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Last updated: Lesson of the Month - October 2017…
on 17 Oct 2017

History Of Renal Biopsy

The history of the renal biopsy is very interesting. It is difficult to state who did the first biopsy, as this depends on how you define a biopsy (eg open, closed) and/or why you are doing it (eg as part of another procedure, or as a goal in itself)

History (Middle Ages)

Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi, an Arab physician, surgeon and pharmacist, was first to describe thyroidectomy for goitre and to perform a needle biopsy (of the thyroid)

He was known in the West as Albucasis or Zahravius (936-1013); and was born in 936 AD in Al-Zahra', a suburb, six miles northwest of Cordoba, the capital of Muslim Spain (Al-Andalus). His ancestors were from the Al Ansar tribes of Al Madina Al Munawwarah who came from the Arabian peninsula with the Muslim armies which conquered and lived in Spain. Al-Zahrawi travelled rarely, and spent most of his life in his hometown

He served as the court physician to Caliph Al ­Hakam-II, at a period considered as the "Golden Age" of Arab Spain when natural and mathematical sciences reached their peak. After a long and distinguished medical career, he died in 1013 AD at the age of 77

Around the year 1000 AD, he wrote his famous book 'Al Tasreef Liman 'Ajaz 'Aan Al-Taleef (or 'al-Tasreef') ('The Clearance of Medical Science for Those Who Can Not Compile It' or 'An Aid for Those Who Lack the Capacity to Read Big Books'). It was a summation of about fifty years of medical education, training, practice and experience. The thirty volumes of the medical encyclopedia covered various aspects of medical knowledge. In addition to sections on medicine and surgery, there were sections on midwifery, pharmacology, therapeutics, dietitics, psychotherapy, weighs and measures, and medical chemistry

This so influential that his book was translated into Latin by Gerard of Cremona (1114-1187 AD), a famous translator of Arab scientific works (Diamantis, 2009). The French surgeon and "Restorer of Surgery," Guy de Chauliac (1300-1368 AD), in his famous book "Inventarium Sive Chirurgia Magna" quoted the work of Albucasis more than 200 times

History (Modern Era)

In the modern era, a Russian, M.M. Rudnev was the first person to perform a diagnostic biopsy in 1875 (Vail, 1979). The term 'biopsy' was introduced into medical terminology in 1879 by Ernest Besnier (Nezelof, 2006). It had became possible towards the end of the 19th century with the development of good histology and microbiology

Ernest Henri Besnier (1831–1909) was a French dermatologist and medicinal director of the Hôpital Saint-Louis in Paris. Needle biopsy of the liver, although first performed in 1895, did not become routine practice until 50 years later

Renal biopsy as part of another procedure

The first renal biopsy, in the modern era, was probaby performed by Eugen Hahn in Berlin in 1881, as part of a nephropexy. This was followed by Reginald Harrison in Liverpool in 1896 (Harrison, 1896), as part of a renal decapsulation procedure for the treatment of Bright's disease. Similar material was obtained soon after in NY, Toronto and Glasgow. Hahn's technique was populised by a NY gynaecologist, George Edebohls (1901) (Horder, 1920) (Campbell, 1930)

Open biopsy

The first renal biopsy, where the primary goal was to remove a small piece of tissue for microscopy and diagnostic purposes, was an open surgical procedure, by Norman B Gwyn, in Toronto, in 1923

Aspiration biopsy

The percutaneous aspiration needle biopsy had been successfully used to acquire liver material by Ehrlich  who obtained liver tissue by aspiration through a needle in research on diabetes (Frerichs, 1884), and Lucatello (1895) used a similar procedure for diagnosis.This early history of the liver biopsy is reviewed by Iversen (1939),  Hoffbauer (1947) and Terry (1949)

But it was not until 1939 that Paul Iversen and Kaj Roholm published the first large, systematic series of liver biopsies. Other organs, not as large and as easily accessible as the more superficial liver, were thought to be poor candidates for this procedure. Renal biopsy was introduced after the development of successful liver biopsy and then demonstration of the value of aspiration needle biopsy in tumours of the kidney. In addition, a number of physicians obtained renal tissue by accident and without problems during intended biopsies of the liver. By 1947, over 1000 liver biopsies had been reported by 21 authors (Hoffbauer, 1947).

It is likely that the advances in liver biopsy led Robert Ball, in Chattanooga, Tennessee, to describe the first percutaneous aspiration renal biopsy in 1934. In 1943, Benjamin Castleman and Reginald Smithwick , in Boston, systematically evaluated 100 surgical biopsies of hypertensive patients and commented, "Pathologists are so accustomed to the microscopicmicroscopic appearance of the hypertensive kidney from autopsy material with the usual postmortem changes, that at the beginning of this study some of the findings due to the early fixation (a matter of seconds) seemed so conspicious that they were at first believed to be pathologic"

Nils Alwall (1904-1986) performed the first systematic aspiration needle biopsies of the kidney in 1944 at the University of Lund (Sweden), although his experience was not published until 1952 (Alwall, 1952), because of an early death which led him to abandon the technique

Nils Alwall is better known for his work on dialysis. Wilhem Johan Kolff constructed the first artificial kidney, however it was not very useful clinically, because it did not allow for removal of excess fluid. Therefore Alwall modified a similar construction to the Kolff kidney by enclosing it inside a stainless steel canister. This allowed the removal of fluids, by applying a negative pressure to the outside canister. Thus making it the first truly practical device for hemodialysis. Alwall treated his first patient in acute renal failure on the 3rd of September 1946, who responded well to the treatment but died of pneumonia a short while afterwards

Alwall also was arguably the inventor of the arteriovenous shunt for dialysis. He reported this first in 1948, where he used such an arteriovenous shunt in rabbits. Subsequently he used such shunts, made of glass, as well as his canister-enclosed dialyser, to treat 1500 patients in renal failure between 1946 and 1960; as reported to the first meeting if the ISN in Evian and Geneva in September 1960

Needle biopsy

The first article that had by subject the practice of a percutaneous renal biopsy was written in 1950 by a Cuban doctor, Antonino Pérez-Ara, who worked at the military hospital in Havana - and published in a local journal with little diffusion (Garcia Nieto, 2009). However, when Iversen and Brun in Copenhagen described their results in 1951, a number of physicians around the world immediately began to attempt renal biopsy, using cutting as well as aspiration techniques

In their classic paper, Iversen and Brun describe placing the patient in a sitting position, and localising the kidney via IV pyelogrophy. Then, after insertion of the needle to the marked length, vacuum suction was applied to the syringe in order to aspirate back a core of renal tissue approximately 1-2 cm in length. Using this method, the authors describe obtaining adequate biopsy tissue in 42 out of 66 patients with a minimum of bleeding complications. In this paper they also describe the ability to make diagnoses of amyloidosis, diabetic nephropathy, hypercalcaemia, and chronic glomerulonephritis based on the resulting pathology

Following this work, success was inconsistent and operator-dependent; the refinements of technique and needles introduced by the group in Chicago led by Robert Kark and Muehrcke (1954), plus their advocacy of the technique and their training of many physicians in the technique, rapidly led to widespread acceptance. They modified the procedure by positioning the patient in the prone rather than in the upright position, using an exploring needle to localise the kidney prior to the insertion of a biopsy needle, and utilising the Franklin modified Vim-Silverman needle

By 1958, a very large series of biopsies had been published by Brun (500 biopsies). Ross (1959) published one of the earliest overviews of renal biopsy appearances in glomerulonephritis. David Kerr, in 1960, published one of the early UK papers on the application of the renal biopsy; using a modified Menghini needle. In March 1961, in the UK, there was an influential CIBA Foundation symposium on  'Renal Biopsy, Clinical and Pathological Significance' (Wolstenholme, 1960). In 1960, at the (previously mentioned) first meeting if the ISN in Evian and Geneva, several papers dicussed renal biopsy

Cameron (1997) and Walker (2009) have reviewed the history of the technique

Etymology

1895, from French biopsie, coined by French dermatologist Ernest Besnier (1831-1909) from Greek, combination of bios ('life') + opsis ('a sight')