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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 6  |  Page : 1278-1281
Retroperitoneum: A forgotten and fatal aspect of kidney biopsy


1 Renal Unit, Royal Derby Hospital, Derby, United Kingdom
2 Renal Department, University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom

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Date of Web Publication10-Nov-2014
 

   Abstract 

A kidney biopsy is an important tool for nephrologists in the diagnosis of renal conditions, but not without the risk of bleeding due to its invasive nature. There is abundance of literature on bleeding complications secondary to this procedure in high-risk patient groups such as amyloidosis and chronic hypertension. An undefined and unrecognized risk is a peritoneal penetration. We report here a case where, despite adequately preparing a patient for a kidney biopsy, distortion of the peritoneum and retroperitoneum from previous surgery resulted in a fatal outcome. This was due to loss of peritoneal integrity and the consequent loss of local anatomical hemostatic mechanism.

How to cite this article:
Mohammed A, Manjanabil P, deTakats D. Retroperitoneum: A forgotten and fatal aspect of kidney biopsy. Saudi J Kidney Dis Transpl 2014;25:1278-81

How to cite this URL:
Mohammed A, Manjanabil P, deTakats D. Retroperitoneum: A forgotten and fatal aspect of kidney biopsy. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2020 Aug 3];25:1278-81. Available from: http://www.sjkdt.org/text.asp?2014/25/6/1278/144267

   Introduction Top


A kidney biopsy is an important tool for nephrologists in the diagnosis of renal condi­tions, and it is considered to be a routine proce­dure albeit a small risk of significant bleeding due to its invasive nature. Much has been learnt over the last 60 years about how to minimize this risk by attention to factors such as hemo­globin concentration, coagulation status and blood pressure.

We report here a case where, despite ade­quately preparing a patient for a kidney biopsy, distortion of the peritoneum and retroperitoneum from previous surgery resulted in penetration and bleeding inside these structures and fatal outcome. This was due to loss of peritoneal integrity and the consequent loss of local anato­mical hemostatic mechanism.


   Case Report Top


A 65-year-old woman was admitted to our hospital with a 6-week history of feeling generally unwell with increasing lethargy, loss of appetite, weight loss and anemia. Gastroscopy for evaluation of anemia showed hiatus hernia and mild gastritis. Oral iron was pres­cribed and aspirin was discontinued. Her illness progressed with continuous vomiting and a generalized rash. She was hospitalized via emergency services.

Her past medical history included endometrial cancer with peritoneal spread in 1972 treated by hysterectomy and radiotherapy. Hysterectomy was complicated by bowel injury requiring bowel surgery and colostomy. Radiotherapy was com­plicated by radiation cystitis causing a urinary leak. This required an ileal conduit.

On examination, the patient looked unwell, dehydrated, hypotensive with acidotic breathing and a non-blanching rash. Investigations re­vealed creatinine level of 1126 μmol/L with possible acute kidney injury, as the serum creatinine level was 69 μmol/L three months prior to admission. Renal ultrasound showed two echo bright kidneys measuring 12 cm on the right and 11.2 cm on the left in bipolar length with no calculi or hydronephrosis. Initial treat­ment using intravenous fluids and sodium bicarbonate failed and hemodialysis was started.

Her urine microscopy showed hematuria and proteinuria with 14 casts. The anti-pANCA test was positive with raised anti-myeloperoxidase titers at 9 u/mL (normal 0-4 u/mL) on the enzyme-linked immunoadsorbant assay. A kid­ney biopsy was arranged.

In preparation for a kidney biopsy, the patient received another session of hemodialysis. Pre-biopsy blood investigations revealed stable levels of urea: 11 mmol/L, creatinine: 223 μmol/L, hemoglobin: 10.7 g/dL, International Normalized Ratio (INR): 1.1 and activated partial thromboplastin time ratio (APTTr): 0.93. Her BP was 128/73 mm Hg. She had DDAVP (1-deamino-8-D-arginine vasopressin) to further reduce the chances of bleeding. A written con­sent was obtained and the biopsy was per­formed under real-time ultrasound guidance using a size 16 needle and an automated gun device. Three passes to the lower pole of the left kidney resulted in three cores, one each for light microscopy, immunofluorescence and electron microscopy.

Patient started to bleed after the biopsy and soon became hemodynamically unstable. Rapid fluid resuscitation was undertaken using crys­talloids and colloids until blood transfusion became available. A total of seven units of blood were transfused. Repeat blood inves­tigations revealed INR: 1.6, APTTr: 2.56 and platelets: 21,000/μL suggestive of transfusion coagulopathy or disseminated intravascular coagulation (DIC). We attempted to correct the coagulopathy by transfusing four units of fresh frozen plasma and one unit of platelets.

An emergency arteriogram of the left renal artery showed a bleeding point at the lower pole artery associated with an arteriovenous fistula [Figure 1]. Selective access to the lower pole vessels proved impossible due to the intense spasm of the intra-renal vessels and, therefore, embolization of the entire left renal circulation was undertaken using a single coil. There was immediate cessation of the flow to the left kidney. Despite these measures, hypovolemic shock ensued due to the continued bleeding and coagulopathy, and the patient was transferred to the intensive care unit for stabilization. She was consented for an emergency surgical nephrectomy but expired before the surgery. She died 11 h after the kidney biopsy.
Figure 1: Renal angiography showing spasm of renal artery, lower pole bleeding and early filling of vein due to arteriovenous fistula.

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Post-mortem examination disclosed massive hemorrhage from the site of kidney biopsy with no evidence of other visceral injury. Approxi­mately 2 L of blood were noted in the abdo­minal cavity tracking along a patent ileal con­duit with minimal retroperitoneal blood.

Hemorrhage after kidney biopsy is a recog­nized complication and is usually self-limiting due to the retroperitoneal position of the kid­neys. Denuded peritoneum and the rare pre­sence of a patent ileal conduit (which normally heals after surgery) prevented tamponade and facilitated a blood leak into the abdominal cavity. Histological examination of the kidney biopsy revealed crescentic glomerulonephritis.


   Discussion Top


Bleeding after kidney biopsy is a common complication, and it is classified as major or minor depending on the hemodynamic insta­bility and blood loss. Major bleeding is broadly defined as one that requires blood transfusion, vascular intervention or surgical nephrectomy, and may end in death of the patient.

The kidney biopsy can be classified as a high-or low-risk procedure. Fatal bleeding can occur despite adequately correcting certain parameters before and during the biopsy. The rate of life-threatening complications including bleeding has been reported in the literature in the range of 0.02% to 0.1%. [1],[2] There are several studied conventional risk factors that have been repor­ted by various authors for a high-risk kidney biopsy and are summarized in [Table 1].
Table 1: High-risk factors affecting hemorrhage after kidney biopsy

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Of these, a significant predictive value was observed with age, gender, partial thromboplastic time, [3] blood pressure, serum creatinine [4] and needle size for the risk of bleeding. For example, patients with uncontrolled high BP before the biopsy procedure are 3.74 times more likely to bleed than those with no history of hypertension, irrespective of the BP at the time of biopsy. [4] Level of expertise is a inde­pendent risk factor.

The complex local anatomy of the retroperitoneum is divided into three spaces by perirenal fascia (renal capsule); [6] the peri-renal space: surrounded by the renal capsule, the anterior para-renal space and the posterior para-renal space. After kidney biopsies, the patients can bleed into one of the three spaces, including the urinary space (hematuria with/ without clot colic/retention), the peri-renal space (hematoma and localized pain due to capsular stretch) and the retroperitoneal space (retro-peritoneal bleed).

The retroperitoneal space is a closed space that usually results in a limited blood loss after a routine kidney biopsy due to tamponade effect. The intrinsic spasm of the renal vessels prevents further blood loss. Any variation to these vital anatomical and physiological hemostatic mechanisms can cause excessive blee­ding, despite adequately correcting other para­meters. Anatomical integrity of the retroperitoneum needs increased recognition as an undefined anatomical risk factor, particularly in the high-risk patient group.

Following any major bleeding, including that after kidney biopsy, DIC may precipitate due to tissue trauma, hypothermia (from blood trans­fusions) and hypoxia. Treatment of DIC by ma­jor transfusion, defined as transfusion of more than 50% of the patient's blood volume in 12- 24 h, itself can result in coagulopathy, which can be extremely challenging, as in our case. [5],[6],[7],[8] High systemic BP due to aggressive fluid resus­citation or sympathetic stimulation (due to pain) may aggravate bleeding and dictates the use of strong analgesics including opiates.

Finally, studies have highlighted the impor­tance of longer periods of observation follo­wing kidney biopsy as only 67-79% of major complications were noticed at 8 h. [9],[10]

A detailed surgical history and knowledge of intrinsic renal and local extra renal anatomy is vital when planning a kidney biopsy in addition to acceptable blood parameters, BP and renal imaging. This may help identify high-risk patients for longer period of observation prior to safe discharge and plan early interventions such as embolization and possible emergency nephrectomy.

Conflict of interest: None declared.

 
   References Top

1.
Korbet SM. Percutaneous renal biopsy. Semin Nephrol 2002;22:254-67.  Back to cited text no. 1
    
2.
Topham PS. Renal Biopsy, Comprehensive clinical nephrology. 3 rd ed, 2007 Ch 6, 69-76.  Back to cited text no. 2
    
3.
Manno C, Strippoli GF, Arnesano L, et al. Predictors of bleeding complications in percutaneous ultrasound-guided renal biopsy. Kidney Int 2004; 66:1570-7.  Back to cited text no. 3
    
4.
Shidham GB, Siddiqi N, Beres JA, et al. Clinical risk factors associated with bleeding after native kidney biopsy. Nephrology 2005; 10:305-10.  Back to cited text no. 4
    
5.
Mackinnon B, Fraser E, Simpson K, Fox JG, Geddes C. Is it necessary to stop antiplatelet agents before a native renal biopsy? Nephrol Dial Transplant 2008; 23:3566-70.  Back to cited text no. 5
    
6.
Burkill GJ, Healy JC. Anatomy of the retro-peritoneum. Imaging. Vol. 12. UK: British Institute of Radiology; 2000. p. 10-20.  Back to cited text no. 6
    
7.
British Committee for Standards in Hematology, Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ. Guidelines on the manage­ment of massive blood loss. Br J Haematol 2006; 135:634-41.  Back to cited text no. 7
    
8.
Hardy JF, De Moerloose P, Samama M; Groupe d'intérêt en Hémostase Périopératoire. Massive transfusion and coagulopathy: Pathophysiology and implications for clinical management. Can J Anaesth 2004; 51:293-310.  Back to cited text no. 8
    
9.
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. 9
    
10.
Whittier WL, Korbet SM. Timing of compli­cations in percutaneous renal biopsy. J Am Soc Nephrol 2004; 15:142-7.  Back to cited text no. 10
    

Top
Correspondence Address:
Dr. Azharuddin Mohammed
Renal Department, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE
United Kingdom
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DOI: 10.4103/1319-2442.144267

PMID: 25394450

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