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Pulsatile Hematuria From Procurement Core Needle Biopsy: A Case Report
Pulsatile Hematuria From Procurement Core Needle Biopsy: A Case Report Y.K. Kwona,*, F.A. Cheemab, J.R. Wagnerc, R. Gordond, P.A. Sheinera, B.T. Maneckshanaa, and C. Rochona a c
Department of Transplant, Hartford Hospital, Hartford, CT; bDepartment of Infectious Disease, Hartford Hospital, Hartford, CT; Department of Urology, Hartford Hospital, Hartford, CT; and dDepartment of Interventional Radiology, Hartford Hospital, Hartford, CT
ABSTRACT Core needle biopsies are still widely performed to evaluate the pathologic suitability of a kidney allograft. Here, we report a case of pulsatile hematuria from a procurement core needle biopsy where the patient had to be taken emergently to interventional radiology for coil embolization immediately after organ reperfusion.
O
UR current Organ Procurement and Transplantation Network policy does not state when to perform a procurement kidney biopsy nor the recommended biopsy method. However, procurement biopsies are still widely performed for various reasons [1]. Although the majority of organ procurement organizations are recommending and employing wedge biopsies as the preferred method, as advocated by a previous Organ Procurement and Transplantation Network policy [2], core needle biopsies are still frequently used. In fact, the New York Organ Donor Network, one of the top 3 organ procurement organizations with the largest kidney waiting list, exclusively uses core needle biopsy to evaluate the pathologic suitability of kidney allografts [3]. Here, we report an operative case of a deceased donor kidney transplant where pulsatile hematuria was encountered immediately after reperfusion as a result of an improperly performed core needle biopsy. CASE REPORT A 74-year-old man was listed at our transplant center for kidney transplant on August 2017. He had 3 years of dialysis wait-time. His kidney failure was secondary to amyloidosis. Other significant medical problems included hypertension, insulin dependent diabetes, chronic obstructive pulmonary disease, and obesity with a body mass index of 38 kg/m2 (height 162 cm; weight 101 kg). His blood type is AB and he had a 0% calculated panel reactive antibody with an estimated posttransplant survival score of 98% at the time of listing. On March 2018, the patient became primary for a regional donation after circulatory death kidney offer at sequence 43. The donor was a 65-year-old man with a history of hypertension and with a 98% Kidney Donor Risk Index score. The donor’s body mass index was 30.7 kg/m2 (height 165 cm; weight 83.7 kg) with a peak creatinine of 1.5 mg/dL and a terminal creatinine of 1.09 mg/dL. ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 3957e3960 (2018)
Extubation to aortic flush time was 28 minutes, and circulatory cessation to flush time was 16 minutes. After the kidneys were removed and on the backtable, an upper pole core biopsy was performed using a standard 16-gauge needle by the procuring surgeon. The biopsy only showed 6 glomeruli. A wedge biopsy was subsequently performed. This showed more than 50 glomeruli of which only 1 glomerulus was sclerosed. The only other notable finding was mild (1þ) tubular interstitial fibrosis without vessel arteriosclerosis or hyalinosis. The kidney was placed on a pulsatile perfusion pump. At the time of the organ offer (6 hours cold ischemia time), it showed a resistance of 0.28 mm Hg/(mL/min/100 g) with a flow rate of 119 mL/min/100 g. Given our recipient’s advanced age and reasonable candidacy at the time of this offer, we accepted this organ. With a cold ischemia time of 18 hours and a warm ischemia time of 28 minutes, the kidney was reperfused. Upon reperfusion, we immediately noticed a profound pulsatile hematuria from the ureter (Fig 1; Video 1). A surgical clip was placed at the tip of the ureter to prevent ongoing hemorrhage. We held an intraoperative multidisciplinary discussion with urology and interventional radiology (IR) to discuss various potential treatment options, and we opted to proceed with an IR-selective embolization procedure. The patient was swiftly transferred to an IR suite located on the same main operative room floor, and a transplant kidney arteriogram was performed via the right common femoral artery. The kidney had one main renal artery with early bifurcation into an upper pole and lower pole artery. The lower pole artery did not show any extravasation of contrast. As suspected, the upper pole artery showed a high-flow arteriovenous fistula with an active extravasation of contrast into a renal calyx (Fig 2). The upper pole artery was successfully coil-embolized using a total of 60 mL of iohexol
*Address correspondence to Yong K. Kwon, 85 Seymour Street, Suite 320, Hartford, CT 06106. Tel: þ1 860-696-2030. E-mail: [email protected] 0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.07.001
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KWON, CHEEMA, WAGNER ET AL
Fig 1. Pulsatile bleeding from the tip of the ureter.
Omnipaque 300 contrast solution (Nycomed Imaging AS, Oslo, Norway), and the resolution of the pulsatile hematuria was confirmed by removing the surgical clip at the end of the ureter (Video 2). This embolization resulted in a loss of roughly 40% of the kidney perfusion as shown by the kidney surface demarcation (Fig 3). Immediately in the postanesthesia care unit, the patient underwent hemodialysis (HD) to minimize contrast-induced nephropathy. His postoperative hospital course was unremarkable in terms of recovery from the surgery. However, the patient remained anuric throughout the hospitalization, requiring scheduled HD. He was discharged home on postoperative day (POD) 6 with outpatient HD arrangements. His urine output began to pick up slowly around POD 21, and we started the HD weaning process. Unfortunately, a urine leak was identified on POD 45 after evaluation of new-onset abdominal pain and distention. A cystogram study showed the urine leak originating from the upper pole area of the kidney (Fig 4). Prolonged urinary catheter placement was required. The patient developed a
catheter-associated urinary tract infection, which subsequently prolonged the renal recovery further. At the time of this manuscript writing, POD 90, the patient is currently making approximately 1.3 L of urine daily and still requiring once a week dialysis.
DISCUSSION
Although the safety of using core biopsy needles on cadaveric kidneys at the time of procurement has not been reported, percutaneous core needle biopsies on native or transplant kidneys have been shown to be a safe procedure with a very low complication rate [4,5]. Although very rare, serious hemorrhagic complications do indeed occur with the percutaneous kidney biopsy. According to the largest metaanalysis review study, 30 of 8445 such biopsies required angiographic interventions and 1 out of 8941 biopsies required nephrectomy as a result of a major hemorrhagic
HEMATURIA FROM PROCUREMENT NEEDLE BIOPSY
3959
Fig 2. Transplant kidney arteriography. (A) Early filling of renal vein consistent with high-flow arteriovenous fistula. (B) Contrast filling a renal calyx. (C) Renal calyx fully filled with contrast in venous phase.
Fig 3. Demarcation on the kidney surface.
Fig 4. Cystogram leaking contrast near the upper pole of the kidney.
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complication [5]. Here, we report a case of a serious hemorrhagic complication after reperfusion because a core needle biopsy was improperly performed on a kidney in the backtable. To our best knowledge, this is the first such report. Our patient had profound hematuria upon reperfusion from a technical error by firing the biopsy needle deeply into the renal hilum, as evidenced by the angiographic images (Fig 2). We entertained several options when we encountered this unexpected problem: accepting graft loss by proceeding with a transplant nephrectomy; leaving the ureter clipped for tamponade and perform a second look operation in 24e48 hours; or selective IR coil embolization, knowing this will inevitably result in loss of some kidney function and potential nonreversible contrast-induced nephropathy. In our case of the 74-year-old recipient with multiple medical conditions and baseline frailty, we opted to proceed with the third option. Our rational for this choice was that we wanted a definitive treatment for the hematuria at that moment in time, while giving the patient a chance to be dialysis free. Although the current marginal graft function was somewhat expected given that the kidney had a 98% Kidney Donor Risk Index score, was a donation after circulatory death organ, lost about 40% of function from the embolization, and was subjected to contrast dye immediately after ischemia-reperfusion injury, we believe that we made the best choice at that time. We hope the graft will eventually
KWON, CHEEMA, WAGNER ET AL
gain enough function to wean the patient off of HD completely. We also hope that procuring surgeons will be more cognizant of potential graft-threatening hemorrhagic complications encountered when a core needle biopsy is not performed properly. ACKNOWLEDGMENTS We would like to thank our local organ procurement organization, New England Donor Services, for their continued support and assistance.
REFERENCES [1] U.S. Department of Health & Human Services. Organ Procurement and Transplantation Network (OPTN) policies. https:// optn.transplant.hrsa.gov/governance/policies/; 2018 [accessed 12. 05.18]. [2] Singh P, Farber JL, Doria C, Francos GC, Gulati R, Ramirez CB, et al. Peritransplant kidney biopsies: comparison of pathologic interpretations and practice patterns of organ procurement organizations. Clin Transplant 2012;26:E191e9. [3] Yushkov Y, Dikman S, Alvarez-Casas J, Giudice A, Hoffman A, Goldstein MJ. Optimized technique in needle biopsy protocol shown to be of greater sensitivity and accuracy compared to wedge biopsy. Transplant Proc 2010;42:2493e7. [4] Simunov B, Gunjaca M, Cingel B, Skegro D, Knotek M. Safety of outpatient kidney biopsies. Nephron 2018;138:275e9. [5] Corapi KM, Chen JL, Balk EM, Gordon CE. Bleeding complications of native kidney biopsy: a systematic review and meta-analysis. Am J Kidney Dis 2012;60:62e73.
Department of Transplant, Hartford Hospital, Hartford, CT; bDepartment of Infectious Disease, Hartford Hospital, Hartford, CT; Department of Urology, Hartford Hospital, Hartford, CT; and dDepartment of Interventional Radiology, Hartford Hospital, Hartford, CT
ABSTRACT Core needle biopsies are still widely performed to evaluate the pathologic suitability of a kidney allograft. Here, we report a case of pulsatile hematuria from a procurement core needle biopsy where the patient had to be taken emergently to interventional radiology for coil embolization immediately after organ reperfusion.
O
UR current Organ Procurement and Transplantation Network policy does not state when to perform a procurement kidney biopsy nor the recommended biopsy method. However, procurement biopsies are still widely performed for various reasons [1]. Although the majority of organ procurement organizations are recommending and employing wedge biopsies as the preferred method, as advocated by a previous Organ Procurement and Transplantation Network policy [2], core needle biopsies are still frequently used. In fact, the New York Organ Donor Network, one of the top 3 organ procurement organizations with the largest kidney waiting list, exclusively uses core needle biopsy to evaluate the pathologic suitability of kidney allografts [3]. Here, we report an operative case of a deceased donor kidney transplant where pulsatile hematuria was encountered immediately after reperfusion as a result of an improperly performed core needle biopsy. CASE REPORT A 74-year-old man was listed at our transplant center for kidney transplant on August 2017. He had 3 years of dialysis wait-time. His kidney failure was secondary to amyloidosis. Other significant medical problems included hypertension, insulin dependent diabetes, chronic obstructive pulmonary disease, and obesity with a body mass index of 38 kg/m2 (height 162 cm; weight 101 kg). His blood type is AB and he had a 0% calculated panel reactive antibody with an estimated posttransplant survival score of 98% at the time of listing. On March 2018, the patient became primary for a regional donation after circulatory death kidney offer at sequence 43. The donor was a 65-year-old man with a history of hypertension and with a 98% Kidney Donor Risk Index score. The donor’s body mass index was 30.7 kg/m2 (height 165 cm; weight 83.7 kg) with a peak creatinine of 1.5 mg/dL and a terminal creatinine of 1.09 mg/dL. ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 3957e3960 (2018)
Extubation to aortic flush time was 28 minutes, and circulatory cessation to flush time was 16 minutes. After the kidneys were removed and on the backtable, an upper pole core biopsy was performed using a standard 16-gauge needle by the procuring surgeon. The biopsy only showed 6 glomeruli. A wedge biopsy was subsequently performed. This showed more than 50 glomeruli of which only 1 glomerulus was sclerosed. The only other notable finding was mild (1þ) tubular interstitial fibrosis without vessel arteriosclerosis or hyalinosis. The kidney was placed on a pulsatile perfusion pump. At the time of the organ offer (6 hours cold ischemia time), it showed a resistance of 0.28 mm Hg/(mL/min/100 g) with a flow rate of 119 mL/min/100 g. Given our recipient’s advanced age and reasonable candidacy at the time of this offer, we accepted this organ. With a cold ischemia time of 18 hours and a warm ischemia time of 28 minutes, the kidney was reperfused. Upon reperfusion, we immediately noticed a profound pulsatile hematuria from the ureter (Fig 1; Video 1). A surgical clip was placed at the tip of the ureter to prevent ongoing hemorrhage. We held an intraoperative multidisciplinary discussion with urology and interventional radiology (IR) to discuss various potential treatment options, and we opted to proceed with an IR-selective embolization procedure. The patient was swiftly transferred to an IR suite located on the same main operative room floor, and a transplant kidney arteriogram was performed via the right common femoral artery. The kidney had one main renal artery with early bifurcation into an upper pole and lower pole artery. The lower pole artery did not show any extravasation of contrast. As suspected, the upper pole artery showed a high-flow arteriovenous fistula with an active extravasation of contrast into a renal calyx (Fig 2). The upper pole artery was successfully coil-embolized using a total of 60 mL of iohexol
*Address correspondence to Yong K. Kwon, 85 Seymour Street, Suite 320, Hartford, CT 06106. Tel: þ1 860-696-2030. E-mail: [email protected] 0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.07.001
3957
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KWON, CHEEMA, WAGNER ET AL
Fig 1. Pulsatile bleeding from the tip of the ureter.
Omnipaque 300 contrast solution (Nycomed Imaging AS, Oslo, Norway), and the resolution of the pulsatile hematuria was confirmed by removing the surgical clip at the end of the ureter (Video 2). This embolization resulted in a loss of roughly 40% of the kidney perfusion as shown by the kidney surface demarcation (Fig 3). Immediately in the postanesthesia care unit, the patient underwent hemodialysis (HD) to minimize contrast-induced nephropathy. His postoperative hospital course was unremarkable in terms of recovery from the surgery. However, the patient remained anuric throughout the hospitalization, requiring scheduled HD. He was discharged home on postoperative day (POD) 6 with outpatient HD arrangements. His urine output began to pick up slowly around POD 21, and we started the HD weaning process. Unfortunately, a urine leak was identified on POD 45 after evaluation of new-onset abdominal pain and distention. A cystogram study showed the urine leak originating from the upper pole area of the kidney (Fig 4). Prolonged urinary catheter placement was required. The patient developed a
catheter-associated urinary tract infection, which subsequently prolonged the renal recovery further. At the time of this manuscript writing, POD 90, the patient is currently making approximately 1.3 L of urine daily and still requiring once a week dialysis.
DISCUSSION
Although the safety of using core biopsy needles on cadaveric kidneys at the time of procurement has not been reported, percutaneous core needle biopsies on native or transplant kidneys have been shown to be a safe procedure with a very low complication rate [4,5]. Although very rare, serious hemorrhagic complications do indeed occur with the percutaneous kidney biopsy. According to the largest metaanalysis review study, 30 of 8445 such biopsies required angiographic interventions and 1 out of 8941 biopsies required nephrectomy as a result of a major hemorrhagic
HEMATURIA FROM PROCUREMENT NEEDLE BIOPSY
3959
Fig 2. Transplant kidney arteriography. (A) Early filling of renal vein consistent with high-flow arteriovenous fistula. (B) Contrast filling a renal calyx. (C) Renal calyx fully filled with contrast in venous phase.
Fig 3. Demarcation on the kidney surface.
Fig 4. Cystogram leaking contrast near the upper pole of the kidney.
3960
complication [5]. Here, we report a case of a serious hemorrhagic complication after reperfusion because a core needle biopsy was improperly performed on a kidney in the backtable. To our best knowledge, this is the first such report. Our patient had profound hematuria upon reperfusion from a technical error by firing the biopsy needle deeply into the renal hilum, as evidenced by the angiographic images (Fig 2). We entertained several options when we encountered this unexpected problem: accepting graft loss by proceeding with a transplant nephrectomy; leaving the ureter clipped for tamponade and perform a second look operation in 24e48 hours; or selective IR coil embolization, knowing this will inevitably result in loss of some kidney function and potential nonreversible contrast-induced nephropathy. In our case of the 74-year-old recipient with multiple medical conditions and baseline frailty, we opted to proceed with the third option. Our rational for this choice was that we wanted a definitive treatment for the hematuria at that moment in time, while giving the patient a chance to be dialysis free. Although the current marginal graft function was somewhat expected given that the kidney had a 98% Kidney Donor Risk Index score, was a donation after circulatory death organ, lost about 40% of function from the embolization, and was subjected to contrast dye immediately after ischemia-reperfusion injury, we believe that we made the best choice at that time. We hope the graft will eventually
KWON, CHEEMA, WAGNER ET AL
gain enough function to wean the patient off of HD completely. We also hope that procuring surgeons will be more cognizant of potential graft-threatening hemorrhagic complications encountered when a core needle biopsy is not performed properly. ACKNOWLEDGMENTS We would like to thank our local organ procurement organization, New England Donor Services, for their continued support and assistance.
REFERENCES [1] U.S. Department of Health & Human Services. Organ Procurement and Transplantation Network (OPTN) policies. https:// optn.transplant.hrsa.gov/governance/policies/; 2018 [accessed 12. 05.18]. [2] Singh P, Farber JL, Doria C, Francos GC, Gulati R, Ramirez CB, et al. Peritransplant kidney biopsies: comparison of pathologic interpretations and practice patterns of organ procurement organizations. Clin Transplant 2012;26:E191e9. [3] Yushkov Y, Dikman S, Alvarez-Casas J, Giudice A, Hoffman A, Goldstein MJ. Optimized technique in needle biopsy protocol shown to be of greater sensitivity and accuracy compared to wedge biopsy. Transplant Proc 2010;42:2493e7. [4] Simunov B, Gunjaca M, Cingel B, Skegro D, Knotek M. Safety of outpatient kidney biopsies. Nephron 2018;138:275e9. [5] Corapi KM, Chen JL, Balk EM, Gordon CE. Bleeding complications of native kidney biopsy: a systematic review and meta-analysis. Am J Kidney Dis 2012;60:62e73.