# Chapter 24: Renal Procedures

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## Chapter 24: Renal Procedures

### Kidney Biopsy

#### Indications

Kidney biopsy provides essential diagnostic and prognostic information for many glomerular diseases and unexplained kidney dysfunction. It is crucial for guiding specific immunosuppressive therapy.

#### Common Indications for Kidney Biopsy

- Nephrotic syndrome in adults
- Nephritic syndrome with reduced GFR
- Unexplained AKI or rapidly progressive glomerulonephritis (RPGN)
- Systemic disease with evidence of kidney involvement (e.g., lupus)
- Kidney transplant dysfunction or surveillance

#### Contraindications

#### Key Contraindications

- Uncorrectable bleeding disorder or coagulopathy
- Uncontrolled severe hypertension
- Single functioning native kidney (relative contraindication)
- Multiple bilateral cysts or small, end-stage kidneys
- Active urinary tract or perinephric infection

#### Procedure and Complications

Percutaneous kidney biopsy is typically performed using real-time ultrasound guidance with the patient in the prone position. After local anesthesia, a spring-loaded biopsy gun is used to obtain core specimens from the lower pole of the kidney. Post-procedure care involves several hours of bed rest and monitoring for complications, the most common of which is bleeding (perirenal hematoma or gross hematuria).

### Vascular Access for Hemodialysis

Timely planning for durable hemodialysis access is critical for patients progressing towards ESRD.

#### The "Fistula First" Initiative

The preferred order of vascular access is: **Arteriovenous Fistula (AVF) \> Arteriovenous Graft (AVG) \> Central Venous Catheter (CVC)**. This hierarchy is based on longevity and complication rates (thrombosis and infection).

- **Arteriovenous Fistula (AVF):** A direct surgical connection between an artery and a vein. It is the gold standard, offering the best long-term patency and lowest infection rates, but requires 2-3 months to mature.
- **Arteriovenous Graft (AVG):** A synthetic tube connects an artery and vein. It can be used sooner (2-3 weeks) but has higher rates of thrombosis and infection.
- **Central Venous Catheter (CVC):** A catheter placed into a large central vein. It provides immediate access but has the highest risk of infection and central venous stenosis. It should be considered a temporary bridge to permanent access whenever possible.

### Peritoneal Dialysis (PD) Catheter Placement

A soft, flexible catheter is surgically placed into the peritoneal cavity. Proper catheter tip positioning in the pelvis is essential for optimal drainage. After placement, a "break-in" period of at least 2 weeks is typically required to allow the exit site to heal before full-volume exchanges are started.

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