Disclaimer. Percutaneous Renal Biopsy in the Outpatient Setting. Background. Technique. ASDIN 10th Annual Scientific Meeting Final

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Claude Abraham Montgomery
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1 Disclaimer Percutaneous Renal Biopsy in the Outpatient Setting Consultant for Bard Peripheral Inc. Ivan D. Maya, MD, FACP Nephrology Associates of Central Florida Background - Percutaneous renal biopsy (PRB) is a valuable procedure for the diagnosis of renal disease, and is helpful in guiding medical therapy and establishing prognosis. - A renal biopsy may cause a serious hemorrhagic complication, requiring additional diagnostic procedures, blood transfusion, vascular interventions, and increased length of hospitalization. - The optimal duration of observation after a PRB has not been established, and patients are frequently hospitalized for overnight observation. Technique PRB has been performed by different specialists (radiologists, urologists, surgeons and nephrologist). Different techniques: Blind (Seldinger) with prior use of KUB (x-ray). Ultrasound localization prior to PRB. Real-time ultrasound guidance. CT scan guided. Laparoscopic technique. Different needles: Silverman needle. Tru-Cut. Automated needle biopsy gun. Silverman technique Tru-Cut technique 14 gauge 1

2 CT guided PRB Real time ultrasound Real time ultrasound Main complications Anemia requiring transfusion. Retroperitoneal bleeding. Intraparenchemal arterio-venous AV fistula. Hematuria. Infection. Timing: 95 % in the first 8 hours. Up to 48 hours after procedure. Complications Complications 2

3 Severe pericapsular bleeding Background Although it is often claimed that the ultrasound-guided technique (real-time) is superior to the blind technique. Adequacy of kidney tissue retrieval and complications by realtime ultrasound-guided percutaneous renal biopsy. UAB study Ref Number of biopsies Adequate tissue (%) Major Complications * Dowd, % <0.5% US-guided biopsy Automated 18 gauge N pts Blind biopsy Tru-Cut 14 gauge P value Doyle, % 0.8% Hergesell, % < 0.5% Age, years 43±16 43± Sex, N (%) male 22 (39%) 31 (48%) 0.11 Race, N (%) white 27 (42%) 31 (48%) 0.48 Diabetes, N (%) 19 (29%) 10 (16%) 0.09 Donovan, % < 1% Burstein, % 5.6% Cozens, % N/A Hypertension, N (%) 44 (68%) 40 (63%) 0.6 Serum creatinine, mg/dl 2.6± ± Pre-biopsy hematocrit (%) 33.6±6 34.3± Marwah, % Maya ID, Allon M. Percutaneous renal biopsy: comparison of blind and real-time ultrasound-guided technique. Semin Dial Jul-Aug; 20(4): Results: tissue and complications US-guided biopsy Automated 18 gauge N pts Blind biopsy Tru-Cut 14 gauge P value Number of glomeruli 18±9 11± No tissue / re-biopsy 0 (0%) 10 (16%) US-guided biopsy Blind biopsy P value N pts All hematomas 5 (8%) 12 (19%) 0.07 Large hematomas * 0 (0%) 6 (9%) 0.01 Vascular intervention 0 (0%) 5 (8%) 0.02 Death 0 (0%) 1 (1.5%) 0.49 Maya ID, Allon M. Percutaneous renal biopsy: comparison of blind and real-time ultrasound-guided technique. Semin Dial Jul-Aug; 20(4): Results: Complications US-guided biopsy Blind biopsy P value N pts Pre-biopsy 33.6±6 34.3± Hematocrit 6 hours post-biopsy 32.7±5 30.6± hours post-biopsy 32.9±5 31.7± hours post-biopsy 32.4±5 29.8± Us- guided biopsy Blind biopsy P value N pts with 5 12 complications Hematuria 1 (20%) 4 (33%) 1.0 Hypotension 2 (40%) 5 (42%) * 1.0 Abdominal pain 0 (0%) 3 (25%) 0.51 *Hypotension was present in 4 out of 6 patients (66%) who developed hematomas 3

4 Study conclusions Real-time ultrasound-guided renal biopsies were associated with both a superior tissue yield and a lower complication rate, as compared to the blind technique. -All the major hemorrhagic complications of renal biopsies were detected within 24 hours. -The use of 18 gauge instead of 14 gauge needles will decrease significantly the risk for bleeding. -Major hemorrhagic complications could be safely treated by selective renal arteriogram with embolization of the bleeding arteriole in all instances, and no patient required surgical intervention. So, the question was Is it safe and cost effective to perform outpatient percutaneous renal biopsies? Study looking into performing PRB in the hospital but as an outpatient service and to keep prospective data for future analysis. Pre biopsy monitoring Real time ultrasound Patients to arrive to the interventional pre-operative area at 6:30 am and are admitted as out-patients to private rooms. Cell blood count (CBC), renal function panel, pro-time, partial thromboplastin time and a type and cross are requested. Patients to be taking to ultrasound suite located in the same pre-operative area at around 7:30 am. Patient s blood pressure, EKG and pulse-oximetry to be monitored throughout the procedure. Initial diagnostic bilateral renal ultrasound with and without color Doppler is performed. Length and depth are measured and any abnormalities are noted. Maya ID, Allon M: Percutaneous renal biopsy: outpatient observation without hospitalization is safe. Semin Dial 2009;22: Post biopsy monitoring Initial results A post-biopsy color Doppler ultrasound imaging is obtained immediately following for the biopsy to exclude active bleeding. Patients are monitored in the pre-operative area and kept at bed rest for 8 hours, with 30 minute interval recordings of blood pressure and heart rate. All voided urine samples are saved and inspected for hematuria. Hematocrit and hemoglobin values are measured 4 and 8 hours following the procedure. A second ultrasound is obtained if the patient develops hypotension, gross hematuria or abdominal pain. If active bleeding is visualized, the patient undergoes selective renal artery embolization by Interventional Radiology. 91 patients. 12 +/- 9 glomeruli per patient. No complications. 13 patients with perinephric hematoma (11%). No late complications. Maya ID, Allon M: Percutaneous renal biopsy: outpatient observation without hospitalization is safe. Semin Dial 2009;22:

5 Follow up after initial study Results Other studies Literature Author, year Alebiosu CO 2004 Outpatient number Major complications % Bairy M % Maya ID. 2009/ / abstract % Lin WC vs Margarvan A Fraser IR vs Simckes AM vs % Perinephric hematomas Alebiosu CO, Kadiri S: Percutaneous renal biopsy as an outpatient procedure. J Natl Med Assoc 2004;96: Bairy M, Beleed K, WebbAT, Bhandari S: Safety of outpatient kidney biopsy: one center s experience with 178 native kidney biopsies. Am J Kidney Dis 2008;52: Maya ID, Allon M: Percutaneous renal biopsy: outpatient observation without hospitalization is safe. Semin Dial 2009;22: Lin WC, Yang Y, Wen YK, Chang CC: Out- patient versus inpatient renal biopsy: a retrospective study. Clin Nephrol 2006;66: Margaryan A, Perazella MA, Mahnensmith RL, Abu-Alfa AK: Experience with outpatient computed tomographic-guided renal biopsy. Clin Nephrol 2010;74: Fraser IR, Fairley KF: Renal biopsy as an out- patient procedure. Am J Kidney Dis 1995;25: Simckes AM, Blowey DL, Gyves KM, Alon US: Success and safety of same-day kidney biopsy in children and adolescents. Pediatr Nephrol 2000;14: Constantin A. Percuatenous US guided reanl biopsy: Aretrospective study comparing the 16 gauge end cut and 14 gauge side notch needles. J Vasc Interv Radiol 2010; 21: What about cost effectiveness? A cost minimization study was performed using decision analysis methodology. Probabilities were obtained from the published literature. Results: Out-patient cost $1,394 per biopsy compared to $1,800 for in-patient. They found less complications in the out-patient setting. Conclusions: PRB was cost effective. Maripuri S. Penson D. IkizlerT. Cavanas K. Outpatient versus Inpatient Observation after Percutaneous Native Kidney Biopsy: A Cost Minimization Study. Am J Nephr 2011; 34:64-70 What about cost effectiveness? 105 pts. A 15 gauge needle. Ultrasoundguided PRB. Patients were discharged after 5 hours of observation. Main finding: the mean cost per patient for each outpatient biopsy was $ 976 vs. $5,489 for inpatients. McMahon GM. Development of an outpatient native kidney biopsy service in low-risk patients A multidisciplinary approach. Am J Nephrol. 2012, 35 (4):

6 Conclusion Outpatient, real-time, ultrasound-guided percutaneous renal biopsy followed by a color Doppler US is safe and effective, and minimizes the need for post-biopsy hospitalization. Outpatient percutaneous renal biopsy can result in significant cost savings without exposing the patients to increased risk of complications. 6

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