UNDERUSE OF KIDNEY
BIOPSY IN ACUTE KIDNEY
INJURY IN THE ICU?
CLAUDE GUERIN MD PHD
RÉANIMATION MÉDICALE
HÔPITAL CROIX-ROUSSE
UNIVERSITÉ DE LYON
LYON, FRANCE
CCCF 2012 1
CCCF Toronto
October 31th 2012
DISCLOSURE
No conflict of interest
CCCF 2012 2
WHAT IS THE PROBLEM?
• Mortality in ICU-AKI high
• No intervention with proven benefits
• Sepsis first cause
• ATN hallmark
• KB rarely done
•Technical advances increase diagnostic yield and decrease complications
CCCF 2012 3
ATN IS CHALLENGED
Liano (Kidney International 1996)
• Seven hundred and forty-eight (748) ARF in Madrid
area
• Forty-six (46) KB done
• Four ATN identified
Langenberg (CC 2008)
• Six studies in sepsis-related AKI: 148 cases
• Two post-mortem
• Two studies reported only one AKI case in each
• Two studies: ATN 50% and 7%
CCCF 2012 4
ATN IS CHALLENGED
Lerolle (ICM 2009)
• Post-mortem KB in patients with AKI and
multiple organ failure from septic shock at
time of death
CCCF 2012 5
LEROLLE ICM 2009CCCF 2012 6
Intense glomerular
Infiltration by
neutrophils
Tubular epithelium vacuolization
Loss of brush border
Neutrophil apoptosis
LEROLLE ICM 2009
CCCF 2012 7
Epithelial cells apoptosis
Septic shock
(N° = 19)
ICU control
(N° = 9)Trauma (N° = 8)
N°tubules 1 707 1 043 424
N°nuclei 12 232 7 064 3 891
N°Apoptotic
bodies353 10 48
% Apoptotic
bodies2.9 ± 3.41* 0.17 ± 0.32 0.54 ± 0.43
N° TUNNEL
Positive
cells/photo
6.4 ± 6.6* 1.7 ± 1.2 ND
N° CASPASE 3
Positive
cells/photo
6.0 ± 2.6* 3.5 ± 1.7 ND
CCCF 2012 8
Lerolle ICM 2009
CCCF 2012 9
Osmotic nephrosis associated with use of
synthetic colloid fluid ressuscitation
HOW KIDNEY BIOPSY MAY
CONTRIBUTE TO
MANAGEMENT?
• Stopping not useful medication and/or introducing specific new drugs/therapies
• Steroids
• Immunosuppressive drugs
• Plasma exchange
• Setting long-term RRT decision
• End-of-life decision
CCCF 2012 10
HOW CAN KIDNEY BIOPSY BE
DONE IN ICU PATIENTS?
• Bedside or Radiology department
• Nephrologist, intensivist or radiologist
• Percutaneous or Transjugular or surgical
• Echo-guided or CT-guided
• Fine needle (16 or 18G)
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CT-GUIDED
CCCF 2012 12
CT scan-guided US-guided
Uppot AJR 2010
ECHO-GUIDED
CCCF 2012 13
Uppot AJR 2010
KIDNEY BIOPSY IN THE CRITICALLY ILL PATIENT, RESULTS OF A
MULTICENTRE RETROSPECTIVE CASE SERIES.
CAROLE PHILIPPONNET
CLAUDE GUÉRIN
EMMANUEL CANET
RENÉ ROBERT
CHRISTOPHE MARIAT
FRÉDÉRIQUE DIJOUD
ELIE AZOULAY
BERTRAND SOUWEINE
ANNE-ELISABETH HENG
MINERVA ANESTHESIOLOGICA IN PRESS
CCCF 2012 14
DATA ENTRY
Augusto Philiponnet
N° patients with KB 77 56
N° ICUs 10 5
Period 2000-2009 2000-2011
SAPSII 41 52
SOFA 7 8
Mechanical ventilation 70% 56%
Vasopressors 38% 29%
RRT 77% 55%
CCCF 2012 15
DATA ENTRY
Augusto Philiponnet
Previous CKD 17% 16%
AKIN 3 90% 61%
Etiological factor of AKI
Sepsis 37%
Shock 25%
Cardiac failure 7%
Contrast media 17%
Rhabdomyolysis 5%
Other nephrotoxic agent 31%
CCCF 2012 16
KB TECHNIQUE
Augusto Philiponnet
Kidney
Native N°
Tx N°
68 (88%)
9 (12%)
51 (91%)
5 (9%)
Operator
Nephrologist N° NA 23 (41%)
Intensivist N° NA 25 (45%)
Radiologist N° NA 8 (14%)
Technique
Percutaneous US-guided N° 67 (87%) 47 (84%)
Percutaneous CT-guided N° 5 (7%) 8 (14%)
Transjugular N° 1 (1%) 1 (2%)
Surgical N° 4 (5%) 0 (0%)
Setting
Bedside N° NA 47 (84%)
Operating room N° NA 0 (0%)
Radiology department N° NA 9 (16%)
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HISTOLOGICAL FINDINGS
CCCF 2012 18
Augusto (N° 77) Philiponnet (N° 56)
ATN N° 15 (19%) 26 (46%)
GN N° 19 (25%) 14 (25%)
Vascular nephritis N° 10 (13%) 11 (20%)
Interstitial nephritis N° 5 (6.5%) 6 (11%)
Deposit disease N° 2 (2.5%) 3 (5.5%)
Normal kidney N° 1 (1.3%) 0
Unspecified lesions N° 25 (42%) 0
CONTRIBUTION OF KB TO MANAGEMENT
CCCF 2012 19
Augusto
(N° 77)
Philiponnet
(N° 56)
Treatment introduction N° 17 (22%) 23 (41.5%)
Steroids N° 9 (12%) 13 (23%)
Cyclophosphamide N° 7 (9%) 6 (11%)
Plasma exchange N° 5 (6%) 8 (14%)
Rituximab N° 2 (3%) 2 (4.5%)
Antihypertensive N° 0 4 (9%)
Anti-infectious N° 0 1 (2.3%)
Treatment discontinuation N° 3 (4%) 9 (16.5%)
Steroids N° 2 (3%) 2 (4.5%)
Cyclophosphamide N° 0 2 (4.5%)
Plasma exchange N° 1 (1.5%) 3 (7%)
Anti-infectious N° 0 1 (2.3%)
Anticoagulation N° 0 1 (2.3%)
Vascular access for chronic dialysis N° NA 13 (23%)
End of life decision N° NA 4 (9%)
N° patients with contributive KB 14/68 (21%) 40 (71%)
CONTRIBUTION OF KB IN
END-OF-LIFE DECISION
CCCF 2012 20
Sex Age Comorbidities Histological diagnosis
Patient
1Male 57
Requiring definite
invasive mechanical
ventilation, NYHA heart
failure (Class IV),
Cirrhosis
Endocapillary GN +
diffuse IF/AT
Patient
2Female 39
HIV with cachexia,
diffuse Kaposi sarcoma,
multiple opportunistic
infections
Membranoproliferative
GN + diffuse IF/AT
Patient
3Female 79 Metastatic cancer Renal cortical necrosis
Patient
4Female 55
Vegetative state after
subarachnoid
hemorrhage
Focal and segmental
glomerulosclerosis +
diffuse IF
BLEEDING
Augusto Philiponnet
With KB N° 77 56
Bleeding N° 17 (22%) 7 (12.5%)
Patients with blood
transfusion N°
15 7
Embolization N° 2 2
Attribuable death N° 0 1*
CCCF 2012 21
* Despite embolization. Normal Coagulation blood tests before KB
KB OUTSIDE ICU
• Trend for KB in outpatients (MacMahon Am J Nephrol
2012)
• Risk factors for complications (Corapi AJKD 2012)
Meta-analysis
• 9474 KB (native) 1980-2011
• Rate of blood transfusions: 0,9% and macroscopic hematuria: 3.5%
• Risk factors for blood transfusions: • 14G needle
• Female
• Serum creatinine > 20 mg/l
• AKI
• SBP > 130 mmHg
• Age > 40 years
CCCF 2012 22
RECOMMENDATIONS FOR
PRATICE
• To not perform percutaneous KB if:
• Hypertension (> 160/95 mmHg)
• Coagulation abnormalities
• Single kidney
• Morphological problem (morbid obesity)
• To track bleeding risk factors (past
history, family history, medication)
• To obtain Informed consent
CCCF 2012 23Fish (CJASN 2010) Bollée et al. NDT 2011
RECOMMENDATIONS FOR
PRATICE
Before KB:
• Renal echography
• Blood group + antibodies
• Platelets counts, PTT, Quick test
• Timing to stop anticoagulation
KB
• Echo-guided
• Automatic spring-loaded gun
• Fine needle (14-18G)
• Analgesia
CCCF 2012 24Fish (CJASN 2010) Bollée et al. NDT 2011
RECOMMENDATIONS FOR
PRATICE
Samples and transport media
• One in alcohol-acetate-formol fixative for light microscopy
• One in Michel transport media for Immunofluorescence
• One in glutaraldehyde for electronic microscopy
After the KB
• Keep patient at rest for 12-24 hours
• Hemoglobin follow-up
• Echography follow-up
• Timing to (re)start anticoagulation
CCCF 2012 25Fish (CJASN 2010) Bollée et al. NDT 2011
KEY MESSAGES
KB may be underused in critically ill patients since it contributes in numerous cases to modifying patient’s treatment
Suggestions for carrying out KB in ICU patients:
(i) suspected systemic disease with renal involvement
(ii) AKI initially related to ATN with unexpected evolution (delay in renal recovery or development of new symptoms or biological abnormalities suggesting an associated cause of AKI requiring a specific treatment)
(iii) AKI patients with a progression suggesting development of unexpected ESRD
ICU patients undergoing KB must be carefully selected because of frequent complications although most adverse events are not considered severe
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CONCLUSIONS
• KB for AKI in ICU: benefits/risks ratio
• Level of evidence 4 (case series)
• Time for larger interventional investigations?
CCCF 2012 27