Abstract
BackgroundPercutaneous renal biopsy is a valuable procedure in the management of and prognostication for patients with renal disease. Complications, although rare, occur with renal biopsies. Arteriovenous fistulas and heavy bleeding are notable complications. In this report, we describe simple suturing of the biopsy tract for salvage of a graft destined for a nephrectomy due to a profusely bleeding arteriovenous fistula.Case presentationA 20-year-old Sri Lankan man with end-stage renal disease due to steroid-resistant nephrotic syndrome underwent a renal transplant. He had poor urine output following the surgery, and a renal biopsy was performed to diagnose his renal pathology. He experienced poorly controlled postprocedural hypertension, and he had four episodes of gross hematuria that required blood transfusion. Coil embolization was delayed due to technical issues, and a graft nephrectomy was planned following the fourth episode of hematuria, which was the most severe. A Doppler scan revealed a slender, iatrogenic arteriovenous fistula corresponding to the biopsy tract, with very high flow rates. With knowledge of the anatomy of the fistula, we performed suturing of the tract to obliterate the fistula as a last resort to salvage the graft. The surgical procedure stopped the bleeding, and the patient made a full recovery with an excellent quality of life.ConclusionsIn our patient, a renal transplant biopsy revealed acute tubular necrosis. The incidence and treatment of fistulas and differences in complication rates among native and graft kidney biopsies are discussed.
Highlights
Percutaneous renal biopsy is a valuable procedure in the management of and prognostication for patients with renal disease
Most of the bleeding episodes respond to conservative management, including bed rest, blood transfusions, and correction of clotting abnormalities
We report a case of a patient in whom suturing of a biopsy tract containing an arteriovenous fistula (AVF) was used to stop the bleeding and eventually salvage the graft
Summary
Percutaneous renal biopsy provides crucial evidence in the assessment and management of allograft dysfunction. The patient was not sensitized and had received massive doses of immunosuppressants, including steroids, cyclosporine, tacrolimus, azathioprine, mycophenolate, and cyclophosphamide He had severe growth retardation with height (1.45 m) and Prasanna et al Journal of Medical Case Reports (2016) 10:82 weight (26 kg) well below the third percentile, lack of secondary sexual characteristics, and cushingoid features. We planned to selectively embolize the feeding vessels of the AVF; the interventional radiology department of the National Hospital of Sri Lanka was experiencing technical difficulties, and selective embolization was possible only on the following morning The patient developed another torrential bleed of 1250 ml in the evening on day 2, and an emergency graft nephrectomy appeared to be the only way to stop his bleeding. A repeat duplex scan done 6 weeks after the biopsy showed no features of AVF and excellent perfusion of the graft (Figs. 5 and 6)
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