Thread by @ERAEDTA

⏳for another #tweetorialERA 🥳 @HDiniz_

➡️Native kidney biopsy plays a crucial role in the diagnosis of many conditions and, while generally safe, can be associated with bleeding complications.

Would you biopsy a patient with aspirin exposure?🤔

Bleeding complication rates are low, with less than 2% of patients requiring transfusion and less than 0.5% requiring an intervention to control the bleeding.

⚠️These complication rates are higher in hospitalized patients and those with AKI.

cjasn.asnjournals.org/content/15/11/…

But not every patient has the same risk of bleeding 🩸

Risk factors include anemia, thrombocytopenia, frailty index, obesity, comorbidities, and kidney function.

cjasn.asnjournals.org/content/15/11/…

Aspirin is one of the most widely used antiplatelet drugs worldwide - approx. 40.000 tones are produced annually worldwide. 😮

➡️Historically aspirin exposure has been considered a contraindication for percutaneous kidney biopsy.

aspirin-foundation.com/history/

@SIRspecialists recommendation is to withhold the drug for at least five days before the biopsy, but this is far from consensual and based on expert opinion.

jvir.org/article/S1051-…

Our own @jennifer_s_lees analyzed 2563 biopsies - 327 reported aspirin use.

⚠️No association was found between aspirin use and major bleeding but there was an increased risk for major bleeding in indication biopsies vs elective procedures.

academic.oup.com/ckj/article/10…

In another @NDTsocial study, 1120 biopsies were retrospectively analyzed - 75 patients were kept on aspirin.

⚠️The risk of Hb drop > 1g/dL was significantly higher but there was no association between aspirin use and major bleeding.

academic.oup.com/ndt/article/23…

Aspirin use within 3 days of the biopsy is associated with an increased bleeding risk, mainly with high doses (325 mg).

⚠️Aspirin use on the day of the biopsy is the most important factor for bleeding complications (OR 12,4 p-value < 0,001).

pubmed.ncbi.nlm.nih.gov/30995091/

➡️But if aspirin use poses a risk factor for bleeding, even if it is small, one could argue for mandatory preprocedural withdrawal 🤔

However, the decision to stop aspirin is not risk-free. ⚖️

⚠️Aspirin withdrawal may precede up to 10,2% of acute cardiovascular syndromes, including acute coronary syndromes, acute cerebrovascular events, and acute peripheral arterial syndromes.

pubmed.ncbi.nlm.nih.gov/15836656/

This is partly explained by rebound phenomena, where prothrombogenic forces (such as thromboxane synthesis) are bolstered after aspirin discontinuation.🫀

The benefit of minimizing bleeding complications must be weighed against the increased CV risk.⚖️

pubmed.ncbi.nlm.nih.gov/1825534/

Real-world data from @scotrenalbiopsy was presented in #ERAEDTA20 by @mcq_emily showing that it is safe to continue aspirin.

Also, there is an x3 increase risk of thrombosis in ~10 days if the aspirin is stopped 🤯

https://twitter.com/ERAEDTA/status/1270014236589162497?s=20

💡Also, the #KHACARI guidelines recommend stopping aspirin at least 3 days before in low CV risk patients and continuing aspirin in high CV risk patients.

onlinelibrary.wiley.com/doi/full/10.11…

So what should we do?

#Individualize ⚖️

In patients with high cardiovascular risk, in whom the risks of suspending aspirin therapy outweigh the increase in bleeding risk, a kidney biopsy may still be performed safely, especially if it is an elective procedure.👍

A special thanks to @mic21892, who helped with the literature review and to the whole @eraedta #SoMe team.

Thank you for your time and we hope this will help you make better clinical decisions in the future😉
#tweetorial #tweetorialERA #medtwitter