Severe haemorrhage and retroperitoneal haematoma secondary to renal biopsy

Juan Carlos Herrero, Enrique Morales, Augustin Carreño, Beatriz Domínguez-Gil, Esther González, Milagros Ortiz and Eduardo Hernández

Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain

Sir,

The percutaneous renal biopsy plays an important role in the diagnostic work-up of renal disease. Several studies have documented a 6–7% incidence of post-biopsy complications consisting of pain, gross haematuria, palpable haematoma, infection, and death [1]. The incidence is decreasing thanks to the use of ultrasound and smaller needles. The development of an intrarenal arteriovenous fistula (AVF) is a well-known complication of renal biopsy [2,3]. Here we report an unusual case of severe haemorrhage and retroperitoneal haematoma secondary to damage of the 12th intercostal artery during renal biopsy.

Case.

A 70-year-old woman with history of hypertension, severe obstructive hypertrophic myocardiopathy, pacemaker, asthma, and morbid obesity, was admitted to hospital for gastric bleeding. Seven days before hospitalization, the patient had an episode of respiratory infection and decrease of oral food intake. She did not present diarrhoea, articular or abdominal pain, skin injury or oliguria, and had not taken non-steroidal anti-inflammatory drugs. Laboratory data at admission were as follows: haematocrit 35%, haemoglobin 11 g/dl, leukocyte count 20 000/mm3 (83% neutrophils, 8% lymphocytes, 0.1% eosinophils), platelet count 120 000/mm3, serum creatinine 6.5 mg/dl. The coagulation study was normal. Urinary analysis was: blood 3+, proteins 2+, sodium 54 mEq/l, potassium 21 mEq/l. An abdominal echography showed two kidneys with normal size and morphology. During admission, the patient had no more vomiting. haematemesis, or gastric bleeding. Fluid infusion treatment was then started under the suspicion of prerenal acute renal failure. The renal function kept worsening (serum creatinine 9 mg/dl) and haemodialysis was initiated. The tentative diagnosis at that point was acute glomerulonephritis or immuno-mediated interstitial nephritis, although the patient had no rash, no fever, and no eosinophilia. She was then treated with intravenous pulses of methylprednisolone (250 mg/day for 4 days) and oral steroids, without an improvement of renal function. At the fifth day of hospitalization, an ultrasound guided left kidney biopsy was performed, with Tru-cut needle (length 15 cm). It showed 8 glomeruli. Only one of them had sclerotic lesions, the remainder were normal. The interstitial area presented zones with eodema and inflammatory lymphocytic infiltrates, plasma cells, neutrophils, and eosinophils. The tubules were normal but the blood vessels showed a sight wall hyperplasia. These findings were in favour of the diagnosis of immuno-allergic interstitial nephritis.

Three hours after the biopsy, the patient experienced a severe haemodynamic deterioration with hypotension, gross and persistent haematuria, and decrease of blood haemoglobin, which required blood transfusion and treatment with vasoactive drugs. Due to the suspicion of an AVF, an arteriograhy was carried out, which showed active bleeding from the distal portion of the l2th left intercostal artery. Surgery was done immediately. It revealed a retroperitoneal haematoma and subcostal bleeding. The haemorrhage was controlled by ligation of the subcostal vascular group. After surgery, the patient continued having haemodynamic instability and was admitted to our intensive care unit. The patient died 2 days later, due to cardiogenic shock.

Comment.

Percutaneous renal biopsy is generally regarded as a useful procedure in the management and clinical investigation of renal disease. Through the years, this procedure has been modified by the use of a variety of radiologic localization techniques and methods of obtaining renal tissue [4]. A number of complications have been reported, with a total incidence of approximately 6–7% [1]. The severity of this complication has been categorized in two groups: minor and major complications. The first include gross haematuria that generally resolves spontaneously, or perirenal haematoma resulting in a decrease of haemoglobin, but requiring no blood transfusion. Major complications are defined as: those requiring blood transfusion; those resulting in haemodynamic instability and may require intervention; those with acute renal obstruction, arteriovenus fistula, renal abscesses or septicaemia; those requiring surgical exploration for either haematoma evacuation or nephrectomy; and those resulting in death [4]. The most worrisome complication is gross haematuria lasting for more than 12 h (2.8%) with a low incidence of death (0.2%) [1]. These complications are less frequent in transplanted than in native kidneys.

With respect to the AVF as a result of simultaneous damage of the walls of adjacent arteries and veins, this is a relatively common complication of renal biopsy. AVF could be proved to occur in 15–18% of patients by arteriography. In most cases these AVF are clinically occult, and most of the remaining fistulas disappear spontaneously (more than 95% resolve within 2 years) [3,5]. However, AVF may occur in other patients together with persistent and severe bleeding, uncontrollable hypertension, deterioration of renal function, or heart failure [2]. These fistulas are usually discovered within the first months after the biopsy procedure, although there was one unusual case of a large intrarenal AVF 25 years after biopsy [2]. Arteriography is the gold standard for the diagnosis of vascular complications. Other non-invasive procedures are colour-coded Doppler sonography and dynamic contrast CT scan [2,3,6]. The main treatment is superselective embolization with coaxial catheter techniques. If this method is not successful, surgical procedures are required, such as total or partial nephrectomy or ligation of the arterial branch [2].

In this patient, the presence of gross haematuria and haemodynamic worsening following renal biopsy suggested an intrarenal AVF. Angiography ruled out any bleeding at such level but instead haemorrhage was observed at an unusual location, namely the 12th left intercostal artery. Although bleeding at this level is rare, when exploring patients with marked obesity making biopsy difficult one should not forget to think of the possible occurrence of this unusual complication.

References

  1. Parrish AE. Complication of percutaneous renal biopsy; a review of 37 years experience. Clin Nephrol1992; 38: 135–141[ISI][Medline]
  2. Alcázar R, de la Torre M, Peces R. Symptomatic intrarenal arteriovenous fistula detected 25 years after percutaneous renal biopsy. Nephrol Dial Transplant1996; 11: 1346–1348[ISI][Medline]
  3. Gainza FJ, Minguella Y, López-Vidau Y, Ruiz OLM, Lamprebe Y. Evaluation of complications due to percutaneous renal biopsy in allografts and native kidneys with color coded Doppler sonography. Clin Nephrol1995; 43: 303–308[ISI][Medline]
  4. Burstein DM, Kobert SM, Schwartz MM. The use of the automatic core biopsy system in percutaneous renal biopsies: a comparative study. Am J Kidney Dis1993; 22: 545–552[ISI][Medline]
  5. Bennet AR, Wiener SN. Intrarenal arteriovenous fistula and aneurysm: a complication of percutaneous renal biopsy. Am J Roentgenol1965; 95: 372–382
  6. Ha SK, Park CH, Kim KW. Use of pulsed Doppler ultrasound in detecting renal arteriovenous fistula. Nephrol Dial Transplant1995; 10: 2150–2152[ISI][Medline]




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