Desmopressin and bleeding risk in high-risk native kidney biopsy: updated meta-analysis of RCTs and observational studies

Desmopressin (DDAVP) is sometimes used prophylactically to mitigate bleeding complications associated with kidney biopsy in patients with impaired kidney function, although its efficacy remains uncertain. We conducted a systematic review and meta-analysis to evaluate whether DDAVP reduces bleeding complications in high-risk patients undergoing native kidney biopsy. We searched PubMed, EMBASE, Cochrane, and ClinicalTrials.gov through April 2025 for randomized or observational studies comparing DDAVP to placebo or no intervention in adults with eGFR &lt;60 mL/min/1.73 m². The primary outcome was overall bleeding. Pooled risk ratios (RRs) were estimated using a random-effects model. Subgroup and sensitivity analyses, including leave-one-out diagnostics, were performed. Nine studies (<i>n</i> = 2,470) were included. The pooled RR for bleeding was 0.61 (95% CI, 0.33–1.11), with substantial heterogeneity (<i>I</i>² = 73.6%). Observational studies showed a significant reduction in bleeding (RR = 0.52; 95% CI, 0.44–0.61; <i>I</i>² = 0%), whereas RCTs did not (RR = 0.87; 95% CI, 0.10–7.69; <i>I</i>² = 89.3%). Sensitivity analysis identified one outlier; its exclusion reduced heterogeneity (<i>I</i>² = 18.3%) and yielded a pooled effect (<i>p</i> &lt; .0001). Safety outcomes were infrequently reported but appeared to be mild. While the overall pooled analysis did not reach statistical significance, results from observational studies and sensitivity analyses suggest a potential protective effect of DDAVP in reducing bleeding after kidney biopsy in high-risk patients. However, given the low certainty of evidence, these findings should be considered exploratory and hypothesis-generating. Larger, well-powered RCTs are warranted to confirm these findings and to better characterize safety.