COMMENTARY Transjugular Kidney Biopsy diagnosis was made in 90.3% of biopsies with major bleeding as a Safe Method complications in 4.5%. Surpris- ingly, smaller biopsy needle size to Increase the Etiological was not associated with a lower Diagnosis in Kidney Disease rate of complications.3 Another study by Cluzel et al.4 compared Mónica Bolufer Cardona1, Maria José Soler Romeo1 and Gearoid 400 transjugular with 400 percu- M. McMahon2 taneous biopsies, concluding that 1 with both techniques, tissue cores Hospital Universitari Vall d’Hebron, Division of Nephrology Autonomous University of Barcelona, Barcelona, Spain; and 2Renal Division, Department of Medicine, Brigham and were adequate for histopathologic Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA diagnosis and the complications were similar. Halimi et al.6 studied a larger Kidney Int Rep (2021) 6, 2535–2536; https://doi.org/10.1016/j.ekir.2021.08.007 Copyright ª 2021, International Society of Nephrology. Published by Elsevier Inc. cohort of patients who underwent This is an open access article under the CC BY-NC-ND license (http:// TJRB (n ¼ 5305) from France. creativecommons.org/licenses/by-nc-nd/4.0/). When they compared their TJRB with 55,026 patients who received See Clinical Research on Page 2594 percutaneous kidney biopsy, they demonstrated that TJRB was enal biopsy is an essential native kidney biopsy performed R procedure for studying pa- for diagnostic and prognostic pur- associated with lower risk of ma- jor bleeding, especially in patients tients with kidney disease, being poses is normally safe; however, at high risk, as defined by “major of great importance in the diag- complication rates were higher in bleeding risk score” developed by nosis and treatment, and to deter- acute kidney disease and hospital- the same group from prior work mine the prognosis of a patient.1 ized patients. that includes parameters such as The percutaneous, ultrasound- the Charlson comorbidity index, guided kidney biopsy is the most The indications for transjugular renal biopsy (TJRB) have not been frailty index, anemia, thrombo- common technique used to obtain cytopenia, cancer, abnormal kidney tissue, but this is associated clearly defined, and it is usually used in specific clinical situations, kidney function, acute kidney with a relatively high risk of failure, glomerular disease, complications. A recent systematic such as morbid obesity, double vasculitis, and thrombotic review and meta-analysis of organ biopsy, solitary kidney, or microangiopathy.6 118,064 native kidney biopsies high bleeding risk (anticoagulants, In the current paper, Halimi cirrhosis, thrombocytopenia) found that biopsy was associated et al.6 divided the patients ac- with a number of complications, (Figure 1). Strategies for the iden- cording to the major bleeding risk including pain at the puncture site tification of patients who will score and studied the bleeding (4.3%), hematomas (11%), gross benefit from TJRB are of great in- risk in the different groups. They hematuria (3.5%), need for trans- terest. A recent paper by Bolufer found that in low-risk patients, fusion (1.6%), intervention to stop et al.1 found that TJRB is safe and the risk of bleeding was similar bleeding (0.3%), and death allowed for a histological diagnosis for transjugular versus percuta- (0.06%).2 Overall, this study in two-thirds of patients for whom neous biopsy (0.4% and 0.5%), demonstrated that percutaneous percutaneous ultrasound renal bi- whereas high-risk patients had opsy was contraindicated. Overall, lower risk of bleeding if a trans- despite the perceived elevated risk jugular biopsy was performed Correspondence: Mónica Bolufer Car- in this patient population, the (19.1% vs. 30.8%). In the multi- dona, Division of Nephrology, Hospital published literature suggests that Universitari Vall d’Hebron, Barcelona, variate analysis, transjugular bi- Spain. E-mail: bolufermonica@gmail. TJRB is in fact safe, with a good opsy was associated with a lower com; or Maria José Soler, Hospital Uni- diagnostic performance and few risk of bleeding. Similarly, the versitari Vall d’Hebron, Division of major complications.3,4 A review of presence of major bleeding was Nephrology Autonomous University of Bar- celona, Barcelona, Spain. E-mail: m.soler@ 17 retrospective articles published associated with a higher risk of vhebron.net on 1321 TJRBs found that a death in both transjugular and Kidney International Reports (2021) 6, 2535–2536 2535 COMMENTARY M Bolufer Cardona et al.: Transjugular Kidney Biopsy When we should think about performing a transjugular kidney biopsy: - High bleeding risk. - Thrombocytopenia. - Morbid obesity. - Double organ biopsy (liver, heart). - Horseshoe kidney. - Single kidney. Figure 1. When we should think about performing a transjugular kidney biopsy. percutaneous biopsy. This large Second, one of the most impor- DISCLOSURE retrospective study thus re- tant components of the risk score GM is a consultant for inforces the idea that TJRB is was the presence of anemia at the GlaxoSmithKline. MJS reports indicated in a patient with high time of the biopsy. However, personal fees from NovoNordisk, risk of bleeding, in whom the recent studies have shown that the Janssen, AstraZeneca, Fresenius, benefit seems clearer.1,6 However, magnitude of change in hemoglo- Mundipharma, Pfizer, Bayer, Vifor, it is important to note that the rate bin following a biopsy is not Esteve, and Eli Lilly, and grants and of TJRB appears to be higher in greater in patients with anemia at nonfinancial support from Boehringer, certain French institutions baseline and that, in fact, the outside the submitted work. MB (included in this study) than higher rate of transfusion is solely declared no competing interests. elsewhere, and familiarity with because the prebiopsy hemoglobin the technique may play an is lower,5 reinforcing the knowl- REFERENCES important role in decreasing the edge that anemia alone should not 1. Bolufer M, García-Carro C, Agraz I, rate of complications seen. be considered a significant risk et al. Biopsia renal transyugular. La There are a number of impor- factor for a hemorrhagic compli- alternativa a la biopsia percutánea en tant limitations of this study that cation post percutaneous renal pacientes de alto riesgo. Nefrología. 2020 Jul;S0211699520300801. may bias the results and reduce its biopsy.6 generalizability. First, because the Overall, despite these limita- 2. Poggio ED, McClelland RL, Blank KN, et al. Systematic review and meta- data were obtained from a national tions, this is an important addition analysis of native kidney biopsy registry, diagnoses were based on to the literature. Using a large complications. Clin J Am Soc Neph- International Classification of Dis- cohort of patients undergoing both rol. 2020;15:1595–1602. eases, 10th Revision codes rather percutaneous and TJRB, Halimi 3. St. Jeor JD, Reisenauer CJ, than chart review. This could et al.6 showed that TJRB is as safe Andrews JC, et al. Transjugular renal potentially overestimate the rate of as the percutaneous route, while biopsy bleeding risk and diagnostic bleeding associated with biopsies, generally providing enough tissue yield: a systematic review. J Vasc Interv Radiol. 2020;31:2106–2112. as all patients who had a trans- for diagnosis. They also found that 4. Cluzel P, Martinez F, Bellin MF, et al. fusion within a defined period the transjugular route is safer for Transjugular versus percutaneous following the biopsy were re- certain high-risk patients. Taken renal biopsy for the diagnosis of ported as having had a complica- together, this suggests that we can parenchymal disease: comparison of tion. This is supported by the fact safely use this technique in patient sampling effectiveness and complica- that the rate of transfusion was populations for whom a percuta- tions. Radiology. 2000;215:689–693. higher than in the recent pub- neous biopsy is relatively contra- 5. Whittier WL, Sayeed K, Korbet SM. lished literature, even in the indicated. Future research should Clinical factors influencing the deci- sion to transfuse after percutaneous lower-risk groups. Similarly, the focus on identifying patients who native kidney biopsy. Clin Kidney J. rate of hematoma was substantially would benefit most from this 2016;9:102–107. lower than would be expected, technique and developing algo- 6. Halimi JM, Gatault P, Longuet H, et al. suggesting that some complica- rithms to aid clinicians in deciding Major bleeding of transjugular active tions were not accurately which route to pursue in higher- kidney biopsies. Kidney Int Rep. recorded. risk individuals. 2021;6:2594–2603. 2536 Kidney International Reports (2021) 6, 2535–2536