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)

CCCF 2012 11

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