Complications of the Percutaneous Kidney Biopsy

Complications of the Percutaneous Kidney Biopsy William L. Whittier Percutaneous kidney biopsy is an integral part of a nephrologist’s practice. It has helped to define nephrology as a subspecialty. When indicated, it is a necessary procedure to help patients, as it allows for diagnostic, prognostic, and therapeutic information. Although very safe, this procedure can give rise to complications, mainly related to bleeding. Since its development in the 1950s, modifications have been made to the approach and the technique, which have improved the diagnostic yield while keeping it a safe procedure. Alterations to the standard approach may be necessary if risk factors for bleeding are present. In addition, obesity, pregnancy, and solitary kidney biopsy are all special circumstances that change the procedure itself or the risk of the procedure. Today, kidney biopsy is a vital procedure for the nephrologist: clinically relevant, safe, and effective. Q 2012 by the National Kidney Foundation, Inc. All rights reserved. Key Words: Kidney biopsy, Complications, Bleeding, Hematoma, Pregnancy

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he etiology of kidney disease can often be determined clinically, by taking a history and examining the patient, serum, and urine, as well as by noninvasive imaging studies such as radiography, ultrasonography (U/S), or computed tomography (CT) scans. When these diagnostic tools cannot provide enough specificity, a kidney biopsy may be indicated. In most cases, this procedure is performed for further evaluation of glomerular diseases and provides not only a diagnosis but also vital information about prognosis and treatment. Percutaneous kidney biopsy (PKB) was originally described in 1951,1 and since that time, advances in this technique have preserved it as a safe and effective method for evaluating nephrologic pathology.2 Although PKB is a safe procedure, complications can occur and are mainly related to bleeding. Before the biopsy, identifying and modifying potential risk factors for bleeding can help to minimize injury. Using different imaging techniques can aid in providing an adequate sample and detect complications after they arise.2 Although a complication could occur at any time after the procedure, knowing the timing when the majority occur helps to define the optimal length of observation.3 Finally, special clinical circumstances arise, such as pregnancy or obesity, which may require modifications to the standard technique. Other situations exist, which may not increase the risk of bleeding but change the safety profile of the entire procedure, such as solitary kidney biopsy. The indications, diagnostic yield, alternative methods than the percutaneous approach, use of the procedure in pediatrics or transplantation, and a description of the technique itself are beyond the scope of this article and are discussed in detail elsewhere.2,4,5 The focus of this review will be on the issues surrounding the safety and complications of native PKB.

History of Complications The kea (Nestor notabilis) parrot is an olive-green-colored alpine bird with a long thin beak native to the South Island of New Zealand6 (Fig 1). Although originally described as a ‘‘honey-eater,’’ its omnivorous and adaptive nature eventually led it to feed on live sheep. The bird has been observed landing on the dorsal surface of sheep

in New Zealand, pecking near the flanks. Although there is some controversy surrounding the parrot’s intent, whether it has developed a taste for perinephric fat or is possibly just searching for insects buried in the wool, a clear consequence of these actions has rendered some unfortunate sheep incapacitated or even dead owing to the development of lacerations of the kidney(s). The early anecdotal experience of PKB has been described as being similar to the actions of this parrot, ‘‘pecking’’ on the dorsal surface ‘‘of sheep.causing them to bleed to death.’’7 However, the original study in human patients of the percutaneous approach with aspiration, described in the literature in 1951 by Iversen and Brun, found the approach to be generally safe.1 This landmark study, the first of percutaneous biopsy of the kidney, described the technique as being similar to aspiration biopsy of the liver, but performed with the patient in the sitting position. This position was noted by others to be uncomfortable for the patient,8 and by 1954, the sitting approach led to a diagnostic yield of kidney tissue in only 38% (82 with kidney tissue/215 attempts).9 The procedure was modified in Chicago by Kark and Muehrcke,8 who placed the patient in the prone position, with a sandbag under the abdomen to push the kidney to the surface to provide hemostasis. The initial series using this modified method described a diagnostic yield of 96% (48 with kidney tissue/50 attempts) and no major complications.8 In addition, the histologic findings were diagnostically useful, as the results of the biopsy differed from the initial clinical diagnosis in more than 50% of the cases.10 Before 1962, localization of the biopsy needle within the kidney was typically done with the patient in the prone position using a ‘‘finder’’ needle without radiological imaging.8 Knowledge of accurate placement in the kidney was From the Division of Nephrology, Rush University Medical Center, Chicago, IL. Address correspondence to William L. Whittier, MD, FASN, Division of Nephrology, Rush University Medical Center, 1426 West Washington Boulevard, Chicago, IL 60607. E-mail: [email protected] Ó 2012 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 doi:10.1053/j.ackd.2012.04.003

Advances in Chronic Kidney Disease, Vol 19, No 3 (May), 2012: pp 179-187

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established by movement of the end of the needle in a wide arc with deep inspiration. Although today this is still a helpful method to suggest correct placement, radiographic imaging techniques were developed that virtually ensured the appropriate position.11,12 Early imaging techniques included intravenous pyelography, fluoroscopy, and plain radiography, but, eventually, real-time U/S13 and CT14,15 replaced the more cumbersome earlier methods. The needle that is typically used today has also changed over the years. Initially, an aspiration needle, as used in the early liver biopsies, was the tool of choice.16 This was later replaced by a Franklin-modified Vim-Silverman needle, which allowed clean shearing of the tissue while collecting it.17 In the 1980s, automated spring-loaded biopsy guns were introduced18,19 and were found to be more effective diagnostically20 and possibly safer21-23 than previous techniques. These modifications to PKB shaped the procedure into what it is today: clinically relevant, safe, and effective.

Bleeding

Microscopic Hematuria. Microscopic hematuria is the most common consequence of the procedure, and when asymptomatic patients are screened using a dipstick urinalysis, blood is universally present.31,32 This resolves spontaneously with time in almost all cases. Thus, there is no diagnostic value for this test in detecting complications. Gross Hematuria. Similar to microscopic hematuria, gross hematuria typically resolves spontaneously.2 If visualized, the color of the urine will most often change in subsequent voids from dark red to pink to lighter pink and finally to yellow again within 24 to 48 hours. Major complications from gross hematuria, such as obstruction from a blood clot in the bladder,3,28 with or without acute kidney injury, can rarely occur. Occasionally, a significant drop in hemoglobin concentration requiring a blood transfusion may occur. Acute Anemia. A fall in hemoglobin concentration of $1 g/dL after PKB has been reported in large series to occur Complications in up to 50% of uncomplicated cases.3,33 In one series of 750 patients, the average Types of Complications change in hemoglobin conCLINICAL SUMMARY centration was 0.9 6 0.8 g/ Although percutaneous nadL in patients without a comtive kidney biopsy is gener
Percutaneous kidney biopsy is an effective and valuable plication. Furthermore, a deally safe, complications can procedure, providing insight into the diagnosis, crease of $2 g/dL occurred occur and can range in seprognosis, and treatment of patients with kidney disease. in 10% of uncomplicated biverity from minimal to cata
The most common complication of the procedure is related opsies. However, in the strophic. Owing to the to bleeding. same series, patients with vascular nature of the ora complication had, on avergan, the most common com
With modern medical techniques and modifications, the procedure remains a safe one, with an improvement in age, a drop in hemoglobin plications (Table 1) are diagnostic yield. concentration of 2.1 6 1.6 related to bleeding,24 which g/dL (P , .0001 compared is typically in the perinephwith 0.9 6 0.8 g/dL in unric area (Figs 2 and 3) or in complicated biopsies), and almost 50% of cases with the collecting system, but rarely may occur with laceraa complication had a change of $2 g/dL, suggesting tion of a blood vessel such as a lumbar25 or mesenteric26 that a minor drop of 1 g/dL can be typical in any biopsy, artery. Complications are divided into 2 categories. Major but a greater degree of acute anemia may be a sign of complications are defined as requiring a treatment or an a complication. In comparing those patients who develintervention to stop the problem. Examples include coil oped a major complication versus a minor one, the averembolization for persistent bleeding, transfusion of blood age change was not different.3 Khajehdehi and products for a significant drop in hemoglobin concentra27 colleagues34 retrospectively evaluated the change in hetion, or even the rare sepsis or acute renal failure from 28 matocrit further in a cohort of 83 patients. They found obstruction. Minor complications are defined as those that the change in hematocrit at 6 hours after PKB had a linthat spontaneously resolve without the need for intervenear correlation to the hematocrit at 24 hours, implying that tion or further treatment, such as gross hematuria or if the 6-hour hematocrit is unchanged from the prebiopsy a symptomatic hematoma that resolves with time. Rarely hematocrit, then it would be unlikely to change at 24 (,0.1%), disastrous complications could occur, such as hours. However, there was no correlation in this study nephrectomy or even death.29 Common or typical conseto complications. quences of the biopsy, but not necessarily complications, What does a change in hemoglobin concentration mean include microscopic hematuria (nearly 100%), minor practically for patients undergoing this procedure? Unforpostprocedure lumbar pain lasting ,12 hours, mild tunately, although patients with a bleeding complication drop in hemoglobin concentration, or a silent perinephric have a greater change in hemoglobin concentration, an abhematoma detected by routine screening imaging evalusolute decrease in this level is not a reliable indicator, ation (up to 90% in a large prospective series).30

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Figure 1. Photograph of the kea (Nestor notabilis), taken by Dr. Edmund J. Lewis, given with permission.

as almost half of all patients without a complication experience this. A more severe ($2 g/dL) drop is more suggestive of a complication, but is also not an absolute indicator, and is not predictive of developing a major complication. Why does the hematocrit drop in uncomplicated cases? The cause is unknown,2 but most likely is related to the development of silent perinephric hematomas, which are quite common when routine screening methods are used.30 Another purported mechanism is dilutional, either from routine administration of intravenous fluids33 or perhaps resorption of interstitial fluid from an insensitivity to atrial natriuretic peptide in patients with nephrosis.35 However, the dilutional effect is minimal, as modern procedures are done without routine intravenous Table 1. Frequency of Complications After PKB Type

Reported Frequency

Minor Bleeding Symptomatic hematoma Gross hematuria Acute anemia (.1 g/dL drop in Hgb) Pain (.12 hours) Page kidney Perirenal infection Arteriovenous fistula Major Bleeding Hematoma requiring blood transfusion Blood transfusion Procedure/surgery required to stop bleeding Outlet obstruction/acute kidney injury Hypotension related to bleeding Nephrectomy Sepsis Renal artery, aorta, or parenchymal organ puncture Death

2%-35% 3%-10% 3%-18% 10%-50% 2%-4% N/A 0.2% 0.4%-18% 1%-7% 1%-5% 1%-6% 0.1%-0.4% 0.3% 1%-2% 0.1%-0.4% N/A N/A 0.02%-0.1%

Abbreviation: Hgb, hemoglobin concentration; PKB, percutaneous kidney biopsy; N/A, not available.

Figure 2. (A) Computed tomography scan (axial) revealing 14-cm right perinephric hematoma 1 hour after a percutaneous kidney biopsy of the inferior pole of the right kidney. White arrows reveal the extent of the hematoma. Black arrow shows the crescentic perinephric hematoma. (B) Coronal scout view. White arrows reveal caudal extension of hematoma.

fluids3,36 and not all patients with acute asymptomatic anemia have nephrosis. Perinephric Hematoma. The development of a perinephric hematoma, similar to microscopic hematuria, occurs in many patients undergoing this procedure, irrespective of the development of a complication. A way to detect an asymptomatic hematoma is to use routine imaging for screening in all cases after the procedure, which is not universally done. In prospective studies that have screened patients after completion of the procedure, the incidence of perinephric hematoma formation ranges from 11% to 91%.30,36-44 The likely reasons for this wide variability are inconsistent timing (ranging from immediate to 72 hours after procedure), differing imaging methods (U/S

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Figure 3. Right renal arteriogram revealing active bleeding (arrow) of the inferior pole of the right kidney 1.5 hours after a percutaneous kidney biopsy. Black arrow points at the ‘‘blush’’ or source of the perinephric bleed.

vs CT) between the studies, improvement in imaging techniques in the modern era, and/or operator dependence. The optimal timing of scanning to detect hematomas is not known. The use of immediate scanning with U/S detects hematomas in ,15% of the cases from earlier reports,21,22,37 and more recent series using immediate postprocedure U/S found perinephric hematomas ranging from 13%45 to 86%46 of procedures. Using later time intervals, the reported frequency of hematomas was 29%44 at 1 hour and 33% within 24 hours.36 The reported frequency of perinephric hematomas using routine CT scan 1 to 72 hours after the procedure is higher, ranging from 57% to 91%.30,39-41 In a prospective study comparing CT scan and U/S, CT scan was found to be more sensitive in detecting postprocedure perinephric hematomas (90% for CT, 70% for U/S).30 Although these imaging modalities have a high sensitivity to detect hematomas, there is no consensus on the routine use of any postprocedure screening imaging technique. As a urine dipstick to detect microscopic hematuria after the procedure is unnecessary, is an expensive routine screening CT or U/S also unnecessary to determine a common finding, that of a perinephric hematoma? Is there value of finding a silent hematoma in an asymptomatic individual? For a study to be relevant, a positive finding should be predictive of a complication, or a negative finding should be predictive of an uncomplicated course. Two studies have evaluated the use of screening U/S to detect the significant outcome of major complications.44,46 Both showed the presence of a hematoma was not predictive of a subsequent major complication, nor were any characteristics of the hematoma. In the prospective study by Waldo and colleagues,44 a hematoma was

present in 29% of the cases at 1 hour and was not prognostic of a complication. However, the absence of a hematoma at 1 hour was highly predictive of an uncomplicated course (95% negative predictive value). Therefore, the routine use of U/S at 1 hour after PKB may have a role to determine an uncomplicated course. The majority (90%) of perinephric hematomas, when detected by U/S, are small and clinically silent.36 However, a perinephric hematoma may develop into a clinically relevant complication, as it can be the cause of lumbar pain, a significant drop in hemoglobin concentration, or the need for a blood transfusion (Table 1). Typically, a hematoma will tamponade and stop enlarging, but can continue to expand, requiring an intervention such as gel-foam or coil embolization to stop the ongoing hemorrhage. Rarely, Page kidney may develop, where a perinephric hematoma causes compression and ischemia of the affected kidney with subsequent reninmediated hypertension (HTN).47 Arteriovenous Fistula An arteriovenous fistula (AVF) may develop owing to trauma to the wall of a blood vessel from the biopsy needle. The majority of these are asymptomatic,48 but rarely can become aneurysmal, presenting clinically with HTN, high output heart failure, hematuria, or renal failure. This may be an elusive diagnosis, as it can present years after the procedure.49,50 An abdominal bruit may be a clue to discovering an AVF, but confirmation requires either Doppler U/S, magnetic resonance imaging, or angiography.48,51 If the AVF is symptomatic or enlarging, based on serial Doppler U/S, superselective transcatheter arterial embolization or surgery is recommended.49

Risk Factors The risk factors for developing a complication (Table 2) are split into those that are patient derived (ie, Table 2. Reported Risk Factors for Complication Patient related* Age Gender (female)† Use of steroids† Increased blood pressure Elevated serum creatinine or reduced GFR Increased PT Increased aPTT Increased bleeding time Underlying disease Procedure related Number of passes .5* Lack of imaging Abbreviations: GFR, glomerular filtration rate; PT, prothrombin time; aPTT, activated partial thromboplastin time. *Based on studies using multivariate logistic analysis. †Study(s) reporting this risk factor included silent hematoma as a complication.

Complications of the PKB

uncontrolled HTN) and those related to the technique itself (ie needle type or size, use of imaging or not). However, some of the studies that evaluated risk factors used screening imaging techniques and reported silent hematomas as complications,36,38,46,52 which, as discussed earlier, may not be clinically relevant. Some risk factors that a patient may have for bleeding are intuitive and not necessarily based on evidence. An example of this would be a patient with an uncontrolled bleeding diathesis. Many investigators have reported on their experience with renal biopsy complications and excluded patients with bleeding diatheses, such as those with an elevated prothrombin time, activated partial thromboplastin time (aPTT), significant thrombocytopenia, or elevated bleeding time.3,38,53-55 Other investigators included patients with abnormal coagulation profiles,56,57 and in one of the studies,57 bleeding developed almost exclusively in those patients with abnormal parameters. In addition, by multivariate analysis, a slightly increased baseline prothrombin time,46 aPTT,36 or bleeding time,58 but still within the reference range, has been shown to be predictive of bleeding. The use of the template bleeding time as a measure of platelet function remains controversial.2,4,24,59-61 This test has been shown to be the most common coagulation abnormality in patients undergoing PKB.62 Although the bleeding time is not predictive of bleeding in open surgical procedures,63 it has been shown to be associated with increased bleeding in the setting of closed percutaneous procedures, when evaluated prospectively64,65 and retrospectively.56-58 However, when the elevated bleeding time is corrected by administering desmopressin (DDAVP), there still seems to be an increased risk of bleeding complications compared with those patients who have a normal baseline bleeding time.44,58 When the bleeding time is unavailable, some measure of platelet function, such as a platelet function assay (ie, PFA-100, Dade-Behring Inc., Miami, FL),66 may be of assistance to uncover a platelet abnormality that may not be apparent by clinical history. This may occur with surreptitious ingestion of aspirincontaining compounds, herbal medications,67 or even omega-3 fatty acids.68 It is recommended that certain medications, such as aspirin, nonsteroidal anti-inflammatory agents, omega-3 fatty acids, and antithrombotic (eg, warfarin or heparin) or other antiplatelet agents (eg, glycoprotein IIb/IIIa inhibitors, persantine), be held in an attempt to decrease the hemorrhagic risk.24,61 Recently, in patients undergoing PKB, the bleeding risk after using antiplatelet agents was assessed.55 In this study, in 1 group of patients, antiplatelet agents (aspirin, dipyridamole, or clopidogrel) and/or nonsteroidal anti-inflammatory agents were stopped 5 days before the PKB, and in the other, they were continued. Although the rate of major complications was low (1.9% overall) and not different between the groups, the patients receiving uninterrupted antipla-

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telet therapy had more minor complications (31% vs 12%, P ¼ .008). Ideally, for minimizing complications, patients should not take these medications for 1 to 2 weeks before an elective PKB and remain off them for 1 to 2 weeks after the procedure.2,61 If the need for a diagnosis is pressing and the patient has a coagulation abnormality or requires uninterrupted antiplatelet therapy, then the risk/benefit of the procedure and development of bleeding or recurrent clotting should be considered and weighed versus empiric therapy. For a patient on anticoagulation with warfarin, heparin, or low-molecular-weight heparin, the risk of bleeding with the PKB must be weighed with the risk of clotting without anticoagulation. There are no studies on the management of anticoagulation for closed procedures such as the renal biopsy. Therefore, the recommendations come from studies of open surgical procedures.69 In general, for elective uncomplicated cases, taking into account possible thrombotic risk, warfarin should be held until the international normalized ratio (INR) is ,1.5 before the procedure. Heparin should be stopped at least 6 hours, and preferably 24 hours, before the PKB, until the aPTT normalizes, and should not be restarted until at least 24 hours after the procedure. While using lowmolecular-weight heparin when the glomerular filtration rate (GFR) is normal, it should be held for at least 24 hours before and after the biopsy. Patients should be observed for at least 24 hours while on heparin or low-molecular weight heparin before discharge from the hospital. Depending on the potential of the underlying disease for thrombosis, it is ideal to minimize bleeding risk by resuming anticoagulation medications 1 week after an uncomplicated elective PKB. Other clinical patient factors that have been reported to increase the risk of bleeding include elevated serum creatinine3,46,70 and elevated blood pressure (systolic .140 mm Hg or diastolic .90 mm Hg).38,56,70 Two studies have reported younger age to be a risk factor,36,56 but older age is associated with an increased risk of major complication.3 However, in a large prospective study of older patients, there was no increased risk of complication from the PKB.71 Similar to an older age, the effect of the underlying histologic diagnosis on developing a complication is not likely relevant. Many diseases, such as end-stage kidney disease,58 acute tubular necrosis,53,58 autoimmune disease,58 amyloidosis,38 hypertensive renal disease,53 or coinfection with hepatitis C and human immunodeficiency virus,72 are associated with an increased risk, but none have been substantiated across multiple studies. For example, Eiro and colleagues38 labeled amyloidosis as a risk factor for bleeding, but in a study from the Mayo Clinic, with more than 100 patients with amyloidosis,73 there was a similar rate of complications compared with patients without amyloidosis. The ideal PKB technique is effective and safe, as it will lead to an adequate tissue sample (at least 10 glomeruli,

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but $20 may be necessary for a diagnosis of a focal disease) without developing a complication. Although there have been several modifications to the procedure since its inception in 1951, the overall major complication rate has been relatively static. One of the earlier modifications was to use radiological imaging for guidance instead of the ‘‘blind’’ approach.11,12 However, it was not until recently that the ‘‘blind’’ approach (using U/S for localization only) was compared directly with real-time U/S. In this study, the group that underwent PKB with the ‘‘blind’’ approach had more major complications, more rebiopsies for inadequate sample, and less diagnostic yield compared with the group that underwent the procedure with real-time U/S74 (Table 2). When the radiological imaging techniques are available, they should be used, as they have a proven safety profile. At present, there is no head-to-head comparison study using CT versus real-time U/S guidance. The use of either of these modalities is physician and patient dependent, taking into consideration variables such as patient size,14 patient and physician comfort, previous experience, radiation exposure, and cost. Other procedural-related factors that may be linked to complications are needle type, gauge, and depth. It is intuitive that a larger needle would induce more trauma and lead to a greater complication rate; however, a smaller needle may lead to less diagnostic yield and require more passes or attempts to obtain adequate tissue, which could also lead to a greater complication rate. Indeed, 1 study has shown that .5 passes is associated with a higher complication rate,38 so the question of needle size remains an important one. The earlier studies that compared needle sizes (14-18 gauge [G]) were confounded by the use of different types of needles (manual vs automated).2 Although the larger manual needles provided more glomeruli per core and per biopsy compared with smaller automated needles,21,42 they were associated with an increased rate of complications.21-23 The only comparative study of the same gauge (14 G) yielded more glomeruli with the automated needle without a difference in complications.20 Recently, a prospective study using 14-G and 16-G automated needles revealed no difference in the frequency of complications or in the number of glomeruli.36 In another prospective study,75 16-G and 18-G automated needles were compared. There was no difference in major complications, but patients had more pain in the 16-G group. The yield was significantly better in the 16-G group, with more glomeruli and less crushing artifact. Furthermore, a prospective randomized controlled trial using automated needles of 3 different sizes (14, 16, and 18 G) in kidney allograft biopsies revealed no difference in complication rates between the 3 sizes, but a higher diagnostic adequacy and more pain in the group with the largest needle.76 Finally, 1 set of investigators determined a formula to calculate the ideal depth to advance the nee-

dle based on the patient’s height and weight. They compared use of this method with historical controls and found it was associated with less minor complications and a greater diagnostic yield.77 Therefore, controversy remains regarding the ideal needle size and method of imaging to obtain tissue. To optimize safety, patient comfort, and diagnostic yield, we use a 14-G automated needle with real-time U/S guidance as our standard approach.3

Methods to Reduce Risk of Bleeding As the most common complications of the PKB are related to hemorrhage, a careful history and physical examination with attention to risk factors for bleeding should be performed. In addition, controlling modifiable risk factors such as coagulopathies or HTN may be of benefit. Recently, prophylactic use of DDAVP was studied at a single center in an attempt to decrease bleeding complications.52 In this double-blinded placebo trial, low-risk patients (GFR .60 mL/min/1.73 m2, normal blood pressure, and normal coagulation profile, including bleeding time) were randomly assigned to receive DDAVP or placebo before undergoing a PKB. There was a decreased rate of silent hematomas in the group receiving DDAVP but no difference in major or minor complications. There was no harm of administering DDAVP in this group of patients, but the study was not powered to detect this possibility. As there was no increased rate of complications in this group of low-risk patients, giving a medication with potential side effects is not warranted.78 A more controversial area is use of DDAVP in patients with high risk based on platelet dysfunction (significantly reduced GFR and/or elevated bleeding time or PFA). Although DDAVP reduces the bleeding time in patients with uremia,79,80 it is not clear whether it reduces their risk of bleeding,44,58 and requires further study. Other methods that improve the bleeding time in uremia (cryoprecipitate, estrogens, erythropoietin) have similarly not been validated for use in high-risk patients before PKB.61

Postprocedure Observation After the procedure, the patient should be supine for at least 4 to 6 hours. Vital signs should be closely monitored during this period. How long a patient requires further observation is controversial, but should ideally be based on the timing when most complications occur.81 One study addressed this issue in a group of 750 patients undergoing native PKB (Table 3)3. In this study, all patients were observed for at least 24 hours, and 90% of complications were detected within that period. Thirty-three percent of both major and minor complications were not detected until after 8 hours, implying that if these patients were

Complications of the PKB

Table 3. Cumulative Timing of Complications After PKB Hours After Biopsy Complications

n

#4

#8

#12

#24

.24

Total Minor Major

91 46 45

42% 46% 38%

67% 67% 67%

85% 80% 89%

89% 87% 91%

11% 13% 9%

Reproduced with permission from Whittier WL, Korbet SM. J Am Soc Nephrol. 2004;15:142-147.3

not observed for at least 12 hours, many complications would have been missed. However, other investigators have reported their experience with smaller windows of observation and same-day discharge in select low-risk patients,43,82-85 and although there is no record of specific timing of complications, the procedures were generally performed safely without significant major complications. Identifying the risk of the patient to develop a bleeding complication is therefore relevant. Those who are at low risk of bleeding, such as those who have no bleeding diathesis, normal blood pressure, preserved renal function, a stable hematocrit at 6 hours,34 and a normal U/S at 1 hour,44 could possibly be followed with a shorter period of observation. At present, it is not clear whether the universal extrapolation of an observation time shorter than 24 hours is in the best interest of the patient.

Special Circumstances The absolute contraindications to a PKB, described more than 20 years ago, are uncontrolled bleeding diathesis, uncontrolled severe HTN, an uncooperative patient, and a solitary native kidney.86 The reason that a solitary kidney is in this category is not because of an increased risk of bleeding, but rather owing to the concern that a major complication may lead to nephrectomy, which would render the patient anephric. There are only a few cases of safe and successful PKBs in patients with solitary native kidneys,87 and, because the overall bleeding risk after a PKB is so low, it has been suggested that it may be more appropriate than an open procedure, as this would avoid the risk of general anesthesia.61,88,89 Furthermore, an allograft kidney biopsy (also solitary) is routinely performed, and although the overall incidence of complications may be lower76,90 compared with native biopsies, it is still done under a similar circumstance, that is, the rare need for nephrectomy would lead to an anephric state. However, at the present time, there is too limited experience to recommend the percutaneous approach in the setting of a solitary native kidney, and although it may not need to be an absolute contraindication,61 caution is advised before undertaking this approach. Other patient factors may alter the procedure as well. Significant obesity may limit visualization with U/S, and

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a CT-guided approach may be warranted.14 Altering the prone positioning to one of supine anterolateral has also been described as being safe and effective91 for obese patients, as well as use of the transjugular renal biopsy.92 Pregnancy is another special circumstance, not only because the prone positioning may need to be altered based on gestational age or patient comfort, but also because the risk of the biopsy or the underlying disease may affect the mother and her fetus. One of the early studies, from 1965, described the bleeding complication rate in 90 pregnant patients who underwent a PKB, which was greater compared with that of nonpregnant patients.93 After this report, biopsy in pregnant patients continued but only with extreme caution. Although the risk of bleeding complications in pregnant patients has been shown in several modern series to be equivalent to that of nonpregnant patients,94,95 the potential for maternal–fetal harm should be considered. Ideally, the procedure should be postponed, if possible, until the postpartum period, unless it may alter management before delivery.96-99

Conclusions PKB is an essential and valuable method to establish the etiology of kidney disease so that potential treatments can be determined. It is a safe procedure, with a minimal rate of complications. The most common complications are related to bleeding, and only rarely are these catastrophic. Since its establishment in the early 1950s, modifications to the procedure and ongoing experience have allowed it to remain the gold standard for diagnosing glomerular disease. Future studies evaluating complications should focus on risk factors and methods to modify this risk for patients who require this procedure.

References 1. Iversen P, Brun C. Aspiration biopsy of the kidney. Am J Med. 1951;11:324-330. 2. Korbet SM. Percutaneous renal biopsy. Semin Nephrol. 2002;22: 254-267. 3. Whittier WL, Korbet SM. Timing of complications in percutaneous renal biopsy. J Am Soc Nephrol. 2004;15:142-147. 4. Whittier WL, Korbet SM. Renal biopsy: update. Curr Opin Nephrol Hypertens. 2004;13:661. 5. Griffin KA. The technique of percutaneous renal biopsy. How to minimize risk while ensuring adequate tissue sampling. J Crit Illn. 1992;7:284-292. 6. Diamond JB. Kea, Bird of Paradox. The Evolution and Behavior of a New Zealand Parrot. Berkeley, CA: University of California Press; 1999. 7. Kark RM. Renal biopsy in the modern era. In: Cameron JS, Glassock RJ, eds. The Nephrotic Syndrome. New York, NY: Decker; 1988:57-86. 8. Kark RM, Muehrcke RC. Biopsy of kidney in prone position. Lancet. 1954;266:1047. 9. Brun C, Raaschou F. Kidney biopsies. Am J Med. 1958;24:676-691. 10. Kark RM, Muehrcke RC, Pirani CL, Pollak VE. The clinical value of renal biopsy. Ann Intern Med. 1955;43:807-847.

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