**Figure 2.**

*Exploratory ultrasound performed on patient with gross hematuria, 24 hours after percutaneous native kidney biopsy. (A and B) Multiple pelvic blood clots (arrow) after renal biopsy.*

#### **Figure 3.**

*Perirenal hematoma, an hour after percutaneous native kidney biopsy. Computed tomography (CT) scan slices of the abdomen revealed voluminous perirenal hematoma (yellow circle), on the left side. (A and B) Axial scan slices. (C) Coronal scan slice. (D) Coronal scan slice.*

Microscopic hematuria, mild low back pain, and a slight drop in the hemoglobin concentration are frequent findings and should not be considered complications [25]. However, the persistence of these symptoms for more than a week may require a detailed investigation with imaging exams. Post-biopsy chronic hypertension, the puncture of other organs, and perirenal soft part infections have been described but are very rare.

The literature reports variable complication rates, generally ranging from 5 to 16%, with macroscopic hematuria in 3–9% of cases and the need for transfusions in 0.1–3.0% of cases [14, 26–29]. In such cases, an exploratory ultrasound examination should be performed (**Figure 2**). Burstein et al. found post-biopsy complications in 14.3% of patients, with 6.6% considered minor and another 7.7% considered major (hemorrhages requiring blood transfusion or another approach) [28]. González-Michaca et al. found major complications in 2.4% of patients and minor complications in 8.65%, the most frequent of which was perirenal hematoma [30, 31]. Native kidneys tend to have a lower complication rate than transplanted kidneys (13.9 and 24.4%, respectively) [32].

**45**

**Figure 4.**

**Figure 5.**

*Post-biopsy procedures and management.*

*Post-Biopsy Complications Associated with Percutaneous Kidney Biopsy*

After a kidney biopsy, patients should remain in observation for at least 4 hours. They are placed at absolute rest in dorsal decubitus and are monitored in this period with the constant evaluation of vital signs. It is also advisable to perform renal ultrasound 1 hour after the procedure in all patients submitted to percutaneous kidney biopsy. The aim of this measure is to evaluate the biopsied area and anticipate possible post-procedure complications, thereby enabling immediate, effective

*Perirenal hematoma, observed an hour after percutaneous native kidney biopsy. (A) Longitudinal ultrasonography exhibiting hematoma area near the posteroinferior border of the left kidney. (B and C) Longitudinal (line 1) and transversal dimension on ultrasound (line 2 and 3) estimated the final volume of* 

The volume of the perirenal hematoma formed and the complication rates associated with this procedure have a direct relation of proportionality. Hematomas formed in the first hour after the procedure with volumes greater than 40 ml are related to a greater risk of developing major complications [14] (**Figure 5**). For cases of minor complications, the patient should receive clear orientation regarding the expected benign evolution of the case and receive medication for the symptoms based on individual need. These patients should be required to return after 7 days for a follow-up ultrasound and definitive discharge of the case if no imaging

abnormalities are found and there are no new complaints. In cases of hemodynamic

therapeutic support (**Figure 3** and **Figure 4**).

*216.73 ml of hematoma area. LK, left kidney; H, hematoma.*

*DOI: http://dx.doi.org/10.5772/intechopen.89226*

*Post-Biopsy Complications Associated with Percutaneous Kidney Biopsy DOI: http://dx.doi.org/10.5772/intechopen.89226*

#### **Figure 4.**

*Renal Diseases*

**Figure 2.**

**44**

are very rare.

**Figure 3.**

24.4%, respectively) [32].

Microscopic hematuria, mild low back pain, and a slight drop in the hemoglobin concentration are frequent findings and should not be considered complications [25]. However, the persistence of these symptoms for more than a week may require a detailed investigation with imaging exams. Post-biopsy chronic hypertension, the puncture of other organs, and perirenal soft part infections have been described but

*Perirenal hematoma, an hour after percutaneous native kidney biopsy. Computed tomography (CT) scan slices of the abdomen revealed voluminous perirenal hematoma (yellow circle), on the left side. (A and B) Axial* 

*Exploratory ultrasound performed on patient with gross hematuria, 24 hours after percutaneous native kidney* 

*biopsy. (A and B) Multiple pelvic blood clots (arrow) after renal biopsy.*

*scan slices. (C) Coronal scan slice. (D) Coronal scan slice.*

The literature reports variable complication rates, generally ranging from 5 to 16%, with macroscopic hematuria in 3–9% of cases and the need for transfusions in 0.1–3.0% of cases [14, 26–29]. In such cases, an exploratory ultrasound examination should be performed (**Figure 2**). Burstein et al. found post-biopsy complications in 14.3% of patients, with 6.6% considered minor and another 7.7% considered major (hemorrhages requiring blood transfusion or another approach) [28]. González-Michaca et al. found major complications in 2.4% of patients and minor complications in 8.65%, the most frequent of which was perirenal hematoma [30, 31]. Native kidneys tend to have a lower complication rate than transplanted kidneys (13.9 and

*Post-biopsy procedures and management.*

#### **Figure 5.**

*Perirenal hematoma, observed an hour after percutaneous native kidney biopsy. (A) Longitudinal ultrasonography exhibiting hematoma area near the posteroinferior border of the left kidney. (B and C) Longitudinal (line 1) and transversal dimension on ultrasound (line 2 and 3) estimated the final volume of 216.73 ml of hematoma area. LK, left kidney; H, hematoma.*

After a kidney biopsy, patients should remain in observation for at least 4 hours. They are placed at absolute rest in dorsal decubitus and are monitored in this period with the constant evaluation of vital signs. It is also advisable to perform renal ultrasound 1 hour after the procedure in all patients submitted to percutaneous kidney biopsy. The aim of this measure is to evaluate the biopsied area and anticipate possible post-procedure complications, thereby enabling immediate, effective therapeutic support (**Figure 3** and **Figure 4**).

The volume of the perirenal hematoma formed and the complication rates associated with this procedure have a direct relation of proportionality. Hematomas formed in the first hour after the procedure with volumes greater than 40 ml are related to a greater risk of developing major complications [14] (**Figure 5**). For cases of minor complications, the patient should receive clear orientation regarding the expected benign evolution of the case and receive medication for the symptoms based on individual need. These patients should be required to return after 7 days for a follow-up ultrasound and definitive discharge of the case if no imaging abnormalities are found and there are no new complaints. In cases of hemodynamic

#### **Figure 6.**

*Renal arteriography, 2 hours after percutaneous native kidney biopsy. (A) Pre-embolization arteriography revealed pseudoaneurysm in a lower renal pole (yellow arrow). (B) Post-embolization superselective arteriography revealed absence of pseudoaneurysm with preservation of the local vasculature (yellow arrow).*

#### **Figure 7.**

*Endovascular embolization. (A) A catheter is inserted into femoral artery, by the groin area to access vessels of the kidney and into vascular rupture site. (B) Rupture in arterial blood vessel, which will receive a catheter and embolization material to achieve occlusion.*

instability, the patient should receive adequate clinical measures at an intensive care unit, followed by an angiographic study. Digital angiography remains the gold standard for the anatomic study of the renal arteries, but computed tomography angiography (angiotomography) has gained popularity, offering comparable accuracy and the advantage of evaluating not only the lumen, but its walls and other visceral changes [32].

**47**

**3. Conclusion**

ment associated with this.

**Acknowledgements**

**Conflict of interest**

*Post-Biopsy Complications Associated with Percutaneous Kidney Biopsy*

After renal vascular mapping and if signs of active bleeding are identified (active escape of contrast medium, pseudoaneurysms, or arteriovenous fistulas), endovascular treatment is indicated, which is a minimally invasive procedure that should be performed by an interventionist radiologist or professional who is duly trained and certified in endovascular techniques (**Figure 6**). The procedure can be performed through femoral or radial artery access, always initiated with an anatomic study of the renal arteries and respective variations. When a probable focal hemorrhage is identified, superselective arteriography is performed in a coaxial system with a microcatheter and microguide, followed by superselective embolization techniques performed on the compromised vessel. For interventional treatment, the selection of appropriate embolic agents for superselective embolization is the key to achieving desirable outcomes (**Figure 7**). Embolic agents include PVA particles, coils, and gelatin sponge strips, which can be used either alone or in combination [33]. The de-vascularized area will suffer infarction, which could cause a momentary change in renal function. Thus, more selective catheterism leads to a lower risk of this complication. Pseudoaneurysms are pulsating masses at puncture sites due to the rupture of the arterial wall and extravasation of blood, generally associated with local pain and hematoma. Hemodynamic instability and a drop in hemoglobin concentration may be related to the rupture of pseudoaneurysms. The treatment for pseudoaneurysms and arteriovenous fistulas is recommended for persistent bleeding for more than 72 hours or in cases of the accentuated loss of kidney function after the procedure. It should be stressed that most pseudoaneurysms less than 2.0 cm and arteriovenous fistulas progress with thrombosis and spontaneous resolution within 4 weeks, making conservative treatment the conduct of choice in cases without hemodynamic instability. Patients should remain in intensive care for at least 24 hours after the procedure and a follow-up imaging method should be

performed prior to the decision regarding the discharge of these patients.

Imaging-guided renal biopsy is a useful tool for the evaluation and management of renal diseases. This chapter summarizes that percutaneous ultrasound-guided renal biopsy is a safe technique which allows the evaluation of renal disease but is associated with post-biopsy complications. We discuss indications and approach to imaging-guided percutaneous renal biopsies as well as complications and manage-

We thank Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte,

Hospital Santa Casa de Belo Horizonte, Brazil and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil.

The authors declare no conflict of interest.

*DOI: http://dx.doi.org/10.5772/intechopen.89226*

#### *Post-Biopsy Complications Associated with Percutaneous Kidney Biopsy DOI: http://dx.doi.org/10.5772/intechopen.89226*

After renal vascular mapping and if signs of active bleeding are identified (active escape of contrast medium, pseudoaneurysms, or arteriovenous fistulas), endovascular treatment is indicated, which is a minimally invasive procedure that should be performed by an interventionist radiologist or professional who is duly trained and certified in endovascular techniques (**Figure 6**). The procedure can be performed through femoral or radial artery access, always initiated with an anatomic study of the renal arteries and respective variations. When a probable focal hemorrhage is identified, superselective arteriography is performed in a coaxial system with a microcatheter and microguide, followed by superselective embolization techniques performed on the compromised vessel. For interventional treatment, the selection of appropriate embolic agents for superselective embolization is the key to achieving desirable outcomes (**Figure 7**). Embolic agents include PVA particles, coils, and gelatin sponge strips, which can be used either alone or in combination [33]. The de-vascularized area will suffer infarction, which could cause a momentary change in renal function. Thus, more selective catheterism leads to a lower risk of this complication. Pseudoaneurysms are pulsating masses at puncture sites due to the rupture of the arterial wall and extravasation of blood, generally associated with local pain and hematoma. Hemodynamic instability and a drop in hemoglobin concentration may be related to the rupture of pseudoaneurysms. The treatment for pseudoaneurysms and arteriovenous fistulas is recommended for persistent bleeding for more than 72 hours or in cases of the accentuated loss of kidney function after the procedure. It should be stressed that most pseudoaneurysms less than 2.0 cm and arteriovenous fistulas progress with thrombosis and spontaneous resolution within 4 weeks, making conservative treatment the conduct of choice in cases without hemodynamic instability. Patients should remain in intensive care for at least 24 hours after the procedure and a follow-up imaging method should be performed prior to the decision regarding the discharge of these patients.
