Survey of Kidney Biopsy Clinical Practice and Training in the United States

Abstract

Background and objectives: Practicing clinical nephrologists are performing fewer diagnostic kidney biopsies. Requiring biopsy procedural competence for graduating nephrology fellows is controversial.

Design, setting, participants, & measurements: An anonymous, on-line survey of all Walter Reed training program graduates (n=82; 1985-2017) and all United States nephrology program directors (n=149; August to October of 2017), regarding kidney biopsy practice and training, was undertaken.

Results: Walter Reed graduates' response and completion rates were 71% and 98%, respectively. The majority felt adequately trained in native kidney biopsy (83%), transplant biopsy (82%), and tissue interpretation (78%), with no difference for ≤10 versus >10 practice years. Thirty-five percent continued to perform biopsies (13% did ≥10 native biopsies/year); 93% referred at least some biopsies. The most common barriers to performing biopsy were logistics (81%) and time (74%). Program director response and completion rates were 60% and 77%. Seventy-two percent cited ≥1 barrier to fellow competence. The most common barriers were logistics (45%), time (45%), and likelihood that biopsy would not be performed postgraduation (41%). Fifty-one percent indicated that fellows should not be required to demonstrate minimal procedural competence in biopsy, although 97% agreed that fellows should demonstrate competence in knowing/managing indications, contraindications, and complications. Program directors citing ≥1 barrier or whose fellows did <50 native biopsies/year in total were more likely to think that procedural competence should not be required versus those citing no barriers (P=0.02), or whose fellows performed ≥50 biopsies (P<0.01).

Conclusions: Almost two-thirds of graduate respondents from a single military training program no longer perform biopsy, and 51% of responding nephrology program directors indicated that biopsy procedural competence should not be required. These findings should inform discussion of kidney biopsy curriculum requirements.

Keywords: Biopsy; Contraindications; Curriculum; Fellowships and Scholarships; Interventional Radiology; Military Personnel; Nephrologists; Nephrology Education; Nephrology Fellowship; Program Directors; Surveys and Questionnaires; Thinking; Transplants; United States; kidney biopsy; nephrology.

Graphical abstract

Figure 1.

Walter Reed graduate opinions regarding kidney biopsy (1985–2017). (A) Reasons for continuing to perform kidney biopsy (n=19). (B) Barriers to performing kidney biopsy (n=54). Adeq, adequate; Post-Bx, post-biopsy; RVU, relative value units.

Figure 2.

Number of native kidney biopsies performed by fellows and available to institution (done institution-wide) in training year 2016–2017. Program director respondents n=70; median number of clinical fellows/program=6. TY, training year.

Figure 3.

Required minimum number of native biopsies performed and desirable minimum number to demonstrate fellow competence (program director respondents n=69).

Figure 4.

Barriers to achieving fellow competence in performing kidney biopsy (program director respondents n=69). BX, biopsy; IN, interventional nephrology; IR, interventional radiology.