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NATIONAL KIDNEY AND TRANSPLANT INSTITUTE
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KIDNEY BIOPSY PROTOCOL
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RISK STRATIFICATION OF
THE NATIVE KIDNEY BIOPSY
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GUIDELINES IN THE MANAGEMENT OF
KIDNEY BIOPSY COMPLICATIONS
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TECHNICAL!WORKING!GROUP
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Richard!T.!Hizon,!MD
!Head,!NKTI!Committee!on!Guidelines!in!Performing!!
Kidney!Biopsy!and!Management!of!it’s!Complications!
Eunice!Bernadette!M.!Go,!MD
!Fellow,!Department!of!Adult!Nephrology!–!NKTI!
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Vida!Rose!Danielle!K.!AcostaEVillanueva,!MD!
Fellow,!Department!of!Adult!Nephrology!–!NKTI
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!Marie!Angelie!L.!Gumba,!MD
Consultant,!Department!of!Adult!Nephrology!–!NKTI!
Romina!A.!Danguilan,!MD
Chair,!Department!of!Adult!Nephrology!–!NKTI!
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ADVISORY!BOARD!
Romina!A.!Danguilan,!MD
Chair,!Department!of!Adult!Nephrology!–!NKTI!
Ferdinand!L.!Morabe,!MD
Chairman,!Department!of!Radiology!–!NKTI!
Leo!Carlo!V.!Baloloy,!MD
Consultant,!Transplant!and!Vascular!Surgery!–!NKTI!
Sigrid!M.!Agcaoili,!MD
Consultant,!Department!of!Urology!–!NKTI!
Lynn!B.!Bonifacio,!MD
Consultant,!Department!of!Internal!Medicine,!Section!of!Hematology!–!NKTI
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MESSAGE!FROM!THE!EXECUTIVE!DIRECTOR
It is with great pride that we are coming out with the guidelines on Renal
Biopsy and the management of its complications. Our core service and training
departments have worked hard in order to come out with a protocol in the
management of patients needing a kidney biopsy.
In this day and age of quality assurance, commitment to standards and
patient safety, it is very timely that no less than the NKTI whose mandate is to
develop, promote and sustain the highest quality of standards in Renal
Medicine in the Philippines has come up with this manual.
My sincere appreciation goes to the people for their hard work and
dedication in creating this document, most especially to the Technical Working
Group and the Advisory Board.
We hope that this will serve the best interests of the trainers and trainees
and continue to share this with all the Nephrology training institutions in the
Philippines.
JOSE DANTE P. DATOR, M.D.
Executive Director
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FOREWORD!
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The National Kidney and Transplant Institute (NKTI) performs more than
500 biopsies per year. With this profound experience, the NKTI has gathered a
lot of knowledge on the identification of high and low risk patients from
complications of biopsies and how these can best be prevented and managed.
May these guidelines assist renal physicians in providing the best care for their
patients, in their pursuit of a renal pathologic diagnosis.
ROMINA!A.!DANGUILAN,!MD!
Chairman,!Department!of!Adult!Nephrology!
National!Kidney!and!Transplant!Institute!
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Foreword
Guideline 1 - Indications and Possible Complications of a Kidney Biopsy
Guideline 2 - Risk Factors for Bleeding Complications and Correction of
Modifiable Risk Factors
Guideline 3 - Other Preventive Measures
Guideline 4 - Algorithm 1 – Assessment Prior to Kidney Biopsy
Guideline 5 - Algorithm 2 – Risk Reduction Strategies
Guideline 6 - Algorithm 3 – Assessment After Kidney Biopsy
Guideline 7 - Algorithm 4 – Management of AVF/Hematoma Formation after
Kidney Biopsy
Guideline 8 - Algorithm 5 – Management of Pseudoaneurysm Formation
after Kidney Biopsy
References
Appendix
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Non$Modifiable$
• Age – 3rd decade and beyond
• Female
$
Modifiable$
• Systolic BP of ≥ 140 mmHg
• Creatinine of ≥ 5 mg/dL
• Prolonged Prothrombin time and Partial Thromboplastin Time
(PT/PTT) > 1.5x upper limit of normal (ULN)
• Platelet count <140 x 10^3/uL
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• Hypertension$
• Intensify anti HPN medications
• Target Systolic BP of <140 mmHg
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•$Creatinine$>$5mg/dl$!
• Heparin free dialysis
• Target creatinine < 5mg/dl
•$Prolonged$PT/PTT,$Low$Platelet$Count$!
• Transfuse FFP or platelet concentrate not more than 24 hours prior to
kidney biopsy
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$
WITHDRAWAL$OF$CONCOMITANT$MEDICATIONS$
Number!of!days!to!withhold!
Medication!
medications!prior!to!Kidney!Biopsy!
Clopidogrel! 5!
Aspirin! 5!
Coumadin! 5!
Fractionated!Heparin! 1!
Cilostazol/Dipyridamole! 1P2!
Sulodexide! 2!
Pentoxyfilline! 1!
GFR!>50!ml/min!–!2P4!days!
Dabigatran!
GFR!30P50!ml/min!P!>5!days!
Rivaroxaban/Apixaban! 2P3!
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RISK!FACTORS!OF!BLEEDING!AFTER!KIDNEY!BIOPSY!
Reference! Whittier!et!al! Manno!!
Meilleur!et!al! Corapi!et!al! Tahmasebi!et!al!
(Author,! J!Am!Soc! et!al!
Nephron(Extra( AJKD(( J(Am(Sci(
Journal,! Nephrol!! Kidney(Int(
2014! 2012! 2012!
Year)! 2004! 2004!
Population!
312! 9474! 60! 750! 471!
(n)!
Abnormal! Prolonged! Prolonged!!
PC!<!140!
Bleeding! ! BT,!PT,!PTT! ! PTT !
(p=0.002)!
Parameters! (p=0.017)! (p=0.032)!
SBP≥130mmHg! SBP!>140mmHg!
HPN! ! ! !
(p=0.09)! (p=0.008)!
Creatinine! Creatinine!≥!2!! Creatinine!≥!5!
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(mg/dL)! (p=0.02)! (p<0.005)!
Young
Young!age!
35±14!vs.!
Age! ! ! 30±9!vs!40+15 !
40+15!!
(p<0.001)!
(p=!0.006)!
Women!! Women!!
Sex! ! ! !
(p=0.03)! (p=!0.004)!
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Transarterial$Embolization$
• P150,000 (Inclusive of 1 coil and gel foam, plus Catheterization lab fee and
Professional fee); P15,000 for each additional coil!
Repair/Ligation$of$Bleeders$
• P60,000 - 80,000 – Operating room fee (use of operating room, instruments,
consumables) • Professional fee of surgeon and anesthesiologist separately
charged
Nephrectomy$
• P60,000 - 80,000 – Operating room fee (use of operating room, instruments,
consumables) • Professional fee of surgeon and anesthesiologist separately
charged
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•! Exploration!of!the!kidney!is!necessary!in!order!to!control!the!
bleeders!whether!by!cauterization,!or!suturing!and!ligation!of!the!
vessels.!!
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•! Nephrectomy!!
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•! Monitored sedation
•! The femoral artery will be punctured and an introducer sheath will be
inserted.
•! An abdominal aortography is then usually obtained.
•! Each renal artery is selectively catheterized followed by selective digital
subtraction angiography (DSA) of the renal vasculature in multiple views.
•! If an active bleeder is identified, a coil or particulate embolic material is
then injected to embolize the lesion.
•! Lastly, a post embolization DSA is done to check for residual lesions.
•! Catheter is removed and hemostasis on puncture site is done.
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Figure 1. Transarterial coil embolization of a bleeding
vessel after kidney biopsy
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•! Brenner and Rector’s The Kidney, 9th Edition, 2012
•! Meilleur MC, Troyanov S, Dalaire LR et al. Risk factors and timing of
native kidney biopsy complications. Nephron Extra. 2014; 22; 4(1): 42-9
•! Corapi KM, Chen JL, Balk EM et al. Bleeding complications of native
kidney biopsy: A systematic review and meta-analysis. Am J Kidney Dis.
2012; 60(1): 62-73
•! Tahmasebi M, Aynehband N, Golzaree Kh et al. Predictors of bleeding
complications in percutaneous ultrasound-guided renal biopsy with spring-
loaded 18G needle biopsy in diffuse renal parenchymal diseases. J Am
Sci. 2012; 8(4)
•! Whittier W and Korbet S. Timing of complications in percutaneous renal
biopsy. J Am Soc Nephrol. 2004; 15(1): 142-147
•! Manno C, Strippoli G, Arnesano L et al. Predictors of bleeding
complications in percutaneous ultrasound guided renal biopsy. Kidney
International. 2004; 66(4): 1570–1577
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