#2543 Effect of desmopressin on post-kidney biopsy bleeding: a randomized, double-blind, placebo-controlled study

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Abstract Background and Aims Percutaneous ultrasound-guided kidney biopsies are the gold standard for diagnosing native and transplant kidney parenchymal diseases. Despite advancements in biopsy techniques, post-biopsy bleeding remains a concern. Desmopressin acetate, a selective V2 receptor agonist, has shown transient hemostatic benefits by increasing von Willebrand factor (VWF) and factor VIII levels. While desmopressin is proven effective in uremic bleeding, evidence in the context of kidney biopsies is conflicting. Few randomized controlled trials (RCTs) have addressed its role in reducing post-biopsy bleeding. This study evaluates the efficacy and safety of intranasal desmopressin in reducing bleeding risk in kidney biopsy patients with varying eGFR levels. Methods This double-blind, randomized, placebo-controlled trial was conducted between February 2020 and January 2023 at a tertiary nephrology center in India. Adults aged 18–65 years undergoing kidney biopsy for glomerular hematuria, proteinuria, or unexplained renal failure were included. Exclusions were coronary artery disease, CKD with small kidneys, congenital anomalies, coagulopathies, pregnancy, or refusal to consent. Dialysis patients were included if dialysis was performed ≥24 hours before biopsy without heparin. Patients were randomized (1:1) to desmopressin (300 µg intranasal) or placebo, stratified by eGFR >30 or ≤30 ml/min/1.73m². All biopsies were percutaneous, ultrasound-guided, and performed using automated biopsy devices. Blinding was maintained for participants, investigators, and nephrologists. Outcomes included bleeding incidence, hematoma formation, hemoglobin drop >1 g/dL, hypotension, gross hematuria, transfusion, or interventions. Factor VIII, VWF, and thromboelastography were assessed at baseline, 2 hours, and 4 hours post-intervention. Results Of 1,200 screened patients, 203 were randomized to desmopressin (n = 101) or placebo (n = 102). Baseline characteristics were comparable. Overall bleeding incidence was significantly lower in the desmopressin group (11.9%) than placebo (33.3%) (P = 0.0003), with a relative risk reduction of 64.4% (RR 0.356, 95% CI: 0.196–0.648). Hematomas were less frequent in the desmopressin group (11.9% vs. 30.4%, P = 0.001), with smaller mean hematoma sizes (2.12 cm vs. 3.51 cm, P = 0.01). Hemoglobin drops >1 g/dL were more common in desmopressin patients (30.7% vs. 17.6%, P = 0.03). Stratified analyses showed consistent bleeding reduction across eGFR categories. Desmopressin significantly increased VWF and factor VIII levels at 2 hours post-administration, but effects waned by 4 hours. Hyponatremia (28.7% vs. 5.8%, P < 0.001) and headaches (7.9% vs. 1.9%, P = 0.04) were more frequent in the desmopressin group. No serious adverse events occurred. Conclusions Desmopressin effectively reduced post-biopsy bleeding and hematomas, particularly in patients with reduced eGFR, with manageable side effects. The higher dose (300 µg) demonstrated superior efficacy, likely due to enhanced VWF and factor VIII levels. Safety analysis confirmed the transient nature of adverse effects, with no impact on major complications or tissue yield. This robust RCT adds to the limited evidence supporting desmopressin in reducing minor bleeding risks during kidney biopsies. Future research should focus on optimal dosing, long-term outcomes, and cost-effectiveness to establish desmopressin as a standard adjunct in kidney biopsies.

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