| Abstract|| |
We report a 50-year-old male patient with diabetes mellitus and hypertension who presented with low-grade fever, anuria and renal failure. He had no prior history of nephropathy and retinopathy. Since anuria persisted, a renal biopsy was performed using automated gun, under ultrasound guidance. Two hours after the renal biopsy was performed, the patient developed severe left loin pain that required analgesics and sedatives. Ultrasound of the abdomen performed immediately, two hours and four hours after the biopsy, did not reveal any hematoma. The hemoglobin was stable when the patient developed loin pain, but after eight hours decreased to 9.1 g/dL, and computed tomography scan of the abdomen revealed a big peri-nephric hematoma around the left kidney. He was managed with blood transfusions and a selective angiogram was done. It revealed a pseudoaneurysm and arterio-venous fistula from the segmental artery of lower pole of the left kidney; both were closed by using microcoils and liquid embolic agent N-butyl-cyanoacrylate (NBCA). The only risk factor the patient had at the time of renal biopsy was severe renal failure. Our case suggests that severe loin pain immediately after renal biopsy in a patient with renal failure warrants careful follow-up of hemoglobin and imaging, even if initial imaging is normal. Further fall of hemoglobin necessitates early evaluation with angiogram, which helps in diagnosing the treatable, although rare, complications like pseudoaneurysm and arterio-venous fistula.
|How to cite this article:|
Madhav D, Ram R, Rammurti S, Dakshinamurty K V. Severe loin pain following renal biopsy in a high-risk patient: A case report of a rare combination of pseudoaneurysm and arterio-venous fistula. Saudi J Kidney Dis Transpl 2011;22:544-8
|How to cite this URL:|
Madhav D, Ram R, Rammurti S, Dakshinamurty K V. Severe loin pain following renal biopsy in a high-risk patient: A case report of a rare combination of pseudoaneurysm and arterio-venous fistula. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Apr 26];22:544-8. Available from: http://www.sjkdt.org/text.asp?2011/22/3/544/80496
| Introduction|| |
The technique of percutaneous renal biopsy was introduced clinically in the early 1950s by Iversen and Brun, and since then, it has become an essential tool in diagnosis, management and assessing the prognosis of various kidney diseases. The biopsy technique has significantly improved over the past few decades because of the introduction of ultrasonography and automated-gun biopsy devices, and the incidence of life-threatening complications has come down significantly. The development of clinically apparent complications, such as gross hematuria, significant decrease in hemoglobin, hematomas, arteriovenous fistulas (AVFs), or severe flank pain post-biopsy has been reported to be between 7% and 15%. 
| Case Report|| |
A 50-year-old male patient with Type-2 diabetes mellitus and hypertension for the past eight years presented in December 2009 with complaints of low-grade fever, not associated with chills and rigors but associated with myalgia. He had received herbal medicine and non-steroidal anti-inflammatory drugs elsewhere before presenting to us (details are not known). Two days after this, he developed anuria and was admitted in Nizam's Institute of Medical Sciences, Hyderabad, India with nausea, vomiting and breathlessness. No past history of diabetic retinopathy and nephropathy could be elicited. Two months earlier, the serum creatinine was normal and proteinuria was 300 mg/day. On examination, pedal edema was present. Laboratory investigations revealed the following: hemoglobin 14 g/dL (normal range 12-15 g/dL); packed cell volume (PCV) 43 vol% (normal 40-50 vol%); total leukocyte count 7,600/mm 3 (normal 4,000-10,000/mm 3 ); platelet count 1.4 lakhs/mm 3 (normal 1.5-4.0 lakhs/mm 3 ); blood urea 126 mg/dL (normal 15-40 mg/dL); serum creatinine 9 mg/dL (normal 0.6-1.5 mg/dL); serum sodium 126 meq/L (normal 135-145 meq/L); serum potassium 4.4 meq/L (normal 3.5-5.0 meq/L); total bilirubin 2.2 mg/dL (normal 0.1-0.8 mg/dL); conjugated bilirubin 0.7 mg/dL (up to 0.25 mg/dL); serum glutamate oxaloacetate transaminase (SGOT) 362 U/L (normal 5-40 U/L); serum glutamate pyruvate transaminase (SGPT) 1,239 U/L (normal 5-40 U/L); alkaline phosphatase 197 U/L (normal up to 270 U/L); total protein g/dL (normal 6.0-7.5 g/dL); albumin 3 g/dL (normal 3.0-5.0 g/dL); creatinine phosphokinase 97 IU/L (normal 51-294 IU/L); amylase 108 U/L (normal up to 200 U/L); lipase 297 U/L (normal up to 160 U/L); calcium mg/dL (normal 8-10.5 mg/dL); phosphorus, 3.9 mg/dL (normal 3.0-4.5 mg/dL); uric acid 12.9 mg/dL (normal 3.0-5.0 mg/dL); urine for myoglobin, negative; urine: albumin 2+, sugar nil, RBC 4-5, leukocytes 4-5; urine culture, sterile; blood culture, sterile; anti-dengue IgG and IgM antibodies negative; anti-chikun-gunya antibody IgM negative (rapid test); anti-leptospira antibody IgG and IgM (rapid test) negative; ultrasound abdomen: right kidney 10.3 × 5.8 cm, left kidney 9.8 × 5.7 cm; anti-nuclear antibodies, negative; anti-neutrophil cytoplasmic antibodies, negative; serology of hepatitis A, B, C and E virus, negative.
The patient was given hemodialysis support and stabilized. Since anuria persisted, a renal biopsy was performed by an experienced nephrologist using automated spring-loaded gun (Bard Biopty guns, C. R. Bard, Inc., USA) 18 G, under real-time ultrasound guidance. Two cores of renal tissue were obtained from lower pole of the left kidney, one for light microscopy and the other for immunofluorescence. Pre-biopsy bleeding time, clotting time, prothrombin time, activated partial thromboplastin time and platelet count were within normal limits. The blood pressure was 120/80 mmHg before and after the procedure. The procedure was uneventful and there was no immediate peri-nephric hematoma post-biopsy. Two hours after the renal biopsy, the patient complained of severe pain in the left loin; ultrasound did not reveal any hematoma and hemoglobin remained the same. The severe pain lasted for about an hour and necessitated use of analgesics and sedatives. Four hours after the procedure, an ultrasound abdomen was normal, but hemoglobin had decreased to 10.3 g/dL. Hematuria was not observed as he was anuric. The patient did not cooperate for renal Doppler because of loin pain and abdominal distension. Eight hours after the biopsy, the patient developed abdominal distension, not associated with pain and hemoglobin dropped further to 9.1 g/dL. Computed tomography (CT) scan of the abdomen was performed; it showed a perinephric hematoma measuring about 300 mL around the left kidney [Figure 1]. He was given two units of packed blood cells. About 15 hours later, the hemoglobin had dropped further to 7.8 g/dL which was managed with two more units of packed blood cells. Selective left renal arteriogram revealed a pseudoaneurysm arising from the segmental artery of lower pole of the left kidney [Figure 2]. Super-selective cannulation of the involved artery was done with microcatheter (Progreat/2.7-2.9 F/Terumo). The distal tip of the microcatheter was placed in proximity to the pseudoaneurysm. Microcoils (0.018″/2 mm diameter, 2 cm length/Cook-Hilal) were used to obliterate the flow [Figure 3]. Post-embolization check arteriogram revealed no flow into the pseudoaneurysm; however, early opacification of the draining vein was seen from the proximal segment of the involved artery, which was suggestive of an AVF. The AVF component was subsequently embolized with liquid embolic agent N-butyl-cyanoacrylate (NBCA) (Histoacryl/BBraun, Germany) in 20% concentration mixed with Lipiodol Ultra fluid (Guerbet, France). Post-NBCA embolization check arteriogram revealed obliteration of flow into the fistula [Figure 4]. After the procedure, the hemoglobin was maintained at 10.4 g/dL. Renal histology showed acute tubular necrosis with acute interstitial nephritis. He received few more sessions of hemodialysis over the next two weeks, following which the urine output improved and renal parameters were normalized.
|Figure 1: Computed tomography scan of the abdomen, showing perirenal hematoma of the left kidney following biopsy (arrow).|
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|Figure 2: Selective renal angiogram showing pseudoaneurysm arising from segmental artery of lower pole of left kidney.|
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|Figure 3: Angiogram showing arteriovenous fistula and microcoils within the pseudoaneurysm (arrow).|
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|Figure 4: Post-embolization angiogram showing successful obliteration of both pseudoaneurysm and arterio-venous fistula.|
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| Discussion|| |
After renal biopsy, a dull ache around the needle entry site is inevitable when the local anesthetic effects wear off. This ache often requires no treatment or just simple analgesia with paracetamol or paracetamol/codeine combinations. Our patient had severe left loin pain that necessitated powerful analgesics (Inj. Tramadol hydrochloride) and sedation (Inj. Pentazocine). Since his pain was unusually severe, we repeated the ultrasound abdomen and hemoglobin after four hours to look for other internal organ injury; both were negative. A small degree of peri-renal bleeding accompanies every renal biopsy and even uncomplicated biopsies will result in a decrease in hemoglobin of almost 1 g/dL.  Thus, a reduction of hemoglobin more than 2 g/dL is associated with over 90% of clinically recognized complications.  However, this is not completely reliable. Khadehdehi et al  showed that patients with a stable hematocrit (Hct) at six hours post-biopsy were at low risk for bleeding at 24 hours while being hospitalized.
About 57-85% of the patients who are evaluated by CT immediately after kidney biopsy show hematomas,  while 85-91% of patients show hematomas on CT scan, 24 hours after the biopsy. , Most of these are clinically occult, perhaps associated with a mild reduction in hemoglobin.  The majority of these hematomas are asymptomatic and small in size, but in up to 50% of cases they may be moderate to large in size.  In 1-2% percent of patients, the peri-nephric hematoma is manifested as flank pain and swelling associated with signs of volume contraction and a decrease in Hct. In a blinded analysis of images obtained in biopsied and unbiopsied control patients, the overall accuracy of CT was 93.8% versus 76.4% for ultrasound.  The incidence of clinically significant hematomas ranges between 2% and 3%.  Peri-renal bleeding usually occurs immediately after biopsy but can be delayed for some days or even weeks. Although clinically significant peri-nephric hematomas occur in 6% or fewer of biopsies, peri-nephric hematomas have been demonstrated at 24-72 hours after biopsy in >90% of cases evaluated prospectively. 
In patients in whom the bleeding is brisk, prolonged and/or associated with hypotension, and fails to subside with bed rest, renal angiography should be performed to identify the source of bleeding. Angiography helps not only in evaluation of bleeding, but also in intervention. In our patient, angiogram showed both pseudo-aneurysm and AVF from the renal arteriole. Clinically, silent AVF may occur in 15-18% of the patients, leading to intermittent gross hematuria. In most cases, these AVFs are clinically occult, and most of them disappear spontaneously (>95% resolve within 2 years). However, AVFs may be associated with persistent and severe bleeding, uncontrolled hyper-tension, deterioration of renal function, or heart failure in some patients.  Life-threatening complications occur in less than 0.5% of cases.  Post-biopsy aneurysms have been reported in less than 1% of patients. 
Whittier et al showed that factors which predispose to complications after renal biopsy include renal insufficiency (>1.2 mg/dL), poorly controlled hypertension (diastolic BP > 90- 110 mmHg), and a prolonged bleeding time.  Patients with estimated glomerular filtration rate (GFR) of <40 mL/min have a sixfold increase in risk, and even those with estimated GFR of 61-80 mL/min have a twofold increase in the risk of serious postoperative bleeding compared with patients with normal renal function.  Patients with serum creatinine ≥5.0 mg/ dL were 2.3 times as likely to have a complication.  Manno et al  showed that female gender, younger age and prolonged partial thromboplastin time are potential predictors of post-biopsy bleeding complications. Conditions cited as predisposing to the formation of AVFs after biopsy are hypertension,  renal insufficiency, multiple attempts to obtain biopsy material,  and deep renal biopsies. Our patient developed peri-nephric hemorrhage despite having well-controlled blood pressure, not using anti-platelet agents, and normal pre-biopsy bleeding and coagulation parameters. The only risk factor the patient had at the time of renal biopsy was severe renal failure.
Severe loin pain that requires analgesia and sedation immediately after renal biopsy in a patient with renal failure warrants careful follow-up of hemoglobin and imaging, even if initial imaging is negative. Further fall of hemoglobin necessitates early evaluation with angiogram, which helps in diagnosing as well as treating rare complications such as pseudoaneurysm and AVF.
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Assistant Professor, Department of Nephrology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad - 500 082, Andhra Pradesh
[Figure 1], [Figure 2], [Figure 3], [Figure 4]