Experience With Autosomal Dominant Polycystic Kidney Disease in Patients Before and After Renal Transplantation: A 7-Year Observation

doi:10.1016/j.transproceed.2008.10.034

Transplantation Proceedings

Volume 41, Issue 1, January–February 2009, Pages 177-180

https://doi.org/10.1016/j.transproceed.2008.10.034 Get rights and content

Abstract

Objective

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the presence of multiple cysts in both kidneys. Symptoms of the disease may arise either from the presence of cysts or from increasing loss of kidney function. First symptoms usually appear in the third decade of life: lumbar pain, urinary tract infections, arterial hypertension, or renal colic due to cyst rupture or coexistent nephrolithiasis. An early diagnosis, male gender, large kidneys by sonography, arterial hypertension, hematuria, and urinary tract infections are predictive factors of a faster progression of the disease. Our aim was to establish the indications for nephrectomy among symptomatic ADPKD patients before kidney transplantation and to assess the risks of posttransplantation complications among ADPKD patients without nephrectomy.

Patients and Methods

The observed group consisted of 183 patients with ADPKD among whom 50 (27.3%) underwent kidney transplantation during a 7-year observation period (2000–2007). Among those subjects were 3 groups: (I) nephrectomy preceding transplantation; (II) nephrectomy during kidney transplantation; and (III) without nephrectomy.

Results

Among group I before transplantation we observed: arterial hemorrhage, wound infections, and splenectomy 4 weeks after ADPKD nephrectomy; afterward we observed: urinary tract infections and contralateral cyst infection. Among group II we only observed 1 case of wound infection. Among group III we observed: ascending urinary tract infections, cyst infections, and cyst hemorrhage. Cyst hemorrhage and cyst infections led mainly to ADPKD kidney nephrectomy. During the observation time, 80.95% of grafts were functioning.

Conclusions

Unilateral nephrectomy is a well-founded preliminary surgical treatment before kidney transplantation. Bilateral nephrectomy before or during transplantation eliminates ADPKD complications and does not significantly increase general complications. The greatest numbers of complications and of graft losses were observed among the group without pretransplantation nephrectomy.

Section snippets

Patients and Methods

During the 7-year observation period (2000–2007), the overall group of 183 ADPKD patients included 50 (27.3%) who underwent kidney transplantation, namely, 29 women and 21 men with a mean age of 55.5 years. We stratified them into 3 groups: (group I) nephrectomy preceding transplantation (n = 25) divided into group A patients with a bilateral nephrectomy by a transperitoneal approach (n = 3); group B patients with a unilateral transperitoneal nephrectomy (n = 17); and group C patients with a

Results

Group I (nephrectomy pretransplantation) included 2 cases of arterial hemorrhage (Pezzer's drainage was kept longer due to persistent hematoma), 2 cases of wound infection, and 1 case of splenectomy performed 4 weeks after ADPKD nephrectomy due to pain and internal bleeding. This group I experienced 4 urinary tract infections and 4 cyst infections on the contralateral side. None of these problems required graftectomy. Among group II we observed 1 case of wound infection. Among group III there

Discussion

A large number of cysts with recurrent infections and pyelonephritis is the indication for nephrectomy before kidney transplantation. The risk of this strategy is lower than the possibility of postoperative complications including graft loss.⁵ Immunosuppression favors the spread of infections including into the graft. An enlarged polycystic kidney can cause mechanical compression on the transplanted kidney and ureter with consequent disturbance of urine flow and vascular disorders.4, 6

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Cited by (44)

Simultaneous Robotic-Assisted Bilateral Native Nephrectomy and Kidney Transplantation for Autosomal Dominant Polycystic Kidney Disease in Recipients With High Body Mass Index: Report of 2 Cases
2022, Transplantation Proceedings
Robotic kidney transplantation is a safe, reproducible, and less morbid technique in high body mass index and end-stage renal disease. Polycystic kidney disease is a relative contraindication to robotic-assisted kidney transplantation because of the mass effect of the native kidneys on the patient's pelvis that prevents ideal exposure.
We report the first 2 cases of robotic-assisted simultaneous bilateral nephrectomy and kidney transplantation for patients with obesity and adult polycystic kidney disease. The recipients were 2 males, 50 and 53 years old, with a body mass index of 35.1 41.6 kg/m² and 41.6 kg/m², respectively. Both recipients had suitable living donors. The average operating time was 395 minutes and the estimated blood loss was on average 250 mL. The postoperative course was uneventful and the patients were discharged home on days 4 and 5.
Performing robotic nephrectomies simultaneously with kidney transplantation can be done safely, allowing patients with obesity and polycystic kidney disease needing bilateral nephrectomy, to take full advantage of minimally invasive kidney transplantation.
Staged versus concurrent native nephrectomy and renal transplantation in patients with autosomal dominant polycystic kidney disease: A systematic review
2022, Transplantation Reviews
Citation Excerpt :
Autosomal dominant polycystic kidney disease (ADPKD) manifests as a progressive cystic enlargement, with up to 50% of patients requiring renal replacement therapy by the age of 50 [1–3]. Haematuria, hypertension, cyst infection, malignancy, pain and other symptoms, in addition to physically impeding graft placement, may become an indication for a unilateral or bilateral native nephrectomy in ADPKD [4–7]. Pre-transplant native nephrectomy, when deemed necessary, may be a staged procedure or undertaken simultaneously with kidney transplantation.
Patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD) frequently undergo native nephrectomy before transplantation. The nephrectomy may be a staged procedure or undertaken simultaneously with transplantation. When performed simultaneously, the transplant procedure is more prolonged, involves a larger operative field and incision. There is also a concern of a greater risk of graft loss with simultaneous nephrectomy and transplantation. Moreover, staged surgery may allow nephrectomy to be performed before immunosuppression introduction via a smaller incision or involving a minimally invasive approach. However, staged nephrectomy may require a period of dialysis not otherwise necessary if a transplant and nephrectomy were simultaneous. Moreover, only a single procedure is needed, implying the avoidance of a prior nephrectomy and its attendant morbidity in a patient with chronic renal insufficiency. To account for these issues, this study aims to compare the cumulative morbidity of two-staged procedures versus a single simultaneous approach in term of morbidity and graft outcomes.
This study aims to systematically review the literature to determine whether a staged or simultaneous approach to native nephrectomy in ADPKD is the optimal approach in terms of morbidity and graft outcomes.
A literature search of MEDLINE and EMBASE was conducted to identify published systematic reviews, randomized control trials, case-controlled studies and case studies. Data comparing outcomes of staged and simultaneous nephrectomy for patients undergoing kidney transplantation was extracted and analyzed. The main outcomes analyzed were length of hospitalization, blood loss, operative time, other early postoperative complications and risk of graft thrombosis. Meta-analysis was conducted where appropriate.
Seven retrospective cohort studies were included in the review. There was a total of 385 patients included in the analysis, of whom 273 patients underwent simultaneous native nephrectomy and kidney transplantation. Meta-analysis showed an increased cumulative operative time in staged procedures (RR 1.86；95% CI 0.43–3.29 p = 0.01) and increased risk of blood transfusions (RR 2.69; 95% CI 1.92–3.46 p < 0.00001). For the transplant procedure, there were no significant difference in the length of stay (RR 1.03; 95% CI -2.01-4.14 p = 0.52), major postoperative complications (RR 0.02; 95% CI -0.15-0.10 p = 0.74) and vascular thromboses (RR 1.42 95% CI 0.23–8.59 p = 0.7).
The results suggest that staged nephrectomy followed by kidney transplantation is associated with a longer cumulative operative time and increased cumulative risk of blood transfusions. There is no evidence to suggest that performing a simultaneous nephrectomy and kidney transplant procedure increases the perioperative mortality rate, major postoperative complication rates or risk of vascular thrombosis.
Abdominal Aortic Aneurysm Associated with Polycystic Kidney Disease: Endovascular Aortic Repair and Renal Embolization
2019, Annals of Vascular Surgery
Citation Excerpt :
Open or laparoscopic nephrectomy can be performed before aortic surgery to decrease aortic compression and to aid in aortic exposure and cross-clamping that could be difficult due to the enlarged polycystic kidney and to decrease the risk of graft infection caused by recurrent cysts infection.11 In these cases, nephrectomy of polycystic kidneys displays a significant level of complications, including hernias, infection, excessive bleeding, or colonic perforation.12 Prevalence of complications of these surgical procedures reaches 28–66%.13
A 79-year old patient with an asymptomatic 63-mm infrarenal abdominal aortic aneurysm, confirmed on computed tomography, was admitted in our unit. The patient had undergone kidney transplantation years before, due to renal failure secondary to polycystic kidney disease. Renal function at admission was normal. The aneurysm had a very short neck, and a standard endovascular aortic repair procedure was not feasible. Therefore, the 2 renal arteries were embolized with coils and endovascular repair of the aneurysm, covering the ostia of the renal arteries, was achieved placing the endoprosthesis up to the level of the superior mesenteric artery. The course of the patient was uneventful and was discharged without complications. Endovascular repair in patients without infrarenal aortic necks and nonfunctional kidneys secondary to polycystic kidney disease can be achieved with safety embolizing and covering the ostia of the renal arteries.
Native Nephrectomy with Renal Transplantation is Associated with a Decrease in Hypertension Medication Requirements for Autosomal Dominant Polycystic Kidney Disease
2016, Journal of Urology
Citation Excerpt :
It would be of benefit to examine how bilateral native Nx at renal Tx affects blood pressure control, and to see if the results are consistent with those of the staged Nx group or if simultaneous bilateral Nx has a synergistic effect. The safety of the procedure, especially when performed by experienced surgeons, has been well demonstrated in previous studies.15,20–22 Ipsilateral native nephrectomy performed at renal transplantation is associated with a significant reduction in the quantity and defined daily dose of antihypertensive drugs needed to adequately control hypertension in patients with ADPKD, and staged contralateral native nephrectomy is associated with an even further reduction in antihypertensive requirement.
We assessed hypertensive control after native nephrectomy and renal transplantation in patients with autosomal dominant polycystic kidney disease.
Blood pressure control was studied retrospectively in 118 patients with autosomal dominant polycystic kidney disease who underwent renal transplantation between 2003 and 2013. Overall 54 patients underwent transplantation alone (group 1) and 64 underwent transplantation with concurrent ipsilateral nephrectomy (group 2). Of these 64 patients 32 underwent ipsilateral nephrectomy only (group 2a) and 32 underwent eventual delayed contralateral native nephrectomy (group 2b). The number of antihypertensive drugs and defined daily dose of each antihypertensive was recorded at transplantation and up to 36-month followup.
Comparing preoperative to postoperative medications at 12, 24 and 36-month followup, transplantation with concurrent ipsilateral nephrectomy had a greater decrease in quantity (−1.2 vs −0.5 medications, p=0.008; −1.1 vs −0.3, p=0.007 and −1.2 vs −0.4, p=0.03, respectively) and defined daily dose of antihypertensive drug (−3.3 vs −1.0, p=0.0008; −2.9 vs −1.0, p=0.006 and −2.7 vs −0.6, p=0.007, respectively) than transplantation alone at each point. Native nephrectomy continued to be a predictor of hypertensive requirements on multivariable analysis (p <0.0001). The mean decrease in number of medications in group 2b from after ipsilateral nephrectomy to 12 months after contralateral nephrectomy was −0.6 (p=0.0005) and the mean decrease in defined daily dose was −0.6 (p=0.009).
In patients with autosomal dominant polycystic kidney disease undergoing renal transplantation, concurrent ipsilateral native nephrectomy is associated with a significant decrease in the quantity and defined daily dose of antihypertensive drugs needed for hypertension control. Delayed contralateral native nephrectomy is associated with improved control of blood pressure to an even greater degree.
Graft Survival in Patients with Polycystic Kidney Disease with Nephrectomy of Native Kidney Pretransplant
2015, Transplantation Proceedings
Autosomal-dominant polycystic disease (ADPKD) represents 5%–10% of cases of end-stage renal failure. However, management of these patients in terms of whether or not to perform a transplant and optimal timing remains controversial. The objective of our analysis was to evaluate graft survival in patients with ADPKD in which we conduct pretransplant nephrectomy.
This retrospective study including renal transplant patients secondary to ADPKD in our hospital between January 2000 and December 2012. Pretransplant native kidney nephrectomy was indicated in cases of need for space or repeated complications (cysts). We compared the initial function and graft survival between groups of transplanted based on whether nephrectomy had been performed or not.
Eighty-seven patients underwent a kidney transplant owing to ADPKD; 62% (n = 54) were male, with an average age of 55.22 years. Twenty-seven patients (30%) underwent nephrectomy native kidneys before transplantation. There were no serious postoperative complications. Patients who underwent nephrectomy (group 1) showed values of creatinine of 1.57 and 1.50 mg/dL at 3 and 6 months, respectively. In the no nephrectomy group, these values were 2.03 and 1.83 mg/dL, respectively. Graft survival after the first year was of 98% for group 1 and 95% for group 2. The 5-year implant survival was 95% and 80%, respectively.
Native kidney nephrectomy before transplantation in ADPKD is safe in an experienced center, both in terms of surgery-related morbidity and mortality and graft survival and function.
Native Nephrectomy in Renal Transplant Recipients With Autosomal Dominant Polycystic Kidney Disease
2018, Transplantation Proceedings
Patients with autosomal dominant polycystic kidney disease (ADPKD) represent about 10% of kidney transplant recipients (KTR) and have unique needs regarding acceptance for this procedure. Whether native kidney nephrectomy (NKN) affects kidney transplantation (KT) outcomes remains a matter of debate, and more data is needed to establish a standard approach to KTR with ADPKD.
To analyze the prevalence, timing, and short- and long-term outcomes of NKN in a cohort of ADPKD recipients in a single institution.
Retrospective, observational study.
In the years 1993 to 2016 we identified 162 KTR with ADPKD; of those, 149 had known NKN status. A high proportion of ADPKD KTR (n = 72) underwent NKN, the majority of which (69.4%) were performed before KT. There was no difference in short-term and long-term transplantation outcomes (including death, graft loss, delayed graft function, acute rejection, bacterial and cytomegalovirus [CMV] infection, and post-transplant diabetes mellitus) between NKN and non-NKN groups in a median of 98 months of follow-up. However, we found a significant difference in time on a waiting list, which was longer in the NKN group vs non-NKN.
There is a need for a consensus regarding indications and timing for NKN in recipients with ADPKD. The systematic acquisition, sharing, and analysis of accessible data on NKN between institutions is an important step toward meeting this need. In our cohort, we found no impact of the NKN procedure on KT impact. However, undergoing NKN significantly prolonged the time on the waiting list.

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ComplicationInfectionExperience With Autosomal Dominant Polycystic Kidney Disease in Patients Before and After Renal Transplantation: A 7-Year Observation

Abstract

Objective

Patients and Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

Lancet

Transplant Proc

J Urol

Genetics and pathogenesis of polycystic kidney disease

J Am Soc Nephrol

Hypertension in autosomal dominanat polycystic kidney disease

Saudi J Kidney Dis Transpl

Pain management in polycystic kidney disease

Kidney Int

Renal replacement therapy in autosomal dominant polycystic kidney disease

Nephron

Complication
Infection
Experience With Autosomal Dominant Polycystic Kidney Disease in Patients Before and After Renal Transplantation: A 7-Year Observation