Menu Search Donate
clinical guideline banner

Renal Biopsy

This document is only valid for the day on which it is accessed. Please read our disclaimer.

Who to Refer for a Renal Biopsy

This is intended as a general guideline only, and each case should be discussed individually. Please discuss any child about whom you are concerned with the Starship nephrologist on call (if urgent), or who covers your region (if non-urgent). Additional information is provided in the Starship guidelines for nephrotic syndrome, glomerulonephritis, haematuria and proteinuria.

Nephrotic Syndrome

Consider renal biopsy in children

  • who have not responded to steroids after 4 weeks of therapy of 60mg/m2
  • who are very young (under 1 yr old)
  • who become steroid resistant having previously been steroid sensitive
  • who you suspect a secondary cause of nephrotic syndrome

Children with steroid dependent disease or frequently relapsing disease are likely to have cyclophosphamide recommended as their second line therapy. It may not be necessary to biopsy these children prior to treating with cyclophosphamide, as the biopsy may not change the treatment recommended.

Children with minimal change disease can have hypertension and/ or microscopic haematuria. Although they should be followed to check for resolution they are not indications for biopsy in the initial presentation.


Consider renal biopsy in children with

  • SLE - any abnormal urine sediment including haematuria+/- proteinuria 
  • HSP - 
    - relapsing purpura
    - impaired renal function at presentation
    - nephrotic range proteinuria (protein:creatinine ratio > 200mg/mmol)
    - persistent or recurrent proteinuria (first am urine protein:creatinine ratio > 40) for more than 6 weeks after the initial presentation.

Children with vasculitis can have significant disease on biopsy with minimal urinary findings. Please keep a low threshold for discussing the possibility of biopsy in these children.

Acute Glomerulonephritis

Consider renal biopsy in children who:

  • Have rapidly progressive renal impairment
  • Have an atypical history for post infectious glomerulonephritis. This includes
    - Persistently low C3 after 3 months
    - "Recurrent" macroscopic haematuria after initial episode of PSGN - this is very unusual and other causes should be sought
    - Ongoing renal impairment after the acute presentation (i.e. failure to improve after the acute phase, usually 2 weeks)
    - Delay in improvement in renal function during the recovery phase 
    - Significant persistent proteinuria after 6 months (first am urine protein creatinine ratio > 40mg/mmol)


Isolated proteinuria should be quantified via first morning urine protein:creatinine ratios (to exclude orthostatic proteinuria). These children should also have a renal ultrasound to exclude renal dysplasia as the cause for their proteinuria.


Please discuss the need for renal biopsy in children with;

  • Persistent haematuria and proteinuria. Basic screening bloods should be done prior to referral e.g. C3, C4, ANA, ANCA and a family history taken.
  • Recurrent macroscopic haematuria.
  • Family history of end stage renal failure and/or deafness.

Isolated microscopic haematuria is unlikely to have a cause that requires treatment in childhood, and the child is unlikely to benefit from a biopsy.

Referral Information Required

Click on the image below to view/download a pdf copy of the 'Renal Biopsy Referral Information'

Renal Referral Info

Information for Families

Click on the image below to view/download a pdf copy of the family information sheet 'Having a Renal Biopsy'

Biopsy information

Did you find this information helpful?

Document Control

  • Date last published: 01 September 2013
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Nephrology
  • Author(s): Tonya Kara
  • Editor: Greg Williams
  • Review frequency: 2 years

More From Starship