Should renal insufficiency be a relative contraindication to bronchoscopic biopsy?

In 1977, Cunningham et al reported a 45% risk of hemorrhage in azotemic patients undergoing flexible bronchoscopy (FB) with biopsy. There have been no recent studies evaluating renal insufficiency as a relative contraindication to biopsy. We reviewed all charts of Bellevue Hospital bronchoscopies from October 1997 to October 2002 for blood urea nitrogen (BUN), creatinine (Cr), hemogram, and coagulation studies as well as the type of biopsy performed, pretreatment medications, and complications from the FB. Patients were included if they had a BUN ≥30 mg/dL and/or a Cr ≥2 mg/dL. Seventy-two patients met criteria. Twenty-five of 72 (35%) patients had bronchoscopic biopsy. Seven of 25 (28%) were hemodialysis (HD) patients and 18 of 25 (72%) were nondialysis (ND) patients. All HD patients received FB within 24 hours after HD and were given desmopressin (DDAVP) prebronchoscopy. One patient with coagulopathy also received platelets and fresh-frozen plasma. Six of 7 HD patients had forceps biopsy (BX) (BUN range 31-65; Cr range 5.2-18.7) and 1 had transbronchial needle aspiration (TBNA) (BUN 32; Cr 4.3). Twelve of 18 ND patients had BX (BUN 20-69; Cr 0.9-2.5), 4 had TBNA (BUN 20-62; Cr 1.1-4.5), and 2 had BX and TBNA (BUN 30-35; Cr 1.4-1.5). One of 25 (4%) ND patients had a major complication of massive bleeding that required intervention. One of 25 (4%) ND patients had minor bleeding. There were no complications in the HD group. These findings suggest a low complication rate of bleeding in patients undergoing biopsy during FB if screened for coagulation abnormalities and, if receiving HD, done after HD with prebronchoscopy DDAVP. Our hemorrhagic complication rate was much lower than that reported in 1977. These data advocate further studies to evaluate whether bronchoscopic biopsy should be considered a relative contraindication in patients with renal insufficiency.