A nomogram based on shear wave elastography for predicting hemorrhage complications after ultrasound-guided percutaneous renal biopsy

A nomogram based on shear wave elastography for predicting hemorrhage complications after ultrasound-guided percutaneous renal biopsy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A nomogram based on shear wave elastography for predicting hemorrhage complications after ultrasound-guided percutaneous renal biopsy Jiaxin Chen, qunyan wu, shuqing wang, songying pi, shushang zhang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4574625/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: To derive a simple risk score based on shear wave elastography (SWE) ultrasound to predict the individual risk of post-procedural hematoma complications in patients who underwent a percutaneous renal biopsy. Methods: A total of 221 patients who underwent ultrasound (US)-guided percutaneous renal biopsy at our institution between April 2019 and November 2023 were enrolled in our study and randomly divided into training (n=155) or validation (n=66) cohorts. After biopsy, ultrasound was employed to evaluate the hematoma, and the maximum diameter of the hematoma was recorded for analysis. A diagnostic nomogram incorporating the selected features was established using multivariable logistic regression analysis. Results: A total of 148 (67%) patients had postprocedure hematoma (106 and 42 patients in the training and validation cohorts, respectively), and the mean hematoma diameter was 31.12±15.01 mm (10–100 mm). The mean cortical SWE value was 42.87 kPa (21.40-69.30 kPa) for patients without hematoma and 40.18 kPa (14.90-64.50 kPa) for patients with hematoma (p=0.032). The established nomogram integrated the mean cortical swe value, triglyceride level and urinary protein level. The area under the receiver operator characteristic curve (AUC) was 0.82 in the training cohort and 0.61 in the validation cohort. Conclusions: The risk of postprocedural hematoma complication could be assessed by a simple risk score that integrated mean cortical SWE value, triglyceride and urinary protein levels. shear-wave elastography prediction renal biopsy nomogram postprocedural hematoma Figures Figure 1 Figure 2 Figure 3 Introduction Chronic kidney disease (CKD) is defined as renal structure and function disorders caused by various diseases including pathological damage, abnormal blood or urine composition, or imaging examination for more than 3 months[ 1 ]. The gold standard for diagnosis of CKD is pathological examination. Although ultrasound (US)-guided renal biopsy is relatively safe. There are still many complications include pain, hemorrhage and adjacent organ injury[ 2 , 3 ]. Hemorrhage is the primary complication of renal biopsy because the kidneys had rich blood supply. Approximately 10%-50% of cases had post-procedural hemorrhage and major complications including blood transfusion and arterial embolization for hemorrhage are estimated to occur in 0.3%-1.6% of biopsies[ 4 ]. Shear wave elastography (SWE), is a novel noninvasive ultrasound modality that can generate shear waves in the body, and calculate the elastic value of the tissue by measuring the propagation speed of the shear waves, thereby measuring tissue mechanical properties. It has received widespread attention and application in various tissues and organs such as liver, thyroid and breast nodule[ 5 ]. Previous studies have applied SWE to evaluate renal fibrosis and the result suggested that the SWE value is significantly lower in CKD patients with moderate-severe renal fibrosis than in those with mild fibrosis[ 6 , 7 ]. As is well known, with decreased of kidney function, the risk of bleeding increased. Certain risk factors have been associated with hemorrhage, including patient age, serum creatinine, ultrasound CKD features, hypertension, and biopsy needle size[ 2 , 3 ]. According to Mehmet's research, patients who had bleeding after the surgery had shear wave velocities that were noticeably lower than those who did not[ 8 ]. This is consistent with the above results, that is, the poorer the renal function, the higher the degree of fibrosis, and the lower the elasticity value. However, there are no nomograms that include the SWE value and clinical characteristics to evaluate the risk of post-procedural hemorrhage. This study aimed to create a nomogram for clinical usage and to retrospectively assess the viability of utilizing SWE prior to kidney biopsy for bleeding prediction. Methods Study population The protocol for the study was approved by the Institutional Ethics Committee of Fifth Affiliated Hospital of Sun Yat-sen University and followed the Helsinki Declaration. All participants provided written informed consent. All CKD patients who underwent renal biopsies and US examinations between April 2019 and November 2023 were enrolled. The inclusion criteria for patients were as follows: (1) diagnosed with CKD according to guidelines published by the Kidney Disease Improving Global Outcomes (KDIGO)[ 9 ]; (2) underwent right renal US examination and SWE examination prior to renal biopsy for no more than 24 h. The exclusion criteria for patients were as follows: (1) whose depth of SWE measurement was greater than 4 cm because of the poor repeatability of SWE[ 10 ]; (2) whose data were incomplete were excluded. The clinical characteristics (gender, age, and body mass index), comorbidities (diabetes, hypertension, and cardiovascular disease), and laboratory test results (hemoglobin, platelet count, blood urea nitrogen, serum creatinine, serum uric acid, serum albumin, urea to creatinine ratio and estimated glomerular filtration rate (eGFR)) were recorded for all participants. Instruments and methods Ultrasound examination Conventional US and SWE examinations were performed with a Supersonic Imagine Aixplorer ultrasound system (Aixen-Provence, France) equipped with an XC6-1 convex array probe with a frequency of 1–6 MHz. Our hospital performs right kidney puncture routinely, thus examination is performed on the right kidney. In supine position, kidney size (maximum length and width) and renal parenchymal/cortex thickness were measured. Then, the resistance index (RI) of the interlobar artery was calculated and recorded in Doppler ultrasound mode. For SWE examination, the size of the elastography sampling box was set to 4×3 cm, and the diameter of the ROI was set to 4 mm. The elastography scale was displayed in kPa, and the range was fixed from 0 to 80 kPa. All patients underwent 2D-SWE examination within 24 hour before renal biopsy. In prone position, SWE sampling box was placed in the middle part of the renal cortex and perpendicular to the surface of the kidney. Patients were required to hold their breath for 3–5 s and the images of the elastic color were captured. In the color imaging area, the circular ROI was fixed with a diameter of 4 mm. Then, the mean renal elastic modulus (unit: kPa) within the ROI and the measurement depth (the distance between the probe and ROI) were recorded. The detection was repeated 5 times, and the average of 5 measurements of mean SWE value was employed for analysis. Renal biopsy Patients were required to stop anticoagulant and antiplatelet agents three days prior to the biopsy. Percutaneous US-guided renal biopsy was performed at the lower pole of right kidney using a 16G needle (Bard Magnum, Covington, GA, USA). The operator has more than 10 years of experience and performed more than 500 renal biopsies. The specimens were divided into three parts and used for electron microscopy, fluorescence scanning, and immunohistochemical examination, respectively. Renal tissues were fixed in formalin, and sections were stained with hematoxin eosin, Masson’s trichrome, and periodic acid-Schif. Outcome definition After biopsy, ultrasound was employed to evaluate complications, including bleeding, hematoma or adjacent organ damage. If a hematoma was documented, the largest diameter was registered for this study(Fig. 1 ). A major complication was defined as any complication that required medical intervention, such as blood transfusion, arterial embolization or surgery even death. Statistical analysis Patients were randomized 7:3 to create “training” and “validation” cohorts. Patient characteristics are summarized as the means or frequencies. Qualitative variables are presented as numbers and percentages. Student’s t test was used for group comparisons of normally distributed continuous variables; otherwise, the Mann‒Whitney U test was applied. Categorical data were tested using chi-square tests. Stepwise multivariate logistic regression analysis was then performed to identify independent predictors of hemorrhage and to estimate individual odds ratios (ORs). The receiver operating characteristic (ROC) curve was plotted to evaluate the discrimination ability of the diagnostic nomogram, and the area under the curve (AUC) was calculated to quantify the diagnostic performance of the nomogram. The optimal cutoff point was determined by the Youden index, and the sensitivity, specificity, and accuracy were obtained. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) 26.0 statistical software for Windows (SPSS Inc, Chicago, IL, USA) and R software (version 4.3.3). A p value < 0.05 was considered significant for each statistical test. Results During the study period, there were 338 CKD patients underwent renal biopsy and SWE; however, 108 patients whose SWE depth was greater than 4 cm were excluded, and 9 patients whose data were incomplete were excluded. The final cohort consisted of 221 patients. All patients had sufficient samples to undergo pathological examinations. There were 155 patients in the training cohort and 66 patients in the validation cohort. The demographic, ultrasonographic and laboratory characteristics and p values of the two groups are summarized in Table 1 . Table 1 Demographic, laboratory and ultrasound characteristics Variable Training cohort(n = 155) Validation cohort(n = 66) Value of P Age (years) 40.58(14–74) 39.44(14–73) 0.608 Gender 0.895 Male 76 33 Female 79 33 Body mass index(kg/m 2 ) 22.47(14.95–29.90) 22.69(15.94–28.76) 0.614 Laboratory tests Serum creatinine (umol/L) 118.52(36.00−929.00) 95.60(36.80–350.00) 0.151 Serum uric acid (umol/L) 392.37(176–1019) 397.53(162.00−837.00) 0.760 Serum albumin (g/L) 32.88(11.00−48.40) 34.30(15.50–48.80) 0.311 eGFR (mL/min/1.73 m 2 ) 83.20(4.41−147.86) 91.00(14.29–154.00) 0.133 blood urea nitrogen (mmol/L) 6.74(2.40−32.51) 5.86(2.48–14.40) 0.101 urea-creatinine ratio 64.22(19.73−174.91) 66.97(32.00−116.00) 0.399 Hemoglobin (g/L) 126.89(62.00−181.00) 126.62(86.00−179.00) 0.934 Platelet (10 9 /L) 249.38(66.00−539.00) 254.07(116.00−376.00) 0.670 Triglyceride 1.66(0.17–6.63) 1.65(0.51–5.60) 0.923 Cholesterol 5.90(1.64–15.84) 5.48(2.36–14.21) 0.265 Ultrasound parameter Right kidney length (mm) 104.04(78.00−130.00) 105.86(91.20−127.30) 0.189 Right kidney width (mm) 44.56(28.60–71.00) 45.39(31.00–61.00) 0.386 Parenchymal thickness (mm) 15.90(10.00−169.00) 15.90(10.00−21.50) 0.990 cortical thickness(mm) 7.58(4.70–13.00) 7.81(5.00−12.20) 0.314 RI of the interlobar artery 0.64(0.47–0.89) 0.63(0.51–0.82) 0.296 Mean SWE value (kpa) 41.76(14.90–69.30) 39.46(23.90–54.30) 0.076 Puncture depth(mm) 39.25(20.00–73.00) 39.96(23.00–56.00) 0.582 Increased parenchymal echo 0.036 Yes 44 10 No 111 56 Comorbidity Diabetes Yes/No 17/138 7/59 0.937 Hypertension Yes/No 55/99 23/43 0.856 Cardiovascular disease Yes/No 13/142 3/63 0.404 In total, 148 (67%) patients had postprocedure hematoma (106 and 42 patients in the training and validation cohorts, respectively), and the mean hematoma diameter was 31.12 ± 15.01 mm (10–100 mm). No patient needed a blood transfusion arterial embolization or surgery, and no deaths occurred during the study period. Therefore, there were no major complications in our study period. Patients were divided into a group with hematoma and a group without hematoma. The mean cortical SWE value was 42.87 kPa (21.40–69.30 kPa) for patients without hematoma and 40.18 kPa (14.90–64.50 kPa) for patients with hematoma. Patients without hematoma had significantly higher SWE value than those with hematoma(p = 0.032). The multivariate logistic analysis and derived model are shown in Table 2 . The independent variables associated with post-procedural hematoma were the mean cortical SWE value and the triglyceride and urinary protein levels. Table 2 Multivariate predictors of post-hematoma complication (training cohort) Variable Model coefficient OR 95% CI P-value Mean Swe value −0.071 0.931 0.873–0.987 0.021 Triglyceride 0.978 2.660 1.416–5.899 0.006 Urinary protein −0.0001 0.999 0.998−1.000 0.016 The AUC of the model was 0.82 (95% confidence interval (CI): 0.75–0.89) in the training cohort and 0.61 (95% CI: 0.47–0.75) in the validation cohort (Fig. 2 ). A nomogram that incorporated the above independent predictors was developed and presented (Fig. 3 ). The Akaike information criterion (AIC) value of the nomogram in the training cohort was 214.64. The sensitivities of the nomograms in the training and validation cohorts were 0.796 and 0.583, respectively. The specificity was 0.717 in the training cohort and 0.667 in the validation cohort. Discussion Kidney biopsy is an essential procedure for diagnosis and therapy as well as for scientific research on kidney diseases. Kidneys have rich blood perfusion, receiving 20% of cardiac output and only constituting < 1% of body mass at resting state[ 11 ]. Although ultrasound-guided renal biopsy is a relatively low risk operation[ 12 ], post-procedural hematoma can always be observed. In our study, the prevalence of postprocedural hematoma was 67%. The average diameter of the hematoma was 31.12 mm. A total of 19 patients (19/148, 12.8%) had a gross hematoma with a maximum diameter greater than 50 mm, and the largest hematoma was 100 mm. After local compression, there was no sign of active bleeding among these patients, and no further treatment, such as blood transfusion or surgery, was administered. In addition, in our hospital, CKD patients were administered vitamin K before renal biopsy and “hemocoagulase for injection” immediately after the procedure to prevent hematoma. Additionally, patients with a high risk of bleeding, such as high blood pressure exceed 160mmHg or coagulation disorders were rejected from biopsy. Therefore, there were no major complications during the study period. Reduced GFR, anemia, older age, high blood pressure, bleeding diathesis, small kidneys, CKD features in prebiopsy US, and larger needle size were known risk factors for bleeding in several previous investigations[ 2 , 3 , 13 – 15 ]. Our results showed that higher triglyceride and urinary protein levels were risk factors for post-procedural hematoma. Increased adiposity is independently associated with a decrease in the glomerular filtration rate[ 16 ] , and hyperlipidemia is also a risk factor for nephrotic syndrome. The greater the urinary protein is, the more severe the damage to renal tubule function. Hence, increased triglycerides and urinary protein may increase the risk of post-procedural hematoma. However, we did not find a statistically significant correlation between hemorrhage after biopsy and risk factors for bleeding, as shown in previous studies. The reason may be following: as is well known, operator experience, biopsy needle size and the number of biopsies may has an impact on the risk of bleeding. In our study, renal biopsies were made by an operator who had more than 10 years of experience in ultrasound intervention. The needle size and number of biopsies were the same in all patients. Besides, most of patients (161/221, 72.8%) enrolled in our study were CKD 1–2 stage and had mild damage to renal function. Also, there was no obvious atrophy of the kidney among most of patients in our study cohort. One mechanism in the development of chronic kidney disease (CKD) that may worsen renal function is fibrosis[ 17 ]. With the decline in renal function, the degree of fibrosis and risk of post hematoma will rise. SWE is a novel technique for assessing renal fibrosis. There are several studies on the relationship between elastography and renal pathological alterations or fibrosis[ 7 ]. Our previous studies revealed that SWE value decreased as the pathological grade of renal fibrosis progressed. The SWE value may be affected by not only the degree of renal fibrosis but also the blood supply of kidney[ 6 , 18 ]. In this study, statistical analysis revealed that a lower SWE value was a risk factor for post-procedural hematoma. This finding is consistent with the result of Mehmet, who reported that a lower renal cortical shear wave velocity is associated with a tendency toward hemorrhage[ 8 ]. Therefore, the lower the renal elasticity value, the higher the degree of fibrosis and the risk of postbiopsy hemorrhage. Also, we incorporated three risk factors derived from multivariate logistic analysis and establish a nomogram for clinical usage. There are several limitations in our study. First, the sample size was small, and there were no major complications. Second, this was a retrospective study. Third, previous studies have reported that renal stiffness was affected not only by the degree of renal fibrosis but also by renal blood perfusion, vascular pressure and urinary flow pressure[ 19 – 21 ]. More studies should be carried out to verified the relation between elastography and postprocedural hematoma. Conclusions In conclusion, US-guided renal biopsy is a safe procedure. Factors associated with an increased risk of postprocedure hematoma included lower cortical swe value and higher triglyceride and urinary protein levels. The application of shear wave elastography in CKD patients is useful for identifying patients at high risk of post-procedural hematoma. Declarations Ethics approval and consent to participate The protocol for the study was approved by the Institutional Ethics Committee of Fifth Affiliated Hospital of Sun Yat-sen University and followed the Helsinki Declaration. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Authors' contributions Jiaxin Chen and Zhongzhen Su designed the study. Qunyan Wu, Shuqing Wang and Songying Pi collected the data. Shushang Zhang, Jianzhong Xian and Wuzhu Lu performed the ultrasound examination during the study. Jiaxin Chen wrote the first draft of the manuscript. Jiaxin Chen，Yuhong Lin and Zhongzhen Su revised the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Kalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. Lancet 2021 , 398(10302): 786-802. Mejia-Vilet JM, Marquez-Martinez MA, Cordova-Sanchez BM, Ibarguengoitia MC, Correa-Rotter R, Morales-Buenrostro LE. Simple risk score for prediction of haemorrhagic complications after a percutaneous renal biopsy. Nephrology (Carlton) 2018 , 23(6): 523-529. Monahan H, Gunderson T, Greene E, Schmit G, Atwell T, Schmitz J. Risk factors associated with significant bleeding events after ultrasound-guided percutaneous native renal biopsies: a review of 2204 cases. Abdom Radiol (NY) 2019 , 44(6): 2316-2322. Poggio ED, Mcclelland RL, Blank KN, Hansen S, Bansal S, Bomback AS, Canetta PA, Khairallah P, Kiryluk K, Lecker SH, Mcmahon GM, Palevsky PM, Parikh S, Rosas SE, Tuttle K, Vazquez MA, Vijayan A, Rovin BH. Systematic review and meta-analysis of native kidney biopsy complications. Clin J Am Soc Nephrol 2020 , 15(11): 1595-1602. Sigrist R, Liau J, Kaffas AE, Chammas MC, Willmann JK. Ultrasound elastography: review of techniques and clinical applications. Theranostics 2017 , 7(5): 1303-1329. Chen Z, Chen J, Chen H, Su Z. A nomogram based on shear wave elastography for assessment of renal fibrosis in patients with chronic kidney disease. J Nephrol 2023 , 36(3): 719-729. Cao H, Ke B, Lin F, Xue Y, Fang X. Shear wave elastography for assessment of biopsy-proven renal fibrosis: a systematic review and meta-analysis. Ultrasound Med Biol 2023 , 49(5): 1037-1048. Cildag MB, Gok M, Abdullayev O. Pre-procedural shear wave elastography on prediction of hemorrhage after percutaneous real-time ultrasound-guided renal biopsy. Radiol Med 2020 , 125(8): 784-789. Kdigo 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int 2024 , 105(4S): S117-S314. Lin Y, Chen J, Huang Y, Lin Y, Su Z. A methodological study of 2d shear wave elastography for noninvasive quantitative assessment of renal fibrosis in patients with chronic kidney disease. Abdom Radiol (NY) 2023 , 48(3): 987-998. Edwards A, Kurtcuoglu V. Renal blood flow and oxygenation. Pflugers Arch 2022 , 474(8): 759-770. Prasad N, Kumar S, Manjunath R, Bhadauria D, Kaul A, Sharma RK, Gupta A, Lal H, Jain M, Agrawal V. Real-time ultrasound-guided percutaneous renal biopsy with needle guide by nephrologists decreases post-biopsy complications. Clin Kidney J 2015 , 8(2): 151-156. Ding JJ, Lin SH, Huang JL, Wu TW, Hsia SH, Lin JJ, Chou YC, Tseng MH. Risk factors for complications of percutaneous ultrasound-guided renal biopsy in children. Pediatr Nephrol 2020 , 35(2): 271-278. Korbet SM, Volpini KC, Whittier WL. Percutaneous renal biopsy of native kidneys: a single-center experience of 1,055 biopsies. Am J Nephrol 2014 , 39(2): 153-162. Corapi KM, Chen JL, Balk EM, Gordon CE. Bleeding complications of native kidney biopsy: a systematic review and meta-analysis. Am J Kidney Dis 2012 , 60(1): 62-73. Chang AR, Grams ME, Ballew SH, Bilo H, Correa A, Evans M, Gutierrez OM, Hosseinpanah F, Iseki K, Kenealy T, Klein B, Kronenberg F, Lee BJ, Li Y, Miura K, Navaneethan SD, Roderick PJ, Valdivielso JM, Visseren F, Zhang L, Gansevoort RT, Hallan SI, Levey AS, Matsushita K, Shalev V, Woodward M. Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium. BMJ 2019 , 364: k5301. Panizo S, Martinez-Arias L, Alonso-Montes C, Cannata P, Martin-Carro B, Fernandez-Martin JL, Naves-Diaz M, Carrillo-Lopez N, Cannata-Andia JB. Fibrosis in chronic kidney disease: pathogenesis and consequences. Int J Mol Sci 2021 , 22(1). Chen Z, Chen J, Chen H, Su Z. Evaluation of renal fibrosis in patients with chronic kidney disease by shear wave elastography: a comparative analysis with pathological findings. Abdom Radiol (NY) 2022 , 47(2): 738-745. Gennisson JL, Grenier N, Combe C, Tanter M. Supersonic shear wave elastography of in vivo pig kidney: influence of blood pressure, urinary pressure and tissue anisotropy. Ultrasound Med Biol 2012 , 38(9): 1559-1567. Liu X, Li N, Xu T, Sun F, Li R, Gao Q, Chen L, Wen C. Effect of renal perfusion and structural heterogeneity on shear wave elastography of the kidney: an in vivo and ex vivo study. BMC Nephrol 2017 , 18(1): 265. Wu J, Li G, Liu J, Sun W, Liu J, Zou G, Lu H, Zheng M. Utility of shear wave-based ultrasound elastography in chronic kidney disease and related pathological quantitative analysis. Eur Radiol 2023 , 33(8): 5625-5633. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4574625","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":323924254,"identity":"3c92e6b1-01dd-4014-9fbf-a159bb55d04d","order_by":0,"name":"Jiaxin Chen","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Jiaxin","middleName":"","lastName":"Chen","suffix":""},{"id":323924255,"identity":"960d4068-d4c5-4d7b-bc82-2df1d3afdcb5","order_by":1,"name":"qunyan wu","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"qunyan","middleName":"","lastName":"wu","suffix":""},{"id":323924256,"identity":"1c227eae-b61b-42db-840f-8ffdafe5610b","order_by":2,"name":"shuqing wang","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"shuqing","middleName":"","lastName":"wang","suffix":""},{"id":323924257,"identity":"0085551e-53d9-4ed7-8dd2-15038c5e43db","order_by":3,"name":"songying pi","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"songying","middleName":"","lastName":"pi","suffix":""},{"id":323924258,"identity":"92e138ce-5352-4c52-8b4d-ab335d6903e5","order_by":4,"name":"shushang zhang","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"shushang","middleName":"","lastName":"zhang","suffix":""},{"id":323924259,"identity":"d849b6ad-08ee-44d9-af17-8ba117d826f8","order_by":5,"name":"jianzhong xian","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"jianzhong","middleName":"","lastName":"xian","suffix":""},{"id":323924260,"identity":"8b25914a-021b-4469-9556-39f4bbc062ed","order_by":6,"name":"wuzhu lu","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"wuzhu","middleName":"","lastName":"lu","suffix":""},{"id":323924261,"identity":"d68c6070-d85f-44e9-998d-c3758259f6be","order_by":7,"name":"yuhong lin","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"yuhong","middleName":"","lastName":"lin","suffix":""},{"id":323924262,"identity":"4eae86ad-5d1e-43bf-8bf0-de7628bca14e","order_by":8,"name":"Zhongzhen Su","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYFAC5sMPEn7Y8PCzNxCthS3N4GFPmoxkzwGitfAYSD5gO2xjcMOBSA3ys3sMDBJ4zvMw3GBg/PAxhwgtBneOFTxIsLjNwzi7gVly5jZitEgkbwDacpuHWeYAGzMvMVrkZyQYSCSwneNhA5LEaWG4kQLScoCHh2gtQL+kGST2JPNI8BxsJs4v8rObDz/88cPO3v5488EPH4lymAScxdhAjHoULaNgFIyCUTAKcAAAE5k2dpU1uPcAAAAASUVORK5CYII=","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Zhongzhen","middleName":"","lastName":"Su","suffix":""}],"badges":[],"createdAt":"2024-06-13 08:24:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4574625/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4574625/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60599840,"identity":"507ae09b-62c8-4aee-a338-a5be3f363899","added_by":"auto","created_at":"2024-07-18 16:00:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":109562,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Ultrasound-guided right renal biopsy; (B) Intraoperative ultrasound assessment showed active bleeding(arrow) in the puncture track; (C) Perirenal hematoma(arrow) with max diameter 100mm; (D) After local compression, there was no sign of active bleeding\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4574625/v1/23506e83c1d555ed32e3f6af.jpg"},{"id":60599839,"identity":"f8a9ef68-6c85-4072-b252-792fcf495240","added_by":"auto","created_at":"2024-07-18 16:00:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32496,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic (ROC) curves in the training and validation cohorts\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4574625/v1/06126e286ae5ea0d32b1af83.jpg"},{"id":60599838,"identity":"2b092fee-ca90-466a-840d-a3fa6551cfc1","added_by":"auto","created_at":"2024-07-18 16:00:13","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":48333,"visible":true,"origin":"","legend":"\u003cp\u003eDeveloped nomogram. The nomogram was developed in the training cohort, incorporating mean SWE value, triglyceride and urinary protein level\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4574625/v1/313bdbb3d0dc059706b45f83.jpg"},{"id":86647887,"identity":"340a4085-4fb3-4288-8249-de8ae907bc32","added_by":"auto","created_at":"2025-07-14 09:09:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":993797,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4574625/v1/448b8f74-debf-40c6-a385-17f4d8d57583.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A nomogram based on shear wave elastography for predicting hemorrhage complications after ultrasound-guided percutaneous renal biopsy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) is defined as renal structure and function disorders caused by various diseases including pathological damage, abnormal blood or urine composition, or imaging examination for more than 3 months[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The gold standard for diagnosis of CKD is pathological examination. Although ultrasound (US)-guided renal biopsy is relatively safe. There are still many complications include pain, hemorrhage and adjacent organ injury[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Hemorrhage is the primary complication of renal biopsy because the kidneys had rich blood supply. Approximately 10%-50% of cases had post-procedural hemorrhage and major complications including blood transfusion and arterial embolization for hemorrhage are estimated to occur in 0.3%-1.6% of biopsies[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eShear wave elastography (SWE), is a novel noninvasive ultrasound modality that can generate shear waves in the body, and calculate the elastic value of the tissue by measuring the propagation speed of the shear waves, thereby measuring tissue mechanical properties. It has received widespread attention and application in various tissues and organs such as liver, thyroid and breast nodule[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Previous studies have applied SWE to evaluate renal fibrosis and the result suggested that the SWE value is significantly lower in CKD patients with moderate-severe renal fibrosis than in those with mild fibrosis[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs is well known, with decreased of kidney function, the risk of bleeding increased. Certain risk factors have been associated with hemorrhage, including patient age, serum creatinine, ultrasound CKD features, hypertension, and biopsy needle size[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to Mehmet's research, patients who had bleeding after the surgery had shear wave velocities that were noticeably lower than those who did not[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This is consistent with the above results, that is, the poorer the renal function, the higher the degree of fibrosis, and the lower the elasticity value. However, there are no nomograms that include the SWE value and clinical characteristics to evaluate the risk of post-procedural hemorrhage. This study aimed to create a nomogram for clinical usage and to retrospectively assess the viability of utilizing SWE prior to kidney biopsy for bleeding prediction.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003e The protocol for the study was approved by the Institutional Ethics Committee of Fifth Affiliated Hospital of Sun Yat-sen University and followed the Helsinki Declaration. All participants provided written informed consent. All CKD patients who underwent renal biopsies and US examinations between April 2019 and November 2023 were enrolled. The inclusion criteria for patients were as follows: (1) diagnosed with CKD according to guidelines published by the Kidney Disease Improving Global Outcomes (KDIGO)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; (2) underwent right renal US examination and SWE examination prior to renal biopsy for no more than 24 h. The exclusion criteria for patients were as follows: (1) whose depth of SWE measurement was greater than 4 cm because of the poor repeatability of SWE[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; (2) whose data were incomplete were excluded.\u003c/p\u003e \u003cp\u003eThe clinical characteristics (gender, age, and body mass index), comorbidities (diabetes, hypertension, and cardiovascular disease), and laboratory test results (hemoglobin, platelet count, blood urea nitrogen, serum creatinine, serum uric acid, serum albumin, urea to creatinine ratio and estimated glomerular filtration rate (eGFR)) were recorded for all participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInstruments and methods\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eUltrasound examination\u003c/h2\u003e \u003cp\u003eConventional US and SWE examinations were performed with a Supersonic Imagine Aixplorer ultrasound system (Aixen-Provence, France) equipped with an XC6-1 convex array probe with a frequency of 1\u0026ndash;6 MHz. Our hospital performs right kidney puncture routinely, thus examination is performed on the right kidney. In supine position, kidney size (maximum length and width) and renal parenchymal/cortex thickness were measured. Then, the resistance index (RI) of the interlobar artery was calculated and recorded in Doppler ultrasound mode. For SWE examination, the size of the elastography sampling box was set to 4\u0026times;3 cm, and the diameter of the ROI was set to 4 mm. The elastography scale was displayed in kPa, and the range was fixed from 0 to 80 kPa. All patients underwent 2D-SWE examination within 24 hour before renal biopsy. In prone position, SWE sampling box was placed in the middle part of the renal cortex and perpendicular to the surface of the kidney. Patients were required to hold their breath for 3\u0026ndash;5 s and the images of the elastic color were captured. In the color imaging area, the circular ROI was fixed with a diameter of 4 mm. Then, the mean renal elastic modulus (unit: kPa) within the ROI and the measurement depth (the distance between the probe and ROI) were recorded. The detection was repeated 5 times, and the average of 5 measurements of mean SWE value was employed for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eRenal biopsy\u003c/h2\u003e \u003cp\u003ePatients were required to stop anticoagulant and antiplatelet agents three days prior to the biopsy. Percutaneous US-guided renal biopsy was performed at the lower pole of right kidney using a 16G needle (Bard Magnum, Covington, GA, USA). The operator has more than 10 years of experience and performed more than 500 renal biopsies. The specimens were divided into three parts and used for electron microscopy, fluorescence scanning, and immunohistochemical examination, respectively. Renal tissues were fixed in formalin, and sections were stained with hematoxin eosin, Masson\u0026rsquo;s trichrome, and periodic acid-Schif.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eOutcome definition\u003c/h2\u003e \u003cp\u003eAfter biopsy, ultrasound was employed to evaluate complications, including bleeding, hematoma or adjacent organ damage. If a hematoma was documented, the largest diameter was registered for this study(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A major complication was defined as any complication that required medical intervention, such as blood transfusion, arterial embolization or surgery even death.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003ePatients were randomized 7:3 to create \u0026ldquo;training\u0026rdquo; and \u0026ldquo;validation\u0026rdquo; cohorts. Patient characteristics are summarized as the means or frequencies. Qualitative variables are presented as numbers and percentages. Student\u0026rsquo;s t test was used for group comparisons of normally distributed continuous variables; otherwise, the Mann‒Whitney U test was applied. Categorical data were tested using chi-square tests. Stepwise multivariate logistic regression analysis was then performed to identify independent predictors of hemorrhage and to estimate individual odds ratios (ORs). The receiver operating characteristic (ROC) curve was plotted to evaluate the discrimination ability of the diagnostic nomogram, and the area under the curve (AUC) was calculated to quantify the diagnostic performance of the nomogram. The optimal cutoff point was determined by the Youden index, and the sensitivity, specificity, and accuracy were obtained. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) 26.0 statistical software for Windows (SPSS Inc, Chicago, IL, USA) and R software (version 4.3.3). A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant for each statistical test.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, there were 338 CKD patients underwent renal biopsy and SWE; however, 108 patients whose SWE depth was greater than 4 cm were excluded, and 9 patients whose data were incomplete were excluded. The final cohort consisted of 221 patients. All patients had sufficient samples to undergo pathological examinations. There were 155 patients in the training cohort and 66 patients in the validation cohort. The demographic, ultrasonographic and laboratory characteristics and p values of the two groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic, laboratory and ultrasound characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining cohort(n\u0026thinsp;=\u0026thinsp;155)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValidation cohort(n\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eValue of \u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.58(14\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.44(14\u0026ndash;73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.895\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.47(14.95\u0026ndash;29.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.69(15.94\u0026ndash;28.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaboratory tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum creatinine (umol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118.52(36.00\u0026minus;929.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.60(36.80\u0026ndash;350.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum uric acid (umol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e392.37(176\u0026ndash;1019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e397.53(162.00\u0026minus;837.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.760\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.88(11.00\u0026minus;48.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.30(15.50\u0026ndash;48.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.311\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR (mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.20(4.41\u0026minus;147.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.00(14.29\u0026ndash;154.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eblood urea nitrogen (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.74(2.40\u0026minus;32.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.86(2.48\u0026ndash;14.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eurea-creatinine ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.22(19.73\u0026minus;174.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.97(32.00\u0026minus;116.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.399\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126.89(62.00\u0026minus;181.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126.62(86.00\u0026minus;179.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet (10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e249.38(66.00\u0026minus;539.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e254.07(116.00\u0026minus;376.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.670\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriglyceride\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.66(0.17\u0026ndash;6.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.65(0.51\u0026ndash;5.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.923\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCholesterol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.90(1.64\u0026ndash;15.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.48(2.36\u0026ndash;14.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.265\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasound parameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight kidney length (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104.04(78.00\u0026minus;130.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105.86(91.20\u0026minus;127.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight kidney width (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.56(28.60\u0026ndash;71.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.39(31.00\u0026ndash;61.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.386\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenchymal thickness (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.90(10.00\u0026minus;169.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.90(10.00\u0026minus;21.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.990\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecortical thickness(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.58(4.70\u0026ndash;13.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.81(5.00\u0026minus;12.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRI of the interlobar artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.64(0.47\u0026ndash;0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.63(0.51\u0026ndash;0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean SWE value (kpa)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.76(14.90\u0026ndash;69.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.46(23.90\u0026ndash;54.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture depth(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.25(20.00\u0026ndash;73.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.96(23.00\u0026ndash;56.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.582\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased parenchymal echo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes Yes/No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17/138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.937\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension Yes/No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55/99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23/43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular disease Yes/No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn total, 148 (67%) patients had postprocedure hematoma (106 and 42 patients in the training and validation cohorts, respectively), and the mean hematoma diameter was 31.12\u0026thinsp;\u0026plusmn;\u0026thinsp;15.01 mm (10\u0026ndash;100 mm). No patient needed a blood transfusion arterial embolization or surgery, and no deaths occurred during the study period. Therefore, there were no major complications in our study period.\u003c/p\u003e \u003cp\u003ePatients were divided into a group with hematoma and a group without hematoma. The mean cortical SWE value was 42.87 kPa (21.40\u0026ndash;69.30 kPa) for patients without hematoma and 40.18 kPa (14.90\u0026ndash;64.50 kPa) for patients with hematoma. Patients without hematoma had significantly higher SWE value than those with hematoma(p\u0026thinsp;=\u0026thinsp;0.032). The multivariate logistic analysis and derived model are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The independent variables associated with post-procedural hematoma were the mean cortical SWE value and the triglyceride and urinary protein levels.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate predictors of post-hematoma complication (training cohort)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Swe value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.873\u0026ndash;0.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriglyceride\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.978\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.416\u0026ndash;5.899\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary protein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.998\u0026minus;1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe AUC of the model was 0.82 (95% confidence interval (CI): 0.75\u0026ndash;0.89) in the training cohort and 0.61 (95% CI: 0.47\u0026ndash;0.75) in the validation cohort (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A nomogram that incorporated the above independent predictors was developed and presented (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The Akaike information criterion (AIC) value of the nomogram in the training cohort was 214.64. The sensitivities of the nomograms in the training and validation cohorts were 0.796 and 0.583, respectively. The specificity was 0.717 in the training cohort and 0.667 in the validation cohort.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eKidney biopsy is an essential procedure for diagnosis and therapy as well as for scientific research on kidney diseases. Kidneys have rich blood perfusion, receiving 20% of cardiac output and only constituting\u0026thinsp;\u0026lt;\u0026thinsp;1% of body mass at resting state[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although ultrasound-guided renal biopsy is a relatively low risk operation[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], post-procedural hematoma can always be observed.\u003c/p\u003e \u003cp\u003eIn our study, the prevalence of postprocedural hematoma was 67%. The average diameter of the hematoma was 31.12 mm. A total of 19 patients (19/148, 12.8%) had a gross hematoma with a maximum diameter greater than 50 mm, and the largest hematoma was 100 mm. After local compression, there was no sign of active bleeding among these patients, and no further treatment, such as blood transfusion or surgery, was administered. In addition, in our hospital, CKD patients were administered vitamin K before renal biopsy and \u0026ldquo;hemocoagulase for injection\u0026rdquo; immediately after the procedure to prevent hematoma. Additionally, patients with a high risk of bleeding, such as high blood pressure exceed 160mmHg or coagulation disorders were rejected from biopsy. Therefore, there were no major complications during the study period.\u003c/p\u003e \u003cp\u003eReduced GFR, anemia, older age, high blood pressure, bleeding diathesis, small kidneys, CKD features in prebiopsy US, and larger needle size were known risk factors for bleeding in several previous investigations[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our results showed that higher triglyceride and urinary protein levels were risk factors for post-procedural hematoma. Increased adiposity is independently associated with a decrease in the glomerular filtration rate[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e and hyperlipidemia is also a risk factor for nephrotic syndrome. The greater the urinary protein is, the more severe the damage to renal tubule function. Hence, increased triglycerides and urinary protein may increase the risk of post-procedural hematoma. However, we did not find a statistically significant correlation between hemorrhage after biopsy and risk factors for bleeding, as shown in previous studies. The reason may be following: as is well known, operator experience, biopsy needle size and the number of biopsies may has an impact on the risk of bleeding. In our study, renal biopsies were made by an operator who had more than 10 years of experience in ultrasound intervention. The needle size and number of biopsies were the same in all patients. Besides, most of patients (161/221, 72.8%) enrolled in our study were CKD 1\u0026ndash;2 stage and had mild damage to renal function. Also, there was no obvious atrophy of the kidney among most of patients in our study cohort.\u003c/p\u003e \u003cp\u003eOne mechanism in the development of chronic kidney disease (CKD) that may worsen renal function is fibrosis[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. With the decline in renal function, the degree of fibrosis and risk of post hematoma will rise. SWE is a novel technique for assessing renal fibrosis. There are several studies on the relationship between elastography and renal pathological alterations or fibrosis[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our previous studies revealed that SWE value decreased as the pathological grade of renal fibrosis progressed. The SWE value may be affected by not only the degree of renal fibrosis but also the blood supply of kidney[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In this study, statistical analysis revealed that a lower SWE value was a risk factor for post-procedural hematoma. This finding is consistent with the result of Mehmet, who reported that a lower renal cortical shear wave velocity is associated with a tendency toward hemorrhage[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, the lower the renal elasticity value, the higher the degree of fibrosis and the risk of postbiopsy hemorrhage. Also, we incorporated three risk factors derived from multivariate logistic analysis and establish a nomogram for clinical usage.\u003c/p\u003e \u003cp\u003eThere are several limitations in our study. First, the sample size was small, and there were no major complications. Second, this was a retrospective study. Third, previous studies have reported that renal stiffness was affected not only by the degree of renal fibrosis but also by renal blood perfusion, vascular pressure and urinary flow pressure[\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. More studies should be carried out to verified the relation between elastography and postprocedural hematoma.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, US-guided renal biopsy is a safe procedure. Factors associated with an increased risk of postprocedure hematoma included lower cortical swe value and higher triglyceride and urinary protein levels. The application of shear wave elastography in CKD patients is useful for identifying patients at high risk of post-procedural hematoma.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol for the study was approved by the Institutional Ethics Committee of Fifth Affiliated Hospital of Sun Yat-sen University and followed the Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJiaxin Chen and Zhongzhen Su designed the study. Qunyan Wu, Shuqing Wang and Songying Pi collected the data. Shushang Zhang, Jianzhong Xian and Wuzhu Lu performed the ultrasound examination during the study. Jiaxin Chen wrote the first draft of the manuscript. Jiaxin Chen，Yuhong Lin and Zhongzhen Su revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. \u003cstrong\u003eLancet\u003c/strong\u003e \u003cstrong\u003e2021\u003c/strong\u003e, 398(10302): 786-802.\u003c/li\u003e\n\u003cli\u003eMejia-Vilet JM, Marquez-Martinez MA, Cordova-Sanchez BM, Ibarguengoitia MC, Correa-Rotter R, Morales-Buenrostro LE. Simple risk score for prediction of haemorrhagic complications after a percutaneous renal biopsy. \u003cstrong\u003eNephrology (Carlton)\u003c/strong\u003e \u003cstrong\u003e2018\u003c/strong\u003e, 23(6): 523-529.\u003c/li\u003e\n\u003cli\u003eMonahan H, Gunderson T, Greene E, Schmit G, Atwell T, Schmitz J. Risk factors associated with significant bleeding events after ultrasound-guided percutaneous native renal biopsies: a review of 2204 cases. \u003cstrong\u003eAbdom Radiol (NY)\u003c/strong\u003e \u003cstrong\u003e2019\u003c/strong\u003e, 44(6): 2316-2322.\u003c/li\u003e\n\u003cli\u003ePoggio ED, Mcclelland RL, Blank KN, Hansen S, Bansal S, Bomback AS, Canetta PA, Khairallah P, Kiryluk K, Lecker SH, Mcmahon GM, Palevsky PM, Parikh S, Rosas SE, Tuttle K, Vazquez MA, Vijayan A, Rovin BH. 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Shear wave elastography for assessment of biopsy-proven renal fibrosis: a systematic review and meta-analysis. \u003cstrong\u003eUltrasound Med Biol\u003c/strong\u003e \u003cstrong\u003e2023\u003c/strong\u003e, 49(5): 1037-1048.\u003c/li\u003e\n\u003cli\u003eCildag MB, Gok M, Abdullayev O. Pre-procedural shear wave elastography on prediction of hemorrhage after percutaneous real-time ultrasound-guided renal biopsy. \u003cstrong\u003eRadiol Med\u003c/strong\u003e \u003cstrong\u003e2020\u003c/strong\u003e, 125(8): 784-789.\u003c/li\u003e\n\u003cli\u003eKdigo 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. \u003cstrong\u003eKidney Int\u003c/strong\u003e \u003cstrong\u003e2024\u003c/strong\u003e, 105(4S): S117-S314.\u003c/li\u003e\n\u003cli\u003eLin Y, Chen J, Huang Y, Lin Y, Su Z. A methodological study of 2d shear wave elastography for noninvasive quantitative assessment of renal fibrosis in patients with chronic kidney disease. \u003cstrong\u003eAbdom Radiol (NY)\u003c/strong\u003e \u003cstrong\u003e2023\u003c/strong\u003e, 48(3): 987-998.\u003c/li\u003e\n\u003cli\u003eEdwards A, Kurtcuoglu V. Renal blood flow and oxygenation. \u003cstrong\u003ePflugers Arch\u003c/strong\u003e \u003cstrong\u003e2022\u003c/strong\u003e, 474(8): 759-770.\u003c/li\u003e\n\u003cli\u003ePrasad N, Kumar S, Manjunath R, Bhadauria D, Kaul A, Sharma RK, Gupta A, Lal H, Jain M, Agrawal V. Real-time ultrasound-guided percutaneous renal biopsy with needle guide by nephrologists decreases post-biopsy complications. \u003cstrong\u003eClin Kidney J\u003c/strong\u003e \u003cstrong\u003e2015\u003c/strong\u003e, 8(2): 151-156.\u003c/li\u003e\n\u003cli\u003eDing JJ, Lin SH, Huang JL, Wu TW, Hsia SH, Lin JJ, Chou YC, Tseng MH. Risk factors for complications of percutaneous ultrasound-guided renal biopsy in children. \u003cstrong\u003ePediatr Nephrol\u003c/strong\u003e \u003cstrong\u003e2020\u003c/strong\u003e, 35(2): 271-278.\u003c/li\u003e\n\u003cli\u003eKorbet SM, Volpini KC, Whittier WL. Percutaneous renal biopsy of native kidneys: a single-center experience of 1,055 biopsies. \u003cstrong\u003eAm J Nephrol\u003c/strong\u003e \u003cstrong\u003e2014\u003c/strong\u003e, 39(2): 153-162.\u003c/li\u003e\n\u003cli\u003eCorapi KM, Chen JL, Balk EM, Gordon CE. Bleeding complications of native kidney biopsy: a systematic review and meta-analysis. \u003cstrong\u003eAm J Kidney Dis\u003c/strong\u003e \u003cstrong\u003e2012\u003c/strong\u003e, 60(1): 62-73.\u003c/li\u003e\n\u003cli\u003eChang AR, Grams ME, Ballew SH, Bilo H, Correa A, Evans M, Gutierrez OM, Hosseinpanah F, Iseki K, Kenealy T, Klein B, Kronenberg F, Lee BJ, Li Y, Miura K, Navaneethan SD, Roderick PJ, Valdivielso JM, Visseren F, Zhang L, Gansevoort RT, Hallan SI, Levey AS, Matsushita K, Shalev V, Woodward M. Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium. \u003cstrong\u003eBMJ\u003c/strong\u003e \u003cstrong\u003e2019\u003c/strong\u003e, 364: k5301.\u003c/li\u003e\n\u003cli\u003ePanizo S, Martinez-Arias L, Alonso-Montes C, Cannata P, Martin-Carro B, Fernandez-Martin JL, Naves-Diaz M, Carrillo-Lopez N, Cannata-Andia JB. Fibrosis in chronic kidney disease: pathogenesis and consequences. \u003cstrong\u003eInt J Mol Sci\u003c/strong\u003e \u003cstrong\u003e2021\u003c/strong\u003e, 22(1).\u003c/li\u003e\n\u003cli\u003eChen Z, Chen J, Chen H, Su Z. Evaluation of renal fibrosis in patients with chronic kidney disease by shear wave elastography: a comparative analysis with pathological findings. \u003cstrong\u003eAbdom Radiol (NY)\u003c/strong\u003e \u003cstrong\u003e2022\u003c/strong\u003e, 47(2): 738-745.\u003c/li\u003e\n\u003cli\u003eGennisson JL, Grenier N, Combe C, Tanter M. Supersonic shear wave elastography of in vivo pig kidney: influence of blood pressure, urinary pressure and tissue anisotropy. \u003cstrong\u003eUltrasound Med Biol\u003c/strong\u003e \u003cstrong\u003e2012\u003c/strong\u003e, 38(9): 1559-1567.\u003c/li\u003e\n\u003cli\u003eLiu X, Li N, Xu T, Sun F, Li R, Gao Q, Chen L, Wen C. Effect of renal perfusion and structural heterogeneity on shear wave elastography of the kidney: an in vivo and ex vivo study. \u003cstrong\u003eBMC Nephrol\u003c/strong\u003e \u003cstrong\u003e2017\u003c/strong\u003e, 18(1): 265.\u003c/li\u003e\n\u003cli\u003eWu J, Li G, Liu J, Sun W, Liu J, Zou G, Lu H, Zheng M. Utility of shear wave-based ultrasound elastography in chronic kidney disease and related pathological quantitative analysis. \u003cstrong\u003eEur Radiol\u003c/strong\u003e \u003cstrong\u003e2023\u003c/strong\u003e, 33(8): 5625-5633.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"shear-wave elastography, prediction, renal biopsy, nomogram, postprocedural hematoma","lastPublishedDoi":"10.21203/rs.3.rs-4574625/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4574625/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTo derive a simple risk score based on shear wave elastography (SWE) ultrasound to predict the individual risk of post-procedural hematoma complications in patients who underwent a percutaneous renal biopsy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA total of\u003cstrong\u003e \u003c/strong\u003e221 patients who underwent ultrasound (US)-guided percutaneous renal biopsy at our institution between April 2019 and November 2023 were enrolled in our study and randomly divided into training (n=155) or validation (n=66) cohorts. After biopsy, ultrasound was employed to evaluate the hematoma, and the maximum diameter of the hematoma was recorded for analysis. A diagnostic nomogram incorporating the selected features was established using multivariable logistic regression analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 148 (67%) patients had postprocedure hematoma (106 and 42 patients in the training and validation cohorts, respectively), and the mean hematoma diameter was 31.12±15.01 mm (10–100 mm). The mean cortical SWE value was 42.87 kPa (21.40-69.30 kPa) for patients without hematoma and 40.18 kPa (14.90-64.50 kPa) for patients with hematoma (p=0.032). The established nomogram integrated the mean cortical swe value, triglyceride level and urinary protein level. The area under the receiver operator characteristic curve (AUC) was 0.82 in the training cohort and 0.61 in the validation cohort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe risk of postprocedural hematoma complication could be assessed by a simple risk score that integrated mean cortical SWE value, triglyceride and urinary protein levels.\u003c/p\u003e","manuscriptTitle":"A nomogram based on shear wave elastography for predicting hemorrhage complications after ultrasound-guided percutaneous renal biopsy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 16:00:09","doi":"10.21203/rs.3.rs-4574625/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ba342bc-462b-47bb-afa7-d438e491f838","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T09:09:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 16:00:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4574625","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4574625","identity":"rs-4574625","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}