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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 43-47

Indications for percutaneous ultrasound-guided renal biopsy and complications associated with it: An observational study


Department of Nephrology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Submission30-Jul-2022
Date of Acceptance20-Sep-2022
Date of Web Publication16-Nov-2022

Correspondence Address:
Manzoor Ahmad Parry
Department of Nephrology, Sher-i-Kashmir Institute of Medical Sciences, SKIMS Main Rd, Soura, Srinagar 190011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DYPJ.DYPJ_56_22

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  Abstract 

Introduction: Renal biopsy is performed for various reasons depending on the signs and symptoms presented. Although percutaneous kidney biopsy is a safe procedure, major or minor complications may occur. Our study aimed to assess the indications for percutaneous renal biopsy and complications associated with the procedure. Materials and Methods: This was a prospective observational study conducted in the Department of Nephrology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar. Patients who underwent percutaneous ultrasound-guided renal biopsy at the Institute between October 2017 and June 2019 were enrolled in the study. Data regarding indications for performing a percutaneous renal biopsy and incidence of minor and major post-biopsy complications were collected. Results: A total of 229 patients who underwent ultrasound-guided percutaneous renal biopsy under ultrasound guidance were enrolled in the study. The most common indications for ultrasound-guided percutaneous renal biopsy were nephrotic syndrome (33.3%), subnephrotic proteinuria with azotemia (14%), and unexplained azotemia with proteinuria and hematuria (13.5%). Post-biopsy complications were observed in 89 (37.55%) patients. Minor complications developed in 83 (36.22%) patients and major complications in 6 (2.62%) patients. Among patients with major complications, two (0.87%) patients underwent invasive procedures (embolization and cystoscopic removal of bladder clot) and four patients developed hemodynamic instability. There was no procedure-related mortality reported in the study. Conclusions: The most common indications for renal biopsy were nephrotic syndrome, subnephrotic proteinuria with azotemia, unexplained azotemia with proteinuria, and hematuria. The incidence of major complications was low.

Keywords: Azotemia, complications, nephrotic syndrome, percutaneous ultrasound-guided renal biopsy, renal biopsy


How to cite this article:
Bhat MA, Sulayman S, Parry MA, Wani MM, Wani IA. Indications for percutaneous ultrasound-guided renal biopsy and complications associated with it: An observational study. D Y Patil J Health Sci 2022;10:43-7

How to cite this URL:
Bhat MA, Sulayman S, Parry MA, Wani MM, Wani IA. Indications for percutaneous ultrasound-guided renal biopsy and complications associated with it: An observational study. D Y Patil J Health Sci [serial online] 2022 [cited 2022 Nov 27];10:43-7. Available from: http://www.dypatiljhs.com/text.asp?2022/10/2/43/361371




  Introduction Top


An ultrasound-guided percutaneous renal biopsy is an important tool in nephrology practice to confirm a diagnosis, recommend a therapy, determine treatment outcome, and establish the degree of active and chronic changes.[1],[2] Percutaneous renal biopsy provides valuable information for the prognosis and management of patients. The renal biopsy procedure has advanced with the addition of tools and technology that optimize the result. The real-time ultrasonography (USG) to localize the kidney and automated biopsy needles have improved the safety of the procedure and the number of procedures considerably.[3],[4],[5],[6]

For the ultrasound-guided percutaneous renal biopsy to be successful, adequate pre-procedure patient evaluation, preparation for the procedure, and post-procedure monitoring are essential. The indications for performing a renal biopsy are determined by the signs and symptoms presented. Although ultrasound-guided percutaneous kidney biopsy is a safe procedure, minor or major complications may occur.[1] Some studies have reported significant complications in less than 1% of cases;[7],[8] however, contrarily some studies have reported higher rates of complications.[9],[10],[11]

We conducted this single-center, observational study to assess the indications for ultrasound-guided percutaneous renal biopsy and to find out the rate of complications associated with it. We evaluated if the number of minor and major complications is comparable to that reported in the literature.


  Materials and Methods Top


Patients

This was a prospective, single-center, observational study conducted at the Department of Nephrology, in a tertiary care hospital of North India. The inclusion criterion of the study was patients who underwent percutaneous ultrasound-guided renal biopsy at the Institute between October 2017 and June 2019. Exclusion criteria of the study were international normalized ratio (INR) >1.3, platelet count <50,000/cu mm, uncontrolled hypertension (systolic blood pressure [BP] >160 mm Hg and diastolic BP >90 mm Hg) or acute exacerbations of chronic obstructive pulmonary disease, chronic liver disease, congestive heart failure, stroke, solitary kidney (native), or antiplatelet drug (Aspirin and Clopidogrel) use within 7 days of the biopsy. In addition, patients with hydronephrosis, cyst, perinephric abscess, and small-sized kidneys (<9 cm proven by ultrasound) were also excluded from the study.

Biopsy procedure

All biopsies were performed under real-time ultrasound guidance (eSoate MyLabSix Mode number 164XX NL 192108) under local anesthesia (1%–2% lignocaine) injected from the skin down to the renal capsule, along the biopsy tract. One pediatric patient required sedation. The biopsies were performed with an automated biopsy gun (Bard TruGuide model number MC1816) with a 16-gauge needle for adults and an 18-gauge needle for pediatric patients.

The patients were placed in the prone position for the biopsy. Renal biopsies were performed preferentially from the left kidney as it is away from the major vessels. The skin was prepped with povidone-iodine and draped to maintain sterility. The USG probe was covered with a sterile cover and placed on the skin after applying the sterile jelly.

Before reaching the renal capsule, the patient was instructed to take a deep inspiration and hold it such that the lower pole came under the needle tip. The needle was advanced to pass the capsule and then triggered to collect the specimen. The needle was then withdrawn immediately, and the patient was instructed to start breathing. We collected two cores of kidney tissue: one core was transferred in a vial containing normal saline for immunofluorescence examination and the other core was transferred in a vial containing 10% formalin for light microscopic examination. The specimens were examined within 24 h of collection. An immediate post-biopsy ultrasound was performed to inspect perinephric hematoma.

Post biopsy observations

Post-biopsy, all patients were kept on 8 h bed rest and observed for 24 h at the hospital. Patients were advised not to perform any strenuous activity for 2 weeks after discharge from the hospital. Patients were monitored for post-biopsy complications. The post-biopsy complications were categorized as minor and major complications. Minor complications included complications that did not require surgical intervention and/or blood transfusion. Major complications included complications that required surgical intervention and/or blood transfusion.

Statistical analysis

Data were analyzed by using the Statistical Package for Social Sciences (SPSS) software program, version 21.0. The data were first keyed in MS Excel 2007 and converted into SPSS for analysis. The results were expressed as percentages or mean ± standard deviation. Pearson chi-square and Fischer’s exact t test was used for comparison of proportions and percentages. A two-tailed P-value was used for calculating statistical significance; a value of P < 0.05 was considered significant.


  Results Top


The study enrolled 229 of 261 patients who underwent renal biopsy at the institute. A total of 32 patients were excluded as they did not meet the inclusion/exclusion criteria. Of 229 patients, 136 were male and 93 were female patients. The mean age of the patients was 39.86 ± 15.22 years.

The most frequent indications for renal biopsy were nephrotic syndrome (76; 33.2%), subnephrotic proteinuria with azotemia (32; 14%), unexplained azotemia, proteinuria, and hematuria (31; 13.5%) [Table 1].
Table 1: Reasons for ultrasound-guided percutaneous renal biopsy

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The most observed complications post percutaneous renal biopsy were pain (89; 38.86%), hematoma (13; 5.67%), gross hematuria (11; 4.8%), and hypotension (5;2.2%) [Table 2]. A statistically significant relation between hematoma and azotemia (P = 0.03) was observed [Table 3]. No statistically significant relationship was observed between frequency of complications and age groups or hypertension [Table 5] and [Table 6]. The gross hematuria was resolved within 24 h post-biopsy in 8 of 11 (3.49%) patients without any hemodynamic instability.
Table 2: Complications of percutaneous renal biopsy

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Table 3: Post-biopsy complication and relation with azotemia

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Table 5: Frequency of complications in different age groups

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Table 6: Frequency of complications and Hypertension

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Most patients had a mean change of <1 and ≥1<2 mg/dL in hemoglobin from baseline to post-biopsy (57.6% and 24.5%) [Table 4]. No substantial difference was observed in the overall mean change in hemoglobin from baseline to post-biopsy. The mean change of ≥2 mg/dL in hemoglobin from baseline to post-biopsy was observed in 13 (5.7%) patients.
Table 4: Change in hemoglobin level

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Six (2.62%) patients developed major complications, and two of six (0.87%) patients underwent an invasive procedure [Table 7]. Three (1.31%) patients with gross hematuria developed major complications-pseudoaneurysm with persistent hematuria, urinary bladder clot, and persistent hematuria 30 h post-biopsy. The patient who developed a pseudoaneurysm with persistent hematuria for 3 days complicated by Hypotension needed angiographic localization of bleed with embolization and 3 units of blood transfusion for hemodynamic instability. The patient who developed a urinary bladder clot after hematuria with retention of urine required a cystoscopic clot removal clot. The third patient with persistent hematuria for 30 h post-biopsy with hypotension also required blood transfusion.
Table 7: Major complications developed during the study

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Three of five patients with hypotension required blood transfusion. One of these three patients had pseudoaneurysm requiring embolization of the feeder artery and two patients required intravenous normal saline. There was no procedure-related mortality in our study.


  Discussion Top


The renal biopsy is an important decision-making tool in nephrology practice. Although percutaneous renal biopsy is a safe procedure, minor or major complications may occur. Various factors are associated with the occurrence of complications during and post-biopsy. This prospective, single-center study aimed to assess the Indications for percutaneous ultrasound-guided renal biopsy and associated post-biopsy complications.

We observed that the most common indications for percutaneous renal biopsy were nephrotic syndrome (33.2%), subnephrotic proteinuria with azotemia (14%) unexplained Azotemia, and proteinuria with hematuria (13.5%). These results were consistent with the studies reporting indications and epidemiologic data of renal biopsies in India.[12],[13],[14],[15] The percentage of patients with other indications was also consistent with that observed in some other studies.[16],[17]

We observed a lower risk of major complications (2.6%). Similar to our results, a prospective study also reported that percutaneous renal biopsy was associated with a 5% risk of major complications.[18] Although the risk of major complications in our study was much lower, it can be due to the comparatively smaller sample size (229 in our study vs. 5304 patients). But unlike our results, the researchers reported a decrease in hemoglobin level of ≥2 mg/dL was the most frequent post-biopsy major complication. Furthermore, they reported that the higher plasma creatinine levels, liver disease, and higher number of needle passes were the risk factors for major complications.[18]

In our study, the most-reported post-biopsy complication was pain (38.86%), hematoma occurred in 5.67% of patients, and of these 2.2% of patients developed a major complication. The observed rate of hematoma was within the range reported by other studies (4% to 33% of patients).[10],[19] Also, the percentage of patients with hematoma developing major complications was similar to these studies reporting major complications in 1.9% of patients with hematoma.

Hematoma can be subcapsular, retroperitoneal, or, rarely due to injury of the lumbar vessels. The post-procedural ultrasound investigation is important to capture the hematoma. The detectable hematoma usually leads to minor or major post-procedure. Hence, it is considered a predictor of bleeding-related complications; however, no significant relationship between the size of hematoma and the extent of bleeding has been found.[20],[21],[22] It can be asymptomatic or associated with hematuria, flank pain, anemia, and shock.

Hematuria is a very common complication of percutaneous biopsy. Microscopic hematuria occurs in almost all patients, whereas gross hematuria occurs in 5%–9%.[21] The hematuria incidence may be increased due to the presence of uncontrolled hypertension or uremia. Hematuria usually resolves spontaneously within 2 days, but in approximately 0.5% of patients, it may persist for 2–3 weeks. Sometimes gross hematuria is observed in patients a few days after the biopsy, which resolves with rest.[21] We observed gross hematuria in 11 (4.8%) patients and 3 (1.31%) of these developed major complications. Our results are also consistent with a study among 750 patients, hematuria was reported in 35 (4.6%) patients, and 12 (1.6%) of these patients required blood transfusion or invasive procedure (CIT36X).[10]

Percutaneous renal biopsy is sometimes associated with severe complications. Hence pre-procedure evaluation of patients to avoid complications is imperative.[6],[23] The pre-procedure evaluation should include the history of bleeding diathesis, recent nonsteroidal anti-inflammatory drug (NSAID) use, hypertension control, recent pyelonephritis or skin infections near the biopsy site, and the ability to comply with instructions during the biopsy.[5] The complete blood count, platelets, and prothrombin time/INR are evaluated pre-procedure on a routine basis. Although bleeding time has no significant correlation to surgical bleeding[24] biopsy complications are mainly related to bleeding. Moreover, Stiles et al.[25] performed renal biopsies without evaluating bleeding time and showed that the bleeding time does not significantly alter the major complication rates. The post-renal bleeding complications are typically related to blood vessels in the perinephric area or the collecting system and rarely to the lumbar or mesenteric artery.[19]

Manno et al.[19] prospectively evaluated the predictive value of demographics, clinical data, baseline chemistry, and needle size for the risk of post-renal biopsy complications in 471 patients. They concluded that only gender, age, and baseline PTT showed a significant predictive value and the other variables investigated did not have any predictive value. Although we did not evaluate the predictive value of these factors, we did not observe any significant statistical relations between the frequency of complications and age groups or preexisting hypertension.

A study performed percutaneous renal biopsies in 394 native kidneys and concluded that observation of patients for 23–24 h is optimal and that observation for 8 h or fewer risks missing approximately 20% of complications.[26] Contrarily, the literature review shows that 3% of complications occur within 8 h and that 91% occur within 24 h.[27] We observed patients for 24 h post-biopsy. Biopsy-related infections are rare; there were no infections observed in our study.[28]


  Conclusion Top


Ultrasound-guided renal needle biopsy is an essential tool in nephrological practice. It is imperative in the diagnosis and therapeutic management of patients. It is a highly standardized invasive procedure, associated with a high technical success rate and a relatively small number of minor or major complications. The most common indications for renal biopsy were nephrotic syndrome, subnephrotic proteinuria with azotemia, unexplained azotemia with proteinuria and hematuria, and subnephrotic proteinuria. The incidence of major complications was low. There was no procedure-related mortality in our study.

Acknowledgement

Our sincere thanks to all the support staff of the Department of Nephrology, Sher-i-Kashmir Institute of Medical Sciences for their contribution and support throughout the study.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Authors’ contributions

MAB, MMW, and IAW were involved in the concept, design, and definition of intellectual content of this study. SS and MAP did the literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, and manuscript review. MAP takes responsibility as a guarantor for the integrity of the work as a whole from inception to published article.



 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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