Kidney biopsy adequacy and complications in children - does technique matter?

Kidney biopsy is part of the diagnostic workup of many children with renal disease. Traditionally, a perpendicular approach to the biopsy has been used, but more recently, some proceduralists have favoured a tangential approach. It is not clear if one technique is superior with regards to tissue adequacy or complication rates. In our centre, interventional radiologists (IR) use general anaesthetic and a tangential approach, whereas paediatric nephrologists (PN) use sedation and a perpendicular approach. We examined consecutive native kidney biopsies performed between January 2008 and December 2017 for adequacy (sufficient tissue for light and electron microscopy and immunofluorescence) and examined the electronic medical records for data regarding technique and complications. IR performed 72 (29%) of the 245 native kidney biopsies, obtaining more total glomeruli (median 39 vs 16, p < 0.001) and more glomeruli per tissue core (median 13 vs 8, p < 0.001) than PN. No differences in specimen adequacy were observed between the two groups (79% IR vs 81% PN, p = 0.75) and a diagnosis could be made in 99% and 94% respectively (p = 0.1). A statistically lower rate of peri-nephric haematoma (28% vs 42%, p = 0.04) was detected in the IR group, but there were no significant differences in other complications. One patient required a blood transfusion (PN) and another required surgical intervention for a perinephric haematoma (IR). CONCLUSION: IR obtained larger samples and number of glomeruli, but the overall adequacy for native kidney biopsies was good using both perpendicular and tangential techniques, with low rates of significant complications. WHAT IS KNOWN: • Kidney biopsy is integral to the diagnostic work-up of many children with kidney disease. • Kidney biopsy is a safe procedure with well-established complications in a minority of children. WHAT IS NEW: • Interventional radiologists had higher biopsy yield than paediatric nephrologists, possibly due to the tangential approach. • Biopsy adequacy rates are high using both techniques and provided a diagnosis in over 95% of cases.

Rural hospital bed management practices during influenza season.

INTRODUCTION: Rural health services face greater challenges in managing infectious patients due to lack of specialty beds and longer lengths of stay. The pressures of seasonal influxes of influenza patients with a heavy burden of chronic disease and an ageing population result in an increased demand for hospital beds. During these peak periods it is common for rural hospitals to experience bed block. The result is that patients may be placed into any available bed or ward at the time, increasing the need for transfer and the risk of spreading hospital-acquired respiratory illnesses to other patients and staff across the hospital. This further exacerbates bed block, with patients then requiring more specialised treatment and longer lengths of stay. This places additional strain on already existing workforce shortages and limited resources that must accommodate higher-than-normal patient loads. The objective of this study was to examine rural hospital bed management practices with a focus on the transfer of patients who are actively diagnosed with influenza (either on admission or during their stay in hospital) and to investigate the association of increased bed movement with the rate of nosocomial transmission and staff workload. METHODS: The rates of patients admitted to a rural hospital in New South Wales, Australia, during the yearly peak influenza season (July to September) during 2016-2019 with either community-acquired or hospital-acquired influenza were examined using an infection control surveillance program. Bed management practices related to these inpatients were audited to examine their contribution towards nosocomial transmissions and staff workload during these periods. RESULTS: A total of 229 patients presented to this hospital with an influenza diagnosis over the study period and generated 175 bed transfers. Forty percent of community-acquired and 70% of hospital-acquired influenza inpatients experienced one or more intrahospital bed transfers during their active infection period. Half of all bed transfers involved patients being transferred to another ward (interward) and the other half consisted of those transferred within the same ward (intraward). These transfers impacted staff workload, requiring a total of 245 extra hours from nursing and cleaning staff to facilitate - time not included when allocating staff at the start of each shift. CONCLUSION: Findings from this study indicate that there is no active strategy for influenza containment during high-occupancy periods for this rural facility. This resulted in multiple bed transfers occurring during the active phase of influenza infection. This then led to an exacerbation of bed block and thus further inappropriate placement of newly admitted patients. The development of an optimal bed management plan for future surges of influenza and other highly infectious respiratory illnesses is essential to reduce nosocomial infection and staff workload, especially given the limited resources available in rural areas compared to metropolitan centres.