NDT Advance Access originally published online on April 19, 2005
Nephrology Dialysis Transplantation 2005 20(6):1274-1275; doi:10.1093/ndt/gfh828
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Functional renal artery obstruction following percutaneous kidney biopsy
Sir,Although uncommon, percutaneous renal biopsy can precipitate acute renal failure from ureteral obstruction, hypotension or parenchymal compression by perinephric haematoma [1–4]. We report a case of acute renal failure following percutaneous renal biopsy resulting from torsion and kinking of the main renal artery secondary to anatomic displacement of the affected kidney by a large retroperitoneal haematoma.
A 50-year-old man with a history of diabetes mellitus, hepatitis C and orthotopic liver transplantation presented with renal insufficiency of several months duration. The patient's blood pressure was 128/49 mmHg, serum creatinine concentration (Scr) was 1.8 mg/dl and the urine albumin to creatinine ratio was 3.5 mg/mg. Additional serological work-up, renal sonogram and urine microscopy were unremarkable. Three months later, the Scr had increased to 2.6 mg/dl and a percutaneous kidney biopsy was performed.
Following the biopsy, the patient developed decreased blood pressure and increasing left flank pain. An emergent computed tomography (CT) scan revealed a 9.5 x 9.4 cm haematoma extending from the lower pole of the left kidney into the left pelvis. Surgical evacuation of the haematoma was not advised due to the high risk for infection. The patient's hospitalization was marked by continued bleeding and transient acute renal failure with a peak Scr of 3.8 mg/dl. The patient was discharged on the ninth day of hospitalization, at which time his Scr was 3.1 mg/dl. His blood pressure had increased to 177/89 mmHg for which hydralazine and metoprolol were prescribed. Findings on the renal biopsy suggested tacrolimus nephrotoxicity and diabetic glomerulosclerosis.
Three weeks later, the patient was readmitted with oedema, dyspnoea and somnolence. The Scr had increased to 5.3 mg/dl, urinalysis demonstrated 4+ blood and 4+ protein, and microscopic analysis was unremarkable. Renal sonogram demonstrated a 26 x 14 cm retroperitoneal haematoma extending caudally from the left kidney with no hydronephrosis. Renal replacement therapy with intermittent haemodialysis was initiated.
Work-up included a MAG3 renal scan showing an asymmetric decrease in renal blood flow and function in the left kidney (split function: 16% left, 84% right). Subsequent magnetic resonance angiography revealed anterior and superior displacement of the left kidney by the haematoma with kinking of the left renal artery at the level of the ostium (Figure 1). Vascular surgery consultation advised against surgical revascularization because of the high risk for infection. The patient was discharged with the continued requirement for renal replacement therapy. A CT scan 4 months after the biopsy demonstrated an evolving left retroperitoneal hematoma unchanged in size or anatomic location with continued cephalad displacement of the left kidney.
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In conclusion, this case demonstrates a new complication ascribed to percutaneous kidney biopsy; anatomic displacement of the kidney from a haematoma resulting in torsion and kinking of the ipsilateral main renal artery and subsequent ischaemic nephropathy.
Conflict of interest statement. None declared.
1 Renal Section, Medical Service,2 Radiology Service VA Pittsburgh Healthcare System3 Renal-Electrolyte Division Department of Medicine VA Pittsburgh Healthcare System4 Department of Radiology University of Pittsburgh School of Medicine Pittsburgh, PA USA Email: steven.weisbord{at}med.va.gov
References
- Parrish AE. Complications of percutaneous renal biopsy: a review of 37 years’ experience. Clin Nephrol 1992; 38: 135–141[Web of Science][Medline]
- Whittier WL, Korbet SM. Timing of complications in percutaneous renal biopsy. J Am Soc Nephrol 2004; 15: 142–147
[Abstract/Free Full Text] - Korbet SM. Percutaneous renal biopsy. Semin Nephrol 2002; 22: 254–267[CrossRef][Medline]
- Wijeyesinghe EC, Richardson RM, Uldall PR. Temporary loss of renal function: an unusual complication of perinephric hemorrhage after percutaneous renal biopsy. Am J Kidney Dis 1987; 10: 314–317[Medline]
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