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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 4  |  Page : 541-546
Outpatient Percutaneous Renal Biopsy in Adult Patients


Department of Nephrology, King Fahd Hospital, King Faisal University, Al-Khobar, Saudi Arabia

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   Abstract 

To study the safety and efficacy of performing percutaneous renal biopsy in the outpatient department compared to the traditional inpatient policy, we studied 44 consecutive patients with proteinuria and other urinary sediment abnormalities, at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, during the period from September 2004 to August 2006. The patients were divided into two groups: group I, in whom kidney biopsy was performed and followed by 1-day hospital admission; and group II, in whom renal biopsy was performed in the outpatient department and followed by 6 hours' observation period and then by regular outpatient visits. All biopsies were performed with the use of real-time ultrasound and automated biopsy needle. Patients with a history of a bleeding diathesis or abnormal coagulation profile and those receiving warfarin, heparin, aspirin, or nonsteroidal anti-inflammatory drugs were excluded from the study. Only minor biopsy-related complications such as gross hematuria, perinephric hematoma that resolved without the need for blood transfusion or surgical intervention occurred in three (13.6%) patients in group I and in two (9.1%) patients in group II. The complications were apparent within 6 hours in all but one patient (97.7%). Overall, hematuria was identified in 52% of patients at :5 2 hours, 85% at :5 4 hours, and 97.7% at < 6 hours. The 24-hour hematocrit levels were not significantly different between the study groups. One (4.5%) patient from group II had a small perinephric hematoma, which was detected by ultrasound examination at 24 hours but not at 6 hours post biopsy period.; it resolved spontaneously without intervention. We conclude that in selected patients, same-day discharge after 6 hours of renal biopsy may be given safely without increased risk of complications.

Keywords: Hematuria, Outpatient, Perinephric, Proteinuria, Renal biopsy

How to cite this article:
Al-Hweish AK, Abdul-Rehaman IS. Outpatient Percutaneous Renal Biopsy in Adult Patients. Saudi J Kidney Dis Transpl 2007;18:541-6

How to cite this URL:
Al-Hweish AK, Abdul-Rehaman IS. Outpatient Percutaneous Renal Biopsy in Adult Patients. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Jul 20];18:541-6. Available from: http://www.sjkdt.org/text.asp?2007/18/4/541/36509

   Introduction Top


Percutaneous renal biopsy is an essential tool to establish histological diagnosis, treatment, and prognosis of renal disease. [1],[2] Its major complication is bleeding, [2],[3],[4] therefore, an overnight hospitalization is a common practice.

Since the first description of percutaneous kidney biopsy in 1951, [5] the introduction of real-time ultrasound guidance[6] and, more recently, the use of spring-loaded biopsy guns[7],[8] have rendered this procedure increa­singly safe and effective.

The technological advances have enabled precise localization of the renal poles, mini­mized the number of passes necessary to obtain adequate tissue, and minimized the dwell time of the needle in the kidney.[4],[9],[10],[11],[12] However, bleeding remains a serious compli­cation of percutaneous renal biopsy.[12],[13]

The optimal period of post-biopsy bed rest and in-hospital observation is controversial, as is the issue of whether or not kidney biopsy should be performed as an outpatient procedure.[13],[14] It is not determined yet whether strict overnight bed rest in the hospital after a kidney biopsy decreases the risk of complications such as perinephric and intra­renal hematoma formation and macroscopic hematuria. A study in adult patients concluded that a minimum of 12 hours of observation post biopsy might be required.[13] A recent study found that a stable hematocrit 6 hours post biopsy was a predictor of low risk of bleeding complications. [15] Few other studies suggested decreasing the observation time to 6-8 hours, indicating that there was no signi­ficant difference in complications between hospitalized patients and those who were followed in intermediate care facilities. [16],[17]

The reports about duration of observation, however, were mainly based on retrospective analysis and did not use post-biopsy ultra­sonography to detect complications such as perinephric hematoma or arteriovenous fistula. In addition, they did not suggest an exact duration for safe observation.

This study prospectively compares the inci­dence of bleeding and perinephric hematoma between patients admitted for 24 hours in­hospital observation and those who were ob­served for only 6 hours post biopsy as out­patients.


   Material and Methods Top


We prospectively studied 44 consecutive percutaneous renal biopsies 20 women, 24 men); all of them had definite indication for renal biopsy. Our Internal Review Board (Ethical Committee) reviewed the protocol and approved it. The procedure was explained to all patients and a written informed consent was obtained. The patients were then rando­mized into two groups: group I, in whom the renal biopsy was followed by one-day hospital admission and observation; and group II, who were observed in the outpatient department by a qualified doctor and nurse for six hours.

The patients of both groups were encouraged to increase fluid intake; and hourly records of pulse, blood pressure, urinalysis, and hematocrit levels were obtained. Abdominal ultrasound was performed immediately after the biopsy was taken, at 6 and 24 hours post biopsy. The patients of group II were instructed to return at the end of 24 hours for repeat of ultrasound, hematocrit, and urinalysis.

Patients with a history of a bleeding diathesis or abnormal coagulation profile and those receiving warfarin, heparin, aspirin, or non­steroidal anti-inflammatory drugs were excluded from the study.

Coagulation parameters, platelet counts, and bleeding time were obtained either one day before the biopsy or in the same morning. Our standard protocol for both inpatient and outpatient renal biopsies required hematocrit > 35%, a platelet count > 150,000/cmm, pro­thrombin time less than 13.0 seconds (with control values of 10.5-12.5 seconds) and normal bleeding time.


   Technique of the renal biopsy Top


All biopsies were performed under ultra-sound guidance using an automated spring­loaded gun device (Meditech; Boston Scientific Co., Watertown, MA); 16 gauge needle was used. The renal biopsies were performed under local xylocaine (2%) anesthesia by a full-time nephrology faculty experienced in the tech­nique.

The indications for kidney biopsy were as follows: nephrotic syndrome (n=4); idiopathic glomerulonephritis (n=12); microscopic hema­turia and/or proteinuria (n=8); systemic lupus erythematosus (n=6); and systemic vasculitis (n=4). All patients were kept on strict bed rest in the supine position for 6 hours, and patients of group I remained in hospital for additional 18 hours.

Vital signs were routinely checked at 15­minute intervals for 1 hour, then 30-minute intervals for 3 hours, and subsequently hourly till the end of 6 hours and then 6-hourly for 24 hours for the inpatients. The coagulation profile, number of passes, and number of cores ob­tained were compared among the two patient groups.


   Statistical analysis Top


Data are presented as mean ± SD. For comparison between different groups, one­way analysis of variance with the Bonferroni/ Dunn post hoc correction was used. The comparison between hematocrit at 6 versus 24 hours post biopsy and number of passes versus number of obtained cores was made using standard linear regression analysis. The differences were considered significant for 'p' value less than 0.05.


   Results Top


The coagulation profile, hematocrit levels, blood urea nitrogen (BUN) levels, and number of passes and cores obtained among patient groups are listed in [Table - 1].

In the entire group, there were 11.6 ± 1.1 glomeruli (range 5-32 glomeruli) and 3.1 ± 0.5 small arteries per biopsy specimen. The hematocrit levels did not decrease signifi­cantly at 6 and 24 hours post renal biopsy when compared with the baseline levels in the entire group, and there were no signi­ficant differences in hematocrit levels bet­ween the inpatient and outpatient groups. One (4.5%) of the patients in group II had a small perinephric hematoma, which was detected at 6 hours; it resolved spontaneously without intervention.

There was no correlation between the decline in hematocrit levels at any time interval and the number of passes or cores obtained. Gross transient hematuria was observed in three (13.6%) patients in group I and two (9.1%) patients in group II. This complication was observed within 6 hours in all but one patient (97.7%) in group I. Overall, hematuria was identified in 52% of patients at < 2 hours, 85% at < 4 hours, and 97.7% at < 6 hours.

One (4.5%) patient of group II had a small perinephric hematoma that was detected at 24 hour and resolved spontaneously upon follow-up without intervention.


   Discussion Top


Most reports in the medical literature evaluating complications after a renal biopsy are based on the use of either Franklin­modified Vim-Silverman or disposable Tru­Cut needles. The most serious complication encountered after a renal biopsy is bleeding.[2],[3],[4] Whereas microscopic hematuria is present in almost all patients, gross hematuria occurs in only 3-9% of the patients.[3],[18] Transfusion is rarely necessary but has been reported in 0.1­-3% of the cases in several reports.[19],[20] Overall, percutaneous renal biopsy has become a relatively safe procedure, with life-threatening complications occurring in less than 0.1% of biopsies in recent reports.[13],[20],[21],[22],[23]

Because of the safety of the technique and the high cost of hospitalization, the potential effect of performing kidney biopsies on out­patients could be substantial. The potential effect on hospital bed use and resource allo­cation could be considerable. The estimated cost of performing a renal biopsy as a day­care procedure is £334 (US$481), whereas an overnight stay in hospital is estimated to cost £1,618 (US$2,330). An estimated saving of £36,586 (US$52,684) per annum has been made by performing biopsies as a day-care procedure. [24] Furthermore, the frequency of serious complications from a renal biopsy is very low; and major complications such as death, nephrectomy, and need for transfusion are very uncommon.[25],[26],[27] Dodge et al.[28] re­viewed data from various investigators regarding percutaneous renal biopsy and reported mortality rate of 0.12% in 4,000 biopsies. They also reported post-'renal biopsy' incidences as 0.8% for transfusion, 0.1% for nephrectomy, and 0.4% for symptomatic peri­renal hematoma.

Post-biopsy intrarenal arteriovenous fistula formation may occur more frequently but is often a transient phenomenon that resolves spontaneously.[29],[30] In another report by Diaz­Buxo and Donadio[31] on 1,000 consecutive renal biopsies in adults and children, the majority performed using the modified Franklin-Vim-Silverman needle, 1 patient died (0.1%) and 14 (1.4%) had a symptomatic peri­renal hematoma.

Bohlin et al. [25] reported no serious compli­cations following 119 consecutive renal biopsies performed in children using an auto­mated needle; the children had ultrasono­graphic examination after 24 hours of in-hos­pital bed rest.

In 1998, Davis et al.[32] suggested that there were practical advantages of the automated renal biopsy needle over a non-automated needle, including fewer passes required to obtain a tissue core, faster procedure, and a reduced risk of bleeding complications and non-organ perforation. The authors suggested that outpatient renal biopsy could be performed safely in cooperative, non-hypertensive patients with no bleeding diathesis. Others also suggested similar exclusions. [33] In our series we excluded these patient categories, which undoubtedly minimized the complication rates.

In our study, the overall rate of compli­cations was 11.4%, which is far better than the complication rate reported by Chesney et al. in 1996. [34] Minor biopsy-related compli­cations occurred in 13.6% and 9.1% of our inpatients and outpatients respectively, com­pared with 17.5% and 11.4% in the Chesney report. However, others had better outcomes than ours. Ogborn and Grimm [35] reported a complication rate of 8.7%, and White and Pool [29] reported a rate of only 2.6% in retrospective studies on the performance of renal biopsy in children on an outpatient basis. Nevertheless, our results compare favor­ably with the incidence reported in other studies, including the large adult patient series published by Parrish et al. [3]

We conclude that percutaneous renal biopsy performed as an outpatient procedure in selec­ted patients, using ultrasound guidance coupled with an automated gun device, is both safe and efficient. This observation may lend support to performing renal biopsy in the outpatient setting with a shorter period of observation.


   Acknowledgement Top


The authors express their deep thanks to the staff nurses of the Day Care Unit for their valuable support during the procedure and for their meticulous patient care. In addition, the authors thank the ultrasound technicians for their help during and after renal biopsies. We would also like to thank the staff members of the Histopathology Department for their assistance.

 
   References Top

1.Reisman L, Dikman S, Churg J, Kupher S. Renal biopsy: Why and when. Mt Sinai J Med 1996;63:178-90.  Back to cited text no. 1    
2.Madaio MP. Renal biopsy. Kidney Int 1990; 38:529-43.  Back to cited text no. 2  [PUBMED]  
3.Parrish AE. Complications of percutaneous renal biopsy: a review of 37 years experience. Clin Nephrol 1992;38:135-41.  Back to cited text no. 3  [PUBMED]  
4.Ballal SH, Nayak R, Dhanraj P, Kocher P, Bastani B. Percutaneous renal biopsy: a single center experience with automated spring­loaded "gun" type device. Clin Nephrol 1995; 44:274-5.  Back to cited text no. 4  [PUBMED]  
5.Iverson P, Brun C. Aspiration biopsy of the kidney. Am J Med 1951;11:324-30.  Back to cited text no. 5    
6.Saitoh M. Selective renal biopsy under ultrasonic real-time guidance. Urol Radiol 1984;6:30-7.  Back to cited text no. 6  [PUBMED]  
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9.Mendelson DC, Cole EH. Outcome of percu­taneous kidney biopsy, including those of solitary native kidneys. Am J Kidney Dis 1995;26:580-5.  Back to cited text no. 9    
10.Bogan ML, Kopecky KK, Kraft JK, et al. Needle biopsy of renal allografts: comparison of two techniques. Radiology 1990;174:273-5.  Back to cited text no. 10    
11.Wiseman DA, Hakins R, Numerow LM, Taub KJ. Percutaneous renal biopsy utilizing real-time ultrasonic guidance and a semi­automatic biopsy device. Kidney Int 1990;38: 347-9.  Back to cited text no. 11    
12.Mahoney MC, Racadio JM, Merhar GL, First MR. Safety and efficacy of kidney transplant biopsy: Tru-cut needle versus sonographically guided biopsy gun. AJR Am J Roentgenol 1993;160:325-6.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Marwah DS, Korbet SM. Timing of complications in percutaneous renal biopsy: What is the optimal period of observation? Am J Kidney Dis 1996;28:47-52.  Back to cited text no. 13  [PUBMED]  
14.Whittier WL, Korbet SM. Timing of complications in percutaneous renal biopsy. J Am Soc Nephrol 2004;15:142-7.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Lin WC, Yang Y, Wenn YK, et al. Outpatient versus inpatient renal biopsy: A retro­spective study. Clin Nephrol 2006; 66:17­-24.  Back to cited text no. 15    
16.Khajehdehi P, Junaid SM, Salinas-Madrigal L, et al. Percutaneous renal biopsy in the 1990s: safety, value, and implications for early hospital discharge. Am J Kidney Dis 1999;34:92-7.  Back to cited text no. 16  [PUBMED]  
17.Smickes AM, Blowey DL, Gyves KM, et al. Success and safety of same-day kidney biopsy in children and adolescents. Pediatr Nephrol 2000;14:964-52.  Back to cited text no. 17    
18.Wicker CG, Gopler TA. Complications of percutaneous needle biopsy of the kidney. Am J Nephrol 1982;2:173-8.  Back to cited text no. 18    
19.Kon SP, Templar J, Dodd SM, et al. Diagnostic contribution of renal allograft biopsies at various interval after trans­plantation. Transplantation 1997;63:547-50.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Korbet SM. Percutaneous renal biopsy. Semin Nephrol 2002;22:254-67.  Back to cited text no. 20  [PUBMED]  
21.Burstein DM, Schwartz MM, Korbet SM. Percutaneous renal biopsy with the use of real-time ultrasound. Am J Nephrol 1991; 11:195-200.  Back to cited text no. 21  [PUBMED]  
22.Alebiosu CO, Kadiri S. Percutaneous renal biopsy as an outpatient procedure. J Natl Med Assoc 2004;96:1215-8.  Back to cited text no. 22  [PUBMED]  
23.Mendelssohn DC, Cole EH. Outcome of percutaneous kidney biopsy, including those of solitary native kidneys. Am J Kidney Dis 1995;26:580-5.  Back to cited text no. 23  [PUBMED]  
24.Hussain F, Watson AR, Hayes J. Standards for renal biopsies: comparison of inpatient and day care procedures. Pediatr Nephrol 2003;18:53-6.  Back to cited text no. 24    
25.Bohlin AB, Edstrom S, Almgren B, et al. Renal biopsy in children: indications, tech­nique and efficacy in 119 consecutive cases. Pediatr Nephrol 1995;9:201-3.  Back to cited text no. 25    
26.Alon US, Perry M. Percutaneous kidney needle biopsy in children is less traumatic than in adults. Nephron 1988;50:57-60.  Back to cited text no. 26    
27.Fraser IR, Fairley KF. Renal biopsy as an outpatient procedure. Am J Kidney Dis 1995;25:876-8.  Back to cited text no. 27  [PUBMED]  
28.Dodge WF, Daeschner CW, Brennan MB, et. Percutaneous renal biopsy in children. Pediatrics 1962;30:287-96.  Back to cited text no. 28    
29.White RH, Poole C. Day care renal biopsy. Pediatr Nephrol 1996;10:408-11.  Back to cited text no. 29  [PUBMED]  
30.Proesmans W, Marchal G, Snoeck L, et al. Ultrasonography for assessment of bleeding after percutaneous renal biopsy in children. Clin Nephrol 1982;18:257-62.  Back to cited text no. 30  [PUBMED]  
31.Diaz-Buxo JA, Donadio JV. Complications of percutaneous renal biopsy: an analysis of 1,000 consecutive biopsies. Clin Nephrol 1975;4:223-7.  Back to cited text no. 31    
32.Davis ID, Oehlenschlager W, Avner ED. Pediatric renal biopsy: should this procedure be performed in an outpatient setting? Pediatr Nephrol 1998;12:96-100.  Back to cited text no. 32  [PUBMED]  [FULLTEXT]
33.Stiles KP, Yuan CM, Chung EM, et al. Renal biopsy in high-risk patients with medical diseases of the kidney. Am J Kidney Dis 2000;36:419-33.  Back to cited text no. 33  [PUBMED]  
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35.Ogborn MR, Grimm PC. Pediatric renal biopsy in the ambulatory environment. Pediatr Nephrol 1992;6:311-2.  Back to cited text no. 35  [PUBMED]  

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Correspondence Address:
Abdulla K Al-Hweish
King Fahd Hospital of the University, PO Box 40246, Al-Khobar 31952
Saudi Arabia
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    Abstract
    Introduction
    Material and Methods
    Technique of the...
    Statistical analysis
    Results
    Discussion
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    References
    Article Tables
 

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