Bleeding prevention with desmopressin for allograft kidney biopsies: a double-blind randomized study

Background Percutaneous kidney allograft biopsy is essential for evaluating graft dysfunction, but post-procedural bleeding remains the most frequent complication, particularly among recipients with impaired renal function. Desmopressin (DDAVP) is often used prophylactically to reduce bleeding risk, yet its efficacy in the transplant setting remains uncertain. Methods We conducted a single-center, double-blind, randomized, placebo-controlled trial at a quaternary transplant center in Brazil. Adult kidney transplant recipients with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m² undergoing allograft biopsy were randomized (1:1) to receive intravenous desmopressin (0.3 μg/kg) or placebo before biopsy. All procedures were ultrasound-guided and performed by experienced nephrologists. The primary endpoint was any biopsy-related bleeding complication. Secondary outcomes included major bleeding (transfusion, embolization, nephrectomy, or death), minor bleeding (macroscopic hematuria, hematoma, hemoglobin drop >20%), and hyponatremia. Results A total of 96 biopsies were randomized (48 per group). Baseline demographics, clinical, and procedural characteristics were well-balanced. Any biopsy-related bleeding complication occurred in 29.1% of procedures overall, without a significant difference between the desmopressin and placebo groups (35.4% vs. 22.9%, p=0.262). One major bleeding event occurred in the desmopressin group (2.1%) and none in the placebo group (p=1.00). Minor bleeding was more frequent with desmopressin-treated patients (35.4% vs. 22.9%, p=0.262) than in placebo, but without statistical significance. In adjusted analyses using penalized logistic regression, desmopressin was not associated with reduced bleeding risk [OR 1.61 (95%CI 0.63–4.20)]. In contrast, surveillance biopsies were independently associated with a markedly higher risk of minor bleeding compared with indication biopsies (adjusted OR 10.2; 95%CI 1.8–68.7). No cases of hyponatremia were documented, and adverse events were rare and balanced across groups. Conclusions In this trial of high-risk kidney transplant recipients, prophylactic desmopressin did not reduce biopsy-related bleeding complications compared with placebo. Routine pre-biopsy administration is not supported when biopsies are performed under optimal technical conditions and patient preparation.