Transjugular renal biopsy: our experience and technical considerations

Hepatitis B–Associated Lupus-Like Glomerulonephritis Successfully Treated With Antiretroviral Drugs and Prednisone: A Case Report and Literature Review

Kidney involvement with hepatitis B virus is varied and mostly limited to nephrotic syndrome with membranous nephropathy and nephritic syndrome with membranous proliferative glomerulonephritis. Lupus nephritis is associated with nephritic or nephrotic range proteinuria with most common finding of sub-endothelial electron-dense deposits and immunological stain demonstrating full-house picture with all immunological marker staining. Our case discusses a young male patient presenting with rapidly worsening renal function along with proteinuria, found to be positive for both hepatitis B core antibody along with hepatitis B surface antibody plus positive anti-neutrophilic antibody but negative anti-double-stranded DNA. Kidney biopsy demonstrated hepatitis B–associated lupus-like glomerulonephritis. He responded successfully with antiretroviral therapy and high-dose prednisone. Patient did not need lupus-specific treatment and recovered with antiretroviral therapy only. Hepatitis B–associated lupus-like glomerulonephritis has rarely been reported and possess a diagnostic and therapeutic challenge to all nephrologists.

Major Bleeding of Transjugular Native Kidney Biopsies. A French Nationwide Cohort Study

Introduction

The risk of bleeding associated with transjugular kidney biopsies is unclear, and which patients are the best candidates for this route is unknown.

Methods

This was a retrospective cohort study comparing proportion of bleeding associated with transjugular versus percutaneous native kidney biopsies in all patients in France in the 2010–2019 period. Major bleeding at day 8 (i.e., blood transfusions, hemorrhage/hematoma, angiographic intervention, nephrectomy) and risk of death at day 30 were assessed, and we used a bleeding risk score initially developed for the percutaneous route.

Results

Our analysis included 60,331 patients (transjugular route: 5305; percutaneous route: 55,026 patients). The observed proportion of major bleeding varied widely (transjugular vs. percutaneous): 0.4% versus 0.5% for the lowest risk scores (0–4) to 19.1% versus 30.8% for the highest risk scores (≥35). Transjugular was more frequently used than percutaneous route (39% vs. 24%) when the risk score was ≥20 (15,133/60,331; 25% of all patients). Transjugular was associated with a lower risk of major bleeding than percutaneous route in multivariate analyses (odds ratio [OR]: 0.88 [0.78–0.99]), especially for scores ≥20 (OR: 0.83 [0.72–0.96], (i.e., 25% of patients). Major bleeding was associated with an increased risk of death both for transjugular (OR: 1.77 [1.00–3.14]) and percutaneous (OR: 1.80 [1.43–2.28]) routes.

Conclusions

The transjugular route is independently associated with a lower risk of bleeding than the percutaneous route, especially in high-risk patients identified by a preprocedure risk score ≥20 (i.e., 25% of patients). Major bleeding is associated with an increased risk of death for both routes.

Safety and effectiveness of transjugular renal biopsy for systemic lupus erythematosus and antiphospholipid antibody syndrome patients taking antithrombotics

BACKGROUND

Renal biopsy is the cornerstone of systemic lupus erythematosus (SLE) nephritis and antiphospholipid syndrome (APS) nephropathy management. However, transcutaneous renal biopsy (TCRB) is hampered by the antithrombotic treatment frequently prescribed for those diseases. Transjugular renal biopsy (TJRB) offers an attractive alternative for patients at increased risk of bleeding. The primary objective of the study was to describe the safety profile and diagnostic performance of TJRB in SLE and APS patients.

METHODS

All SLE and/or APS patients who underwent a renal biopsy in our department (between January 2004 and October 2016) were retrospectively reviewed. Major complications were death, haemostasis nephrectomy, renal artery embolization, red blood cell transfusion, sepsis and vascular thrombosis; macroscopic haematuria, symptomatic perirenal/retroperitoneal bleeding and renal arteriovenous fistula without artery embolization were considered as minor complications.

RESULTS

Two hundred and fifty-six TJRBs-119 without antithrombotics (untreated), 69 under aspirin and 68 on anticoagulants and 54 TCRBs without antithrombotics-were analysed. Their major and minor complication rates, respectively, did not differ significantly for the four groups: 0 and 8% for untreated TJRBs, 1 and 6% for aspirin-treated, 6 and 10% for anticoagulant-treated and 2 and 2% for TCRBs. The number of glomeruli sampled and the biopsy contribution to establishing a histological diagnosis was similar for the four groups.

CONCLUSIONS

TJRBs obtained from SLE and APS patients taking antithrombotics had diagnostic yields and safety profiles similar to those of untreated TCRBs. Thus, TJRB should be considered for SLE and APS patients at risk of bleeding.

Transjugular Renal Biopsy Bleeding Risk and Diagnostic Yield: A Systematic Review

This study aimed to better define the safety and efficacy of transjugular renal biopsy (TJRB) based on published studies. Seventeen published articles were included (1,321 biopsies). Complications were classified as major if they resulted in blood transfusion or additional invasive procedures. All other bleeding complications were considered minor. Diagnostic tissue was obtained in 1,193 procedures (90.3%). The total incidence of bleeding complications among 15 articles with complete data was 202 of 892 procedures (22.6%): 162 (18.2%) minor and 40 (4.5 %) major. These results show that TJRB is a feasible procedure for obtaining renal tissue for diagnosis and that most complications are self-limiting.

Utility of transjugular renal biopsy as an alternative to percutaneous biopsy

BACKGROUND AND OBJECTIVES

Transjugular renal biopsies (TRB) are an alternative when percutaneous ultrasound renal biopsy is contraindicated. Few sites are currently carrying out this procedure, with limited literature existing on the indications, complications and diagnostic yield thereof. The aim of the study is to analyse the indications, diagnostic yield, safety and complications of percutaneous transjugular renal biopsies in our site over the last 15 years.

MATERIAL AND METHODS

Retrospective descriptive study of all transjugular renal biopsies performed in our site, the Hospital Vall d'Hebron, between 2003 and 2018. For this, an exhaustive review of the clinical records of patients subjected to this procedure during the study period was conducted.

RESULTS

56 TRBs were performed during the study period. Out of the patients, 31 were men (55.4%) and 25 were women (44.6%), with a median age of 62 years (IQ range 25-75 [52.5-69.5]). More than half presented with haematuria at the time of biopsy, with a median creatinine of 2.69 mg/dL (IQ 25-75 [1.7-4.3]) and median proteinuria at 24 hours of 2000 mg (IQ 25-75 [0.41-4.77]).The mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 140 +/- 26 mmHg and 75 +/- 15 mmHg, respectively. The biopsy was carried out owing to acute kidney failure in 19 patients, chronic kidney disease in 12 patients and nephrotic syndrome in 10 patients; in 15 patients it was carried out for other reasons. The most frequent TRB indication was technical impossibility in 16 of 56 cases (including infracostal kidneys, obesity and COPD), alterations in haemostasis (n = 6), thrombocytopenia (n = 5) and solitary kidney (n = 7). 12.5% of the biopsies were hepato-renal. Histological diagnoses were obtained in two thirds of the renal biopsies. The average number of cylinders obtained was 2.5 ± 1.3, with the average number of glomeruli being 6.6 ± 6.2. The most frequent histological diagnoses were IgA nephropathy, membranoproliferative glomerulonephritis and thrombotic microangiopathy. Three major complications were observed: fornix rupture and two transfusion requirements due to bleeding and subcapsular hematoma.

CONCLUSIONS

In our site, TRB allowed for a histological diagnosis in 2/3 of patients for whom percutaneous ultrasound renal biopsy is contraindicated. This allowed us to diagnose and subsequently treat said patients.

Narrative Review of Hypercoagulability in Small-Vessel Vasculitis

Pauci-immune necrotizing and crescentic glomerulonephritis (GN) is the most common etiology of rapidly progressive GN. Clinical presentation in those afflicted is usually related to rapid loss of kidney function. We report the case of a 70-year-old woman who came to medical attention for signs and symptoms related to lower-extremity deep vein thrombosis (DVT). At presentation, the patient had biochemical abnormalities consistent with active GN, which quickly progressed to rapid loss in kidney function requiring renal replacement therapy. Kidney biopsy revealed small-vessel vasculitis with glomerular crescents. Serologic studies were negative for antineutrophil cytoplasmic antibody antibodies and other causes of acute GN. Plasmapheresis, immunosuppressive, and anticoagulant therapies were prescribed. Absence of other apparent end-organ involvement with vasculitis pointed toward renal-limited small-vessel vasculitis, yet presence of unprovoked DVT argues for systemic vascular inflammation. This case illustrates that venous thrombosis can be the presenting manifestation in patients with vasculitis and silent, severe end-organ involvement. The epidemiology and pathophysiology of venous thromboembolism in small-vessel vasculitis are discussed in this report.

Safety and effectiveness of transjugular renal biopsy: A single center study

Although percutaneous renal biopsy remains the preferred method, there are several scenarios where transjugular approach is more suitable. We hereby describe our technique of transjugular renal biopsy (TJRB) and evaluate its safety and efficacy. We retrospectively collected data regarding indication for the transjugular route of biopsy, its complications, clinical and laboratory data, and adequacy of samples from patients' records. TJRB was performed when the patients were at a high risk for bleeding from percutaneous renal biopsy. Tissue samples were assessed by a pathologist for adequacy. All patients were followed up with ultrasonographic scan 3 h after the procedure and on day 3. Nine patients (age 41.5 ± 15.4 years; 8 men) underwent 9 TJRB procedures. The procedure was technically successful in all patients. Six patients (66.67%) had a platelet count of <50,000/mcL, 2 (33.3%) had an elevated International Normalized Ratio of more than 1.4, and 1 had both. 3.2 ± 0.4 cores were obtained, with median (range) number of glomeruli being ten (7-11). Adequate renal tissue sample was obtained in all the patients. Though capsular perforation developed in 5 patients, none had major complication requiring management (endovascular treatment or blood transfusion). TJRB is a safe and effective in patients with contraindications to percutaneous biopsy.

Complications of transjugular biopsies

Transvenous biopsy was first performed in 1964 by Charles Dotter. Now routinely performed in the liver and kidney by interventional radiologists, the transjugular approach to biopsy has assumed a central role in coagulopathic patients. Major arterial complications from transjugular liver and renal biopsy are rare. In this article, the authors describe such complications in both organs that necessitated selective endovascular coil embolization.

Factors that can minimize bleeding complications after renal biopsy

Renal biopsy is a very important diagnostic tool in the evaluation of renal diseases. However, bleeding remains to be one of the most serious complications in this procedure. Many new techniques have been improved to make it safer. The risk factors and predictors of bleeding after percutaneous renal biopsy have been extensively reported in many literatures, and generally speaking, the common risk factors for renal biopsy complications focus on hypertension, high serum creatinine, bleeding diatheses, amyloidosis, advanced age, gender and so on. Our primary purpose of this review is to summarize current measures in recent years literature aiming at minimizing the bleeding complication after the renal biopsy, including the drug application before and after renal biopsy, operation details in percutaneous renal biopsies, nursing and close monitoring after the biopsy and other kinds of biopsy methods.

Transvenous Renal Transplant Biopsy via a Transfemoral Approach

Percutaneous renal biopsy (PRB) of kidney transplants might be prevented by an elevated risk of bleeding or limited access to the allograft. In the following, we describe our initial experience with 71 transvenous renal transplant biopsies in 53 consecutive patients with unexplained reduced graft function who were considered unsuitable candidates for PRB (4.2% of all renal transplant biopsies at our institution). Biopsies were performed via the ipsilateral femoral vein with a renal biopsy set designed for transjugular renal biopsy (TJRB) of native kidneys. Positioning of the biopsy system within the transplant vein was achievable in 58 of 71 (81.7%) procedures. The specimen contained a median of 10 glomeruli (range 0-38). Tissue was considered as adequate for diagnosis in 56 of 57 (98.2%) biopsies. With respect to BANFF 50.9% of the specimen were adequate (>10 glomeruli), 47.4% marginally adequate (1-9 glomeruli) and 1.8% inadequate (no glomeruli). After implementation of real-time assessment all specimen contained glomeruli. One of the fifty-eight (1.8%) procedure-related major complications occurred (hydronephrosis requiring nephrostomy due to gross hematuria). Transfemoral renal transplant biopsy (TFRTB) is feasible and appears to be safe compared to PRB. It offers a useful new alternative for histological evaluation of graft dysfunction in selected patients with contraindications to PRB.

Risk of end-stage renal disease among liver transplant recipients with pretransplant renal dysfunction

Guidelines recommend restricting simultaneous liver-kidney (SLK) transplant to candidates with prolonged dialysis or estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m(2) for 90 days. However, few studies exist to support the latter recommendation. Using Scientific Registry of Transplant Recipients and Medicare dialysis data, we assembled a cohort of 4997 liver transplant recipients from February 27, 2002-January 1, 2008. Serial eGFRs were calculated from serum creatinines submitted with MELD reports. We categorized recipients by eGFR patterns in the 90 days pretransplant: Group 1 (eGFR always >30), Group 2 (eGFR fluctuated), Group 3 (eGFR always <30) and Group 4 (short-term dialysis). For Group 2, we characterized fluctuations in renal function using time-weighted mean eGFR. Among liver-alone recipients in Group 3, the rate of end-stage renal disease (ESRD) by 3 years was 31%, versus <10% for other groups (p < 0.001). In multivariable Cox regression, eGFR Group, diabetes (HR 2.65, p < 0.001) and black race (HR 1.83, p = 0.02) were associated with ESRD. Among liver-alone recipients in Group 2, only diabetics with time-weighted mean eGFR <30 had a substantial ESRD risk (25.6%). In summary, among liver transplant candidates not on prolonged dialysis, SLK should be considered for those whose eGFR is always <30 and diabetic candidates whose weighted mean eGFR is <30 for 90 days.

[Renal biopsy practice: results of a French study and recommendations]

BACKGROUND

Although several risk factors associated with complications after renal biopsy (RB) have been identified, recommendations for RB procedures are still lacking. Our working group, appointed by the scientific commission of the Société de néphrologie in France, aimed to depict the main aspects of the practice of RB in adults in France, before establishing some guidelines.

METHODS

Members of the Société de néphrologie in France were asked to participate to a questionnaire survey on RB procedures.

RESULTS

Eighty-eight nephrologists from 74 units (27 in teaching hospitals, 35 in public general hospitals, and 12 in private centers) participated in our study. Native kidney and graft biopsies were performed in 73 and 35 units, respectively. RB activity was highly variable among units, ranging from several hundred to less than ten per year. Transjugular RB was judged to be smoothly accessible in 28 out of 73 units (38.4%). Significant variations in practices were observed regarding patient information before RB, assessment of hemorrhagic risk factors, care of patients with antiplatelet agents and hemorrhagic risk factors, and radiological guidance. Early discharge (<12 hours) was the rule in three (4.1%) units for native kidney biopsies and in ten (28.6%) units for graft biopsies.

CONCLUSIONS

Our study is the first to provide a representative picture of "everyday" RB practices in a country. Consensual recommendations on all points mentioned are provided here.

Abdominal pain in special populations

Evaluation and management of acute abdominal pain in special populations can be challenging for the emergency physician. This article focuses on two specific populations: patients with altered immunologic function and postprocedural patients. Recognition of life-threatening abdominal diseases may be delayed in immunosuppressed patients because of the atypical presentations of these conditions. In postprocedural patients, evaluation of acute abdominal symptoms requires an understanding of the complications of procedures often performed by others. The unique characteristics of abdominal pain in these two populations and, more specifically, which diseases to consider and how to use appropriate testing to detect life-threatening conditions, are discussed.

Complications of percutaneous procedures

Minimally invasive percutaneous procedures are increasingly being performed by both interventional radiologists and noninterventionalists. Patients with postprocedural issues will likely present to the emergency department for evaluation and treatment. This review focuses on the evaluation and management of the complications of common percutaneous procedures.