MO018: The Need for Routine Native Nephrectomy in the Work-Up for a Kidney Transplantation in Autosomal Dominant Polycystic Kidney Disease Patients
Paul GeertsemaRonald GansevoortIris W. KoorevaarAnna M. LeliveldEsther MeijerRobert A. PolJan‐Stephan SandersNiek F. Casteleijn
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Abstract BACKGROUND AND AIMS In some patients with autosomal dominant polycystic kidney disease (ADPKD), one or both native kidneys are removed in the work-up for kidney transplantation. There is no consensus if and when a nephrectomy should be performed. Some centers advocate to routinely perform a (bilateral) nephrectomy to prevent complications associated with the native polycystic kidneys in the post-transplantation period. In our ADPKD expertise center, a restrictive approach is pursued: a nephrectomy is only performed in case of serious volume related complaints, lack of space for the allograft, recurrent cyst infections, persistent cyst bleedings or chronic invalidating pain. We analyzed in a retrospective study whether this approach is justified. METHOD All records of patients ≥18 years with ADPKD who received a kidney transplantation (Tx) in our ADPKD expertise center between January 2000 and January 2019 were reviewed. Data were collected on incidence, timing, indication and complications of nephrectomy, as well as on the kidney transplantation, graft function and mortality. Patients were subdivided into three groups: no nephrectomy (no-Nx), nephrectomy prior to (pre-Tx) or after kidney transplantation (post-Tx). Patients were followed for at least 12 months after transplantation. RESULTS About 391 ADPKD (54 ± 9 years, 55.2% male) patients were included. The majority of patients did not undergo a nephrectomy (n = 257, 65.7%). A unilateral nephrectomy was performed pre-Tx in 114 patients (29.2%), in most cases because of a lack of space (49.6%) or recurrent kidney cyst infection (28.1%). More male patients underwent a nephrectomy compared to women (65.7% versus 34.3%, P = 0.003). After Tx, nephrectomy was performed in only 30 patients (11%, median 4.4 years post-Tx), of which 10 were contralateral nephrectomies in patients who also had a nephrectomy pre-Tx. Most frequent indications for nephrectomy post-Tx were recurrent kidney cyst infection (51.4%) or severe pain (24.3%). Duration of nephrectomy was slightly longer when performed post-Tx (3.1 h post-Tx versus 2.6 h pre-Tx, P = 0.052). However, the median length of hospital admission was significantly shorter in these patients (6.0 days post-Tx versus 10.0 days pre-Tx, P < 0.001). Surgery related complication rates did not differ between both groups (38.3% pre-Tx versus 27.0% post-Tx, P = 0.3), nor were there any differences in 10-year patient survival (74.4% pre-Tx versus 80.7% post-Tx versus 67.6% no-Nx, P = 0.4), or 10-year death-censored graft survival (84.4% pre-Tx versus 85.5% post-Tx versus 90.0% no-Nx, P = 0.9). CONCLUSION This study indicates that a minority of ADPKD patients require a native nephrectomy in the work-up for a kidney transplant. With a restrictive nephrectomy policy, only few patients need a nephrectomy after kidney transplantation for indications not foreseen before transplantation. Nephrectomy is a relatively safe procedure, even when performed in transplanted ADPKD patients where it did not result in more complications, graft failure or mortality. These data suggest that a restrictive nephrectomy policy in ADPKD is justified.Keywords:
Bilateral Nephrectomy
Abstract BACKGROUND AND AIMS In autosomal dominant polycystic kidney disease (ADPKD), the enlarged kidneys can cause clinical problems, for instance pain or gastro-intestinal complaints, recurrent infections, or cause a lack of space for a kidney transplant. In selected ADPKD patients, a nephrectomy is required in the work-up for a kidney transplantation. Currently, it is unknown how this procedure affects quality of life (QoL), nor how leaving both kidneys in situ influences wellbeing. The aim of this study was to investigate the impact of pretransplantation nephrectomy on quality of life in APDKD patients. METHOD In this retrospective cohort study all ADPKD patients, ≥18 years, who received a kidney transplantation in 2 ADPKD expertise centers in the Netherlands (UMC Groningen and UMC Leiden) between January 2000 and January 2016, were asked to participate. Of these two centers, one has a restrictive approach, wherein a unilateral procedure is only performed when strict indications are met, and one a proactive approach, wherein a bilateral procedure is performed routinely in the work-up for transplantation. Data were collected on patients characteristics, date of nephrectomy, date of kidney transplantation and QoL. QoL was assessed using validated questionnaires (the SF-36, PHQ-9 and ADPKD-Impact Score) on three different time points (12 months before transplantation, 12 months after transplantation and date of filling out the questionnaire). Patients were followed for at least 24 months after transplantation. RESULTS 321 ADPKD (61 ± 9 years, 57.9% male) patients were included. The minority of patients (n = 99, 30.8%) underwent native nephrectomy in preparation for transplantation, of which 43 patients (13.4%) underwent bilateral nephrectomy. Lack of space was the most common indication for nephrectomy (68.7%), followed by recurrent cyst infection (18.2%) and refractory pain complaints (9.1%). Age, sex and comorbidities did not differ before transplantation between patients who would later undergo a pretransplantation nephrectomy when compared to those who would not undergo this procedure, except for QoL. The SF-36 physical component score (PCS) and mental component score (MCS) were lower in the nephrectomy group vs. no nephrectomy group (33.8 versus 38.4, P = 0.003; 48.7 versus 51.7, P = 0.04, respectively). In addition, the PHQ-9 and ADPKD-IS were significantly lower in patients who would later undergo a pre-transplantation nephrectomy compared to patients who would not undergo this procedure (P = 0.01, P = 0.01, respectively). After transplantation the PCS and MCS improved significantly in both groups, with this improvement in PCS and MCS being significantly more in patients who had a pretransplant nephrectomy compared with those who did not have a nephrectomy (change in PCS 17.3, P < 0.001 versus 13.4, P < 0.001; change in MCS 9.7, P < 0.001 versus 4.5, P < 0.001). Similar findings were noted for the PHQ-9 and APDKD-IS. At the end of follow-up, 7.9 ± 4.6 years after transplantation, PCS and MCS were still better in both groups (PCS 45.9, P < 0.001 versus 49.7, P < 0.001; MCS 57.4, P < 0.001 versus 55.1, P < 0.001, respectively). No differences in the PCS, MCS, PHQ-9 and ADPKD impact scores were observed between both expertise centers as well as in patients who underwent unilateral versus bilateral nephrectomy. CONCLUSION This study shows that ADPKD patients who underwent a pretransplantation nephrectomy experienced more complaints compared with patients without nephrectomy. After nephrectomy and transplantation, QoL significantly improved in these patients, resulting in a similar QoL level in all transplanted ADPKD patients on short as well as long-term follow-up. Bilateral nephrectomy had no additional benefit on QoL compared with unilateral nephrectomy. Together, this indicates that a restrictive approach, wherein a unilateral procedure is performed only when strict indications are met, may improve QoL in these patients and is therefore justified.
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Study Type - Therapy (case series).4. What's known on the subject? and What does the study add? The indications and timing of native nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) is controversial, especially for those undergoing renal transplantation. Post-transplant unilateral native nephrectomy appears to be the preferred intervention compared to pre-transplant native nephrectomy. There seems to be substantial additive risk to bilateral over unilateral nephrectomy, especially prior to transplantation. Pre-transplant native nephrectomy should only be carried out when there are clear indications such as massive size preventing allograft placement, severe pain, early satiety, recurrent bleeding and infections, or suspected malignancy.To analyse indications, timing and outcomes of native nephrectomy in autosomal dominant polycystic kidney disease (ADPKD) patients listed for kidney transplantation.A retrospective analysis of all ADPKD patients who had a native nephrectomy prior to or following transplantation between January 2003 and December 2009 at a single centre, including those undergoing the sandwich technique (removal of the most severely affected native kidney prior to transplantation, and the other afterwards), was undertaken.There were 35 individuals in our cohort (M : F = 16 : 19), with a median age of 51.5 years (range 43-65). Twenty patients were in the pre-transplant nephrectomy group, 12 in the post-transplant group, and three underwent the sandwich technique. Indications for nephrectomy varied but were most commonly pain/discomfort, space for transplantation, ongoing haematuria, recurrent infections, and gastrointestinal pressure symptoms (early satiety). Seven individuals in the pre-transplant group and three in the post-transplant group required critical care admission after nephrectomy. Transient renal graft dysfunction occurred in two post-transplant bilateral nephrectomy patients. Two patients in the bilateral nephrectomy pre-transplant group and one in the bilateral nephrectomy post-transplant group died in the immediate post-operative period. No complications were noted in the sandwich technique group.Native nephrectomy in ADPKD is a major undertaking associated with significant morbidity especially in the pre-transplant group. Post-transplant unilateral nephrectomy appears to be the safest approach with fewest complications.
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Aim. To investigate the renal transplantation results for patients with end-stage renal disease (ESRD) due to autosomal dominant polycystic kidney disease (PKD). Materials and methods . The study included a prospective and retrospective analysis of the kidney transplantation results in 46 patients with ESRD caused by PKD, performed in the period from 2003 to 2018. Two groups of patients were formed. The comparison group consisted of 23 (50%) cases of kidney transplantation in patients whose polycystic-changed kidneys were preserved at the time of transplantation. The study group included 23 (50%) patients who underwent pretransplantation nephrectomy of native kidneys for clinical indications or to prepare for the waiting list. During the study, an algorithm of examination and surgical preparation for inclusion patients with PKD in the waiting list for kidney transplantation was developed and actively used. Results. The mean follow up period of patients who underwent pretransplantation nephrectomy was 3.6 ± 2.5 years, patients with preserved native kidneys - 5.3 ± 3.08 years (p > 0.05). Periodic pain in the lumbar region disturbed 12 (52.2%) patients with preserved polycystic-changed kidneys. The frequency of episodes of leukocyturia, bacteriuria and(or) hematuria significantly differed and amounted to 0.27 ± 0.35 cases per year in the study group, 1.49 ± 0.54 (p < 0.05) in the comparison group. Posttransplant nephrectomy of polycystic-changed kidneys at different times after transplantation was required in 5 (21.7%) patients. Five-year graft survival in the study group was 87.5%, in the comparison group - 76.1%. Among the patients of the comparison group, 76.4% of transplants lost their function after 10 years. The 5 and 10-year survival rates of patients with preserved native kidneys were 90.5% and 80%, respectively. In particular, there was one fatal outcome due to sepsis on the background of infection with cysts of preserved polycystic kidney. There were no deaths in the study group. Conclusion. Among patients whom polycystic-changed kidneys removed, there is a more favorable course of the post-transplant period due to the low frequency of infectious complications. More than 60% of patients with PKD need to perform nephrectomy of native kidneys during life for various reasons, including more than 21,7% need it after kidney transplantation due to complications during immunosuppressive therapy. Reasonable assessment of the polycystic kidneys and timely pretransplantation nephrectomy are an integral part of the preparation and management of the waiting list for transplantation of a patient with PKD.
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Transplantation is the optimal choice for renal replacement therapy in patients with autosomal dominant polycystic kidney disease (ADPKD). However, some specific issues should be addressed before transplantation, including nephrectomy of native kidneys, cystic liver involvement, screening for intracranial aneurysms and living related-donor transplantation. After kidney transplantation, patient and graft survival rates are excellent and the size of native kidneys typically declines. Nevertheless, a number of renal and extrarenal complications have been documented in kidney transplant recipients with ADPKD. In particular, renal cyst infections may occur in patients who did not undergo pretransplant nephrectomy. Moreover, an increased risk in new-onset diabetes mellitus and non-melanoma skin cancer has been reported, even though recent studies challenged these findings. In patients with ADPKD who did not undergo preventive nephrectomy, the risk of malignancy in native kidneys after renal transplantation is comparable to that reported in patients with other nephropathies. There is no evidence supporting the preferential use of mammalian target of rapamycin inhibitors as immunosuppressive drugs in transplant recipients with ADPKD.
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Abstract Background: In patients suffering from autosomal dominant polycystic liver and kidney disease (ADPLKD), organ transplantation often poses a technical challenge due to the large volume of both organs. To simplify the transplantation procedure by improving the exposure of anatomical structures, we introduce a novel surgical technique. Methods: Seven patients with ADPLKD were evaluated for simultaneous liver and kidney transplantation at the Jena University Hospital. The modified transplantation approach included hepatectomy and right-sided nephrectomy. After reperfusion of the liver graft, orthotopic kidney transplantation to the right-sided hemiabdomen was performed. Results: Preoperatively, the median liver volume and right kidney volume were morphologically determined by CT to be 9343 ml (± 3698.56) and 2770 ml (± 1128.78). The mean operation time was 342.43 minutes (± 68.77). Postoperatively, the patients were treated 6.28 days (± 2.50) in the intensive care unit and were discharged from the surgical ward approximately 28 days (± 5.66) after the operation with normal graft function. Conclusion: The modified simultaneous liver and kidney transplantation technique is an effective alternative surgical transplantation method for patients with ADPLKD. The new transplantation technique simplifies the transplantation procedure by improving the exposure of anatomical structures.
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Objective:To study the special characteristics of renal transplanatation in polycystic kidney disease, its postoperative complications and impacts on transplantation results.Methods:In this study, 42 cases of polycystic kidney receiving kidney transplantation (polycystic kidney disease group) and 80 cases of other diseases (control group) were retrospectively analyzed. Postoperative complications and patient/renal 1-year/5-year survival rates after renal transplantation were compared between two groups. Within the polycystic kidney disease group, we compared the patients with bilateral and unilateral nephrectomy to the patients without original kidney being removed for postoperative complications and 1-year/5-year patient/renal survival rates.Results:No significant differences in delay graft function, acute rejection, cardiovascular events and lung infections were found between the two groups (P 0.05). The ratio of urinary tract infections for patients within the polycystic kidney disease group was remarkably higher than for those within control group (P 0.05). Patients 1-year/5-year survival rates in the polycystic kidney disease and control group were respectively 95.24% and 97.50%, 83.81% and 88.92%; 1-year/5-year graft survival rate in the polycystic kidney disease and control group were respectively 90.48% and 94.97%, 69.55% and 66.54%. There was no significant difference in the aforementioned postoperative complications and 1-year/5-year patient/renal survival rates between the patients with nephrectomy and the patients without original kidney being removed within the polycystic kidney disease group (P 0.05).Conclusions:It was feasible that the polycystic kidney patients receive renal transplantation. The overall patient and graft survival rates did not differ between the polycystic kidney disease and control groups. The satisfactory clinical results could be obtained without removing the original polycystic kidney. We should take effective measures to prevent and control the urinary tract infections because of its high incidence after transplantation.
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A 48-year-old man presented for evaluation of the transplantation of a kidney from a living donor. He had a 14-year history of autosomal dominant polycystic kidney disease with progression to end-stage renal disease that required hemodialysis. Initially, transplantation was not possible because his voluminous, bilateral polycystic kidneys did not leave any space in his abdomen (Panel A). He underwent bilateral nephrectomy; the removed kidneys weighed a total of 22 kg (48.4 lb; 21.6% of his total body weight), and the larger right kidney measured 51 cm (Panel B). Three months after the nephrectomy, he underwent successful kidney transplantation from a . . .
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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.
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