Desmopressin Acetate in Percutaneous Ultrasound-Guided Kidney Biopsy: A Randomized Controlled Trial

Role of Desmopressin Acetate before Percutaneous Ultrasound-Guided Kidney Biopsy in Patients with Kidney Dysfunction

Background

The most common complication of percutaneous kidney biopsy is bleeding, which can be seen in up to one-third of cases. The aim of this study was to evaluate the effect of prebiopsy administration of intranasal desmopressin acetate in reducing the incidence of biopsy-related bleeding complications.

Materials and Methods

This was a prospective randomized double-blind pilot study conducted at our center from January 2021 to September 2022. Consecutive adult patients who underwent native percutaneous kidney biopsy with an estimated glomerular filtration rate (eGFR) ≤45 ml/min/1.73 m2 were randomized into a placebo (saline intranasal spray) group versus intranasal desmopressin group. The bleeding complications were compared between the two groups.

Results

A total of 80 patients who underwent kidney biopsy at our center from January 2021 to September 2022 with eGFR ≤45 ml/min/1.73 m2 were included (40 patients in desmopressin group and 40 patients in non-desmopressin group) in the study. The mean age of the patients was 44 ± 12 years with a mean eGFR of 20.82 ± 12.64 ml/min/1.73 m2. Intranasal desmopressin administration before kidney biopsy was associated with a significantly higher number of minor bleeding complications (P = 0.02) and no significant reduction in major complications (P = 0.15) when compared with a group that did not receive desmopressin. Other complications like hypotension, flushing, and vasovagal syncope were not statistically significantly associated with the use of desmopressin.

Conclusion

Our study did not find any utility of prophylactic desmopressin use before kidney biopsy in patients with kidney dysfunction.

Desmopressin to reduce periprocedural bleeding and transfusion: a systematic review and meta-analysis

We systematically reviewed the literature to investigate the effects of peri-procedural desmopressin in patients without known inherited bleeding disorders undergoing surgery or other invasive procedures. We included 63 randomized trials (4163 participants) published up to February 1, 2023. Seven trials were published after a 2017 Cochrane systematic review on this topic. There were 38 trials in cardiac surgery, 22 in noncardiac surgery, and 3 in non-surgical procedures. Meta-analyses demonstrated that desmopressin likely does not reduce the risk of receiving a red blood cell transfusion (25 trials, risk ratio [RR] 0.95, 95% confidence interval [CI] 0.86 to 1.05) and may not reduce the risk of reoperation due to bleeding (22 trials, RR 0.75, 95% CI 0.47 to 1.19) when compared to placebo or usual care. However, we demonstrated significant reductions in number of units of red blood cells transfused (25 trials, mean difference -0.55 units, 95% CI - 0.94 to - 0.15), total volume of blood loss (33 trials, standardized mean difference - 0.40 standard deviations; 95% CI - 0.56 to - 0.23), and the risk of bleeding events (2 trials, RR 0.45, 95% CI 0.24 to 0.84). The certainty of evidence of these findings was generally low. Desmopressin increased the risk of clinically significant hypotension that required intervention (19 trials, RR 2.15, 95% CI 1.36 to 3.41). Limited evidence suggests that tranexamic acid is more effective than desmopressin in reducing transfusion risk (3 trials, RR 2.38 favoring tranexamic acid, 95% CI 1.06 to 5.39) and total volume of blood loss (3 trials, mean difference 391.7 mL favoring tranexamic acid, 95% CI - 93.3 to 876.7 mL). No trials directly informed the safety and hemostatic efficacy of desmopressin in advanced kidney disease. In conclusion, desmopressin likely reduces periprocedural blood loss and the number of units of blood transfused in small trials with methodologic limitations. However, the risk of hypotension needs to be mitigated. Large trials should evaluate desmopressin alongside tranexamic acid and enroll patients with advanced kidney disease.

Renal Biopsy for Diagnosis in Kidney Disease: Indication, Technique, and Safety

Renal biopsies are the gold standard for diagnosis, staging, and prognosis of underlying parenchymal kidney disease. This article provides an overview of the current indications and highlights ways to reduce bleeding complications in order to achieve optimal diagnostic yield with minimal risk to the patient. Novel indications have emerged from the increasing use of new molecularly targeted oncologic therapies in recent years, which often induce immune-mediated renal disease. On the other hand, the detection of specific antibodies against target antigens on podocytes in the sera of patients with new-onset nephrotic syndrome has now relativized the indication for biopsy in membranous nephropathy. The use of semi-automatic spring-loaded biopsy devices and real-time ultrasound considerably declined the complication rate and is the current standard. Percutaneous renal biopsies are overall a safe procedure if contraindications are considered. A coagulation disorder needs to be excluded beforehand, and an elevated blood pressure must be reduced to the normotensive range with medications. A laparoscopic approach or a radiology interventional procedure through the internal jugular vein may be considered for obtaining a kidney tissue sample if there is an urgent indication and a bleeding tendency cannot be adequately corrected. Major bleeding after a percutaneous renal biopsy can usually be managed with selective arterial embolization of the injured renal vessel. The use of a 16-gauge needle is the most reasonable compromise between diagnostic benefit and risk of complication. In the routine diagnostic, the biopsy specimen is examined with light microscopy, immunohistochemistry, and electron microscopy. Combination with modern molecular pathology techniques will contribute to more precise insights into the development and progression of kidney disease, which will likely refine future treatments in nephrology.

Effect of Hemocoagulase on the Prevention of Bleeding after Percutaneous Renal Biopsy

A percutaneous renal biopsy is an essential tool for the diagnosis of various renal diseases; however, post-biopsy bleeding is a major complication. Hemocoagulase is a detoxified and purified snake venom enzyme that is widely used to prevent post-procedural bleeding. In this study, we retrospectively analyzed the effect of hemocoagulase on post-renal biopsy bleeding. We included 221 patients who underwent percutaneous renal biopsy between April 2017 and December 2020 and analyzed post-renal biopsy hemoglobin (Hb) decline in patients who were administered a periprocedural hemocoagulase injection. After the renal biopsy, the mean Hb decrease in the entire patient cohort was 0.33 ± 0.84 g/dL. Periprocedural hemocoagulase injection lowered the Hb decline post-renal biopsy (0.50 ± 0.87 vs. 0.23 ± 0.80 g/dL, p = 0.0204). The propensity-matched cohort was also adjusted for factors influencing postprocedural bleeding; periprocedural hemocoagulase injection reduced the Hb decline post-renal biopsy (0.56 ± 0.89 vs. 0.17 ± 0.74 g/dL, p = 0.006). There were no adverse events (e.g., thrombosis and anaphylactic shock) due to hemocoagulase. Our study demonstrated the beneficial effect of hemocoagulase on post-renal biopsy Hb decline, suggesting its clinical value in preventing post-renal biopsy bleeding.

Safety of Obtaining an Extra Biobank Kidney Biopsy Core

Background and objectives: Kidney biopsy (KB) is the “gold standard” for the diagnosis of nephropathies and it is a diagnostic tool that presents a low rate of complications. Nowadays, biobank collections of renal tissue of patients with proven renal pathology are essential for research in nephrology. To provide enough tissue for the biobank collection, it is usually needed to obtain an extra kidney core at the time of kidney biopsy. The objective of our study is to evaluate the complications after KB and to analyze whether obtaining an extra core increases the risk of complications. Material and methods: Prospective observational study of KBs performed at Vall d’Hebron Hospital between 2019 and 2020. All patients who accepted to participate to our research biobank of native kidney biopsies were included to the study. Clinical and laboratory data were reviewed and we studied risk factors associated with complications. Results: A total of 221 patients were included, mean age 56.6 (±16.8) years, 130 (58.8%) were men, creatinine was 2.24 (±1.94) mg/dL, proteinuria 1.56 (0.506–3.590) g/24 h, hemoglobin 12.03 (±2.3) g/dL, INR 0.99 (±0.1), and prothrombin time (PT) 11.86 (±1.2) s. A total of 38 patients (17.2%) presented complications associated with the procedure: 13.1% were minor complications, 11.3% (n = 25) required blood transfusion, 1.4% (n = 3) had severe hematomas, 2.3% (n = 5) required embolization, and 0.5% (n = 1) presented arterio-venous fistula. An increased risk for complication was independently associated with obtaining a single kidney core (vs. 2 and 3 cores) (p = 0.021). Conclusions: KB is an invasive and safe procedure with a low percentage of complications. Obtaining an extra kidney core for research does not increase the risk of complications during the intervention, which remains low in concordance with previously published reports.

Desmopressin Acetate Before Percutaneous Ultrasound-Guided Kidney Biopsy in Patients with Renal Failure - Is it Really Beneficial?

Introduction

The most common complication of percutaneous renal biopsy is bleeding, which can be seen in up to one-third of cases. The aim of this study was to evaluate the effect of prebiopsy administration of intranasal desmopressin acetate in reducing the incidence of biopsy-related bleeding complications in patients with significant renal dysfunction who underwent renal biopsy.

Methods

This was a retrospective, observational study of percutaneous native renal biopsies performed at our center from July 2014 to June 2018. Bleeding complication rates of patients with renal failure (estimated glomerular filtration rate [eGFR] <30 mL/minute/1.73 m²) who received desmopressin and those who did not receive desmopressin were compared.

Results

Desmopressin administration before renal biopsy in patients with eGFR <30 mL/minute/1.73 m² was associated with a significant reduction of bleeding complications (major and minor together; P = 0.025) and no significant reduction in major complications (P = 0.616) or intervention rates (P = 0.251) when compared with a group that did not receive desmopressin.

Conclusions

While prebiopsy intranasal desmopressin use was associated with a significant reduction of overall bleeding complications including major and minor complications, there was no reduction in the rate of other major complications and interventions.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding

BACKGROUND/AIMS

The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy.

METHODS

In this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed.

RESULTS

Before propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120).

CONCLUSIONS

We do not recommend desmopressin administration before kidney biopsy.

Complications after native kidney biopsy: definitive data

PURPOSE OF REVIEW

To assess the risk of complications associated with native kidney biopsies. This review will highlight recent advances on the risk factors for major bleeding and risk management in patients with native kidney biopsy.

RECENT FINDINGS

Recent studies provided new important data regarding the individualization of the risk of bleeding after kidney biopsy. A new bleeding risk score was proposed as a risk stratification tool, useful for shared decision making and procedure choice.

SUMMARY

The risk of complications is low (<1%) in most patients but varies widely. Risk factors include Charlson index, frailty index, female gender, dyslipidemia, anemia, thrombocytopenia, cancer, abnormal kidney function, glomerular disease, autoimmune disease, vasculitis, hematologic disease, and thrombotic microangiopathy. A new bleeding score can help physicians and patients to assess the risk of bleeding enabling informed consent, and decide to perform it or not, and to prefer transjugular vs percutaneous route.

Safety of renal biopsy bleeding prophylaxis with desmopressin

BACKGROUND

Percutaneous renal biopsy (PRB) is invasive, and bleeding-related complications are a concern. Desmopressin (DDAVP) is a selective type 2 vasopressin receptor-agonist also used for haemostasis.

AIM

To evaluate the side effects of intravenous (IV) weight-adjusted desmopressin preceding PRB.

METHODS

This was a retrospective study of renal biopsies performed by nephrologists from 2013 to 2017 in patients who received single-dose DDAVP pre-PRB.

RESULTS

Of 482 PRBs, 65 (13.5%) received DDAVP (0.3 µg/kg); 55.4% of the PRBs were native kidneys. Desmopressin indications were altered platelet function analyser (PFA)-100 results (75.3% of the patients), urea >24.9 mmol/L (15.5%), antiplatelet drugs (6.1%) and thrombocytopaenia (3%). Of the 65 patients, 30.7% had minor asymptomatic complications, and 3 patients had major complications. Pre-PRB haemoglobin (Hb) <100 g/L was a risk factor for Hb decrease >10 g/L, and altered collagen-epinephrine (Col-Epi) time was a significant risk factor for overall complications. Mean sodium decrease was 0.6 ± 3 mmol/L. Hyponatraemia without neurological symptoms was diagnosed in two patients; no cardiovascular events occurred.

CONCLUSION

Hyponatraemia after single-dose DDAVP is rare. A single IV dose of desmopressin adjusted to the patient's weight is safe as pre-PRB bleeding prophylaxis.

Case Report: Hyponatremia Secondary to Desmopressin Administration Prior to Percutaneous Kidney Biopsy: A Case-Based Review

Bleeding remains the most clinically relevant complication of kidney biopsy and several prophylactic approaches were proposed, including desmopressin administration. We present the case of a 60-year-old man with a history of liver transplantation, admitted for the evaluation of a renal dysfunction. As part of our department protocol, desmopressin 60 μg was administered orally, 2 h before the percutaneous kidney biopsy. The patient developed acute, severe, symptomatic hyponatremia (i.e., headache and recurrent vomiting), followed by a life-threatening upper gastrointestinal bleeding due to a Mallory-Weiss syndrome. Although it is often used as bleeding prophylaxis prior to kidney biopsy, data regarding the efficacy and safety of desmopressin in this setting are inconsistent. Accordingly, we performed a thorough literature review of the use of desmopressin as bleeding prophylaxis prior to kidney biopsy, focusing on the incidence of hyponatremia. The reported incidence of hyponatremia (<130 mmol/l) was 7–11%, probably because serum sodium was monitored in few studies. Nevertheless, hyponatremia was rarely symptomatic but, in some cases, like the one presented here, its complications could be severe. Pre-biopsy low serum sodium and estimated glomerular filtration rate as well as high spot urine sodium and non-restricted fluid intake were reported to be associated with hyponatremia incidence. However, the current evidence cannot clearly establish which patients benefit the most from desmopressin use with respect to bleeding complications. We propose that when desmopressin is used for bleeding prophylaxis prior to kidney biopsy, measurements of serum sodium levels, before and every 6 h after, should complement ultrasound and hemoglobin as part of the patient post-procedural monitoring. Also, water intake should be restricted in the day of biopsy. However, this proposed approach should be adequately evaluated in a clinical trial.

Desmopressin acetate to prevent bleeding in percutaneous kidney biopsy: a systematic review

BACKGROUND

Kidney biopsy is the gold standard for diagnosing kidney disease but may result in bleeding, especially in uraemia. DDAVP (1-deamino-8-d-arginine vasopressin) may reduce uraemic bleeding but guidelines on its use are lacking.

AIM

To evaluate whether DDAVP reduced bleeding complications after percutaneous kidney biopsies.

METHODS

We searched CENTRAL, PubMed, Embase, LILACS, WHO Trials Registry and ClinicalTrials.gov until May 2019 for randomised controlled trials (RCT), quasi-RCT and prospective cohort studies that compared DDAVP with placebo or no intervention, prior to native or allograft kidney biopsy. The primary outcome was post-biopsy bleeding. Secondary outcome was adverse events related to DDAVP.

RESULTS

Abstracts of 270 identified papers were examined and 24 selected for evaluation. Two studies, one RCT and one prospective cohort that collectively evaluated 738 native kidney biopsies, met the inclusion criteria. One enrolled individuals with serum creatinine ≤1.5 mg/dL (132 μmol/L) and/or estimated glomerular filtration rate ≥60 mL/min/1.73 m² while the other evaluated biopsies with serum creatinine >150 μmol/L. DDAVP was administered as a single subcutaneous dose of 0.3 μg/kg in both studies. Data were not pooled for meta-analysis due to clinical heterogeneity. GRADE quality of evidence from these two studies was low for DDAVP preventing any bleeding complication after native kidney biopsy. Low quality evidence suggested that adverse effects were not increased in DDAVP therapy. No prospective studies evaluated DDAVP in transplant kidney biopsies.

CONCLUSION

Currently available prospective data are insufficient to support the routine use of DDAVP prior to percutaneous kidney biopsies hence high quality trials are required.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding

BACKGROUND/AIMS

The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy.

METHODS

In this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed.

RESULTS

Before propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120).

CONCLUSIONS

We do not recommend desmopressin administration before kidney biopsy.

Renal transplant biopsy complications: assessment of risk factors and potential of desmopressin to decrease risk of hemorrhage

BACKGROUND

Renal transplant biopsies are essential in nephrology; however, they are invasive and complications can occur.

PURPOSE

To explore the risk of transplant kidney biopsy (TxB) complications in relation to possible preventive effects of desmopressin prophylaxis.

MATERIAL AND METHODS

A total of 515 consecutive TxB (375 patients, median age 53 years) were analyzed. In 252 TxB, the Resistive Index (RI) was measured right before the biopsy. A total of 282 patients had serum creatinine >150 µmol/L. In one of the six hospitals 39/282 patients consecutively received desmopressin (dose 0.3 µg/kg subcutaneously) as prophylaxis within 1 h before the biopsy. Fisher's exact and χ² test were used (odds ratio [OR], 95% confidence interval [CI]). Univariate and multiple binary logistic regression analyses were performed. A two-sided P value <0.05 was considered significant.

RESULTS

RI ≥ 0.8 was a risk factor for major TxB complications (OR 4.2, 95% CI 1.13-15.76). The risk for minor complications decreased with mean arterial blood pressure (MAP) (97.9 vs. 89.5 mmHg, OR 0.97, 95% CI 0.95-0.997). In a multiple regression analysis for overall biopsy complications, the risk remained increased for patients with RI ≥ 0.8 (OR 4.45, 95% CI 1.32-15.04). No patients (0/39) with desmopressin prophylaxis had a major complication versus 8/243 in the other group. In patients with serum creatinine >150 µmol/L, those with a higher MAP had more overall TxB complications (104.5 vs. 98.2 mmHg, OR 1.05, 95% CI 1.004-1.1).

CONCLUSION

RI ≥ 0.8 was a risk factor for major and overall complications and a lower MAP for minor biopsy complications. Desmopressin prophylaxis showed yet no verified benefit as prophylaxis in TxB.

Use of Desmopressin Prior to Kidney Biopsy in Patients With High Bleeding Risk

INTRODUCTION

To prevent bleeding after native kidney biopsy (NKB), nephrologists often prescribe desmopressin, especially for patients with reduced estimated glomerular filtration rate (eGFR) at risk of uremia-related platelet dysfunction. However, only 1 randomized study has suggested a beneficial effect for desmopressin in patients with eGFR ≥60 ml/min per 1.73 m2. This retrospective cohort study aimed to evaluate desmopressin effect on postbiopsy bleeding in all patients, regardless of eGFR and other comorbidities.

METHODS

In this retrospective cohort study, all adult patients who underwent an NKB from April 1, 2013, to April 30, 2018, in a tertiary hospital were identified. The association between desmopressin use and bleeding complications, including hemoglobin fall, transfusion, hematoma, symptomatic hematoma, urgent radiologic study, and hypotension, was analyzed using multivariable logistic regression models.

RESULTS

A total of 413 native kidney biopsies were studied, 79% of which were performed after receiving desmopressin. Patients receiving desmopressin had worse chronic kidney disease (eGFR 28 vs. 45 ml/min per 1.73 m2; P < 0.001) and were more often hospitalized (48% vs. 32%; P = 0.009). Despite higher bleeding risk, patients using desmopressin had a similar likelihood of symptomatic hematomas (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.13-1.14) and a lower need for urgent radiologic studies (OR, 0.33; 95% CI, 0.11-0.98).

CONCLUSION

Patients at higher risk of bleeding using desmopressin before kidney biopsy had bleeding complications similar to those not using desmopressin. These results highlight potential important clinical and financial benefits of desmopressin use before kidney biopsy.

Thromboelastography versus bleeding time for risk of bleeding post native kidney biopsy

Introduction

The risk of bleeding has led to screening of the primary hemostasis before renal biopsy. A bleeding time test (BT) is considered standard practice, but reliance on this test is controversial and its benefits remain questionable. A possible alternative is thromboelastography (TEG). However, data regarding TEG in patients with renal dysfunction is limited.

Objectives

To determine TEG abnormalities and their consequences in patients who underwent a native kidney biopsy.

Methods

A retrospective study of 417 consecutive percutaneous native renal biopsies performed in our Center. If serum creatinine >1.5 mg/dL, the patient underwent either a BT test (period A, January 2015–31 December 2016) or TEG (period B, January 2017–August 2018). In patients with prolonged BT, or an abnormal low maximal amplitude (MA) parameter of TEG, or suspected clinical uremic thrombopathy, the use of desmopressin acetate (DDAVP) was considered.

Results

Most biopsies (90.6%) were done by the same dedicated radiologist. Fifty-one patients had a BT test, which was normal in all tested patients. Seventy-one patients underwent TEG, and it was abnormal in 34 of them, most patients had combined abnormalities. The only parameter related to abnormal TEG was older age (Odds Ratio 1.21 [95% CI 1.09–2.38] p = 0.04 for abnormal Kinetics; OR 1.37 (1.05–1.96) p = 0.037 for abnormal MA). Twenty-six patients (6.23%) had bleeding complications. Risk of bleeding was significantly related to age (1.4 [1.11–7.48] p = 0.04), systolic blood pressure (1.85 [1.258–9.65] p = 0.02), and serum creatinine (1.21 [1.06–3.134] p = 0.048).

Conclusions

TEG abnormalities in patients with renal dysfunction are variable and fail to predict bleeding during kidney biopsy. The decision to administer DDAVP as a preventive measure during these procedures should be based on clinical judgment only.

Bleeding Complications After Percutaneous Native Kidney Biopsy: Results From the Boston Kidney Biopsy Cohort

Background

The major risk of kidney biopsy is severe bleeding. Numerous risk factors for bleeding after biopsy have been reported, but findings have been inconsistent.

Methods

We retrospectively reviewed medical records of adult patients enrolled in a native kidney biopsy cohort study to identify major bleeding events (red blood cell [RBC] transfusions, invasive procedures, kidney loss, or death). We used logistic and linear regression models to identify characteristics associated with postbiopsy RBC transfusions and decline in hemoglobin within a week after the procedure.

Results

Major bleeding events occurred in 28 of 644 (4.3%) patients (28 required an RBC transfusion, 4 underwent angiographic intervention, and 1 had open surgery to control bleeding). No patient lost a kidney or died because of the biopsy. Postbiopsy RBC transfusion risk was driven by the baseline hemoglobin level (odds ratio [OR] 13.6; 95% confidence interval [CI] 5.4–34.1 for hemoglobin <10 vs. ≥10 g/dl). After adjusting for hemoglobin, no other patient characteristics were independently associated with RBC transfusions. Female sex (β = 0.18; 95% CI: 0.04–0.32), estimated glomerular filtration rate (eGFR) <30 ml/min per 1.73 m² (β = 0.32; 95% CI: 0.14–0.49), and baseline hemoglobin (β = 0.09; 95% CI: 0.05–0.13, per g/dl increase) were independently associated with a larger drop in hemoglobin. Histopathologic lesions were not independently associated with major bleeding after biopsy.

Conclusion

Biopsies were generally well tolerated. Baseline hemoglobin was the dominant risk factor for RBC transfusions, but female sex and eGFR <30 ml/min per 1.73 m² were also associated with a larger decline in hemoglobin after the procedure.

Bleeding Complications and Adverse Events After Desmopressin Acetate for Percutaneous Renal Transplant Biopsy

Introduction: Percutaneous renal biopsy remains critical for the workup of renal allograft dysfunction but is associated with the risk of bleeding. Prophylactic intravenous desmopressin has been proposed to reduce bleeding risk in native renal biopsies, but its efficacy in the renal transplant population is unclear and adverse events such as severe hyponatraemia have been reported. Materials and Methods: We conducted a single-centre retrospective cohort study involving adult (≥21 years old) renal transplant recipients with impaired renal function (serum creatinine ≥150 μmol/L) who underwent ultrasound-guided renal allograft biopsies from 2011‒2015 to investigate the effect of prebiopsy desmopressin on the risk of bleeding and adverse events. Results: Desmopressin was administered to 98 of 195 cases who had lower renal function, lower haemoglobin and more diuretic use.Postbiopsy bleeding was not significantly different between the 2 groups (adjusted odds ratio [OR] 0.79, 95% confidence interval [CI] 0.26‒2.43, P = 0.68) but desmopressin increased the risk of postbiopsy hyponatraemia (sodium [Na] <135 mmol/L) (adjusted OR 2.24, 95% CI 1.10‒4.59, P = 0.03). Seven cases of severe hyponatraemia (Na <125 mmol/L) developed in the desmopressin group, while none did in the non-desmopressin group. Amongst those who received desmopressin, risk of hyponatraemia was lower (OR 0.26, 95% CI 0.09‒0.72, P = 0.01) if fluid intake was <1 L on the day of biopsy. Conclusion: Prophylactic desmopressin for renal allograft biopsy may be associated with significant hyponatraemia but its effect on bleeding risk is unclear. Fluid restriction (where feasible) should be recommended when desmopressin is used during renal allograft biopsy. A randomised controlled trial is needed to clarify these outcomes. Key words: Adverse effects, Deamino arginine vasopressin, Haematoma, Haemorrhage, Hyponatraemia

Desmopressin and bleeding risk after percutaneous kidney biopsy

Background

Desmopressin is used to reduce bleeding after kidney biopsy but evidence supporting its use is weak, especially in patients with elevated creatinine. The present study was undertaken to evaluate efficacy of desmopressin in reducing bleeding after percutaneous kidney biopsy.

Methods

Retrospective cohort study. 269 of 322 patients undergoing percutaneous kidney biopsy between January 1, 2014 and January 31, 2018 were included. Patients had normal bleeding time, platelet count and coagulation profile. Primary outcome was defined as composite of hemoglobin drop ≥1 g/dL, hematoma on post biopsy ultrasound, gross hematuria, erythrocyte transfusion or angiography to stop bleeding. Association of desmopressin with outcomes was assessed using linear (for continuous variables) and logistic (for binary variables) regression models. Propensity score was used to minimize potential confounding.

Results

Desmopressin was administered to 100/269 (37.17%) patients. After propensity score adjustment patients who received desmopressin had increased odds of post biopsy bleeding [OR 3.88 (1.95–7.74), p < 0.001]. Creatinine at time of biopsy influenced bleeding risk; gender, emergent vs elective biopsy, obesity, AKI, diabetes, hypertension or bleeding time did not influence bleeding risk. Administration of desmopressin to patients with serum creatinine ≥1.8 mg/dL decreased bleeding risk [OR 2.11 (95% CI 0.87–5.11), p = 0.09] but increased bleeding risk when serum creatinine was < 1.8 mg/dL (OR 9.72 (95% CI 2.95–31.96), p < 0.001).

Conclusion

Desmopressin should not be used routinely prior to percutaneous kidney biopsy in patients at low risk for bleeding but should be reserved for patients who are at high risk for bleeding.

Clinical parameters predicting complications in native kidney biopsies

Background

Renal biopsies are essential in nephrology but they are invasive and complications can occur. The aim of this study was to explore clinical parameters that can be used as predictors for biopsy complications.

Methods

Clinical parameters such as demographics, biopsy indications, serology, comorbidities and clinical chemistry were retrieved from a regional biopsy registry between 2006 and 2015 and from a nationwide registry between 2015 and 2017. Clinical data before biopsy were compared with data on major biopsy complications. Fisher’s exact and χ² tests were used and odds ratios (ORs) with 95% confidence intervals (CIs) were presented. Univariate and multiple binary logistic regression analyses were performed with complications as outcome. A two-sided P-value <0.05 was considered significant.

Results

In total, 2835 consecutive native kidney biopsies were analysed (39% women and 61% men, median age 57 years). No death and nephrectomy due to biopsy complications were registered. The frequency of major biopsy complications was 5.65%. In the multiple logistic regression, the risk for complications increased in women [OR 1.51 (95% CI 1.08–2.11)] and decreased with age: 45–64 years age group [OR 0.66 (95% CI 0.44–0.99)] and >74 years age group [OR 0.51 (95% CI 0.27–0.96)]. Among comorbidities, patients with diabetes mellitus type 2 [OR 2.07 (95% CI 1.15–3.72)] and non-ischaemic heart disease [OR 3.20 (95% CI 1.64–6.25)] had a higher risk for major biopsy complications.

Conclusions

Female gender, younger age (≤44 years), diabetes mellitus type 2 and non-ischaemic heart disease were found as risk factors for major biopsy complications.

Intranasal desmopressin reduces renal biopsy-related bleeding and serum sodium levels in patients with reduced renal function

Background

The use of desmopressin in preventing renal biopsy-related bleeding is not established and its effects on serum sodium levels are not well studied. The study aimed to compare the bleeding complication rates between the groups with and without desmopressin use prebiopsy and to observe the effect of desmopressin on postbiopsy serum sodium levels.

Methods

In this single-center, prospective and retrospective interventional study, from June 2018 onwards, patients with serum creatinine >132.6 μmol/L but not on dialysis and undergoing ultrasound-assisted needle-guided renal biopsy received 150 μg of desmopressin (D-amino D-arginine vasopressin (DDAVP)) (Group II). Data from patients from June 2017 to May 2018 were included in Group I in whom desmopressin was not used. Bleeding complications were monitored by clinical and ultrasound surveillance. Serum sodium levels were checked prior to and 24 h following desmopressin in Group II.

Results

A total of 194 patients were included in the study: 105 in Group I and 89 in Group II. Group II had lower overall minor bleeding complications and perinephric hematomas than Group I (15.7% versus 31.4%, 14% versus 27% and 7.8% versus 19% in Group II and Group I, respectively, with P < 0.05). Not using desmopressin and female sex were significant predictors for overall risk of bleeding on multivariate logistic regression. Serum sodium levels fell in 94% of patients in Group II. Lower prebiopsy serum sodium, higher estimated glomerular function rate and higher spot urine sodium values were associated with a greater decrease in serum sodium after desmopressin.

Conclusion

Intranasal desmopressin reduces bleeding complications during renal biopsies performed in patients with reduced renal function not requiring dialysis, albeit with a risk of developing hyponatremia.

Complications of Percutaneous Renal Biopsy

Percutaneous renal biopsy is widely used for diagnosis, prognosis, and management of nephropathies. Complications may arise after renal biopsy, most commonly in the form of bleeding. Efforts should be taken to optimize modifiable risk factors such as hypertension, thrombocytopenia, and coagulopathy prior to the procedure. Unmodifiable risk factors such as poor renal function, gender, and underlying histologic diagnosis may be used to identify high-risk patients. Delayed presentation of bleeding complications is common, and close clinical follow-up is crucial.

Desmopressin for the prevention of bleeding in percutaneous kidney biopsy: efficacy and hyponatremia

BACKGROUND

Desmopressin is used to reduce bleeding complications for kidney biopsies with azotemia but little is known about desmopressin-induced hyponatremia in these individuals. We aimed to evaluate the impact of desmopressin prophylaxis on severe hyponatremia and bleeding after kidney biopsies in individuals with renal impairment.

METHOD

This is a single-center retrospective cohort study of consecutive adults with serum creatinine ≥ 150 µmol/L and had ultrasound-guided percutaneous native or transplant kidney biopsies between June 2011 and July 2015. Data were retrieved from electronic medical records. Primary outcomes were the use of desmopressin prophylaxis and severe hyponatremia (serum sodium ≤ 125 mmol/L) within 7 days post-biopsy. Secondary outcome was post-biopsy bleeding.

RESULTS

240 native kidney and 196 allograft biopsies were performed. Median age was 51 (IQR 42.3, 60) years and eGFR was 21.9 (12.9, 30.1) ml/min/1.73 m². Although patients prescribed desmopressin prophylaxis (n = 226) had higher serum creatinine [279 (201, 392) vs. 187 (160, 241), p < 0.001], bleeding (15.0% vs. 13.3%, p = 0.60) was not significantly different with and without desmopressin. Severe hyponatremia occurred in 30 biopsies (6.9%) with nadir serum sodium level of 122 (119, 124) mmol/L at 3 (2, 5) days after biopsy, more frequently among those with desmopressin prophylaxis (10.7% vs. 3.0%, p = 0.002). Multi-variate analysis found that pre-biopsy serum sodium level [adjusted OR 0.80 (95% CI 0.72, 0.90), p < 0.001] and desmopressin prophylaxis [adjusted OR 4.02 (95% CI 1.58, 10.21), p = 0.003] were independently associated with severe hyponatremia after kidney biopsy.

CONCLUSION

Pre-biopsy desmopressin was associated with severe hyponatremia in individuals with renal impairment; hence, susceptible patients given desmopressin should be closely monitored.

Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN)

Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.

Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN)

Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.

Renal biopsy: it is time for pragmatism and consensus

To obtain truly informed consent, we must be able to advise our patients accurately about the relative risk and benefit of any treatment plan. Percutaneous renal biopsy remains the gold standard investigation in the evaluation of intrinsic renal disease. There have been significant improvements in practice over the past decades with regards to percutaneous renal biopsy. Across centres, we appear now to have reached agreement on many aspects of this procedure, such as the need for blood pressure control, avoidance of coagulopathy, use of spring-loaded needles under direct imaging guidance and a need to monitor for complications. The authors from Rush University Medical Centre provide reassurance that renal biopsy in the modern era remains a safe procedure with a low rate of significant bleeding. There remain areas of divergence in practice that may have unintended and deleterious consequences: administration of desmopressin and discontinuation of aspirin, for example, both carry a risk of thrombosis. It is our opinion that it is time to reach consensus on our interpretation of the available data and to draw up guidelines to standardize our biopsy practice internationally.

Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN)

Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.

Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN)

Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.

Desmopressin (Octostim®) before a native kidney biopsy can reduce the risk for biopsy complications in patients with impaired renal function: A pilot study

AIM

To evaluate whether the administration of desmopressin alters the risk for renal biopsy complications.

METHODS

A multicenter registry containing 576 native kidney biopsies (NKb) with a serum creatinine above 150 μmol/L in 527 patients (372 men and 155 women, median age 61 years) was used. Most of the data were prospective. At one of the hospitals all biopsies with creatinine above 150 μmol/L received desmopressin before biopsies (NKb 204). These were compared to outcome of biopsy complications against other centres where desmopressin was not given (NKb 372). Fisher's exact test, χ² analyses, univariate and multiple binary logistic regression were used. Data were given as odds ratio (OR) and confidence interval (CI). A two sided P-value of <0.05 was considered significant.

RESULTS

In NKb with creatinine >150 μmol/L, those with desmopressin had less overall (3.4% vs 8.4%, OR 0.39, CI 0.17-0.90) whereas major or minor complications were not different. While desmopressin did not exhibit difference in complications in men, women received less major (0% vs 8.6%, P = 0.03) and overall complications (0% vs 12.1%, P = 0.006). A multiple logistic regression revealed that, after adjusting for BMI, age and sex, prophylaxis with desmopressin showed less major (OR 0.38, CI 0.15-0.96) and overall complications (OR 0.36, CI 0.15-0.85).

CONCLUSION

Desmopressin given before a native kidney biopsy in patients with impaired renal function can reduce the risk for complications.

Comparison of native and transplant kidney biopsies: diagnostic yield and complications

Background

The safety and adequacy are established for the native percutaneous renal biopsy (PRB) but no prospective studies exist that directly compare these with transplant PRB.

Methods

From 1995 to 2015, 1705 adults underwent percutaneous native [native renal biopsy (NRB)] or transplant renal biopsy (TRB) by the Nephrology service. Real-time ultrasound and automated biopsy needles (NRB, 14 or 16 gauge; TRB, 16 gauge) were used. Patients were observed for 24 h (NRB) or 8 h (TRB) post-procedure. Adequacy was defined as tissue required for diagnosis plus glomerular yield. Complications were defined as those resulting in the need for an intervention, such as surgery, interventional radiologic procedure, readmission, blood transfusion and death. Data were collected prospectively in all biopsies.

Results

At the time of biopsy, NRB patients were younger (mean ± SD, 47 ± 17 versus 50 ± 14 years, P < 0.0001) and more often female (62 versus 48%, P < 0.0001) compared with TRB. A fellow supervised by an attending performed the procedure in 91% of NRB compared with 63% of TRB (P < 0.0001). TRB patients were more hypertensive [systolic blood pressure (SBP) 140 ± 22 versus 133 ± 18 mmHg, P < 0.0001] and had a higher serum creatinine (3.1 ± 1.8 versus 2.3 ± 2.2 mg/dL, P < 0.0001), activated partial thromboplastin time (28 ± 4.3 versus 27 ± 5 s, P < 0.0001) as well as lower hemoglobin (Hgb) (11.2 ± 1.8 versus 11.7 ± 2.1 g/dL, P < 0.0001) compared with NRB. Adequate tissue for diagnosis was obtained in > 99% of NRB and TRB (P = 0.71). Compared with TRB, NRB had a greater drop in Hgb after the biopsy (0.97 ± 1.1 versus 0.73 ± 1.3 g/dL, P < 0.0001), a higher complication rate (6.5 versus 3.9%, P = 0.02) and higher transfusion rate (5.2 versus 3.3%, P = 0.045). There was one death in each group attributed to the biopsy.

Conclusions

Although death is equally rare, the complication rate is higher in NRB compared with TRB despite TRB having more of the traditional risk factors for bleeding. Differences in technique, operator (fellow or attending) or needle gauge may explain this variability.

Needle guides enhance tissue adequacy and safety of ultrasound-guided renal biopsies

Background

Needle guides have recently come into use for ultrasound-guided percutaneous renal biopsies; however, it is not yet clear if the use of needle guides leads to decreased post-biopsy complication rates and improved tissue yields. Thus, we conducted a retrospective single center study comparing biopsy yield, adequacy, and rates of complications before and after utilization of a needle guide device.

Methods

A retrospective analysis was performed on all native kidney biopsies performed before and after June 2015 corresponding to the start of needle guide use. All biopsies in the latter period of the study were performed by a single operator. We compared clinical characteristics, indications, type of investigation, tissue yield, adequacy of procedure, and rates of major and minor complications.

Results

A total of 343 biopsies were analyzed, 140 in the pre-needle guide use period (Period I) and 203 in the needle guide use period (Period II). Biopsy yields were similar, irrespective of the use of needle guides. Tissue adequacy was better in Period II (93.7% vs. 84%, P < 0.001, with respect to pathologist-reported inconclusive biopsies. There were no differences in terms of major complications (1.7%) for the two periods; however, the rate of minor complications (8.4%) was significantly reduced in Period II (P = 0.006). According to multiple logistic regression analysis, not using a needle guide (odds ratio, 3.70; P < 0.001) along with low hemoglobin level, higher pre-dialysis serum creatinine level, and high urinary red blood cell count were significant predictors of biopsy complications.

Conclusion

Use of a needle guide improves biopsy adequacy and is associated with reduced rates of minor complications in native renal biopsies. Therefore, needle guides may be recommended in percutaneous renal biopsies, especially when transitioning to single-operator performed procedures.

Routine haemostasis testing before transplanted kidney biopsy: a cohort study

Kidney biopsy can result in bleeding complications. Prebiopsy testing using bleeding time (BT) is controversial. New whole blood haemostasis tests, such as platelet function analyser-100 (PFA-100) and multiple electrode aggregometry (MEA), might perform better. We postulated that PFA-100 would be suitable to replace BT prebiopsy. In 154 patients, transplanted kidney biopsies were performed after measurement of bleeding time, PFA-100, MEA and mean platelet volume (MPV). Bleeding outcome (haemoglobin (Hb) drop, haematuria (±bladder catheterization), ultrasound finding of a bleeding, need for (non)surgical intervention and/or transfusion) after the biopsy was correlated to each test. Male-female ratio was 2:1. 50% had a surveillance biopsy at either three or 12 months. Around 17% (had) used acetylsalicylic acid (ASA) prebiopsy. Of 17 bleeding events, one subject needed a transfusion. Most bleeding events were Hb reductions over 1 mmol/l and all resolved uneventful. BT, PFA-100, MEA and MPV did not predict a bleeding outcome; prior ASA use however could (odds ratio 3.19; 95%-CI 1.06 to 9.61). Diagnostic performance data and Bland-Altman analysis showed that BT could not be substituted by PFA-100. ASA use was the best determinant of bleeding after kidney biopsy. Routine haemostasis testing prebiopsy has no added value.

Desmopressin use for minimising perioperative blood transfusion

BACKGROUND

Blood transfusion is administered during many types of surgery, but its efficacy and safety are increasingly questioned. Evaluation of the efficacy of agents, such as desmopressin (DDAVP; 1-deamino-8-D-arginine-vasopressin), that may reduce perioperative blood loss is needed.

OBJECTIVES

To examine the evidence for the efficacy of DDAVP in reducing perioperative blood loss and the need for red cell transfusion in people who do not have inherited bleeding disorders.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2017, issue 3) in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (from 1937), the Transfusion Evidence Library (from 1980), and ongoing trial databases (all searches to 3 April 2017).

SELECTION CRITERIA

We included randomised controlled trials comparing DDAVP to placebo or an active comparator (e.g. tranexamic acid, aprotinin) before, during, or immediately after surgery or after invasive procedures in adults or children.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified 65 completed trials (3874 participants) and four ongoing trials. Of the 65 completed trials, 39 focused on adult cardiac surgery, three on paediatric cardiac surgery, 12 on orthopaedic surgery, two on plastic surgery, and two on vascular surgery; seven studies were conducted in surgery for other conditions. These trials were conducted between 1986 and 2016, and 11 were funded by pharmaceutical companies or by a party with a commercial interest in the outcome of the trial.The GRADE quality of evidence was very low to moderate across all outcomes. No trial reported quality of life. DDAVP versus placebo or no treatmentTrial results showed considerable heterogeneity between surgical settings for total volume of red cells transfused (low-quality evidence) and for total blood loss (very low-quality evidence) due to large differences in baseline blood loss. Consequently, these outcomes were not pooled and were reported in subgroups.Compared with placebo, DDAVP may slightly decrease the total volume of red cells transfused in adult cardiac surgery (mean difference (MD) -0.52 units, 95% confidence interval (CI) -0.96 to -0.08 units; 14 trials, 957 participants), but may lead to little or no difference in orthopaedic surgery (MD -0.02, 95% CI -0.67 to 0.64 units; 6 trials, 303 participants), vascular surgery (MD 0.06, 95% CI -0.60 to 0.73 units; 2 trials, 135 participants), or hepatic surgery (MD -0.47, 95% CI -1.27 to 0.33 units; 1 trial, 59 participants).DDAVP probably leads to little or no difference in the total number of participants transfused with blood (risk ratio (RR) 0.96, 95% CI 0.86 to 1.06; 25 trials; 1806 participants) (moderate-quality evidence).Whether DDAVP decreases total blood loss in adult cardiac surgery (MD -135.24 mL, 95% CI -210.80 mL to -59.68 mL; 22 trials, 1358 participants), orthopaedic surgery (MD -285.76 mL, 95% CI -514.99 mL to -56.53 mL; 5 trials, 241 participants), or vascular surgery (MD -582.00 mL, 95% CI -1264.07 mL to 100.07 mL; 1 trial, 44 participants) is uncertain because the quality of evidence is very low.DDAVP probably leads to little or no difference in all-cause mortality (Peto odds ratio (pOR) 1.09, 95% CI 0.51 to 2.34; 22 trials, 1631 participants) or in thrombotic events (pOR 1.36, 95% CI, 0.85 to 2.16; 29 trials, 1984 participants) (both low-quality evidence). DDAVP versus placebo or no treatment for people with platelet dysfunctionCompared with placebo, DDAVP may lead to a reduction in the total volume of red cells transfused (MD -0.65 units, 95% CI -1.16 to -0.13 units; 6 trials, 388 participants) (low-quality evidence) and in total blood loss (MD -253.93 mL, 95% CI -408.01 mL to -99.85 mL; 7 trials, 422 participants) (low-quality evidence).DDAVP probably leads to little or no difference in the total number of participants receiving a red cell transfusion (RR 0.83, 95% CI 0.66 to 1.04; 5 trials, 258 participants) (moderate-quality evidence).Whether DDAVP leads to a difference in all-cause mortality (pOR 0.72, 95% CI 0.12 to 4.22; 7 trials; 422 participants) or in thrombotic events (pOR 1.58, 95% CI 0.60 to 4.17; 7 trials, 422 participants) is uncertain because the quality of evidence is very low. DDAVP versus tranexamic acidCompared with tranexamic acid, DDAVP may increase the volume of blood transfused (MD 0.6 units, 95% CI 0.09 to 1.11 units; 1 trial, 40 participants) and total blood loss (MD 142.81 mL, 95% CI 79.78 mL to 205.84 mL; 2 trials, 115 participants) (both low-quality evidence).Whether DDAVP increases or decreases the total number of participants transfused with blood is uncertain because the quality of evidence is very low (RR 2.42, 95% CI 1.04 to 5.64; 3 trials, 135 participants).No trial reported all-cause mortality.Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 2.92, 95% CI 0.32 to 26.83; 2 trials, 115 participants). DDAVP versus aprotininCompared with aprotinin, DDAVP probably increases the total number of participants transfused with blood (RR 2.41, 95% CI 1.45 to 4.02; 1 trial, 99 participants) (moderate-quality evidence).No trials reported volume of blood transfused or total blood loss and the single trial that included mortality as an outcome reported no deaths.Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 0.98, 95% CI 0.06 to 15.89; 2 trials, 152 participants).

AUTHORS' CONCLUSIONS

Most of the evidence derived by comparing DDAVP versus placebo was obtained in cardiac surgery, where DDAVP was administered after cardiopulmonary bypass. In adults undergoing cardiac surgery, the reduction in volume of red cells transfused and total blood loss was small and was unlikely to be clinically important. It is less clear whether DDAVP may be of benefit for children and for those undergoing non-cardiac surgery. A key area for researchers is examining the effects of DDAVP for people with platelet dysfunction. Few trials have compared DDAVP versus tranexamic acid or aprotinin; consequently, we are uncertain of the relative efficacy of these interventions.

Outpatient percutaneous native renal biopsy: safety profile in a large monocentric cohort

OBJECTIVES

We aim to evaluate the safety of performing percutaneous native kidney biopsy (PKB) as an outpatient procedure (implying an observation period of 6 hours) compared with the traditional inpatient policy.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Group I, in whom PKB was performed in the outpatient department (2012-2016) and followed by 6 hours' observation period and then by regular outpatient visits and group II, in whom PKB was performed and followed by at least 1 day hospital admission. Group II included retrospectively retrieved patients who underwent PKB in our Institution between January 2000 and November 2012 as an inpatient procedure. All biopsies were performed by a single nephrologist following a structured protocol.

RESULTS

462 biopsies were reviewed, 210 (45.5%) of patients were women and the mean age was 54.7±17.9 years. One hundred and twenty-nine (27.9%) of these biopsies were performed in outpatients. A total of 36 (7.8%) of patients developed a complication, and of those, 9 (1.9%) suffered for a major complication (arteriovenous fistula (six cases, 1.2%), ischaemic stroke (2; 0.4%), thromboembolic pulmonary embolism (1; 0.2%)) and 27 (5.8%) for minor(macroscopic haematuria (12 cases, 2.6%), haematomas on sonography not requiring intervention (15 cases, 3.2%)). When comparing the complication rate between groups I and II, no statical difference was observed. When analysing together both groups, after multivariate analysis, serum creatinine >3 mg/dL (OR 2.03, 95% CI 1.18 to 6.81) and known severe hypertension (OR 2.01, 95% CI 1.2 to 4.7) were found to be independent risk factors for minor and major complications, respectively. Conversely, we found no association of risk with the number of biopsy passes, gender, age, diagnosis, presence of haematuria before the kidney biopsy nor the degree of proteinuria.

CONCLUSIONS

Outpatient biopsy could be a valuable, safe and perhaps cost-effective method of obtaining diagnostic renal tissue in the majority of patients.

Quantification of bleeding volume using computed tomography and clinical complications after percutaneous renal biopsy

Background: The aim of this study was to investigate specific bleeding volume after percutaneous renal biopsy (PRB) and the correlation between bleeding volume and clinical parameters.

Methods: A retrospective study of 252 consecutive patients (153 male patients and 99 female patients) who underwent PRB at the Department of Nephrology, Japanese Red Cross Ishinomaki Hospital, between July 2013 and January 2016 was conducted. PRB was performed under ultrasound guidance using an automated spring-loaded biopsy device and a 16-cm, 16-gauge needle. Patients underwent computed tomography (CT) the day after PRB. Bleeding volume after PRB was evaluated using reconstructed CT data.

Results: The median bleeding volume after PRB was 38 mL (25th–75th percentile, 18–85 mL), with ≥4 punctures identified as a risk factor for massive bleeding. The incidence rates of macrohematuria, transient hypotension and bladder obstruction were 14.3, 8.7 and 4.7%, respectively. Post-PRB blood transfusion and intervention were required in 4.7 and 0.8% of patients, respectively.

Conclusion: Although it is difficult to assess the risk for massive bleeding prior to PRB, we do provide evidence of a specific increased risk with ≥4 puncture attempts, and recommend careful follow-up of these patients.

Image-guided intervention in the coagulopathic patient

Determining practice parameters for interventional procedures is challenging due to many factors including unreliable laboratory tests to measure bleeding risk, variable usage of standardized terminology for adverse events, poorly defined standards for administration of blood products, and the growing numbers of anticoagulant and antiplatelet medications. We aim to address these and other issues faced by radiologists performing invasive procedures through a review of available literature, and experiential guidance from three academic medical centers. We discuss the significant limitations with respect to using prothrombin-time and international normalized ratio to measure bleeding risk, especially in patients with synthetic defects due to liver function. Factors affecting platelet function including the impact of uremia; recent advances in laboratory testing, including platelet function testing; and thromboelastography are also discussed. A review of the existing literature of fresh-frozen plasma replacement therapy is included. The literature regarding comorbidities affecting coagulation including malignancy, liver failure, and uremia are also reviewed. Finally, the authors present a set of recommendations for laboratory thresholds, corrective transfusions, as well as withholding and restarting medications.

IgA nephropathy

Globally, IgA nephropathy (IgAN) is the most common primary glomerulonephritis that can progress to renal failure. The exact pathogenesis of IgAN is not well defined, but current biochemical and genetic data implicate overproduction of aberrantly glycosylated IgA1. These aberrant immunoglobulins are characterized by galactose deficiency of some hinge-region O-linked glycans. However, aberrant glycosylation alone is insufficient to induce renal injury: the participation of glycan-specific IgA and IgG autoantibodies that recognize the undergalactosylated IgA1 molecule is required. Glomerular deposits of immune complexes containing undergalactosylated IgA1 activate mesangial cells, leading to the local overproduction of cytokines, chemokines and complement. Emerging data indicate that mesangial-derived mediators that are released following mesangial deposition of IgA1 lead to podocyte and tubulointerstitial injury via humoral crosstalk. Patients can present with a range of signs and symptoms, from asymptomatic microscopic haematuria to macroscopic haematuria. The clinical progression varies, with 30-40% of patients reaching end-stage renal disease 20-30 years after the first clinical presentation. Currently, no IgAN-specific therapies are available and patients are managed with the aim of controlling blood pressure and maintaining renal function. However, new therapeutic approaches are being developed, building upon our ever-improving understanding of disease pathogenesis.

Current Safety of Renal Allograft Biopsy With Indication in Adult Recipients: An Observational Study

Renal biopsy remains the golden standard diagnosis of renal function deterioration. The safety in native kidney biopsy is well defined. However, it is a different story in allograft kidney biopsy. We conduct this retrospective study to clarify the safety of allograft kidney biopsy with indication.All variables were grouped by the year of biopsy and they were compared by Mann-Whitney U test (for continuous variables) or Chi-square test (for categorical variables). We collected possible factors associated with complications, including age, gender, body weight, renal function, cause of uremia, status of coagulation, hepatitis, size of needle, and immunosuppressants.We recruited all renal transplant recipients undergoing allograft biopsy between January of 2009 and December of 2014. This is the largest database for allograft kidney biopsy with indication. Of all the 269 biopsies, there was no difference in occurrence among the total 14 complications (5.2%) over these 6 years. There were only 3 cases of hematomas (1.11%), 6 gross hematuria (2.23%), 1 hydronephrosis (0.37%), and 2 hemoglobin decline (0.74%). The outcome of this cohort is the best compared to all other studies, and it is even better than the allograft protocol kidney biopsy. Among all possible factors, patients with pathological report containing "medullary tissue only" were susceptible to complications (P < 0.001, 1.8 of relative risk).In modern era, this study demonstrates the safety of allograft kidney biopsy with indication. Identifying the renal capsule before biopsy to avoid puncture into medulla is the most important element to prevent complications.

The Native Kidney Biopsy: Update and Evidence for Best Practice

The kidney biopsy is the gold standard in the diagnosis and management of many diseases. Since its introduction in the 1950s, advancements have been made in biopsy technique to improve diagnostic yield while minimizing complications. Here, we review kidney biopsy indications, techniques, and complications in the modern era. We also discuss patient populations in whom special consideration must be given when considering a kidney biopsy and the important role that the kidney biopsy plays in nephrology training. These data are presented to develop best practice strategies for this essential procedure.

Percutaneous native kidney biopsy in patients receiving antiplatelet agents- is it necessary to stop them routinely?

Percutaneous renal biopsy plays an important role in the investigational approach of the nephrologist. Though the technique and the safety of the procedure has improved over the last two decades it remains an invasive procedure and can be associated with bleeding complications. To minimize the risk of bleeding, it has been the practice of many centers and nephrologists to advise patients receiving antiplatelet agents to discontinue them 5-7 days before planned procedure. This advice is based on opinion and pre-established procedure or norms rather than sound evidence based guidelines. This article aims to be a critical appraisal of this unnecessary and sometimes not so safe practice of routine stoppage of antiplatelet agents prior to kidney biopsy.