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Small Ruminant Research 103 (2012) 211– 219

Contents lists available at SciVerse ScienceDirect

Small Ruminant Research

jou rn al h om epa ge: www. elsev ier .com/ locate /smal l rumres

ltrasound-guided hepatic and renal biopsy in camels (Camelusromedarius): Technique development and assessment of the safety

ohamed Tharwata,1, Fahd Al-Sobayil a, Sébastien Buczinskib,∗

Department of Veterinary Medicine, College of Agriculture and Veterinary Medicine, Qassim University, Saudi ArabiaBovine Ambulatory Clinic, Departement des Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Canada

r t i c l e i n f o

rticle history:eceived 29 June 2011eceived in revised form 1 September 2011ccepted 2 September 2011vailable online 22 October 2011

eywords:iopsyameliveridneysltrasonography

a b s t r a c t

The purpose of this study was to develop a safe ultrasound-guided technique for biopsyof the liver and kidneys in camels (Camelus dromedarius). Eighteen camels divided into 3groups were used; 6 each for biopsy of the liver and right and left kidneys. Of each group, 2were biopsied and immediately slaughtered. The remaining 4 in each group were biopsiedand then kept for 9-day observation period. When the liver was biopsied, single pass wasadequate for obtaining an adequate hepatic sample in all camels. When the right kidneywas biopsied, sufficient sample was obtained from the first endeavor in 5 of the 6 camels.Two attempts were necessary in the other camel. When the left kidney was biopsied, suffi-cient sample was obtained from the first attempt in 4 of the 6 camels. Two attempts werenecessary in one camel and 3 attempts were necessary in the remaining camel. No evidenceof immediate or delayed haematuria was observed post-biopsy. In camels with liver biopsy,only aspartate aminotransferase was elevated (P < 0.05) for 2 days post-biopsy. When thekidneys were biopsied, a neutrophilic leukocytosis (P < 0.05) was detected for the 24–48 hpost-biopsy. In the 6 camels immediately slaughtered after hepatic and renal biopsy, therewas a small subcutaneous haematoma. One camel with biopsy of the left kidney had a

0.8 cm subcapsular haematoma. In the 12 camels kept for 9-day observation period, therewere insignificant subcutaneous traces of blood with no gross changes indicative of peri-tonitis in any of the camels. Only one camel with biopsy of the left kidney had a smallperirenal haematoma. Ultrasound-guided hepatic and renal biopsy in camels is safe, fast,cost-effective, and practical as long as it is performed properly.

. Introduction

In human medicine, ultrasound-guided, percutaneousepatic and renal biopsies are frequently performed inrder to obtain samples for pathologic and cytologic exam-

nation (Hergesell et al., 1998; Saloura et al., 2010; Yesudast al., 2010). Through the histological analysis of the hepaticnd renal tissue an etiological diagnosis can be performed, a

∗ Corresponding author. Tel.: +1 450 773 8521x8675.E-mail address: s.buczinski@umontreal.ca (S. Buczinski).

1 Permanent address: Department of Animal Medicine, Faculty of Vet-rinary Medicine, Zagazig University, Egypt.

921-4488/$ – see front matter © 2011 Elsevier B.V. All rights reserved.oi:10.1016/j.smallrumres.2011.09.006

© 2011 Elsevier B.V. All rights reserved.

prognosis can be issued and the therapy of the majority ofparenchymal hepato-nephropathies can be oriented. Thetechnique is also a well-documented procedure in cattle(Mohamed and Oikawa, 2008), horses (Modransky, 1986)and dogs and cats (Leveille et al., 1993; Osborne et al.,1996). It has been demonstrated that diagnosis and therapyare modified in about 40% of cases following renal biopsy(Richard et al., 1994) and that the technique used alters theclinical prognosis in about 50% of cases (Turner et al., 1986).

Percutaneous ultrasound-guided tissue core biopsy and

fine-needle aspiration are minimally invasive and cost-effective methods of obtaining specimens for histologicevaluation and bacteriologic culture in cattle (Mohamedand Oikawa, 2008) and dogs and cats (Leveille et al.,

inant Research 103 (2012) 211– 219

In this part of the study, 6 camels were used; 2 for liver biopsy, 2 forright kidney and 2 for left kidney biopsy. Hepatic and renal biopsies werecarried out under ultrasound control and then the animal was slaughtered

212 M. Tharwat et al. / Small Rum

1993). In cattle, the risk of serious renal biopsy-inducedcomplications is extremely low when ultrasound visu-alization is used (Mohamed and Oikawa, 2008). It hasbeen concluded that utilizing the ultrasound-guided biopsytechnique, biopsy of the renal parenchyma is safe, practicaland reliable and requires only one operator.

In camels, hepatic and renal diseases are relatively com-mon (Al-Ani, 2004; Bakhsh, 2004). Most of these diseasesare usually misdiagnosed as a cause of illness because signsmay be subtle. In addition, diagnostic laboratory methodsare insufficient as hepatic enzymes can also be elevated incamels with cardiac or skeletal muscle damage (Bakhsh,2004; Fowler, 2010). Ultrasonography is a valuable andapplicable diagnostic method that can be used to evaluatehepatic and renal structures (Braun, 2009; Floeck, 2009).A complete ultrasonographic examination of the liver andkidneys is supposed to give detailed information about thesize, position, and ultrasonographic parenchymal patternof the liver and kidneys. At present, there are no reportsdescribing a technique for hepatic and renal biopsy underultrasound guidance in adult camels and its safety. The pur-pose of this study was therefore to develop and verify theusefulness of a safe ultrasound-guided technique for biopsyof the hepatic and renal parenchyma in camels that can beused in veterinary practice and research.

2. Materials and methods

2.1. Animals and physical examination

Eighteen camels (Camelus dromedarius) (age: 7.5 ± 4.0 years) wereused in this study. Of the camels, 2 (11%) were males and 3 (17%) were2–3 months pregnant, while the others were non-pregnant and non-lactating females. Camels underwent a thorough physical examination(Köhler-Rollefson et al., 2001) including general behavior and condition,auscultation of the heart, lungs, first stomach compartment and intestine,detection of heart and respiratory rates and rectal temperature. All camelswere apparently healthy and they had full access to feed and water. Basedon a 1 (very thin) to 5 (fat) scale, the body condition score (BCS) of camelswas determined (Sghiri and Driancourt, 1999).

2.2. Preparation for biopsy

First, the foreleg of each camel was bent and tied with a rope on thecarpal joint. The head was then held and the animal was pushed till layin a position of sternal recumbency. The fore-and-hind legs were thentied by a rope near the carpal and hock joints, respectively. Both sidesof thorax and abdomen were then clipped and skin shaved (Fig. 1). Theshaved abdominal area was sterilized using standard surgical disinfectiontechniques. To obtain adequate restraint, camels were slightly sedatedwith xylazine (0.07 mg/kg BW, Bomazine 10%, Bomac Laboratories Ltd,New Zealand), and the region chosen for collecting hepatic or renal biopsywas infiltrated with 10 ml of 2% lidocaine hydrochloride. The experimentalprotocol has been accepted by the Animal Ethical Committee, Deanshipfor Scientific Research, Qassim University, Saudi Arabia.

2.3. Echo-assisted percutaneous biopsy of the liver and right and leftkidneys

After application of a generous amount of alcohol to the skin, imag-ing of the liver and kidneys was performed using an ultrasound scanner(SSD-500, Aloka, Tokyo, Japan) equipped with a 3.5 MHz sector transduc-ers. The liver and kidneys were firstly scanned to determine the optimalbiopsy sites. After the application of transmission gel to the transducer, the

liver was examined beginning at the right paralumbar fossa and extend-ing forward to the 5th intercostal space (ICS). The right and left kidneyswere examined at the upper right and caudal left paralumbar fossa.

Prior to biopsy, and under aseptic conditions, a small incision wasmade in the skin over the suggested biopsy site with the point of a scalpel

Fig. 1. A camel scheduled for liver biopsy. The animal was placed in asitting position and both sides of the abdomen and thorax were clippedand skin shaved.

blade. Using a free-hand technique, a 14 G × 150 mm spinal biopsy nee-dle (Kurita Co., Ltd, Tokyo, Japan) was used. The biopsy needle was thenadvanced through the skin incision, and then under real-time ultrasoundguidance toward the hepatic or renal parenchyma. During biopsy of thekidneys, advancement of the needle was halted when the tip of the nee-dle was seen to penetrate the renal capsule. The needle was directedobliquely in an attempt to sample cortical tissue only and avoid the renalmedulla, renal pelvis and hilar and renal vessels. When the needle wasconsidered to be in the correct position, the plain stylet was withdrawnand a notched part was inserted and advanced 1 cm into the renal cor-tex beyond the renal capsule. Always the needle could be identified onthe ultrasound within the hepatic parenchyma (Fig. 2) and renal cortex(Fig. 3) while the specimen was being obtained, thus confirming the loca-tion of the biopsy. Both the needle and forked stylet were then removedwith a sample of hepatic or renal tissue. Repeat passes were performed,if required, to obtain sufficient biopsy specimens. Immediately after theprocedure, the kidney was scanned to assess the presence of haematomaor active bleeding. All camels subjected to biopsy were kept under closeobservation for a period of 6 h post-procedure. This included hourly detec-tion of heart and respiratory rates and rectal temperature, and visualizingthe conjunctival mucus membranes.

2.4. Immediate effects of hepatic and renal biopsy

Fig. 2. Hepatic biopsy in a camel. The needle is clearly visible within thehepatic parenchyma. PV: portal vein; Ds: dorsal; Vt: ventral.

M. Tharwat et al. / Small Ruminant R

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ig. 3. Renal biopsy in a camel. The needle is clearly visible within theenal cortex. Ds: dorsal; Vt: ventral.

mmediately to evaluate possible biopsy-related pathological changes inhe liver, kidneys, peritoneum and omentum.

.5. Safety of ultrasound-guided biopsy of the liver and kidneys

Twelve camels were used in this part. Four animals were used foriver biopsy, 4 for biopsy of the right kidney and 4 for the left kid-ey. Camels were monitored for 6 h post-biopsy, and all urine passedas carefully examined for macroscopic haematuria. After hepatic and

enal biopsy, camels were monitored during a 9-day observation period.aily evaluation included assessment of general appearance, activity andppetite; determination of rectal temperature, pulse rate, respiratory ratend intestinal and gastric motility; and auscultation of the thorax andeart.

.6. Haematological and biochemical examinations

During the 9-day observation period, 2 blood samples from the jugu-ar vein were collected daily from each camel. One sample was collectednto EDTA-containing tubes for haematological tests. The other sample

as collected in plain tubes to obtain serum for biochemical parame-ers. Haematological examinations (red blood cells, total and differentialeukocyte count, haematocrit, haemoglobin, mean corpuscular volume,

ean corpuscular haemoglobin, mean corpuscular haemoglobin con-entration) were carried out using automated veterinary analyser (Vetcan HM5, ABAXIS, Hungary). For serum samples, commercial kits weresed to determine the concentrations of total protein, albumin, aspar-ate aminotransferase (AST), �-glutamyl transferase (GGT), blood ureaitrogen (BUN) and creatinine. Automated biochemical analyser (Biosys-ems A15, Spain) was used for measurement of all serum parameters.lobulin concentration was calculated by subtracting albumin from totalrotein concentration. At the end of the observation period, camels werelaughtered, and the liver, kidneys, peritoneum, omentum and bowelere examined.

.7. Statistical analysis

Data are presented as means ± SD and the analysis was conductedsing SPSS program, version 16.0 (2007). Haematological and biochemicalata were compared between values, using repeated measures of ANOVA.he level of significance was set at P < 0.05.

. Results

The BCS in the camels used in this study was 3.6 ± 0.5.nsuring the healthy status of the studied camels, clot-ing profile was not carried out in this study. The hepaticarenchyma was visible in all camels through the 11th to

esearch 103 (2012) 211– 219 213

6th ICS. In 4 of the 6 camels used for liver biopsy, right10th ICS was the preferred site for needle insertion. Inthe remaining 2 camels, 9th ICS was the preferred site.In the group used for right kidney biopsy, the right kid-ney could be visualized from in the 11th ICS and upperright flank. In 5 of the 6 camels in this group, the 11thICS was the preferred site for biopsy; where the upperright flank was the best biopsy site in only 1 camel. Inall camels, the left kidney was imaged from the caudalleft flank where this site was the preferred site for biopsyin all 6 camels of this group. The differentiation betweenthe renal cortex and medulla was clearly visible in theultrasonograms. The renal cortex was in all camels rel-atively hyperechoic compared to the renal medulla. Inboth kidneys, the hyperechogenic renal sinus was well dif-ferentiated than the cortex and medulla. The right andleft renal parenchyma was less echogenic than the neigh-boring hepatic and splenic parenchyma. The medullarypyramids had a coronary arrangement, appeared as tri-angular structures and were less echogenic than the restof the parenchyma. Intra-parenchymal renal arteries andveins were easily visible at the corticomedullary junc-tion.

When the liver was biopsied, single pass was adequatefor obtaining a sufficient hepatic sample in all camels.When the right kidney was biopsied, sufficient sample wasobtained from the first endeavor in 5 of the 6 camels. Twoattempts were necessary in the other camel. When the leftkidney was biopsied, sufficient sample was obtained fromthe first attempt in 4 of the 6 camels. Two attempts werenecessary in one camel and 3 attempts were necessaryin the remaining camel. The average length of time (frompreparing the animal to finishing the procedure) for biopsyof the liver, right kidney and left kidney was 10 ± 8, 15 ± 5and 17 ± 10 min, respectively. No evidence of immediate ordelayed (after 12 h) haematuria was observed post-biopsy.

At no time during the 9-day observation period post-biopsy was appetite, general behavior, rectal temperatureor attitude abnormal in any of the camels. During theobservation period, the mean rectal temperature was36.4 ± 0.8 ◦C, the mean heart rate was 40 ± 10 beat/minand the mean respiratory rate was 15 ± 6 breath/min. Inaddition the color of the mucus membranes and capillaryrefill time were normal. Table 1 shows haematological andbiochemical measurements in 4 camels with liver biopsyduring the 9-day observation period. Except for eleva-tions in AST values (P < 0.05) 2 days after hepatic biopsy,no significant differences in mean serum chemistry val-ues were recorded. In addition, no changes indicative ofinflammation were apparent in the total and differen-tial WBC counts or in the albumin/globulin ratio. Table 2shows haematological and biochemical measurements in4 camels with biopsy of the right kidney during the 9-dayobservation period. Except for a neutrophilic leukocy-tosis (P < 0.05) detected 24 h post-biopsy, no significantdifferences in mean haematological and serum chem-istry values were recorded. Table 3 shows haematological

and biochemical measurements in 4 camels with biopsyof the left kidney during the 9-day observation period.Except for a neutrophilic leukocytosis (P < 0.05) detected24 and 48 h post-biopsy, no significant differences in

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Table 1Haematological and biochemical measurements (mean ± SD) in four camels with liver biopsy during the nine-day observation period.

Parameter Unit Time after liver biopsy (day)

0 1 2 3 4 5 6 7 8 9

Red blood cells ×1012/L 5.1 ± 0.3 5.3 ± 0.2 4.9 ± 0.3 5.2 ± 0.2 4.9 ± 0.2 4.8 ± 0.3 5.5 ± 0.4 5.6 ± 0.6 5.0 ± 0.2 4.9 ± 0.4White blood cells ×109/L 17.1 ± 4.8 16.0 ± 4.0 15.5 ± 4.3 14.3 ± 3.4 14.1 ± 3.5 16.8 ± 2.8 17.9 ± 3.9 15.0 ± 1.1 16.3 ± 3.5 18.6 ± 3.6Neutrophils ×109/L 8.9 ± 1.7 8.2 ± 1.7 9.0 ± 2.0 7.7 ± 1.9 7.1 ± 1.4 8.3 ± 2.1 7.9 ± 2.5 7.3 ± 0.9 7.5 ± 2.0 7.9 ± 1.5Lymphocytes ×109/L 7.3 ± 1.6 5.4 ± 2.0 5.6 ± 1.6 5.9 ± 1.0 6.4 ± 1.1 7.0 ± 1.0 7.6 ± 1.3 6.4 ± 1.6 8.6 ± 2.1 9.4 ± 4.2Hematocrit % 21 ± 4.7 21 ± 4.5 19.5 ± 3.7 20.4 ± 3.8 19.7 ± 2.9 18 ± 1.4 20 ± 3.1 20 ± 3.8 18 ± 3.8 19 ± 5.8Haemoglobin g/dL 10.6 ± 1.0 10.6 ± 1.1 10.4 ± 1.1 10.2 ± 1.2 10.1 ± 1.3 10.0 ± 1.3 10.6 ± 1.1 10.9 ± 1.0 9.9 ± 1.5 10.1 ± 1.3MCV fl 37.5 ± 0.6 38.5 ± 0.5 36.7 ± 0.6 37.5 ± 0.6 37 ± 0.8 38 ± 1.0 38 ± 0.5 37.5 ± 1.0 37.5 ± 0.6 37.5 ± 1.3MCH pg 20.1 ± 1.4 19.1 ± 1.3 19.9 ± 1.6 18.9 ± 1.3 19.4 ± 1.3 19.9 ± 1.5 18.5 ± 1.0 18.6 ± 1.0 18.9 ± 1.3 19.7 ± 1.4MCHC g/dL 53.4 ± 5.0 50.8 ± 4.5 55.5 ± 3.4 50.7 ± 3.7 51.9 ± 4.6 50.6 ± 3.3 49.2 ± 6.6 49.3 ± 4.2 50.1 ± 4.6 50.8 ± 5.3Total protein mg/dL 9.9 ± 1.1 10.5 ± 1.5 10.2 ± 1.3 9.4 ± 0.8 9.1 ± 0.6 10.2 ± 0.7 9.6 ± 1.1 9.5 ± 0.9 9.3 ± 1.1 9.2 ± 1.4Albumin mg/dL 5.1 ± 0.2 5.1 ± 0.1 5.1 ± 0.1 5.0 ± 0.2 4.8 ± 0.1 4.9 ± 0.3 4.8 ± 0.3 4.8 ± 0.1 4.8 ± 0.4 4.9 ± 0.14Globulin mg/dL 4.9 ± 0.8 5.5 ± 1.4 5.1 ± 1.2 4.4 ± 0.6 4.3 ± 0.5 5.4 ± 0.4 4.8 ± 0.7 4.7 ± 0.8 4.5 ± 0.7 4.4 ± 1.3A/G ratio 1.04 ± 0.21 0.93 ± 0.07 1 ± 0.1 1.1 ± 0.35 1.1 ± 0.21 0.9 ± 0.82 1 ± 0.46 1.04 ± 0.12 1.06 ± 0.52 1.1 ± 0.06AST U/L 61 ± 15 82 ± 8* 79 ± 11* 70 ± 12 65 ± 21 68 ± 15 70 ± 14 70 ± 11 69 ± 13 68 ± 10GGT U/L 6 ± 3 6 ± 2 5 ± 3 7 ± 1 6 ± 2 4 ± 2 4 ± 1 4 ± 2 5 ± 2 4 ± 2BUN mg/dL 59 ± 20 50 ± 15 51 ± 5 50 ± 4 49 ± 8 51 ± 3 50 ± 1 50 ± 1 49 ± 3 54 ± 3Creatinine mg/dL 1.1 ± 0.07 0.9 ± 0.15 0.9 ± 0.1 0.9 ± 0.1 0.8 ± 0.1 1.1 ± 0.2 1.1 ± 0.2 1 ± 0.1 0.9 ± 0.1 0.9 ± 0.1

MCV: mean corpuscular volume; MCH: mean corpuscular haemoglobin; MCHC: mean corpuscular haemoglobin concentration; A/G: albumin/globulin ratio; AST: aspartate aminotransferase; GGT: �-glutamyltransferase; BUN: blood urea nitrogen.

* P < 0.05.

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Table 2Haematological and biochemical measurements (mean ± SD) in four camels with biopsy of the right kidney during the nine-day observation period.

Parameter Unit Time after right kidney biopsy (day)

0 1 2 3 4 5 6 7 8 9

Red blood cells ×1012/L 4.6 ± 0.8 4.4 ± 0.3 4.0 ± 0.5 4.1 ± 0.6 4.3 ± 0.6 4.0 ± 0.5 4.1 ± 0.3 3.9 ± 0.6 3.8 ± 0.7 3.9 ± 0.5White blood cells ×109/L 17.4 ± 7.0 18.6 ± 1.2* 17.0 ± 4.0 16.6 ± 4.1 16.8 ± 4.2 15.5 ± 2.8 15.9 ± 3.8 15.6 ± 2.2 16.7 ± 1.8 16.5 ± 2.2Neutrophils ×109/L 7.0 ± 1.4 8.2 ± 0.9* 7.5 ± 1.1 6.9 ± 1.6 6.8 ± 1.2 6.7 ± 1.0 6.4 ± 0.9 6.5 ± 1.1 7.0 ± 0.7 6.9 ± 0.8Lymphocytes ×109/L 9.3.3 ± 1.5 9.7 ± 1.7 8.2 ± 1.9 8.4 ± 1.8 7.9 ± 2.2 7.1 ± 2.8 7.6 ± 2.4 8.0 ± 0.9 8.0 ± 1.5 8.1 ± 0.5Hematocrit % 20.3 ± 4.3 19.6 ± 4.8 18.6 ± 5.8 19 ± 5.6 19 ± 5.7 18.6 ± 6.0 18.2 ± 5.9 18.2 ± 5.9 19.6 ± 5.7 21.3 ± 3.2Haemoglobin g/dL 10.2 ± 0.8 9.9 ± 0.8 9.6 ± 1.1 9.5 ± 1.1 9.1 ± 1.1 9.5 ± 1.2 9.1 ± 0.3 9 ± 0.4 8.5 ± 0.2 8.9 ± 0.4MCV fl 32.5 ± 9.3 32.5 ± 8.6 32.6 ± 7.8 32.2 ± 8.5 32 ± 8.7 32.5 ± 9.3 32.5 ± 8.6 32.9 ± 8.9 33 ± 8.3 32.7 ± 8.4MCH pg 17.7 ± 6.7 18 ± 6.8 18.7 ± 8.1 18.1 ± 7.6 17.4 ± 7.5 17.6 ± 8.0 17.4 ± 7.2 18 ± 7.6 17.6 ± 8.1 17.9 ± 7.9MCHC g/dL 57.8 ± 2.4 60 ± 4.1 64.7 ± 3.5 62 ± 4.8 59.4 ± 4.6 60.7 ± 3.0 59 ± 4.0 61 ± 3.6 60.4 ± 4 61.6 ± 4.0Total protein mg/dL 8.2 ± 2.7 9.6 ± 0.7 9.4 ± 1.2 9.9 ± 0.9 10 ± 1 9.5 ± 0.6 9.4 ± 1 9.9 ± 0.5 9.1 ± 0.4 9.8 ± 1.1Albumin mg/dL 4.9 ± 0.1 4 ± 0.7 5 ± 0.3 4.9 ± 0.1 5 ± 0.2 5 ± 0.2 4.9 ± 0.2 5.1 ± 0.2 4.9 ± 0.1 4.9 ± 0.1Globulin mg/dL 3.3 ± 2.6 5.6 ± 0.4 4.4 ± 0.9 5.0 ± 0.8 5 ± 0.8 4.5 ± 0.4 4.5 ± 0.8 4.8 ± 1.5 4.1 ± 1.2 4.7 ± 1.6A/G ratio 1.5 ± 0.03 0.8 ± 1.7 1.1 ± 0.33 0.98 ± 0.12 1 ± 0.25 1.1 ± 0.5 1.1 ± 0.25 1.1 ± 0.66 1.19 ± 0.33 1.04 ± 0.1AST U/L 57 ± 13 58 ± 10 62 ± 21 53 ± 19 52 ± 11 56 ± 14 52 ± 8 48 ± 16 49 ± 10 45 ± 11GGT U/L 8 ± 5 6 ± 3 8 ± 7 7 ± 6 7 ± 4 9 ± 4 8 ± 4 9 ± 6 7 ± 5 9 ± 4BUN mg/dL 54 ± 5 54 ± 3 56 ± 6 53 ± 3 53 ± 8 53 ± 4 53 ± 2 50 ± 3 54 ± 4 54 ± 4Creatinine mg/dL 1.1 ± 0.4 0.7 ± 0.2 0.8 ± 0.3 1 ± 0.2 0.8 ± 0.3 0.9 ± 0.2 1.2 ± 0.3 1.4 ± 0.1 1.1 ± 0.1 1.3 ± 0.3

MCV: mean corpuscular volume; MCH: mean corpuscular haemoglobin; MCHC: mean corpuscular haemoglobin concentration; A/G: albumin/globulin ratio; AST: aspartate aminotransferase; GGT: �-glutamyltransferase; BUN: blood urea nitrogen.

* P < 0.05.

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Table 3Haematological and biochemical measurements (mean ± SD) in four camels with biopsy of the left kidney during the 9-day observation period.

Parameter Unit Time after left kidney biopsy (day)

0 1 2 3 4 5 6 7 8 9

Red blood cells ×1012/L 5.4 ± 0.4 4.8 ± 0.3 4.7 ± 0.2 4.5 ± 0.2 4.4 ± 0.1 4.2 ± 0.1 4.0 ± 0.3 4 ± 0.3 4 ± 0.3 4.2 ± 0.4White blood cells ×109/L 18.8 ± 0.7 20.7 ± 2.0* 21 ± 2.0* 20.7 ± 2.6* 19.2 ± 4.4 18 ± 2.3 19.3 ± 3.0 19.2 ± 1.6 19.5 ± 2.0 17.2 ± 3.8Neutrophils ×109/L 8.5 ± 1.2 9.7 ± 0.7* 11.1 ± 2.1* 10.2 ± 1.0* 9.1 ± 1.8 8.5 ± 2.6 8.5 ± 2.7 8.6 ± 1.8 8.6 ± 2.2 7.2 ± 1.6Lymphocytes ×109/L 9.2 ± 1.6 9.8 ± 1.4 9.2 ± 1.9 8.9 ± 1.2 8.8 ± 2.7 8.5 ± 2.4 10.0 ± 4.5 10.2 ± 2.2 9.9 ± 1.7 9.1 ± 1.0Haematocrit % 21 ± 1 19 ± 1 18 ± 1 17 ± 1 17 ± 1 16 ± 1 15 ± 2 16 ± 1 16 ± 2 16 ± 5Haemoglobin g/dL 11.1 ± 1.3 10.2 ± 1.2 10 ± 0.9 9.6 ± 0.8 9.8 ± 0.6 9.9 ± 0.8 9.5 ± 0.9 9.8 ± 1.1 9.7 ± 1.2 9.5 ± 1.2MCV fl 40 ± 2 39 ± 2 39 ± 1 38 ± 2 38 ± 1 38 ± 1 37 ± 2 38 ± 1 38 ± 2 38 ± 2MCH pg 21 ± 1 21 ± 1 21 ± 1 21 ± 1 22 ± 2 23 ± 1 23 ± 2 24 ± 1 24 ± 3 23 ± 2MCHC g/dL 52 ± 4 54 ± 5 55 ± 5 57 ± 6 59 ± 10 61 ± 13 63 ± 11 63 ± 7 63 ± 9 60 ± 8Total protein mg/dL 9.7 ± 0.9 9.9 ± 0.4 9.7 ± 0.7 9.2 ± 0.8 9.7 ± 0.4 9.6 ± 0.9 9.7 ± 0.8 9.8 ± 0.4 9.6 ± 0.4 8.1 ± 1.8Albumin mg/dL 5.1 ± 0.2 5.1 ± 0.3 4.9 ± 0.1 5.1 ± 0.2 5 ± 0.2 5 ± 0.3 5.2 ± 0.1 4.8 ± 0.1 4.9 ± 0.2 4.7 ± 0.4Globulin mg/dL 4.6 ± 0.7 4.8 ± 0.5 4.8 ± 0.6 4.1 ± 0.6 4.7 ± 0.2 4.6 ± 0.6 4.5 ± 0.7 5 ± 0.3 4.5 ± 0.3 3.4 ± 1.4Albumin/Globulin ratio 1.1 ± 0.28 1.1 ± 0.6 1.0 ± 0.16 1.24 ± 0.33 1.1 ± 1 1.1 ± 0.5 1.2 ± 0.14 0.96 ± 0.33 1.08 ± 0.66 1.4 ± 0.28AST U/L 60 ± 10 67 ± 15 62 ± 12 64 ± 11 53 ± 6 67 ± 6 65 ± 6 57 ± 12 53 ± 6 58 ± 14GGT U/L 7 ± 3 7 ± 3 5 ± 3 5 ± 4 5 ± 2 4 ± 3 5 ± 2 6 ± 1 5 ± 2 7 ± 1BUN mg/dL 58 ± 6 54 ± 3 53 ± 4 55 ± 7 58 ± 9 55 ± 2 53 ± 3 54 ± 4 55 ± 4 54 ± 3Creatinine mg/dL 0.9 ± 0.13 1.1 ± 0.13 0.9 ± 0.1 0.9 ± 0.2 0.8 ± 0.2 0.9 ± 0.2 0.8 ± 0.1 0.9 ± 0.2 0.7 ± 0.2 0.9 ± 0.1

MCV: mean corpuscular volume; MCH: mean corpuscular haemoglobin; MCHC: mean corpuscular haemoglobin concentration; AST: aspartate aminotransferase; GGT: �-glutamyl transferase; BUN: blood ureanitrogen.

* P < 0.05.

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ig. 4. Subcapsular haematoma in a camel with biopsy of the left kidney.

ean haematological and serum chemistry values wereecorded. After biopsy of the right and left kidneys, thereere no significant differences in mean serum values of UN

r creatinine during the 9-day observation period.In the 6 camels immediately euthanised after hepatic

nd renal biopsy, a small subcutaneous haematoma wasbserved. The needle biopsy path was hardly detected athe liver surface. One camel with biopsy of the left kid-ey had a 0.8 cm subcapsular haematoma (Fig. 4). Afteremoval of this haematoma, the needle biopsy path waslearly seen on the renal capsule. Needle traces were lim-ted in all camels to the renal cortex (Fig. 5). In the 12 camelsept for 9-day observation period, there were insignificantubcutaneous traces of blood. No gross changes indicativef peritonitis were seen in any of the camels observed for

days after biopsy. Only one camel with biopsy of theeft kidney had a small perirenal haematoma. A small scar

ig. 5. At postmortem examination, biopsy needle path was easily iden-ified within the renal cortex.

esearch 103 (2012) 211– 219 217

was detected on the surface of the kidneys at the biopsysite.

4. Discussion

The aim of the present work was to provide practition-ers with a safe technique for biopsy of the liver and kidneysin camels that could be used in veterinary practice and alsoin research. A free-hand biopsy technique with ultrasoundguidance was used in all camels (Mohamed and Oikawa,2008; Mohamed and Buczinski, in press). This was accom-plished by holding the transducer with one hand whileinserting the needle with the other. It enabled good visu-alization of the needle and it entered at an oblique angleto the long axis of the transducer. The procedure requiresmore experience than using a biopsy needle guide. Theuser should pay attention not only to ultrasound anatomy,but also to hand–eye coordination and confidence that theneedle will not only pass at an appropriate angle, but alsoremain within the plane parallel with the ultrasound beam.There was a definite learning curve, but once mastered, thetechnique was relatively straightforward. If the needle can-not be seen during ultrasonography, moving the transducerslightly into the path of the needle, gently agitating theneedle or injecting air or microbubbles in saline solutionthrough the needle usually allows the needle’s position tobe determined (Mohamed et al., 2003a,b).

In the camels with liver biopsy, all camels required onlyone single pass to get a hepatic sample. In all renal biop-sies, the number of passes ranged from 1 to 3. This numberwas higher when collecting biopsies from the left kidney.The movability of this kidney may be a factor. The loca-tion of the left kidney and its loose attaches may explainthe higher level of difficulty for this organ. In this study,despite the fact that we did not have the pathologist atthe site to check for sample adequacy, the yield of materialobtained by the hepatic and renal biopsy procedure wasalmost always sufficient for an adequate histopathologi-cal analysis. We feel that this is rather important on twocounts: to confirm the quality of the biopsy and further-more to offer an additional account of the health statusof the camels in this case. This finding is in line with thedata of Mohamed and Oikawa (2008), who used the samegauge spinal needle for biopsy of the right kidney in cattle.In all the camels, the time required from preparing the ani-mal to finishing the procedure ranged from 10 to 17 min.In cattle, the left kidney is only examined ultrasonographi-cally transrectally (Braun, 1993). In camels, the left kidneyis examined ultrasonographically through the caudal leftflank and also transrectally. This made the left kidney inthis study accessible for ultrasound-guided percutaneousbiopsy as the right kidney.

The safety of percutaneous ultrasound-guided hep-atic and renal biopsy was evaluated in 12 camels thatwere biopsied and then kept for 9-day observation period.Throughout this period, we did not encounter any imme-diate or late complications. No evidence of immediate or

delayed (after 12 h) haematuria was observed after renalbiopsy. In two large retrospective studies of human abdom-inal biopsies, complication rates of 0.1% and mortality rateof 0.03–0.04% were reported (Nolsoe et al., 1990; Smith,

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1991). Both complications and mortalities were typicallyattributed to haemorrhage, especially after liver and pan-creatic biopsy. The low complication rate in this study mayhave resulted, at least in part, from the fact that ultrasonog-raphy allowed highly vascularized parts to be avoided. Inonly one camel with biopsy of the left kidney, a smallhaematoma of no clinical significance was noted at thesite of biopsy. Ultrasound-guidance, which provided moreaccurate localisation of the needle in relation to the kidneyand subsequent biopsy site in the renal cortex, seemed tobe the reason for the low complication rate encountered.

Direct real time ultrasound control allows the correc-tion of the needle position at any moment during the biopsyprocedure (Mohamed and Oikawa, 2008). Knowledge of theexact location of the needle in the cortex prevents deeppenetration into the medulla. In contrast, manual inser-tion of the needle in the blind biopsy technique leads touncontrolled penetration and often traumatizes the kidney(Mohamed and Oikawa, 2008). In cattle, according to ourunpublished data, blind biopsy of the left kidney produceda sufficient amount of materials in only 12 of 25 cases. Inaddition, there was evidence of haematuria attributable tothe biopsy procedure in 16% of the cases.

Although the studied camels were healthy, it is indeedunfortunate that the clotting profiles were not performed.When applying the procedure to diseased camels, someprecautions should be followed. In order to minimize therisks, it is not only important to adopt an adequate biopsytechnique, but it is also imperative to exclude high-riskanimals. Performing biopsy of the liver or kidneys is con-traindicated if the animal has a high risk of bleeding.Thorough scanning of the liver and kidneys may detectabnormalities; however, the diseased animal should alsobe evaluated for haemostatic disorders prior to biopsybecause distention of the hepatic veins is a clear indica-tion of enlargement of the liver, which mostly arises fromright-sided heart failure (Mohamed and Oikawa, 2008,2007; Mohamed et al., 2002, 2003a,b, 2004). In diseasedcamels it is recommended to carry out a clotting profilebefore hepatic and renal biopsy to detect bleeding disor-ders which is different when performed in healthy patients.Patients at high risk should be excluded from biopsy,particularly those with coagulation disorders. It shouldbe emphasised that performing percutaneous ultrasound-guided biopsy of the liver and kidneys in camels is thereforecontraindicated if the animal has a high risk of bleed-ing. Distention of the hepatic veins is a clear indication ofenlargement of the liver that mostly arises from right-sidedheart failure (Mohamed et al., 2002, 2003a,b). It shouldbe stressed that scanning of the liver may detect suchabnormalities, but the animal should also be evaluated forhaemostatic disorders prior to biopsy. Haemorrhage is usu-ally minor and self-limiting if coagulation parameters arenormal.

5. Conclusions

This study confirms that real-time ultrasound-guidedhepatic and renal biopsy can be performed easily in camelswithout assistant. The procedure is a safe and accuratemethod in hands of trained and experienced personnel

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to perform percutaneous hepatic and renal biopsy andcan be performed in Veterinary Teaching Hospitals andalso in the field. More and more veterinarians shouldtake up this simple yet vital and rewarding procedurefor early diagnosis of hepatic and renal disorders incamels.

Acknowledgement

This study was supported by the Deanship for Scien-tific Research (SR-D-010-078), Qassim University, SaudiArabia.

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