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      Ultrasound-Guided Percutaneous Renal Biopsy in 295 Children and Adolescents: Role of Ultrasound and Analysis of Complications

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          Abstract

          Introduction

          Percutaneous renal biopsy (PRB) is a decisive diagnostic procedure for children and adolescents with renal diseases. Aim of this study was to evaluate retrospectively the complication rates of percutaneous kidney biopsies and their therapeutic consequences to assess the role of ultrasound-guidance including Doppler ultrasound examinations in preparation, execution and follow-up care and to present a recommended protocol.

          Patients and Methods

          Institutional review board approved this retrospective study; informed consent was waived. Between 1997 and 2011 a total of 438 ultrasound-guided biopsies were performed in 295 patients, 169 of the biopsies were performed on kidney transplants. Average age of patients was 10.2+/−5.2 years (range of 15 days until age of 23). Before and post biopsy ultrasound examination including Doppler examination was carried out. Biopsy itself was ultrasound monitored. Complications were analysed with regard to age of patient, kidney transplants, year of occurrence, number of punctures, performing physician and time interval of occurrence to develop an optimized protocol for ultrasound-guidance.

          Results

          In 99% of cases successful PRB were performed, i.e. enough kidney parenchyma for histological analysis was obtained. No lethal or major complication that required surgical intervention occurred. Eighteen relevant complications were observed (complication rate: 4.1%). Except in one case in which additional MRI diagnostic was necessary, ultrasound examination after 4 hours post biopsy or even earlier when symptoms occurred, was able to detect complications and determine indications for intervention.

          Conclusion

          Ultrasound-guided PRB is an established and effective method in children and adolescents, but shows a certain rate of complications and therefore should not be indicated without diligence. Ultrasound including Doppler ultrasound is a valuable tool in preparation, guidance of biopsy, detection of complications and in follow-up care. Ultrasound examinations (including Doppler) pre-, during and 4 hours post kidney biopsy and, depending from case, a few days until weeks after biopsy is recommended.

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          Most cited references26

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          Safety and adequacy of renal transplant protocol biopsies.

          The protocol biopsy strategy has been criticized because of risks and marginal utility. We tested the risk. We performed 1171 protocol biopsies in 508 patients at 6, 12 and 26 weeks after renal transplantation, as well as 499 biopsies as indicated in 429 transplant patients. Biopsies were done as an outpatient procedure using an 18- or 16-gauge automated biopsy needle followed by 4 h bed rest. Complications were: gross hematuria 3.5%, perirenal hematomas 2.5%, arterio-venous fistulas 7.3% and vasovagal reactions 0.5%. Major complications requiring invasive procedures such as blood transfusions or urinary catheter were seen in 1% of cases. The hospitalization rate for observation was 1.9%. According to the Banff criteria of specimen adequacy, biopsies with 18-gauge needles yielded >7 glomeruli and at least one artery in 53% of cases. Changing the needle size in October 2003, those biopsies done with 16-gauge needles yielded >7 glomeruli and at least one artery in 76% of cases, while the rate of major complications did not change. In conclusion, transplant protocol biopsies with 16-gauge needles provide better utility and similar risk as biopsies with 18-gauge needles. A 4-h recovery after biopsy appears adequate for discharge.
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            The value of post-biopsy ultrasound in predicting complications after percutaneous renal biopsy of native kidneys.

            Clinically significant bleeding complications occur in >30% of patients undergoing percutaneous renal biopsy (PRB) of native kidneys and can be severe in up to 10% of patients. A noninvasive measure that would reliably predict which patients will do well with an uncomplicated post-biopsy course or which patients may be at risk of developing a clinically significant complication is in great demand. PRB of native kidneys was performed in 162 adult patients from February 2002 through February 2007 using real-time ultrasound and automated needle. Renal ultrasound (US) was performed at 1-h post-PRB to assess biopsy-related bleeding. Patients were observed for 24 h post-PRB to monitor clinically apparent biopsy-related complications. The value of the post-biopsy ultrasound in predicting complications was assessed. A clinically apparent complication was observed in 26 (16%) patients post-PRB (13 minor not requiring any intervention and 13 major requiring intervention). In patients with complicated courses, a haematoma at 1 h was seen in 77% (69% with minor and 87% with major complications). However, only 27 (20%) of 136 patients without complications (P < 0.0001) had a haematoma at 1 h. The presence of a haematoma 1-h post-PRB had a sensitivity of 77%, specificity of 80%, positive predictive value of 43% but a negative predictive value of 95% for predicting clinical complications. We find that with the use of renal ultrasound 1-h post-PRB, the absence of perinephric bleeding is predictive of an uncomplicated course while the presence of a perinephric haematoma is not reliably predictive of a clinically significant complication post-renal biopsy.
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              Risk management of renal biopsy: 1387 cases over 30 years in a single centre.

              Although renal biopsy is largely employed, even in old patients with systemic diseases, few clinical studies have addressed its risk management. We aimed to obtain a comprehensive assessment of safety/utility ratio of percutaneous renal biopsy. Retrospective review of all the 1387 patients who consecutively underwent renal biopsy in a single centre over three decades (1973-2002) was made, with calculation of complications, multivariate logistical analyses to evaluate risk factors of complications, and rate of alteration of clinical hypotheses by pathological diagnosis. There were no deaths and five major complications, (0.36%). One nephrectomy (0.07%), two surgical revisions (0.1%) and two arterial-venous fistulae (0.1%). There were also 337 minor bleeding complications (24.2%) (16.4% gross haematuria and 7.8% clinically relevant haematomas needing at least prolonged bed rest). Multivariate analyses demonstrated that the risk for complications was significantly increased by systemic autoimmune diseases with odds ratio (OR) 2.06, 95% confidence interval (CI)=1.40-3.01, end-stage kidney/acute-tubular necrosis (OR 2.96, 95% CI=1.19-7.30), and prolonged bleeding time test (BTT) (OR 1.87, 95% CI=1.17-2.83). Among the 1288 cases in which a clinical hypothesis before renal biopsy was recorded, renal pathology changed previous diagnoses in 423/1,288 (32.8%) of cases. Risk assessment demonstrates that renal biopsy is a useful procedure with a low incidence of serious complications. Platelet function is the only modifiable factor significantly related to bleeding complications, suggesting the need for a more standardized alternative to the BTT. Platelet function should be evaluated to select low-risk patients for renal biopsy as 'a day case procedure', in order to build adequate risk management strategies.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                9 December 2014
                : 9
                : 12
                : e114737
                Affiliations
                [1 ]Department of Radiology, University Hospital Cologne, Cologne, Germany
                [2 ]Department of Pediatrics, University Hospital Cologne, Cologne, Germany
                [3 ]Department of Pediatrics, University Hospital Bonn, Bonn, Germany
                University Hospital Oldenburg, Germany
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: FK BH. Performed the experiments: FK BH AK CT MF. Analyzed the data: MF FK BH DM AK CT. Contributed reagents/materials/analysis tools: FK BH DM. Wrote the paper: MF FK BH AK CT DM.

                Article
                PONE-D-14-28960
                10.1371/journal.pone.0114737
                4260870
                25489731
                a5701874-aa93-4c3e-82b1-a9004e2cfc9b
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 6 July 2014
                : 13 November 2014
                Page count
                Pages: 16
                Funding
                The authors have no support or funding to report.
                Categories
                Research Article
                Medicine and Health Sciences
                Infectious Diseases
                Inflammatory Diseases
                Nephrology
                Oncology
                Pediatrics
                Radiology and Imaging
                Surgical and Invasive Medical Procedures
                Urology
                Custom metadata
                The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper.

                Uncategorized
                Uncategorized

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