|Year : 2015 | Volume
| Issue : 2 | Page : 158-160
Perinephric hematoma following renal biopsy: A case report and literature review
Girish P Vakrani1, Nambakam T Subramanyam2, Harish Babu1
1 Department of Nephrology, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
2 Department of General Medicine, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
|Date of Web Publication||6-May-2015|
Girish P Vakrani
A-29, Vydehi Hospital Staff Quarters, 82, EPIP Area, Whitefield, Bengaluru - 560 066, Karnataka
The risks associated with performing a percutaneous renal biopsy have substantially decreased in the past two decades because of technical advances in the method. However, bleeding complications still occur, resulting in increased hospital stay, treatment costs and even mortality. The purpose of this case report is to discuss the life threatening complications like perinephric hematoma following a renal biopsy in a high risk patient with severe renal failure. The clinical, radiological findings, prognosis of a massive perinephric hematoma following a renal biopsy in a high risk patient with severe renal failure are discussed. We report a case of 39-year-old male, non-diabetic, hypertensive since 5 years who presented with unexplained severe renal failure. After dialyzing adequately, he was subjected to right renal biopsy using real time ultrasound guided automated renal biopsy gun. Post-biopsy was uneventful, until 72 h when he developed massive right perinephric hematoma following a heparin-free hemodialysis. He continued to be hypotensive despite hemostatics, blood products, plasma expander transfusion. Unfortunately, he expired before definitive management like renal angiogram and intervention was attempted. To the best of our knowledge, this is one of few reports of the occurrence of life-threatening complication like perinephric hematoma in a patient with severe renal failure on heparin free hemodialysis following a renal biopsy after 72 h.
ملخص البحث :
تبين هذه الحالة المضاعفات المهددة للحياة كالنزيف الدموي حول الكلية الناتج عن أخذ خزعة من الكلية لمريض مصاب بفشل كلوي مزمن. تمت مناقشة النتائج السريرية والاشعاعية وتطور حالة المريض. يعرض الباحثون حالة هذا المريض البالغ من العمر 93 عامًا. والذي تعرض لنزيف بعد 27 ساعة من أخذ العينة بعد خضوعه لغسيل دموي خال من الهيبارين، ولم تنجح بالمحاولات الطبية بإنقاذ حياة المريض وقد توفي. تعتبر هذه المضاعفات نادرة الحدوث.
Keywords: Automated renal biopsy gun, perinephric hematoma, ultrasound guided renal biopsy
|How to cite this article:|
Vakrani GP, Subramanyam NT, Babu H. Perinephric hematoma following renal biopsy: A case report and literature review. Saudi J Med Med Sci 2015;3:158-60
|How to cite this URL:|
Vakrani GP, Subramanyam NT, Babu H. Perinephric hematoma following renal biopsy: A case report and literature review. Saudi J Med Med Sci [serial online] 2015 [cited 2021 Feb 27];3:158-60. Available from: https://www.sjmms.net/text.asp?2015/3/2/158/156432
| Introduction|| |
The risks associated with performing a percutaneous renal biopsy (PRB) have substantially decreased in the past two decades because of technical advances in the method. However, bleeding complications still occur, resulting in increased hospital stay, treatment costs and even mortality.
| Case report|| |
We report a case of 39-year-old, male, non-diabetic, hypertensive since 5 years on medications presented with swelling of legs and decreased urine since 1 week duration. Physical examination revealed blood pressure of 140/94 mmHg, a pulse rate of 72 beats/min and pitting pedal edema. Systemic examination was normal.
Investigations showed sub-nephrotic proteinuria, microscopic hematuria, hemoglobin was 9 g/dL (normal range 12-15 g/dL), serum creatinine was 6.56 mg/dL (normal 0.6-1.5 mg/dL), blood urea was 114 mg/dL (normal 15-40 mg/dL), serum albumin was 2.3 g/dL (normal 3.0-5.0 g/dL); viral serology (human immunodeficiency virus, hepatitis C virus and hepatitis B surface antigen) were negative (serum Ferritin was 171 ng/ml, transferrin saturation was 21%), ultrasound of the abdomen showed grade 1 nephropathy (right kidney 89 mm, left kidney 89 mm length), chest radiograph showed cardiomegaly, echocardiogram showed concentric left ventricular hypertrophy, grade 2 left ventricular diastolic dysfunction, ejection fraction was 60%.
Patient was admitted and was initiated on hemodialysis after inserting double lumen hemodialysis catheter into right internal jugular vein. After few sessions of hemodialysis, he was subjected to right renal biopsy using real time ultrasound guided 16 gauge automated renal biopsy gun after checking bleeding parameters such as bleeding time, clotting time, platelet count, prothrombin (PT) and activated partial thromboplastin time (aPTT) which were normal, serum creatinine was 2.16 mg/dL, blood urea was 59 mg/dL. The procedure was uneventful and there was no immediate peri-nephric hematoma post-biopsy.
Renal biopsy revealed chronic glomerulosclerosis. Light microscopy showed nine Glomeruli, of which eight were obsolescent. One viable glomerulus showed segmental sclerosis with synechiae. Capillary loops were patient with single basement membrane. No crescents, fibrinoid necrosis nor mesangial proliferation were noted. There was marked tubule-interstitial chronicity (approximately >50% of cortical surface area) including thyroidization of tubules. Mild interstitial lymphocytic infiltrate was noted. Vessels showed intimal hyalinosis. No vasculitis or luminal thrombosis were noted.
Immunofluorescence was negative for antisera against complements and immunoglobins. Kappa and lambda stain showed no restriction.
After 72 hours, the patient complained of severe right loin pain following a heparin free hemodialysis. He was noted to be pale, hypotensive, without visible hematuria.
Abdominal ultrasound study showed a massive right perinephric hematoma with active ongoing bleed without extension into renal pelvis. Drop in hemoglobin to 6 g/dL, Leucocytosis without neutrophilia, serum creatinine of 2.16 mg/dL, blood urea of 31 mg/dL, with normal PT, aPTT, platelet count were noted. Hemostatics, blood products, plasma expanders were transfused. Empirically he was covered with antibiotics.
Unfortunately, he expired in a very short time before definitive management like renal angiogram and intervention was attempted.
| Discussion|| |
The risks associated with performing a PRB have substantially decreased in the past two decades due to technical advances in the method. However, bleeding complications still occur, resulting in increased hospital stay, treatment costs and even mortality. 
Independent predictors of post-biopsy bleeding are anemia, raised baseline blood urea, serum creatinine, high diastolic blood pressure, need of hemodialysis. Needle size used for biopsy would not had an impact on the outcome. Bleeding occurred considerably later in duration after biopsy as noted in this study and may be triggered by hemodialysis though it was heparin free.  This finding could be related to the role of uremia in platelet dysfunction. An in vitro study showed that an increase in urea nitrogen altered the platelet aggregation process  and clinical studies have suggested that there is an increased risk of developing a hemorrhagic complication after PRB in patients with uremic syndrome. , Although other studies have demonstrated an association between serum creatinine levels and complications. ,
The mechanism by which diastolic hypertension increases the development of major complications perhaps is related to the known association of diastolic hypertension and the development of microbleeds,  which associated with renal puncture per se may increase the risk of developing major bleeding. ,,
The biopsy technique has significantly improved over the past few decades due to 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, or severe flank pain post-biopsy has been reported to be between 7% and 15% respectively. ,
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. 
The incidence of clinically significant hematomas ranges between 2% and 3% respectively. 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 h after biopsy in >90% of cases evaluated prospectively. ,
We perform real time ultrasound guided 15-20 renal biopsies per month. We have very minimal rate of complications with perinephric hematoma/bleeding rate needing a blood transfusion following biopsies of 0.5%.
Uremic patients have a bleeding tendency associated with platelet dysfunction because platelets from uremic patients have a reduced aggregating response to adenosine diphosphate, epinephrine and collagen. Uremic platelets also have a defective interaction with vessel subendothelium and radioligand studies have indicated an impaired binding of fibrinogen to adenosine diphosphate-stimulated uremic platelets. Anemia increases in nitric monoxide and irregularities in von Willebrand factor are also related to a bleeding tendency, regardless of the platelet status. 
Prevention and treatment options for bleeding include one or a combination of the following: erythropoietin, cryoprecipitate, desmopressin and conjugated estrogens. 
Several factors such as heparinization during dialysis, functional platelets abnormalities, intimal arterial fibrosis often combine to cause perirenal haemorrhage. 
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, though functional assay of platelet was not done. The only risk factor the patient had at the time of renal biopsy was severe renal failure along with slightly small kidneys.
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 life-threatening complications.
| Conclusions|| |
To the best of our knowledge, this is one of few reports on the occurrence of life-threatening complication like perinephric hematoma in a patient with severe renal failure on heparin free hemodialysis following a renal biopsy after 72 h.
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