Question 4

a) List five patient factors associated with an increased risk of bleeding after a renal biopsy. (20% marks)

b) List three steps that may be taken prior to the procedure to reduce the risk of bleeding after a renal biopsy. (20% marks)

c) Outline three management strategies of major bleeding after a renal biopsy. Include the advantages and disadvantages of each approach. (60% marks)

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College answer

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a) Risk factors for bleeding after kidney biopsy include:

Modifiable risk factors  Non-modifiable risk factors
  • Coagulopathy
  • Thrombocytopenia
  • Anticoagulation or antiplatelet agents
  • Uraemia
  • Hypertension (SBP > 140 during the procedure)
  • Agitation, tachypnoea
    (i.e. moving target)
  • Obesity
  • Pregnancy
  • Age
  • Female sex
  • Aetiology of renal failure (autoimmune disease, amyloid, acute tubular necrosis)
  • Use of high dose steroids
  • Poor baseline renal function
    (i.e. smaller target)


Possible steps to reduce the risk of bleeding include:

  • Assess coagulation: ideally, with TEG or ROTEM
  • Withhold anticoagulation and antiplatelet agents
  • Administer DDAVP to control the uraemia-associated platelet dysfunction
  • Control BP during the procedure with a mixture of short-acting antihypertensives and adequate sedation
  • Use general anaesthetic or sedation to reduce patient movement during the procedure
  • Use ultrasound guidance


Three options are surgery, endovascular repair/embolisation, or conservative management.

  • Endovascular repair/embolisation:
    • Advantages:
      • Minimally invasive: can be tolerated by a reasonably awake patient, which means no need for a general anaesthetic
      • Stents and suchlike can be deployed via an endovascular approach, i.e. embolisation is not the only possible solution
      • Less blood loss than with an open approach
    • Disadvantages:
      • This bleeding needs to be arterial, or you will get nowhere.
      • There needs to be a significant rate of bleeding for it to be detectable as an extravasation of contrast
      • You do often end up embolising various useful structures (eg. kidney).
      • The bleeding may continue without your knowledge, i.e. it may not be immediately apparent from imaging
      • Interventional radiology services may not be available everywhere
      • Radiation and contrast exposure are necessary
  • Surgical control
    • Advantages:
      • Haemostasis is easier to confirm by direct vision
      • Repair of damaged vessels is possible, preserving the function of the kidney
      • Contrast is not required
      • Venous bleeding can be controlled in this manner
      • Allows the abdomen to be left open, preventing abdominal compartment syndrome
    • Disadvantages:
      • Highly invasive procedure, with nontrivial associated pain and potentially long recovery time
      • Requires a general anaesthetic
      • Requires trained surgical staff, i.e. also not available everywhere
      • More blood loss than IR procedure
  • Conservative management
    • Advantages:
      • No invasive procedures, no radiation or contrast, no complications of anaesthetic
      • Haematoma may tamponade itself and the bleeding will eventually stop
      • If the haematoma is caused by coagulopathy and antiplatelet effects, the bleeding should stop once these are corrected
      • No embolisation or ligation means no loss of organ perfusion and function 
    • Disadvantages:
      • This is the option with the highest transfusion and blood product requirement
      • Transfusion is itself not without risk
      • Tense haematoma may put pressure on surrounding structures, and the kidney may lose blood supply anyway
      • Abdominal compartment syndrome may develop
      • In a proportion of cases, this management strategy will fail, and open surgery or IR procedures will become necessary.


Palsson, Ragnar, et al. "Bleeding complications after percutaneous native kidney biopsy: results from the Boston kidney biopsy cohort." Kidney International Reports 5.4 (2020): 511-518.

Whittier, William L. "Complications of the percutaneous kidney biopsy." Advances in chronic kidney disease 19.3 (2012): 179-187.

Chan, Y. C., et al. "Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery?." International journal of clinical practice 62.10 (2008): 1604-1613.