NDT Advance Access published online on May 21, 2008
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfn253
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Successful interventional treatment of arteriovenous fistula after kidney biopsy in pediatric patients—a report of three cases
1 Department of Pediatric Nephrology, University Hospital, Erlangen, Germany 2 Department of Pediatrics, University Hospital, Erlangen, Germany 3 Department of Radiology, University Hospital, Erlangen, Germany
Correspondence and offprint requests to: Eva Maria Rüth, Department of Pediatric Nephrology, University Hospital, Loschgestr. 15, 91054 Erlangen, Germany. Tel: +49-9131-85-33118; Fax: +49-91-9131-85-33706; E-mail: Eva-Maria.Rueth{at}uk-erlangen.de
 |
Abstract |
|---|
 Top Abstract IntroductionCase reportsDiscussionReferences |
|---|
With an incidence of up to 16%, arteriovenous fistula (AVF) is a frequent complication after renal biopsy. We report on three cases, where renal biopsy in pediatric and adolescent patients led to various but clinically significant complications. In each patient two cores of renal parenchyma from the upper pole of the renal transplant or the lower pole of the right native kidney, respectively, were obtained with two attempts. Immediate post-bioptic ultrasound did not show any abnormalities. Setting of an AVF was suspected when complications occurred and ultrasound and Doppler studies showed AVF. The diagnosis was confirmed by angiography and occlusion of the fistulae was performed in the same session. We conclude that persistent AVF is an uncommon but serious complication after renal biopsy. Well-timed angiography when AVF is suspected can prevent loss of function, especially in transplant recipients.
Keywords: renal biopsy; arteriovenous fistula; pediatric renal transplants; interventional therapy
|
Introduction |
|---|
|
TopAbstractIntroductionCase reportsDiscussionReferences |
|---|
Renal biopsy is the most sensitive tool to evaluate both causes for kidney diseases as well as rejections in allograft recipients [1]. However, with an incidence of up to 16%, arteriovenous fistula (AVF) is a frequent complication after renal biopsy [2]. In most of the cases there are no clinical consequences of AVF. In more severe cases, however, macroscopic haematuria, haemodynamic changes due to a high shunt flow and loss of kidney function are observed. In the past, without the option of a radiological intervention, these complications required in many cases an emergency surgical procedure and, as ultima, ratio nephrectomy.
We report on three cases, where renal biopsy in paediatric and adolescent patients led to different but significant clinical complications. The setting of an AVF was suspected when classical complications such as decline of renal function, significant blood loss with macroscopic haematuria and/or a blood flow murmur during auscultation of the organ occurred. Ultrasound and Doppler studies showed an AVF, the diagnosis was confirmed by angiography and the occlusion of the fistulae was performed in the same setting.
|
Case reports |
|---|
|
TopAbstractIntroductionCase reportsDiscussionReferences |
|---|
Patient 1
A 16-year-old female with chronic renal failure due to juvenile nephronophthisis received a cadaver kidney transplant at the age of 14 with good graft function after transplantation. Thirty-five months after transplantation she showed a significant rise in serum creatinine (from 199 to 370 µmol/l) and an ultrasound-controlled percutaneous renal biopsy was performed. The biopsy showed an interstitial and vascular rejection (BANFF IIa) and as there was no improvement after the application of intravenous steroids and change from cyclosporine A to tacrolimus, sirolimus was added to the immunosuppressive therapy. Postbioptically, our patient only showed intermittent microscopic haematuria. However, serum-creatinine showed a further rise during the following weeks, requiring a second biopsy 4 weeks later proving no amelioration of vascular and interstitial rejection. Renal function further deteriorated up to a serum creatinine of 753 µmol/l and the patient required haemodialysis. None of the Doppler ultrasound studies performed showed any signs of an AVF. Ten days after the second renal biopsy the patient was admitted to the emergency department during the night with fever, abdominal cramps and macroscopic haematuria. Clinical examination revealed a soft murmur over the transplant. Ultrasound demonstrated the bladder filled with blood clumps, pyelectasis and finally confirmed the diagnosis of an AVF by the Doppler study. The patient continued bleeding and needed nine blood transfusions due to significant blood loss. After haemodynamical stabilization the next day, the patient was referred to the Department of Diagnostic Radiology where the AVF of a segmental artery in the lower pole of the renal transplant and a small pseudoaneurysma were occluded by seven platinum coils in an angiographic intervention (Figures 1 and 2). After intervention, the haematuria stopped, and creatinine descended to the pre-rejection baseline (Figure 3). Nine months after the intervention the patient is in a transferral state to an adult renal centre, there are no residuals from the AVF.
|
|
|
Patient 2
A 13-year-old girl was admitted to our hospital with end-stage renal failure (serum-creatinine 1610 µmol/l, blood urea nitrogen 49.5 mmol/l). Evaluation of the patient's history, clinical examination, laboratory specimens and ultrasound examination did not reveal the origin of kidney disease. Therefore, ultrasound-controlled percutaneous kidney biopsy was performed, showing a pauci-immune glomerulonephritis. Immediately after biopsy the girl showed macroscopic haematuria and a significant blood loss (haemoglobin decreased from 6.21 to 4.16 mmol/l), requiring three blood transfusions. Renal ultrasound and Doppler studies revealed an arteriovenous fistula with a high shunt volume. Approximately 3 h after biopsy the AVF of a subsegmental artery was occluded and bleeding into the pyelon was stopped in an interventional angiography setting using multiple platinum coils. Six months later the patient is on haemodialysis three times per week and listed for cadaver renal transplantation.
Patient 3
A 16-year-old female patient with chronic renal failure due to steroid-resistant nephrotic syndrome and biopsy-proven focal-segmental glomerulosclerosis received a cadaver renal transplant at the age of eight, after 2 years on haemodialysis. Seven years after transplantation the patient showed a gradual rise in her serum-creatinine baseline from 106 to 140 µmol/l over 1 year. As chronic transplant nephropathy was suspected, renal biopsy was performed, revealing hints of calcineurin-inhibitor toxicity and chronic-interstitial changes but no acute rejection. After the reduction of cyclosporine A the serum-creatinine remained stable and ultrasound controls showed no abnormalities. Four months after renal biopsy the patient presented again with a rise of serum-creatinine (169 µmol/l) and Doppler studies showed an AVF. There were no other clinical signs than a murmur, changes in the blood pressure measurements or macroscopic haematuria, except for the decline of renal function. Angiography was performed confirming the diagnosis of AVF connected to the upper main renal artery, reducing the perfusion of the upper pole and causing the impairment of renal function. In the same setting the fistula was occluded with platinum coils. There were no complications following the intervention and the patient's renal function is stable at this moment with a serum creatinine of 140 µmol/l.
|
Discussion |
|---|
|
TopAbstractIntroductionCase reportsDiscussionReferences |
|---|
Renal biopsies have been performed as a basis for ration- al therapeutics since the 1930s. Using ultrasound-guided automated biopsy guns has lowered the complication rate in a significant way [3] so the procedure has been carried out more frequently and the performance of a renal biopsy can be considered as a safe procedure. Minor complications of the biopsy such as microscopic haematuria and post-biopsy haematoma are common features and usually resolve within weeks after biopsy [4]. Riccabona et al. showed that in paediatric patients the rate of AVF was 11%, which is comparable to adult populations, with an incidence of 16% [2,5]. AVFs are formed from the attempt to repair the damage set by the biopsy needle to the walls of adjacent arteries and veins. The result is a communication between the vessels shunting blood from the capillaries in the glomeruli. Depending on size, growth and blood flow rate the clinical presentation can be very distinct, as it is shown by the three cases from our clinic and AVF can also present without definite clinical signs such as a blood flow murmur, as shown in our third patient. The time period between the creation of the fistula and the clinical presentation can be very variable, ranging up to 1 year or even longer [6]. This variable time span is reflected very well by our three patients. Most AVF diminish spontaneously, however, intricacies such as bleeding and haemodynamic changes due to persistent fistulae, can still lead to organ damage or even loss if there is no possibility of intervention or if the fistula is not diagnosed [7]. As in one of our patients, severe complications may occur sequentially. In some cases diagnosis is hindered or postponed when there are no clinical signs or in Doppler studies where no definite evidence of an AVF is seen.
When methods of interventional radiology were not available there was only surgical intervention to prevent organ loss. In 2005 Brantsma et al. reported on an adult patient developing end-stage renal failure requiring haemodialysis with recovery after angiography with coiling of the fistula [8], a case very similar to that of our first patient, where interventional radiology could prevent an organ loss. Although total or partial nephrectomy might still be considered as the only option available in severe acute bleeding [9], we showed that angiography with selective embolization, using platinum micro coils, of the fistula stopped the bleeding and in two patients saved in the function of the renal transplant. It is well known, that haemostatic defects in patients with renal impairment can lead to bleeding diathesis. Gotti et al. reported on a series of preliminary results of desmopressin infusions prior to renal biopsy in 12 patients with prolonged bleeding time [10], where bleeding time was temporarily restored and no major bleeding complications occurred. Additionally, the use of DDAVP might be helpful in cases where bleeding following intervention cannot be stopped [11]. The use of DDAVP in children and adolescents with von Willebrandt's disease is a routine measure. As a screening procedure we therefore test for prolonged bleeding time and haemostatic imbalances before renal biopsy. Potentially, the patient might have benefited from the administration of DDAVP when bleeding occurred, although this cannot be proven. In order to legitimate the routine use of DDAVP in adolescents with renal disorders, we feel that randomized studies are needed.
In the last years it has been shown that interventional therapy of vascular complications is safe and selective occlusion of the feeding artery of the fistula preserves the surrounding renal parenchyma, which is not possible to that extent with surgical methods [12]. These cases reported from our clinic show all the different possibilities of clinical features of AVF. From acute bleeding, to slow and acute organ failure there is a broad variety of clinical presentation and in order to detect a fistula; a detailed physical examination as well as a careful medical history is essential.
Although persisting and clinically significant AVF are scarce, any suspicious case should be evaluated and, in sufficient time, be referred to a centre with the possibility to perform radiological intervention.
Conflict of interest statement. None declared.
|
References |
|---|
|
TopAbstractIntroductionCase reportsDiscussionReferences |
|---|
- Vogler C, Wang Y, Brink DS, et al. Renal pathology in the pediatric transplant patient. Adv Anat Pathol (2007) 14:202–216.[CrossRef][Web of Science][Medline]
- Brandenburg VM, Frank RD, Riehl J. Color-coded duplex sonography study of arteriovenous fistulae and pseudoaneurysms complicating percutaneous renal allograft biopsy. Clin Nephrol (2002) 58:398–404.[Web of Science][Medline]
- Riehl J, Maigatter S, Kierdorf H, et al. Percutaneous renal biopsy: comparison of manual and automated puncture techniques with native and transplanted kidneys. Nephrol Dial Transplant (1994) 9:1568–1574.
[Abstract/Free Full Text] - Feneberg R, Schaefer F, Zieger B, et al. Percutaneous renal biopsy in children: a 27-year experience. Nephron (1998) 79:438–446.[CrossRef][Web of Science][Medline]
- Riccabona M, Schwinger W, Ring E. Arteriovenous fistula after renal biopsy in children. J Ultrasound Med (1998) 17:505–508.[Abstract]
- Tarif N, Dunne PM, Parachuru PR, et al. Life-threatening hematuria from an arteriovenous fistula complicating an open renal biopsy. Nephron (1998) 80:66–70.[CrossRef][Web of Science][Medline]
- Smaldone MC, Stein RJ, Cho JS, et al. Giant idiopathic renal arteriovenous fistula requiring urgent nephrectomy. Urology (2007) 69:576 e1–3.
- Brantsma AH, Prins TR, de Maar EF, et al. To haemodialysis and back: saving a kidney graft by treatment of an arteriovenous fistula. Nephrol Dial Transplant (2005) 20:2870–2871.
[Free Full Text] - Mansy H, Khalil A, Bafaqeeh M, et al. Transplant nephrectomy for a large AV fistula following renal biopsy. Nephron (1995) 71:481–482.[Web of Science][Medline]
- Gotti E, Mecca G, Valentino C, et al. Renal biopsy in patients with acute renal failure and prolonged bleeding time: a preliminary report. Am J Kidney Dis (1985) 6:397–399.[Web of Science][Medline]
- Dave SP, Greenstein AJ, Sachar DB, et al. Bleeding diathesis in amyloidosis with renal insufficiency associated with Crohn's disease: response to desmopressin. Am J Gastroenterol (2002) 97:187–189.[CrossRef][Web of Science][Medline]
- Libicher M, Radeleff B, Grenacher L, et al. Interventional therapy of vascular complications following renal transplantation. Clin Transplant (2006) 20(Suppl_17):55–59.[Web of Science][Medline]
Accepted in revised form: 14. 4.08
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||