2019KHA-CARI肾活检建议指南.pdf

R E V I E W A R T I C L EKHA-CARI Guideline recommendations for renal biopsyRob MacGinley1|Paul J Champion De Crespigny2,3|Talia Gutman4,5|Pamela Lopez-Vargas5|Karine Manera4,5|Solomon Menahem6|John Saunders7|Emily See8|David Voss9|Jeffrey Wong101Department of Renal and General Medicine, Eastern Health Clinical School, Monash University Melbourne, Melbourne, Victoria, Australia2Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia3Royal Womens Hospital, Melbourne, Victoria, Australia4Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia5Centre for Kidney Research, The Childrens Hospital at Westmead, Sydney, New South Wales, Australia6Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia7Renal Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia8Department of Nephrology, Monash Health, Melbourne, Victoria, Australia9Counties Manukau Health, Auckland, New Zealand10Department of Nephrology, Liverpool Hospital, Liverpool, New South Wales, AustraliaCorrespondenceDr Rob MacGinley, Centre for Kidney Research, Kids Research Institute, Childrens Hospital at Westmead, Hawkesbury Road, Westmead, NSW 2145, Australia.Email: cari.schnhealth.nsw.gov.auFunding informationAustralian and New Zealand Society of Nephrology; Better Evidence AndTranslation in Chronic Kidney Disease (BEAT-CKD); Kidney Health AustraliaKE Y WORD S:biopsy, chronic kidney disease, guideline1|SCOPE OF THE GUIDELINEThis guideline addresses issues relevant to the preparation, intervention andcare of patients undergoing native or transplant kidney biopsies. The guide-line provides recommendations concerning the impact of education onpatients and caregivers prior to undertaking renal biopsy and the use of anti-coagulants, antiplateletsanddesmopressinpre-andpost-biopsy. Italso exam-ines the available evidence for comparing needle use, imaging techniques andthe position of the patient during biopsy. Lastly, it addresses issues relevantto the management of post-renal biopsy care and outlines the evidence basefor techniques to detect and reduce the possibility of bleeding; the mostcommon complication following renal biopsy. An overview of the guidelinedevelopment process is provided in Appendix A. A description of the gradesand levels assigned to recommendations is provided in Tables A1 and A2.2|PART I: PRE-BIOSPY MEDICATIONSAND PATIENT INFORMATIONPercutaneous renal biopsies are the gold standard for the investiga-tion of causes of renal parenchymal disease, for native or transplantkidney biopsies. Despite this, there is limited evidence regardingpatients experiences and requirements when undergoing a renalbiopsy. Education, psychosocial support and self-management havebeen identified as a requirement for those in need of a renal biopsy.1,2The method in which the information is conveyed to patients as wellas the provision of support for the decision-making process are alsoimportant.3Although the procedure is considered to be safe, especially sincethe introduction of spring-loaded needles and real-time imaging,4-11bleeding is the most common complication. Routine care prior tobiopsy involves measuring haemoglobin, platelet count, internationalnormalized ratio (INR) and activated partial thromboplastin time. Tominimize the risk of bleeding, patients are usually advised to stop anti-platelet and anticoagulant agents prior to renal biopsy. These agentsare common in patients with kidney disease, who are at increased riskof vascular disease. Although policies and practices vary between cen-tres, non-urgent biopsies are often postponed until antiplatelet andanticoagulant agents have been ceased for several days. This can leadto delays in diagnosis and treatment, unnecessary administration ofblood products such as fresh frozen plasma or platelets, and mayReceived: 21 July 2019Revised: 13 August 2019Accepted: 17 August 2019DOI: 10.1111/nep.13662Nephrology. 2019;24: 2019 Asian Pacific Society of Nephrology1205increase the likelihood of ischaemic and thromboembolic events, inparticular when there is discontinuation of aspirin.9,10There is a lack of evidence that uremic bleeding is due to deficiencyor abnormality of factor VIII and von Willebrand Factor (vWF), and thatthe similar biological effects of desmopressin and cryoprecipitate onthese haemostatic proteins led some investigators to postulate thatdesmopressin might be therapeutically effective. Desmopressin acetateis a synthetic analogue of antidiuretic hormone which is occasionallyadministered prior to percutaneous renal biopsy to reduce the risk ofbleeding complications.12,13It acts as a selective agonist of endothelialvasopressin-2 receptors, augmenting plasma levels of factor VIII andvWF.14,15Studies have demonstrated that infusion of desmopressinelicits a rapid but transient increase in the circulating levels of vWFand factor VIII, reaching a peak between 90 min and 2 h afteradministration.15A single dose can be expected to increase the factorVIII level 3- to 6-fold. It has been shown to normalize bleeding time inuraemia for up to 48 h,14,16-18presumably through its vasopressin-2receptor agonist activity. The other effects of desmopressin includevasodilation,andanoxytociceffectatintranasaldosesof1520 g.Theaimofthisguidelineistohelptominimizeharmsassociatedwithpre-biopsycare.Evidence ontheemotional well-beingandpsychologicalimpact of educational interventions and provision of information forpatients undergoing a renal biopsy will be examined. Secondly, evidencesurrounding antiplatelet and anticoagulant medication, along withdesmopressinusepriortorenalbiopsywillbecoveredinthissection.2.1 | Biopsy information and education for patientsand caregiversGuideline recommendationsa. We recommend patients and their carers be provided with educa-tion and information about renal biopsies including reasons for itsuse, risks and complications, pre- and post-biopsy managementwith particular regard to psychological issues such as anxiety. Theeducation and information provided should be in a format suitedto their learning needs (1C).Ungraded suggestions for clinical care We suggest healthcare providers consider following the processoutlined in Figure 1 to establish methods of communication andinteraction with patients undergoing a renal biopsy, to adequatelyprepare them for the procedure and alleviate unnecessary anxietythroughout the process.2.2 | Pre-biopsy medication Antiplatelet andanticoagulant agentsGuideline recommendationsa. We recommend continuation of aspirin in patients at high risk for acardiovascular event, including those with a history of coronarystent (particularly within 3 months of bare metal stent or 12 monthsof drug eluting stent insertion), symptomatic myocardial ischaemiaor peripheral vascular disease (including patients with a peripheralstent), or previous ischaemic stroke (1C).b. We recommend cessation of aspirin for patients at low risk for acardiovascular event either 3 days (to prevent major bleeding) or7 days (to prevent minor bleeding) prior to the renal biopsy (1C).c. We suggest the use of bridging anticoagulation in patients athighest risk for thromboembolism. This includes patients with amechanical mitral valve, a mechanical aortic valve and additionalstroke risk factors, antiphospholipid syndrome, an embolic eventwithin the previous 3 months, atrial fibrillation (CHADS2 score5 or 6), and a previous thromboembolic event with interruption ofanticoagulation (2C).Ungraded suggestions for clinical care We suggest all patients stop taking:- Adenosine diphosphate (ADP) inhibitors (clopidogrel, prasugrel,ticagrelor) 5 to 7 days before the renal biopsy- Warfarin 5 days before the renal biopsy- Direct thrombin inhibitors (dabigatran) and factor Xa inhibitors(rivaroxaban, apixaban) 4872 h before the renal biopsy- Unfractionated heparin 46 h before the renal biopsy- Low molecular weight heparin 24 h before the renal biopsy We suggest that antiplatelets and anticoagulants should not berestarted until 2448 h following an uncomplicated biopsy, sincemost complications will occur within this time. We suggest that prior to renal biopsy, the platelet count should beabove 50 000/L and the INR should be less than 1.5.2.3 | Pre-biopsy medication Desmopressin acetateGuideline recommendationsNo recommendations or suggestions can be made due to lack ofevidence.Ungraded suggestions for clinical care There is a lack of evidence to support the benefit or harm ofdesmopressin acetate 0.3 g/kg administered intravenously over30 min prior to renal biopsy. Units should continue their existingpractice until a higher level of evidence is available. However, weSummary at a glanceThis KHA-CARI Guideline laid down principles for the careof patients undergoing kidney biopsy, and provides manage-ment guidelines from with-holding of antiplatelet and anti-coagulant agents, application of desmopressin to post-biopsy bleeding care.1206MACGINLEYET AL.suggest this is considered only for patients with Stage 3b chronickidney disease and onwards. Careful attention to fluid balance should be paid if desmopressin isadministered and excessive fluid intake should be discouraged for68 h after its administration. There is no evidence in any reports of a negative effect by usingdesmopressin in patients with cardiovascular disease. However,due to the hypothetical potential risk of thrombosis, desmopressinacetate should be avoided in patients with significant occlusive car-diovascular disease, including those with a vascular stent in situ.3|PART II: RENAL BIOPSY IMAGING,NEEDLES AND POSITIONINGPercutaneous renal biopsy is an important diagnostic and prognostictool for nephrologists. While it is generally safe, it is an invasive proce-dure and bleeding complications are the most frequently reported inpublished literature.19,20Although the purpose of a renal biopsy is toestablish a diagnosis, in the published literature the adequacy of asample is often described by the number of glomeruli sampled. In thesetting of renal transplant biopsies, published guidelines are availabledescribing an adequate sample.21,22In the setting of native kidneybiopsies descriptions of adequacy are more varied and often dependon the underlying pathology,23however, more than 10 glomeruli isoften used to define an adequate sample.24-26There are many devicesavailable for performing percutaneous renal biopsies and they come inthree different size options; 14, 16 and 18 G, as well as different con-figurations of cutting surfaces. The length of the needle throw is gen-erally not reported in the published studies, but devices are nowbecoming available with a variable throw which can be selected bythe operator at the time of biopsy.Historically, native and transplant renal biopsies were performedblind or by palpation, but a variety of adjunctive imaging techniqueshave since been employed to improve efficacy and safety. As ultrasoundhas become increasingly available, it has developed into the standard ofcare in most recent renal biopsy publications.27Few direct comparisonsbetween imaging modalities exist, with observational studies predomi-nantly describing the contemporary imaging methods, changes inmethods over a period, and comparisons with a historical cohort.5,28-31Current imaging questions in renal biopsy relate to the contemporaryimagingmodalities ofultrasoundandcomputedtomography (CT) and thebiopsy methods employed in conjunction with these: Real-time imaging(direct image-guided needle entry) versus localization or marking (image-guided marking on skin surface +/ depth estimation) followed by blindbiopsy. Difficult patients who may require CT-guided biopsy includethose with structural kidney disease, body mass index 30 kg/m2andthosesituationswherethereisnoaccesstoanyultrasoundservices.Percutaneous renal biopsy is an important tool in the diagnosis ofdiseases affecting native and transplanted kidneys. Early percutaneousnative renal biopsies were performed with the patient in the sitting posi-tion32,33but soon the prone position on a sandbag or pillow to splint thekidneys was used which may improve patient comfort, improve tissueyield and can make real-time ultrasound easier.34The prone positionmay not always be comfortable or even possible in some patient groups,including obese patients, pregnant women and those with significantrespiratory compromise. The supine antero-lateral position for obeseand non-obese patients has been reported to provide superior compli-ance, comfort and respiratory comfort assessed by visual analogue scalecompared with the prone position.35Biopsy of a renal transplant hasbeen described exclusively with the patients in the supine position,35-37however, like native kidney biopsy patient position in transplant biopsyisfrequentlynotreported.38,39FIGURE 1Process of renalbiopsy: Communicationthroughout the patient journey(Adapted from Gutman et al.,1(p. 26) with permission.)MACGINLEYET AL.12073.1 | Renal biopsy: NeedlesGuideline recommendationsa. We recommend the use of a spring-loaded automatic needledevice for native renal biopsy because they are associated withfewer complications and better tissue samples (1B).b. We recommend the use of a spring-loaded automatic needledevice for transplant renal biopsy because they are associatedwith fewer complications and better tissue samples (1C).c. We suggest using a 16 G needle for native and transplant renalbiopsy provides the best balance between sample adequacy andrisk of bleeding (2C).Ungraded suggestions for clinical care Consideration should be given to the throw length of the biopsyneedle in relation to the size of the kidney being biopsied and cor-tical thickness. Throw length is often fixed and related to a specificneedle type, however, there are some devices that have an adjust-able throw length, and these could be considered for smallerkidneys.3.2 | Renal biopsy: ImagingGuideline recommendationsa. We recommend percutaneous native renal biopsy to be image-guided (1B).b. We recommend Real-Time Ultrasound Guidance be used as thefirst line imaging for percutaneous renal biopsy in patients with akidney transplant (1C).c. We suggest the use of Real-Time Ultrasound Guidance or ultra-sound localization for native renal biopsy (2C).d. We suggest the use of CT localization for native renal biopsy indifficult cases (defined below) (2D).Ungraded suggestions for clinical careNo ungraded suggestions for clinical care.3.3 | Positioning for renal biopsyGuideline recommendationsa. We suggest the supine anterolateral position for obese patients orthose with respiratory difficulty for native renal biopsy (2B).Ungraded suggestions for clinical care We recommend the prone position with a pillow or sandbag underthe abdomen to splint the kidneys for native renal biopsy We recommend the supine position for transplant biopsy For exceptional situations (intubated, pregn