Dividing Renal Biopsies: Instructions for Residents After hours/ on Weekend Call
IF6.04 / Version #8
Department of Renal and IF Laboratory
Current Written By:
Gyongyi Nadasdy
Original Date Adopted:
2005
Supersedes Document #:
New
New or revised documents must be signed by Medical
Director and authorized Division Director
IF6.04/07
Signature: Original in Renal IF Procedure
Manual Starling Loving Hall
A044___________
Date Approved: 11/21/2011
Division Director: Dr. Tibor Nadasdy
New:
Date Approved: 11/22/2011
Medical Director: Dr. Amy Gewirtz
Revised:
Date Approved:
Medical Director:
Date Approved:
Medical Director:
Date Reviewed: 12/27/2012
DR. Tibor Nadasdy
Date Reviewed: 4/29/13
Medical Director- NY: JoAnna Williams MD.
Date Reviewed: 4/30/13
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Medical Director: Daniel Sedmak MD.
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New Medical
Director
Effective:2/11/13
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Effective Date:12/1/2011
DATE PRINTED: 2/17/16
Do not print copies from the I Drive for prolonged use at the work area.
Page 1 of 6
Dividing Renal Biopsies: Instructions for Residents After hours/ on Weekend Call
IF6.04 / Version #8
Department of Renal and IF Laboratory
Annual Review
1.
Date Reviewed:
PRINCIPLE
1.1 Renal biopsies, either from native or transplant kidneys, submitted to Surgical Pathology after
work hours or during the weekend for which light microscopy (LM), immunofluorescent staining
(IF), and/or electron microscopy (EM) have been requested may need to be processed.
1.2 Renal biopsies are preserved in three different ways in order to achieve the best results for all
three diagnostic methods; Light microscopy (LM), Immunofluorescence (IF), Electron microscopy
(EM) that are employed in native or transplant renal biopsy diagnostic testing. After procuring the
biopsies and ensuring the presence of cortical tissue, the samples are divided and appropriately
preserved in order to allow the application of a wide range of diagnostic methods.
Renal biopsy specimens are divided and submitted in the following order of priority:
1.
LM (largest piece, should contain > 20 glomeruli).
2.
IF (>5 glomeruli).
3.
EM (>2 glomeruli).
As a general rule, approximately 70% of the cortical portion of the biopsy should go to LM, 20%
to IF and 10% for EM. The actual size and proportion of samples will depend on the amount of
tissue and glomeruli available and the clinical history. If the sample is small, the renal pathologist
on call should be contacted for further instructions.
1.3 Points to remember:
1.3.a The resident on call contacts the renal pathologist on service when renal biopsy
is received.
1.3.b Never use forceps
1.3.c At no time during biopsy processing, should the specimen be allowed
to dry out, or be placed on dry paper or gauze. Doing so will
compromise specimen integrity.
2.
SPECIMEN COLLECTION
2.1
2.2
2.3
3.
The specimen, if it is fresh, should be received in saline-soaked gauze,
If the specimen was pre-divided by the submitting nephrologist, it is received in formalin
and tissue transport medium (Zeus)
The accompanying paperwork should indicate the following:
2.3.1. Type of kidney biopsied (native or transplant).
2.3.2. Clinical history
2.3.3. Signature of the requesting physician
REAGENTS/SUPPLYES:
3.1 Supplies
Most of these are found in the Surgical Pathology gross room dissecting microscope area, E-415
Doan Hall.
Effective Date:12/1/2011
DATE PRINTED: 2/17/16
Do not print copies from the I Drive for prolonged use at the work area.
Page 2 of 6
Dividing Renal Biopsies: Instructions for Residents After hours/ on Weekend Call
IF6.04 / Version #8
Department of Renal and IF Laboratory
3.1.1.Scalpel blade
3.1.2. Glass slide
3.1.3. Wooden applicator
3.1.4. Renal Biopsy dictation sheet
3.1.5. Cassette
3.1.6. Gloves, aprons, eye protection
3.2. Reagents
3.2.1. Vial of Zeus Scientific Tissue Fixative or tissue holding medium stored in the Gross room
white refrigerator supplied by the IF laboratory (293-9258).
3.2.2. 10% neutral buffered formalin
3.2.3. “Mopec” bench spray and wipe for disinfection of the work area.
4.
SPECIAL SAFETY PRECAUTION
4.1 Always wear gloves, eye protection and protective clothing when working with the specimen.
5.
CALIBRATION, PROGRAMING, MAINTENANCE
N/A
6.
PROCEDURE
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
The Surgical Pathology Resident on-call is contacted when a kidney biopsy needs to be
processed on the weekend. For in-house cases usually the nephrologists or transplant
surgeon initiates the request. For outside cases the renal pathologist on-call will contact
the resident on-call.
If rush processing is requested, the resident on call contacts the renal pathologist on
service.
As a general rule, the guidelines below are to be followed, when triaging a renal
biopsy. Histology processes the formalin fixed portion and generates 2 HE slides. If
IF is needed to establish the diagnosis, the renal pathologist on service will tell the
resident to contact the IF technician on-call.
With the help of this list please decide which diagnostic methods are necessary.
6.3.1. Native kidney: LM, IF and EM.
6.3.2. Transplant kidney treated as native (included are cases transplanted more than a
year ago or the clinical history suggests recurrent or de novo glomerular disease): LM, IF
(full IF panel and C4d) and EM.
6.3.3. Transplant kidney: LM and IF (C4d only).
6.3.4. Transplant kidney, baseline does not need triaging.
Accession in the CoPath system all in house cases, however outside cases are processed
with the patient’s name.
Following the renal pathologist’s instructions, decide which fixatives you will need
(formalin for light Tissue transport medium for IF and 10% Formalin for EM)
Gather all supplies and reagents, use gloves and gowns and eye protection.
Label all containers with patient’s name and surgical number.
For specimens received in saline or saline soaked gauge: Very gently use a wooden
application stick to handle the specimen. Make sure that no exposure to any fixative
occurs at this stage. [Never use forceps and always keep the tissue wet.]
Effective Date:12/1/2011
DATE PRINTED: 2/17/16
Do not print copies from the I Drive for prolonged use at the work area.
Page 3 of 6
Dividing Renal Biopsies: Instructions for Residents After hours/ on Weekend Call
IF6.04 / Version #8
Department of Renal and IF Laboratory
6.9
6.10
6.11
6.12
6.13
6.14
6.15
Examine tissue under the stereo microscope (located in the frozen section area) and
identify glomeruli. Triage the biopsy under the stereo microscope with the specimen
immersed in a drop of 0.9% saline on a glass slide. If there is enough tissue for all three
studies, the first priority [the more time the tissue is in saline the less detailed the EM will
be] is to cut a piece for EM; a 10% Formalin is used. Plastic vials with the white stopper
are located by the dissecting scope. Attach a copy of the requisition slip to the vial and
place the specimen into the EM box in the gross room refrigerator.
If there are two or more cores with glomeruli, place one piece in 10% buffered formalin
for LM and the second piece is divided for IF and EM.
The tissue for IF needs to be placed in Zeus tissue transport medium (tissue holding
medium vials are in the gross room refrigerator glass vial with black stopper). Attach a
copy of the requisition slip to the vial and place the specimen into the IF bucket on the
cart between the tissue procurement area and grossing stations.
If the specimen is too small (only one core with some cortex) discuss the triaging with
the renal pathologist on service.
The piece for light microscopy should be wrapped in wet lens paper and placed in the
prelabeled lilac (for native) or tan (for transplant) cassette. The cassette has to be
placed in a formalin filled container immediately.
In case the specimen was received already divided into two containers Formalin and
Tissue holding medium resident should examine the pieces in their respective fixative
being conscientious about not cross contaminating. Always take the piece for EM from
the formalin fixed tissue.
Clean up the work area after you finished with the biopsy triaging.
Kidney Biopsy undivided (renal cores black arrows; soft tissue black arrowheads)
Effective Date:12/1/2011
DATE PRINTED: 2/17/16
Do not print copies from the I Drive for prolonged use at the work area.
Page 4 of 6
Dividing Renal Biopsies: Instructions for Residents After hours/ on Weekend Call
IF6.04 / Version #8
Department of Renal and IF Laboratory
Kidney biopsy divided (Tissue for light microscopy black arrows; tissue for EM
arrowhead; tissue for IF long black arrow)
Glomeruli in renal cortex (4x)
Glomeruli in renal cortex (4x)
6.16
6.17
6.18
While triaging the biopsy, complete the gross dictation sheet (located in the frozen
section area). After you finish with the triaging, time stamp the gross sheet.
A copy of the original paperwork is left in the accessioners’ area with a note explaining
the specimen. The original paperwork and the “Same-Day Stat Biopsy Custody Sheet”
are delivered to the histotechnologist together with the biopsy, if it is a stat case. During
week days a biopsy is received after 5 PM, the resident on-call should put the casette with
the biopsy in the “short” bucket.
Contact the histotechnologist and if needed the IF technician on-call to ensure immediate
processing. Please do not batch rush kidney/transplant biopsies during the weekend, even
if a nephrology/transplant fellow or faculty tells you that there will be another biopsy
within an hour or so. It is very common that the second biopsy will be delayed and it is
not unusual that the biopsy will be cancelled. Therefore, waiting for the second biopsy
can unnecessarily delay the urgent diagnosis on the first one. Tell the histotechnologist
on call to process the biopsy ASAP
Effective Date:12/1/2011
DATE PRINTED: 2/17/16
Do not print copies from the I Drive for prolonged use at the work area.
Page 5 of 6
Dividing Renal Biopsies: Instructions for Residents After hours/ on Weekend Call
IF6.04 / Version #8
Department of Renal and IF Laboratory
6.19 Pager numbers:
Renal biopsy attending: 346-2982
Histotechnologist on-call: 303-8821
IF technician: 346-4190
7.
QUALITY CONTROL N/A
8.
9.
10.
11.
12.
CALCULATION N/A
REPORTING RESULTS: N/A.
INTERPRETATION OF RESULTS: N/A.
LIMITATION OF PROCEDURE: N/A
REFERENCES
Procedure developed in-house.
Effective Date:12/1/2011
DATE PRINTED: 2/17/16
Do not print copies from the I Drive for prolonged use at the work area.
Page 6 of 6