Renal and Electrolyte Disorders, Hospital Medicine (for Hospitalists) - Full Vignette with Extended

Описание: A 5-year-old boy is admitted with several weeks of progressive edema and dark, foamy urine, accompanied by laboratory evidence of nephrotic-range proteinuria, dysmorphic red blood cells in urine, and a complex coagulation profile. How should you approach the procedural bleeding risk before a planned percutaneous renal biopsy in a child with multisystem findings? What clinical and laboratory factors must be carefully evaluated to ensure patient safety during kidney biopsy in pediatric nephrotic syndrome?

VIDEO INFO
Category: Renal and Electrolyte Disorders, Hospital Medicine (for Hospitalists)
Difficulty: Hard - Advanced level - Challenges experienced practitioners
Question Type: Contraindications
Case Type: Typical Presentation

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QUESTION
A 5-year-old boy is admitted to a general pediatric ward in a U.S. community hospital for progressive edema and dark, foamy urine noted by his parents over 3 weeks. On triage, an oxygen saturation of 89% on room air is immediately repeated on a well-perfused probe and reads 98%. Blood pressure measured with a pediatric cuff is 104/64 mmHg. He has focal epilepsy diagnosed at age 3 years, seizure-free for 18 months on valproate syrup and levetiracetam solution....

OPTIONS
A. Uncorrected coagulopathy at the time of biopsy, specifically platelet count 32,000/muL with INR 2.1, necessitating correction before percutaneous native-kidney biopsy.
B. Solitary native kidney in an otherwise stable child when using real-time ultrasound guidance with an experienced pediatric interventionalist.
C. Controlled blood pressure in the normal pediatric range on repeat measurements after an initially artifactual oscillometric value.
D. NSAID exposure 48 hours earlier without ongoing use, in a child with stable hemodynamics and no gross hematuria at presentation.

CORRECT ANSWER
A. Uncorrected coagulopathy at the time of biopsy, specifically platelet count 32,000/muL with INR 2.1, necessitating correction before percutaneous native-kidney biopsy.

EXPLANATION
The child s bleeding profile is the single decisive issue. Percutaneous native-kidney biopsy is a high-bleeding-risk procedure, and active, uncorrected coagulopathy markedly increases the chance of hematoma, gross hematuria, transfusion, or intervention. This patient s platelet count is 32,000/muL with an INR of 2.1, both well outside standard safety targets for biopsy. Before proceeding, the team should correct coagulation parameters (for example, platelet transfusion to achieve at least a procedural threshold, vitamin K and/or plasma to normalize INR) and then reassess. This aligns with interventional radiology consensus that mandates correction of significant thrombocytopenia and coagulopathy before high-risk image-guided procedures.

By contrast, the other checklist items do not constitute absolute contraindications in this specific scenario. A solitary native kidney is no longer considered an absolute bar to biopsy when performed by an experienced operator under real-time ultrasound; it is a relative consideration that increases the need for expertise and post-biopsy monitoring. Controlled blood pressure in the pediatric reference range is appropriate for biopsy; the initially low oxygen saturation and artifact blood pressure were promptly clarified and are not relevant barriers....


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