoma, wilms tumour. 6. Drugs - Sulphonamied. anticoagulants. 7. Trauma - Ruptured kidney. 9. Oxalurla. 9 Posl-oparative .After naphro or pyelolithotomy or partial nephroiclamy 10 Radation damage 11 Heradrtary nephrite - Airporlfe syndrome, farrtllal recurreni haernaiurla 12 Renal errbollzatfen/infaictlon 13 Analgesic nephropathy 14 Unknown origin -Essential haamaluna 1'renal apblajds"). Loin pain/haemalur[a: syn^ome Urater - (1J Trauma. (2J Calculi (3) Infection (4) Tumours - paplPoma. carcinoma Prostate - Benign hypertrophy, carcinoma Bladder - [1) Dlvertlculum (2)Trauma -following prostatectomy or other operations or Instrumental (3) Calculus or (orejgn body (4) Tuberculosis (5) Tumoura - Simple, papilloma, carcinoma. (6). Ulcers. (7). Chemical cysistis - e.g. after cylophosphamide (8)Parasitic-Schistosomiasis, Bancroftian filariasis Urethra - (1) Malformationgs.(2) lnjuries. (3). Calculus or foreign bady. (4) infectioin .(5) Tumours. (6) Naevus 2. Systemic causes -1 Bleeding dathasis. 2. Collagen disorders - SLE, PAN .3. Subacute Infective endocarditis 4.