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Transvenous Renal Biopsy of Critically Ill Patients

Safety and Diagnostic Yield

de Chambrun, Marc Pineton, MD, MSc1,2; Cluzel, Philippe, MD, PhD3; Brocheriou, Isabelle, MD, PhD4; Bréchot, Nicolas, MD, PhD1; Hékimian, Guillaume, MD1; Turki, Mohamed-Wafik, MD3; Franchineau, Guillaume, MD1; Rouvier, Philippe, MD4; Bourcier, Simon, MD1; Bureau, Côme, MD1; Nieszkowska, Ania, MD1; Le Guennec, Loïc, MD1; Mathian, Alexis, MD, PhD2; Amoura, Zahir, MD, MSc2; Schmidt, Matthieu, MD, PhD1; Combes, Alain, MD, PhD1; Luyt, Charles-Edouard, MD, PhD1

doi: 10.1097/CCM.0000000000003634
Clinical Investigations

Objectives: Transvenous renal biopsy is an alternative way to obtain kidney samples from patients with bleeding risk factors (e.g., antiplatelet therapy and anticoagulation or coagulation disorders). This study was undertaken to determine the safety and diagnostic yield of transvenous renal biopsy of critically ill patients.

Design: Monocenter, retrospective, observational cohort study.

Setting: A 26-bed French tertiary ICU.

Patients: All patients undergoing in-ICU transvenous renal biopsy between January 2002 and February 2018.

Interventions: None.

Measurements and Main Results: Eighty patients (male/female sex ratio, 0.95; mean ± SD age, 47.3 ± 18.3 yr) were included. A histologic diagnosis was obtained for 77 patients (96.3%), with acute tubular necrosis being the most frequent: 23 (29.9%). A potentially treatable cause was found for 47 patients (58.7%). The numbers of patients with 0, 1, 2, or 3 factors (i.e., antiplatelet therapy, thrombopenia [< 150 G/L], and preventive or curative anticoagulation) at the time of the biopsy were, respectively: seven (8.8%), 37 (46.2%), 31 (38.7%), and five (6.3%). Four (5%) and two (2.5%) patients, respectively, had renal hematoma and macroscopic hematuria; none required any specific treatment. Six patients (7.5%) died in-ICU, and 90-day mortality was 8 of 80 (10%). No death was related to transvenous renal biopsy, and median biopsy-to-death interval was 38 days (interquartile range, 19.7–86 d).

Conclusions: Based on this cohort of ICU patients with acute kidney injury, transvenous renal biopsy was safe and obtained a high diagnostic yield for these selected critically ill patients, even in the presence of multiple bleeding risk factors.

1Service de Médecine Intensive Réanimation, Institut de Cardiométabolisme et Nutrition (iCAN), Hôpital La Pitié–Salpêtrière, Sorbonne Université, Assistance Publique–Hôpitaux de Paris (APHP), Paris, France.

2Service de Médecine Interne 2, Institut E3M, Hôpital La Pitié–Salpêtrière, Sorbonne Université, APHP, Paris, France.

3Département d’imagerie cardiovasculaire, radiologie interventionnelle et thoracique, Hôpital La Pitié-Salpêtrière, Sorbonne Université, APHP, Paris, France.

4Service d’Anatomopathologie, Hôpital La Pitié–Salpêtrière, Sorbonne Université, APHP, Paris, France

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Luyt received funding from Bayer Healthcare, Merck Sharp and Dohme, and ThermoFischer Brahms. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: marc.pinetondechambrun@aphp.fr

Acute kidney injury (AKI) develops in 1 of 3 to 2 of 3 adult patients admitted to ICUs and strongly impacts patients’ prognoses (1–4). Although acute tubular necrosis (ATN), is one of the leading causes of in-ICU AKI, some patients have kidney disease that will require specific treatment to regress. For such patients, histologic examination remains the keystone for diagnosis and therapeutic management (5–7).

First described in the early 1990s (8–10), after adaptation of the transjugular liver-biopsy technique, transvenous renal biopsy (TVRB) is a way to obtain kidney samples when percutaneous renal biopsy (PCRB) is contraindicated (e.g., uncorrectable bleeding disorders, anticoagulation, antiplatelet therapies, need for combined organ biopsies). The TVRB technique was compared with PCRB in a large study on 800 noncritically ill patients and found to have similar diagnostic yield and safety (11).

TVRB use to investigate AKI in ICU patients has been poorly studied. The objectives of this study were to determine TVRB safety in critically ill patients and its diagnostic yield.

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MATERIALS AND METHODS

Patients

We retrospectively included patients from our 26-bed ICU who underwent TVRB between January 2002 and February 2018. Patients were not included if the TVRB had been obtained before ICU admission or after discharge. Since 2002, because of local TVRB availability and its safety, all ICU patients requiring a renal biopsy underwent TVRB, regardless of their PCRB contraindication(s). As TVRB is associated with a significant risk of adverse events, there were no criteria for systematic TVRB in our department. The indication for TVRB was retained after multidisciplinary discussion between intensivists and an external consultant (internal medicine or nephrology physician) weighting the benefit-risk ratio in every patient. Briefly, the main indications for TVRB were; suspicion of renal involvement of a systemic rheumatic disease, AKI of unknown origin, unresolving AKI in critically ill patients, suspicion of acute renal graft rejection, and evaluating the need for combined heart/kidney transplantation. Cardiovascular interventional radiologists from our Radiology Department, adjacent to the ICU, performed all TVRBs under fluoroscopy.

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TVRB

The TVRB protocol has been described previously (11). Briefly, the patient was placed in the supine position, with his/her head angled slightly away from the side to be punctured. The skin was cleaned, and local anesthetic was administered subcutaneously. The internal jugular vein was punctured, and a venous sheath was inserted over a guidewire. A catheter, filled with nonionic contrast medium was advanced into the inferior vena cava under fluoroscopic control. Renal venograms were obtained to choose the best-suited vein. The catheter was advanced into the right renal vein as distally as possible into a peripheral cortical vein in the lower pole of the kidney. Its position was checked by flushing it with a small amount of contrast medium. The position was deemed satisfactory when a wedge of cortical parenchyma was enhanced. The TVRB needle, attached to a 20 mL syringe filled with normal saline was advanced down the catheter. The needle was plunged into the renal parenchyma and removed in one continuous motion while maintaining suction with the syringe. The renal tissue sample was retained in the syringe and then expelled onto a sterile compress. Two kidney samples were routinely obtained for every patient, one for light microscopy and one for immunofluorescence. As part of the local protocol for TRVB, a renal ultrasound was performed in every patient the day following the procedure to detect a renal hematoma.

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Data Collection and Statistical Analyses

Standardized forms were used to collect the following information: epidemiologic variables, clinical manifestations, laboratory findings, in-ICU treatments, TVRB modalities and histologic findings, complications, and outcomes. Histopathologic diagnoses were reviewed by an expert in nephropathology. RBCs transfusion requirement was reviewed using “l’Etablissement Français du Sang” database. Results for categorical variables, expressed as n (%), were compared with chi-square tests; those for continuous variables, expressed as mean ± SD or median (25–75th percentile interquartile range), were compared using Student t test or Wilcoxon rank test. First, we conducted a descriptive analysis of the 80 patients’ clinical characteristics, laboratory findings, TVRB results, and complications. Then, we constructed a composite complication endpoint consisting of any one of the following complications: renal hematoma, macroscopic hematuria, transfusion days 1–3 post-TVRB, TVRB day-to-day +3 post-TVRB Sequential Organ Failure Assessment (SOFA) score increase greater than or equal to 1 point, or TVRB day-to-day +3 hemoglobin decrease less than or equal to –2 g/dL. Patients’ demographic, clinical, and laboratory characteristics were subjected to univariable analyses to identify associations with a composite complication endpoint. Thereafter, a multiple logistic regression model, including TVRB day SOFA score, vasopressor support, extracorporeal membrane oxygenation (ECMO), prothrombin time, and platelet count, and using backward-stepwise variable elimination, was run (with the variable exit threshold set at p > 0.10). All potential explanatory variables included in the multivariable analyses were subjected to collinearity analysis with a correlation matrix. In case of collinearity, both variables were not included altogether in the model. Statistical significance was defined as p value of less than 0.05. Analyses were computed with IBM SPSS Statistics v22.0 software (IBM Corp, Armonk, NY).

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Ethics

In accordance with the ethical standards of our hospital’s institutional review board, the Committee for the Protection of Human Subjects, informed consent was not obtained for demographic, physiologic, and hospital-outcome data analyses because this observational study did not modify existing diagnostic or therapeutic strategies. The database is registered at the “Commission Nationale de l’Informatique et des Libertés” (number 1950673).

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RESULTS

General Characteristics and Main Outcomes

Figure 1 reports the yearly number of TVRBs since 2002. Among the 10,887 admitted to our ICU during the study period, 80 (0.73%) underwent TVRB. Their characteristics are reported in Table 1. The male/female ratio was 0.95, with mean age at admission 47.3 ± 18.3 years. Twenty-four patients (30%) had preexisting renal disease, with median preadmission serum creatinine: 150 µmol/L (119–200 µmol/L) (n = 20) and four patients (5%) had end-stage renal disease (all four subsequently underwent kidney transplantation). Twenty-one patients (26.3%) underwent organ transplantation before or during this ICU stay (heart n = 13, combined heart/kidney n = 5, allogenic bone marrow transplant n = 2, and combined liver/kidney n = 1). Median pre-TVRB Simplified Acute Physiology Score (SAPS)–II was 42 (30–63); SOFA score was 8 (5–14). Fifty-two patients (65%) developed AKI, 30% with AKI on chronic kidney disease (CKD), and 5% had proteinuria without AKI. Median proteinuria was 2.5 g (1.35–4.36 g) of urine protein/g of urine creatinine, hematuria 93 (17–956) ×103 RBCs/mL, and serum creatinine 404 µmol/L (268–484 µmol/L). Six patients (7.5%) died in-ICU, and 90-day mortality was 10%. Among the 19 dialysis-dependent patients at ICU discharge, 15 had end-stage renal disease.

TABLE 1

TABLE 1

Figure 1

Figure 1

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TVRB Diagnostic Yield

Characteristics and diagnostic yield of the 80 patients’ TVRBs are reported in Table 2. For the TVRB, the puncture route was transjugular (right internal jugular vein) for 75 patients (93.8%) and transfemoral (femoral vein) for five (6.2%). The median ICU-admission-to-TVRB interval was 8.5 days (2–24 d). Renal cortex was obtained from 78 patients (97.5%) with a median of 14 (7–20) glomeruli. A histologic diagnosis was obtained for 77 patients (96.3%) with ATN being the most frequent: n = 23 (29.9%). Histologic diagnoses were distributed as follows: 29.9% ATN, 14.3% thrombotic microangiopathy, 13% lupus nephritis, 7.8% drug toxicity, 7.8% acute interstitial nephritis, 3.9% membranoproliferative glomerulonephritis, 3.9% antineutrophil cytoplasm antibody-associated vasculitis, 2.6% Goodpasture syndrome, 2.6% acute renal graft rejection, 2.6% diabetes, 2.6% hemosiderosis, and 1.3% hypertension. A potentially treatable cause was found for 47 patients (58.8%).

TABLE 2

TABLE 2

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Patients’ TVRB Day Characteristics

Patient’s clinical and biologic characteristics and bleeding risk factors are reported in Table 3. TVRB day organ-failure treatments were: 75% renal replacement therapy, 28.7% mechanical ventilation, 13.8% vasopressor support, 7.5% ECMO, 3.8% left ventricular assist device, and 1.3% total artificial heart. Preventive and curative anticoagulation on TVRB day were administered, respectively, to 42.5% and 31.3% of the patients and were transiently interrupted for 64.7% and 60% of the patients. Antiplatelet therapy (mainly aspirin) was given to 27.5% of the patients at the time of TVRB and interrupted for none. At the time of TVRB, the numbers of patients with platelet count less than 150 G/L, less than 100 Giga (G)/L, and less than 50 G/L, respectively, were 35 (43.8%), 17 (21.3%), and five (6.3%). Considering antiplatelet therapy, thrombopenia (< 150 G/L) and preventive or curative anticoagulation as bleeding risk factors, seven (8.8%), 37 (46.2%), 31 (38.7%), and five (6.3%) patients, respectively, had 0, 1, 2, or 3 bleeding risk factors at the time of TVRB.

TABLE 3

TABLE 3

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Complications and Factors Associated With Them

Complications, transfusions, and SOFA score or hemoglobin changes post-TVRB are reported in Table 4. Four (5%) and two (2.5%) patients, respectively, developed renal hematoma and macroscopic hematuria; none required any specific treatment. During days 1–3 post-TVRB, 28 patients (35%) required transfusions, mostly RBCs (median: two [2–2] packs). TVRB day and day-3 post-TVRB SOFA scores were, respectively, 6 (4–7.7) and 6 (4–7.2). The day-3 SOFA score varied for 56.1% of 66 patients: increasing for 12 (18.2%). No deaths were attributed to TVRB, and median TVRB-to-death interval was 38 days (19.7–86 d). Thirty-six patients (45%) had a composite complication endpoint. Univariable and multivariable analyses of factors associated with a composite complication endpoint post-TVRB are reported in Supplemental Tables 1 and2 (Supplemental Digital Content 1, http://links.lww.com/CCM/E333). Multivariable logistic-regression analyses retained vasopressor use at the time of TVRB (odds ratio [OR], 6.8; 95% CI, 1.2–37.4; p = 0.026) and platelet count on TVRB day less than 175 G/L (OR, 3.1; 95% CI, 1.1–8.7; p = 0.026) as independent predictors of a composite complication endpoint. There were no differences in term of diagnostic yield and complications when comparing TVRB performed less than or equal to 2012 (n = 38) or greater than 2012 (n = 42) (Supplemental Table 3, Supplemental Digital Content 1, http://links.lww.com/CCM/E333).

TABLE 4

TABLE 4

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Therapeutic Consequences of TVRB

TVRB and its histologic diagnoses (Supplemental Table 4, Supplemental Digital Content 1, http://links.lww.com/CCM/E333) led to treatment modifications: introduction for 18 patients (22.5%), discontinuation for 11 (13.8%), and continuation for 22 (27.5%). Immunosuppressants initiated during the ICU stay were: corticosteroids for 34 patients (42.5%), corticosteroid pulses for 23 (28.8%), plasmapheresis for 21 (26.3%), cyclophosphamide for 12 (15%), and rituximab for two (2.5%).

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ATN-Associated Factors

Univariable analyses identified the main following factors, associated with an in-ICU TVRB-based ATN diagnosis versus other diagnoses, respectively: age (53.8 ± 17.2 vs 44.7 ± 18 yr; p = 0.04), admission-to-TVRB interval (17 d [8–62 d] vs 5 d [2–17 d]; p = 0.003), admission-to-TVRB interval/in-ICU days (0.56 [0.37–0.83] vs 0.37 [0.17–0.6]; p = 0.028), ICU-admission cardiovascular SOFA score (13 [56.5%] vs 16 [28.1%]; p = 0.02), and any in-ICU vasopressor use (17 [73.9%] vs 27 [47.4%]; p = 0.046). There were no differences in terms of bleeding risk factors, complications, and outcomes between both groups (Supplemental Table 5, Supplemental Digital Content 1, http://links.lww.com/CCM/E333).

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Comparison Between Transplant and Nontransplant Patients

When comparing transplant versus nontransplant patients, univariable analyses identified the main following differences: admission-to-TVRB interval (32 d [12.5–62 d] vs 4 d [2–10 d]; p < 0.0001), admission-to-TVRB interval/in-ICU days (0.58 [0.43–0.7] vs 0.37 [0.18–0.6]; p = 0.02), any in-ICU vasopressor use (19 [90.5%] vs 25 [42.4%]; p < 0.0001), mechanical ventilation (19 [90.5%] vs 30 [50.8%]; p = 0.001) or ECMO support (14 [66.7%] vs 12 [20.3%]; p < 0.0001), the presence of two bleeding risk factors on TVRB day (13 [61.9%] vs 18 [30.5]; p = 0.01), and tendency toward more frequent composite complication endpoint (13 [61.9%] vs 23 [39%]; p = 0.08) (Supplemental Table 6, Supplemental Digital Content 1, http://links.lww.com/CCM/E333).

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DISCUSSION

AKI is a severe condition that dramatically impacts the prognosis of critically ill patients. ATN is the leading cause of kidney failure in ICU patients and usually does not require renal biopsy for its management. However, for some patients with another AKI etiology, obtaining a renal biopsy for histologic examination can be crucial for entity diagnosis and treatment. PCRB carries a nonnegligible risk for ICU patients because many of them have contraindication(s) to it (hemodynamic instability, coagulation disorders, anticoagulation, antiplatelet therapy). However, TVRB, as an alternative to conventional renal biopsy, has been poorly investigated in critically ill patients.

The authors of two earlier studies specifically reported on renal biopsy in 77 and 56 ICU patients, respectively, from 10 and five French ICUs over 10 years (12 , 13). All but one biopsy in each study had been obtained percutaneously. Our patients were similar to theirs in terms of initial disease severity, defined by SAPS II and SOFA scores, but differed by being younger (mean age 47.3 vs 62.3 and 60 yr), having more frequent preexisting CKD (30% vs 17% and 16%), being mixed medical and surgical patients requiring several mechanical cardiopulmonary supports and more having received organ transplants. Our patients’ in-ICU mortality (7.5% vs 22% and 23%) and dialysis-dependence at discharge (25.6% vs 55% and 43%) were less frequent, probably reflecting our center’s specificities (younger patients, high access to cardiopulmonary supports, and organ transplantation).

Herein, the number of diagnosis-contributive TVRBs and the median number of glomeruli were high and comparable to those of the PCRB studies. A specific diagnosis was obtained for 96% of the patients, most frequently ATN (29.9%), with a potentially treatable cause for ~ 60% of them. The frequency of ATN in our patients was concordant with the data from literature. Indeed, ATN was identified in 15 of 78 (19%) and 26 of 56 (46%) patients in the two previous study on kidney biopsy in ICU. Furthermore, in a postmortem renal biopsies study of critically ill children, ATN was the most frequent lesion (n = 19/62 [30.6%]) (14). One of the identified ATN-associated factors was the long admission-to-TVRB interval, independently of time spent in the ICU. Conversely, for patients with a treatable cause of AKI, admission-to-TVRB interval (4 d [2–17 d] vs 13 d [4–62 d]; p = 0.001) was significantly shorter and admission-to-biopsy interval/in-ICU days ratio was significantly lower (0.31 [0.16–0.61] vs 0.56 [0.41–0.81]; p = 0.002) (data not reported). Those findings suggest that TVRB is of particular interest early during the ICU stay, whereas, later during that stay, TVRBs from patients without recovery from AKI more frequently contained ATN lesions. Pertinently, even a diagnosis of ATN or chronic noninflammatory lesions can be determinant for the management of an ICU patient, as it can: prevent administration of deleterious inappropriate immunosuppressants, accelerate the start of chronic dialysis, help decide whether or not a combined transplantation is required.

As reported above, numerous patients’ TVRB histologic findings led to treatment changes. Even though the progress of noninvasive diagnostic tests (e.g., antineutrophil cytoplasm, anti-glomerular basement membrane, antinuclear, anti-DNA, a disintegrin and metalloprotease with thrombospondin type-I repeats-13 antibodies) allows treatment of systemic rheumatic disease without histologic proof, renal biopsy retains an important place in evaluating prognosis and determining appropriate treatment intensity. Therefore, assessment of the clinical impact of TVRB on the management of an ICU patient is difficult and should not be limited to the introduction, continuation or interruption of immunosuppressant(s).

The two previous studies provided little information about their patients’ coagulation disorders, anticoagulation or antiplatelet agent(s), which are contraindications for PCRB, and probably led to exclusion of patients receiving such treatments. Most of our patients had at least one bleeding risk factor(s) (91.3%), and 45% cumulated two or three. Anticoagulation was temporarily interrupted for a few hours to minimize the bleeding risk but many patients were biopsied under their full anticoagulation doses, sometimes combined with aspirin, because anticoagulation could not be safely stopped (left ventricular assist device, antiphospholipid syndrome). Despite those multiple bleeding risk factors, only six of our patients (7.5%) experienced a clinically significant TVRB complication, none requiring specific management or causing death. Conversely, 17 (22%) (12) and 7 (12.5%) (13) ICU patients who underwent PCRB experienced a complication, with two in each study requiring arterial embolization and one was fatal. Nevertheless, a significant number of our patient (35%) required a blood transfusion during the 3 days after TVRB. Even though, all transfusions were not necessarily linked to the procedure itself and could be associated with other factors (as being under ECMO).

Owing the retrospective nature of this work, to maximize the identification of TVRB-related complications, we constructed a composite complication endpoint comprising, during days 1–3 post-TVRB, any transfusion, or SOFA or hemoglobin changes. The objective of this composite score was to be in a “maximum bias hypothesis” in case some biopsy-related adverse events have gone unnoticed during the ICU stay. Although those endpoint items are frequent in unstable, critically ill patients, herein they were not necessarily linked to TVRB itself. Vasopressor use and low platelet counts, but not the number of bleeding risk factors, were independently associated with a composite complication endpoint. Pertinently, those factors should not, in our opinion, preclude TVRB if it is needed to improve patient management. Notably, TVRB complications in critically ill patients were infrequent and rarely serious, even in the presence of multiple bleeding risk factors.

When comparing transplant patients versus nontransplant patients, we found no differences in term of TVRB diagnostic yield. Although transplant patients had more frequent and severe circulatory failure, ATN frequency was similar between both groups. As transplant patients had more frequently two bleeding risk factor on TVRB day, there was a tendency toward more frequent composite complication endpoint, through a higher number of RBCs transfusions. Altogether, those results suggest that TRVB diagnostic yield is good in transplant patients but may be at the cost of higher RBCs transfusions.

Augusto et al obtained PCRBs from 8.4 of 10,000 patients admitted to the ICU during their study period, whereas our TVRB frequency was 73 of 10,000. This more extensive experience underscores TVRB safety in critically ill patients and highlights some unmet needs of ICU patients’ diagnoses based on PCRB histology.

Our study has several limitations. First, it is a single-center study with a retrospective design. Second, TVRB was the only biopsy technique used, as part of our local protocol, regardless of the presence or absence of contraindication(s). Third, the study population is very particular with young patients, high numbers of transplantees, connective tissue diseases, or vasculitides and patients receiving mechanical cardiopulmonary support. Fourth, there were no criteria for systematic TVRB in our ICU during the time of the study. The indication for TVRB was retained on a patient-basis after weighting the benefice-risk ratio during a multidisciplinary discussion. The population of our study is therefore highly selected, and the findings of our study may not be relevant for any ICU patient. Last, TVRB safety and efficacy in our center relies strongly on the remarkable dexterity and experience of our interventional radiologists, and those results may not be immediately reproducible in every center.

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CONCLUSIONS

TVRB use to investigate AKI in selected ICU patients was shown to be safe, with high diagnostic yields for in critically ill patients, even in the presence of multiple bleeding risk factors.

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REFERENCES

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Keywords:

acute kidney injury; acute tubular necrosis; critically ill; intensive care unit; transjugular renal biopsy; transvenous renal biopsy

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