026 - Use of Recombinant Activated Factor VII in Pediatric Setting of Post-Kidney Biopsy Hemorrhage

Publication Number: 26.6761

Elena C. Park, Geisinger Commonwealth School of Medicine, King of Prussia, PA, United States; Stephanie P. Kerkvliet, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Amy J. Kogon, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States

Background: Severe bleeding following a kidney biopsy is a complication with few non-invasive interventions available. Recombinant activated factor VII (rFVIIa) has been used in pediatric patients for controlling severe hemorrhage during cardiac and neurologic surgeries, and in at least one adult case of post-kidney biopsy hemorrhage. rFVIIa interacts with tissue factor, activating platelets and leading to thrombin formation at injury sites, enabling targeted bleeding control.

Objective: To describe the novel use of rFVIIa for post-kidney biopsy hemorrhage in a pediatric patient.

Design/Methods: We reviewed the patient's medical history and literature on rFVIIa use in post-procedural bleeding.

Results: A previously healthy 10-year-old female presented with four days of diarrhea, vomiting, epistaxis, and headache. Evaluation revealed hypertension, respiratory distress, hyperkalemia, acidosis, azotemia, acute kidney injury, normocytic anemia, prolonged PTT, and extensive bilateral pulmonary infiltrates on chest Xray. Labs at presentation are detailed in Table 1. Initial management included intubation, continuous kidney replacement therapy, blood transfusion, and nicardipine, stabilizing her condition before a diagnostic kidney biopsy. Prior to the biopsy, she received vitamin K (5 mg) and DDAVP (0.3 mcg/kg). Using ultrasound guidance, three passes were made with a 16-gauge biopsy needle. Post-biopsy, ultrasound revealed an expanding hematoma (max 9.1 cm) with active bleeding that did not resolve after 90 minutes of manual pressure, DDAVP, platelet and fresh frozen plasma transfusions. Interventional radiology planned emergent embolization. While awaiting the procedure, hematology was consulted regarding the use of a rFVIIa. After weighing the potential benefit of stopping a life-threatening hemorrhage without an invasive procedure against the thromboembolic risk of administration, the team gave one dose of Novo Seven (90 mcg/kg). The bleeding stopped almost immediately, and no further interventions were needed. There were no thromboembolic complications. The patient was diagnosed with and treated for p-ANCA vasculitis and discharged three weeks later in stable condition to outpatient hemodialysis.

Conclusion(s): Recombinant FVIIa successfully stopped post-kidney biopsy hemorrhage in a pediatric patient. The use of rFVIIa may allow children who have severe bleeding complications from kidney biopsies to avoid more invasive treatments such as vascular embolization and surgical intervention. Practitioners must weigh the risk of undesired thromboembolic events associated with rFVIIa administration.

Table 1. Blood Pressure and Laboratory Data at Presentation and Preceding Kidney Biopsy


Figure 1. Coagulation cascade highlighting the role of factor VIIa in the extrinsic pathway and platelet interaction.