Management of post-renal biopsy pseudoaneurysm and rapidly progressive renal failure in a patient with IgA nephropathy

Thanga Durai1*, Shalini H S2, Vijayakumari. D3

1In charge, Department of Nephrology Kauvery Hospital, Electronic city, Bangalore

2Chief Nursing Officer, Kauvery Hospital, Electronic city, Bangalore

3Nurse Educator, Kauvery Hospital, Electronic city, Bangalore

*Correspondence

Introduction

Rapidly progressive renal failure (RPRF) necessitates urgent diagnostic evaluation, often through a renal biopsy, to guide immunosuppressive therapy. While generally safe, percutaneous renal biopsy carries risks of vascular complications, including the formation of pseudoaneurysms. This case report details the management of a young male presenting with severe renal derangement who developed a life-threatening post-biopsy bleed requiring emergency arterial embolization.

Case presentation

A 24-year-old male with a history of young-onset hypertension presented to the emergency department with a two-week history of nausea, tiredness, and one week of fever. He reported two episodes of vomiting and constipation for three days. Clinical examination on arrival revealed a blood pressure of 165/100 mmHg, a pulse of 89 bpm, and a GRBS of 107 mg/Hg. The patient was conscious and oriented, with bilateral air entry in the lungs and normal S1/S2 heart sounds. His initial lab results from an outside centre on 13 October 2025 showed severely deranged renal parameters: creatinine of 17.21 mg/dl and potassium of 7.4 mmol/L. He was admitted to the ICU on 14 October 2025 for emergency management of metabolic acidosis and hyperkalaemia.

 Investigations

  • Imaging: USG of the abdomen and pelvis revealed grade III renal parenchymal changes, mild splenomegaly, and ascites.
  • Laboratory Workup: Urine analysis showed 3+ albumin. A serological workup, including C3, C4, C-ANCA, P-ANCA, anti-GBM, and ANA profile, returned normal results.
  • Histopathology: A renal biopsy was eventually performed, revealing IgA Nephropathy with diffuse mesangial and endocapillary proliferative glomerulonephritis, focal sclerosis (collapsing variant), solitary crescent, moderate IFTA (<50%), and vascular form TMA.
  • Post-Biopsy Imaging: A CT KUB (Plain) and subsequent CT angiogram identified a large acute subcapsular and lower perinephric haematoma extending to the flanks and pelvis, with active contrast extravasation and two small pseudoaneurysms from the inferior polar segmental arteries of the left kidney.

Pre-operative Nursing Care

  • Informed Consent: Obtaining and verifying informed consent from the patient and attenders for biopsy and subsequent emergency procedures.
  • Vitals Stabilisation: Continuous monitoring of blood pressure and heart rate, particularly given the patient’s resistant hypertension.
  • Access Management: Ensuring patency of the right IJV HD 3-lumen catheter inserted for dialysis.
  • Haemodynamic Preparation: Crossmatching and preparing blood products due to normocytic normochromic anaemia (Hb 9.7 g/dl).

Surgical Management / Procedure

  • Haemodialysis Access (14/10/2025): Insertion of a Right IJV temporary HD catheter under aseptic precautions for emergency dialysis.
  • Renal Biopsy (17/10/2025): After BP optimisation, a USG-guided renal biopsy was performed; one core of tissue was obtained from the lower pole.
  • Renal Artery Embolization (17/10/2025): Following post-biopsy instability, the patient was shifted to the Cath lab. Digital Subtraction Angiography (DSA) confirmed pseudoaneurysms in the left kidney, and successful embolization of the renal artery branch was performed.
  • Tunnelled Catheter Insertion (24/10/2025): A Right IJV tunnelled cuffed catheter was inserted under USG guidance for long-term dialysis access.

Post-operative Course

Immediately following the biopsy, the patient experienced an episode of hypotension and bradycardia after attempting to void urine. He was resuscitated and moved to the MICU. The patient received a total of three units of leucodepleted, irradiated PRBC throughout his stay to manage anaemia and blood loss. He was maintained on a nitro-glycerine (NTG) infusion for blood pressure control and received pulse steroid injections (Methylprednisolone) followed by oral steroids (0.5 mg/kg).

Post-operative Nursing Care

  • Strict Bed Rest: Enforcing absolute bed rest post-biopsy to prevent haematoma expansion.
  • Serial Monitoring: Frequent checks of vitals, GRBS, and haematoma size via USG and CT.
  • Catheter Care: Maintaining the hygiene and patency of the tunnelled HD catheter; checking for soakage or redness.
  • Medication Administration: Ensuring timely delivery of a complex multi-drug antihypertensive regimen including Nicardia, Arkamin, Telmisartan, Prazopress, and Lonitab.
  • Activity Restriction: Instructing the patient to avoid lifting heavy weights, strenuous exercise, or bike rides for two weeks.

Outcome & Follow-Up

The patient was discharged on 25 October 2025 in stable condition. At discharge, his creatinine was 8.0 mg/dl and haemoglobin were 9.4 g/dl. He was advised to continue thrice-weekly haemodialysis (Mon/Wed/Fri) and follow a strict diet of 750ml–800ml fluid per day, low salt (<4g/day), and no red meat.

Discussion

This report highlights the challenges of managing RPRF complicated by resistant hypertension and biopsy-induced vascular injury. The presence of the “collapsing variant” of focal sclerosis in IgA Nephropathy indicates a guarded prognosis. The development of pseudoaneurysms is a rare but severe complication where arterial walls are breached, creating a perfused sac contained by perirenal tissue. Rapid identification via CT angiogram and definitive treatment through angio-embolization are critical to preventing catastrophic haemorrhage.

Conclusion

Successful management of complex renal cases requires a multidisciplinary approach involving nephrology, interventional radiology, and specialized surgical nursing. Despite the vascular complication, prompt intervention allowed for the stabilisation of the patient and the initiation of a long-term dialysis and immunosuppressive plan.

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