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Teh SP, Ho QY, Kee YST, Thangaraju S, Tan RY, Teo SH, Tan HK, Tan CS, Choong HLL, Ng LC, Abdul Rahman M, Lim AEL, Kaushik M. Regional citrate anticoagulation vs systemic heparin anticoagulation for double-filtration plasmapheresis. J Clin Apher 2023; 38:16-23. [PMID: 36197100 DOI: 10.1002/jca.22019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/21/2022] [Accepted: 09/13/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Double-filtration plasmapheresis (DFPP) has been utilized for immunomodulation in kidney transplantation. Anticoagulation is important to maintain circuit patency during DFPP. We aimed to compare the efficacy and safety of regional citrate anticoagulation (RCA) with systemic heparin anticoagulation during DFPP in kidney transplant recipients. METHODS A retrospective cohort study was conducted to compare the efficacy and safety of RCA (RCA-DFPP) to systemic heparin anticoagulation (Hep-DFPP) for DFPP among kidney transplant recipients in a single tertiary center. RESULTS A total of 112 sessions of DFPP were performed for 23 subjects, of which 62 sessions were RCA-DFPP and 50 sessions were Hep-DFPP. There were 13 sessions (11.6%) of premature circuit clotting, 10 sessions (16.1%) for RCA-DFPP and 3 sessions (6.0%) for Hep-DFPP (P = .10). All premature circuit clotting episodes occurred in subjects who underwent DFPP through a vascular catheter. Premature circuit clotting was associated with the use of a vascular catheter (odds ratio [OR] 14.2, 95% confidence interval [CI] 2.7-73.7; P < .01) and high postfilter ionized calcium (OR 12.7, 95% CI 1.4-112.5; P < .01). There was no major bleeding event. Hep-DFPP was associated with higher occurrence of hypocalcemia (OR 1.1, 95% CI 1.0-1.2; P < .01) and metabolic acidosis (OR 1.4, 95% CI 1.2-2.0; P = .04), while hypomagnesemia was more common for RCA-DFPP (OR 2.9, 95% CI 1.1-7.4; P = .03). CONCLUSION Amongst kidney transplant patients who receive DFPP therapy, RCA-DFPP may be comparable to Hep-DFPP for the maintenance of circuit patency. Functioning vascular access is vital in avoiding premature clotting of the circuit. Close monitoring of electrolyte imbalances and coagulopathy related to DFPP is recommended.
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Affiliation(s)
- Swee Ping Teh
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore.,Department of General Medicine-Renal Medicine, Sengkang General Hospital, Singapore, Republic of Singapore
| | - Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore.,SingHealth Duke-NUS Transplant Centre, Singapore Health Services, Singapore, Republic of Singapore
| | - Yi Shern Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore.,SingHealth Duke-NUS Transplant Centre, Singapore Health Services, Singapore, Republic of Singapore
| | - Sobhana Thangaraju
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore.,SingHealth Duke-NUS Transplant Centre, Singapore Health Services, Singapore, Republic of Singapore
| | - Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore
| | - Su Hooi Teo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore
| | - Han Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore
| | - Hui Lin Lina Choong
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore
| | - Li Choo Ng
- Nursing Division, Singapore General Hospital, Singapore, Republic of Singapore
| | - Maslinna Abdul Rahman
- SingHealth Duke-NUS Transplant Centre, Singapore Health Services, Singapore, Republic of Singapore.,Nursing Division, Singapore General Hospital, Singapore, Republic of Singapore
| | - Amy Ee Lin Lim
- Nursing Division, Singapore General Hospital, Singapore, Republic of Singapore
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Republic of Singapore
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Ho QY, Lim CC, Tan HZ, Sultana R, Kee T, Htay H. Complications of Percutaneous Kidney Allograft Biopsy: Systematic Review and Meta-analysis. Transplantation 2022; 106:1497-1506. [PMID: 35019898 DOI: 10.1097/tp.0000000000004033] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Kidney biopsy is important to guide the management of allograft dysfunction but has a risk of complications. This review aimed to determine the incidence and risk factors of complications after kidney allograft biopsy. METHODS This is a systematic review and meta-analysis of randomized controlled trials, cohort studies, or case-control studies indexed on PubMed, Embase, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry, and ClinicalTrials.gov, limited to the English language, from January 2000 to December 2020, including adult and pediatric kidney allograft biopsies. Primary outcomes were gross hematuria, bleeding requiring transfusion, and major complications (requiring interventions such as blood transfusion or surgical or radiological interventions). RESULTS The review included 72 studies (40 082 biopsies). The quality of included studies was suboptimal. Pooled rates of gross hematuria, bleeding requiring transfusion, and major complications were 3.18% [95% confidence interval (95% CI), 2.31-4.19], 0.31% (95% CI, 0.15-0.52) and 0.89% (95% CI, 0.61-1.22), respectively. Gross hematuria rates were lower in high-income compared with middle-income countries (2.59% versus 6.44%, P < 0.01) and biopsies performed by radiology as compared with nephrology departments (1.25% versus 3.71%, P < 0.01). Blood transfusion rates were lower in pediatrics than adults (0.0% versus 0.65%, P < 0.01). Major complications were lower in biopsies performed by specialists as compared with trainees (0.02% versus 3.64%, P < 0.01). Graft loss and mortality were extremely rare. Limitations included missing data, few randomized controlled trials, and possible publication bias. CONCLUSIONS The risk of complications after kidney allograft biopsy was low. Given the low quality of included studies, risk factors for complications should be further examined in future studies.
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Affiliation(s)
- Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore
| | | | - Hui Zhuan Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore
| | - Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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Pirklbauer M, Berger M, Boban MD, Tiefenthaler M. The Tangential Extraperitoneal Retrorenal Approach in Kidney Transplant Biopsy: An Observational Study to Assess Complication and Adequacy Rates. Transpl Int 2022; 35:10068. [PMID: 35185363 PMCID: PMC8842347 DOI: 10.3389/ti.2021.10068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/21/2021] [Indexed: 01/20/2023]
Abstract
Introduction: Ultrasound-guided percutaneous kidney allograft biopsy is the gold-standard for pathology work-up. Recent studies postulate better safety and efficacy for tangential approaches, however, there is no recommendation regarding biopsy needle path. In this context, we previously described the unified tangential extraperitoneal retrorenal (TER) approach for standard allograft biopsy. Methods: A single-center retrospective observational study evaluated safety and efficacy of the TER biopsy approach among 250 patients that underwent 330 ultrasound-guided kidney transplant biopsies between January 2011 and May 2020. Results: The overall major complication rate was 0.56% per biopsy attempt (1.21% per biopsy) including blood transfusion, arterial embolization and bladder catheterization for gross hematuria in 0.28, 0.14 and 0.14% of biopsy attempts, respectively (0.61, 0.30 and 0.30% of biopsies, respectively). Minor complications included subcapsular and/or perinephric hematoma, superficial bleeding, arteriovenous fistula and gross hematuria in 12.6, 3.0, 2.5 and 1.4% of biopsy attempts, respectively (27.0, 6.4, 5.5 and 3.0% of biopsies, respectively). Sample adequacy rate was 86.7%, ranging from 82.2 to 94.1% if one or ≥two cores were analyzed, respectively. Residents and consultants yielded similar complication and adequacy rates. Conclusion: According to current literature, ultrasound-guided TER kidney transplant biopsy is a safe and efficient approach eligible for nephrology training.
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O'Hara DV, Wong JK, Cooper B, Wong G, Wong MG, Cheikh Hassan HI. Lessons for the clinical nephrologist: ureteric obstruction secondary to blood clot after kidney biopsy. J Nephrol 2021; 34:2131-2136. [PMID: 33856685 PMCID: PMC8610936 DOI: 10.1007/s40620-021-01012-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Daniel V O'Hara
- Renal Unit, Wollongong Hospital, Wollongong, NSW, Australia.
- The George Institute for Global Health, UNSW, 1 King St Newtown, SydneyAustralia, NSW, 2042, Australia.
- Renal Unit, Royal North Shore Hospital, Sydney University of Sydney, Sydney, Australia.
| | | | - Bruce Cooper
- Renal Unit, Royal North Shore Hospital, Sydney University of Sydney, Sydney, Australia
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
- Centre for Kidney Research, Kids Research Institute, The Children's Hospital, Westmead, Australia
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Muh Geot Wong
- The George Institute for Global Health, UNSW, 1 King St Newtown, SydneyAustralia, NSW, 2042, Australia
- Renal Unit, Royal North Shore Hospital, Sydney University of Sydney, Sydney, Australia
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Ho QY, Teh SP, Thangaraju S, Teo SH, Tan HK, Abdul Rahman MB, Ng LC, Lim AEL, Choong LHL, Kee T, Kaushik M. Regional Citrate Anticoagulation during Double-Filtration Plasmapheresis in Kidney Transplant Recipients: A Single-Center Retrospective Cohort Study. Blood Purif 2021; 51:376-382. [PMID: 34198288 DOI: 10.1159/000517233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Double-filtration plasmapheresis (DFPP) may be used for immunomodulation in kidney transplant (KTx). While DFPP reduces plasma product exposure, risk of circuit clotting merits adequate anticoagulation. Regional citrate anticoagulation (RCA) avoids the risks of systemic anticoagulation, but a protocol for RCA-DFPP is not previously widely described. METHODS We conducted a single-center retrospective cohort study involving adult (≥21 years old) KTx recipients who underwent RCA-DFPP from 2018 to 2020 to investigate efficacy and safety for an RCA protocol during DFPP in KTx recipients. RESULTS Fifty-one (85%) of 60 RCA-DFPP sessions in 17 patients completed without circuit clotting. Circuit clotting was associated with high post-filter ionized calcium (28 vs. 3.7%, odds ratio 10.1, 95% CI 1.1-89.4, p = 0.037). Hypo- and hypercalcemia developed in 5 (8.3%) and 8 (13.3%) sessions, respectively, but no adverse effects were noted despite severe hypocalcemia in one. There was no significant change in pre- and post-RCA-DFPP sodium, bicarbonate, albumin, and platelet levels. With regards DFPP procedure, prolongation of prothrombin time (PT) and activated partial thromboplastin time (aPTT) was observed following 38 (64.4%) and 12 (20.3%) sessions, respectively. Severely prolonged (>1.5 × upper limit normal) PT and aPTT were recorded in 2 sessions each. Expectedly, hypofibrinogenemia developed after 31 (51.7%) sessions: including 4 (6.7%) severe hypofibrinogenemia (<0.5 g/L). Two patients developed bleeding requiring blood product transfusion. The median total volume of fluids administered per session was 1.495 (1.373-1.612) L; post-RCA-DFPP significant weight gain of 0.5 (0-1.25) kg was noted. Diuretic was commenced or dose increased following 20 (33.3%) sessions for fluid balance management. DISCUSSION/CONCLUSION Protocol-based RCA for DFPP is feasible and safe in KTx recipients. However, DFPP-related coagulopathy can develop consequent to treatment; caution should be exercised for patients with bleeding risk. Close monitoring and management of the patients' electrolytes, especially hypocalcemia and hypomagnesemia, and fluid status is recommended.
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Affiliation(s)
- Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Swee Ping Teh
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Sobhana Thangaraju
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Su Hooi Teo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Han Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Maslinna Binte Abdul Rahman
- SingHealth-Duke NUS Transplant Centre, Singapore, Singapore.,Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Li Choo Ng
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Amy Ee Lin Lim
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Lina Hui Lin Choong
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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Vornicu A, Obrişcă B, Cotruta B, Dulămea AO, Caceaune N, Ismail G. Case Report: Hyponatremia Secondary to Desmopressin Administration Prior to Percutaneous Kidney Biopsy: A Case-Based Review. Front Med (Lausanne) 2021; 8:696904. [PMID: 34235164 PMCID: PMC8255479 DOI: 10.3389/fmed.2021.696904] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/27/2021] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Bogdan Obrişcă
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Cotruta
- Department of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania
| | - Adriana Octaviana Dulămea
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Neurology, Fundeni Clinical Institute, Bucharest, Romania
| | - Nicu Caceaune
- Department of Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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