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Navratil P, Chalupnik J, Merkl T, Spacek J, Matyskova Kubisova M, Safranek R, Novak I, Pacovsky J, Navratil P, Gunka I. Native nephrectomy in patients with autosomal dominant polycystic kidney disease in kidney transplant program: long-term single-center experience. Int Urol Nephrol 2025; 57:391-398. [PMID: 39402323 DOI: 10.1007/s11255-024-04234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 10/05/2024] [Indexed: 01/29/2025]
Abstract
INTRODUCTION Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder that frequently leads to end-stage renal disease. In this study, we examine the indications, procedures, and outcomes of native nephrectomy (NN) in ADPKD patients at our transplant center. Drawing on 25 years of clinical practice, we aim to provide insights into the surgical management of ADPKD, focusing on the specific factors influencing NN. MATERIALS AND METHODS A retrospective study was conducted involving ADPKD patients who underwent KT and NN between 1999 and 2023. Collected data encompassed demographics and surgery parameters, such as duration, hospital stay length, blood loss, and complications. Patients were classified based on the urgency (acute/planned) of the NN and its type (unilateral/bilateral), followed by an analysis of the outcomes per group. RESULTS Out of 152 patients post-KT for ADPKD, 89 (58.6%) underwent NN. The procedures were predominantly unilateral (71; 64%), with bilateral NN accounting for 40 (36%) cases. NN timing relative to KT was 31 (27.9%) pretransplant, 9 (8.1%) concomitant, 51 (45.9%) posttransplant, and 10 (9%) patients undergoing the sandwich technique. Acute NN were performed in 42 cases, while 69 were planned. Acute NNs were associated with longer surgeries, greater blood loss, and a higher incidence of perioperative complications compared to planned NNs. Specifically, unilateral acute NN had a 23.8% complication rate compared to 2.9% in planned cases; bilateral acute NN showed a 28.6% complication rate versus 4.3% in planned cases. CONCLUSION This investigation accentuates the significance of planning and selection in NN for ADPKD, factoring in the heightened risk of complications. Acute NN are linked to worse outcomes, including higher rates of complications. The data emphasize the necessity of tailored surgical approaches based on individual patient circumstances.
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Affiliation(s)
- Pavel Navratil
- Department of Urology, University Hospital Hradec Kralove, Sokolska 581, 500 05, Hradec Králové, Czech Republic.
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic.
| | - Jiri Chalupnik
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
| | - Tomas Merkl
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
- Military Faculty of Medicine, Department of Military Surgery, University of Defence, Hradec Králové, Czech Republic
- Department of Pediatric Surgery and Traumatology, University Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Jiri Spacek
- Department of Urology, University Hospital Hradec Kralove, Sokolska 581, 500 05, Hradec Králové, Czech Republic
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
| | - Michaela Matyskova Kubisova
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
- Department of Nephrology, University Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Roman Safranek
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
- Department of Nephrology, University Hospital Hradec Kralove, Hradec Králové, Czech Republic
| | - Ivo Novak
- Department of Urology, University Hospital Hradec Kralove, Sokolska 581, 500 05, Hradec Králové, Czech Republic
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
| | - Jaroslav Pacovsky
- Department of Urology, University Hospital Hradec Kralove, Sokolska 581, 500 05, Hradec Králové, Czech Republic
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
| | - Pavel Navratil
- Department of Urology, University Hospital Hradec Kralove, Sokolska 581, 500 05, Hradec Králové, Czech Republic
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
| | - Igor Gunka
- Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
- Department of Surgery, University Hospital Hradec Kralove, Hradec Králové, Czech Republic
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Gadelkareem RA, Abdelgawad AM, Mohammed N. Simultaneous kidney transplantation and ipsilateral native nephrectomy in patients with autosomal dominant polycystic kidney disease. World J Transplant 2022; 12:310-312. [PMID: 36187882 PMCID: PMC9516487 DOI: 10.5500/wjt.v12.i9.310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/14/2022] [Accepted: 08/26/2022] [Indexed: 02/05/2023] Open
Abstract
The simultaneous kidney transplantation and ipsilateral native nephrectomy for autosomal dominant polycystic kidney disease does not seem to be associated with increased rates of comorbidity and complications. This outcome can efficiently be achieved when the indication and surgical approach of native nephrectomy are properly justified.
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Affiliation(s)
- Rabea Ahmed Gadelkareem
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Amr Mostafa Abdelgawad
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Nasreldin Mohammed
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
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Abrol N, Prieto M. Simultaneous Hand-assisted Laparoscopic Bilateral Native Nephrectomy and Kidney Transplantation for Patients With Large Polycystic Kidneys. Urology 2020; 146:271-277. [PMID: 32858084 DOI: 10.1016/j.urology.2020.06.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe our technique of simultaneous hand-assisted laparoscopic bilateral native nephrectomy (BNN) and kidney transplantation (KT) in patients with autosomal dominant polycystic kidney disease and present our experience. MATERIALS AND METHODS We retrospectively reviewed a cohort of adult ESRD patients with symptomatic autosomal dominant polycystic kidney disease who underwent a hand-assisted laparoscopic BNN at the time of KT. We reviewed patients' and donor characteristics, and perioperative and postoperative outcomes. RESULTS A total of 52 patients underwent hand-assisted laparoscopic BNN at the time of KT from January 2014 to October 2019. The median age of the recipients was 53.4 years, 57.7% were males, and the median body mass index was 29.0 kg/m2. All but one received a kidney from a living donor and the majority (86.5%) were pre-emptive. One patient required a small bowel resection due to an intraoperative small bowel injury. There was no solid organ injury during the procedure. All patients showed immediate allograft function and a steady decline in serum creatinine. The median decline in the creatinine and hemoglobin on day 1 was 1.2 mg/dL (inter quartile range 0.6-2.3) and 2.2 g/dL (inter quartile range 1.4-3.0), respectively. CONCLUSION Simultaneous hand-assisted laparoscopic bilateral nephrectomy with KT through a modified Gibson incision is feasible and safe in the hands of an experienced laparoscopic surgeon without compromising allograft function.
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Affiliation(s)
- Nitin Abrol
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Mikel Prieto
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.
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Jänigen BM, Hempel J, Holzner P, Schneider J, Fichtner-Feigl S, Thomusch O, Neeff H, Pisarski P, Glatz T. Simultaneous ipsilateral nephrectomy during kidney transplantation in autosomal dominant polycystic kidney disease: a matched pair analysis of 193 consecutive cases. Langenbecks Arch Surg 2020; 405:833-842. [PMID: 32705344 PMCID: PMC7471159 DOI: 10.1007/s00423-020-01939-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND In end-stage renal transplant recipients with autosomal-dominant polycystic kidney disease (ADPKD), the imperative, optimal timing, and technique of native nephrectomy remains under discussion. The Freiburg Transplant Center routinely performs a simultaneous ipsilateral nephrectomy. METHODS From April 1998 to May 2017, we retrospectively analyzed 193 consecutive ADPKD recipients, receiving per protocol simultaneous ipsilateral nephrectomy and compared morbidity, mortality, and outcome with 193 non-ADPKD recipients of a matched pair control. RESULTS The incidence of surgical complications was similar with respect to severe medical, surgical, urological, vascular, and wound-related complications as well as reoperation rates and 30-day mortality. Intraoperative blood transfusions were required more often in the ADPKD (22.8%) compared with the control group (6.7%; p < 0.0001). Early postoperative urinary tract infections occurred more frequent (ADPKD 40.4%/control 29.0%; p = 0.0246). Time of surgery was prolonged by 30 min (ADPKD 169 min; 95%CI 159.8-175.6 min/control 139 min; 95%CI 131.4-145.0 min; p < 0.0001). One-year patient (ADPKD 96.4%/control 95.8%; p = 0.6537) and death-censored graft survival (ADPKD 94.8%/control 93.7%; p = 0.5479) were comparable between both groups. CONCLUSIONS With respect to morbidity and mortality, per protocol, simultaneous native nephrectomy is a safe procedure. Especially in asymptomatic ADPKD KTx recipients, the number of total operations can be reduced and residual diuresis preserved up until transplantation. In living donation, even preemptive transplantation is possible.
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Affiliation(s)
- Bernd Martin Jänigen
- Faculty of Medicine, Department of General and Digestive Surgery, Section of Transplant Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Johann Hempel
- Faculty of Medicine, Department of General and Digestive Surgery, Section of Transplant Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Philipp Holzner
- Faculty of Medicine, Department of General and Digestive Surgery, Section of Transplant Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Johanna Schneider
- Faculty of Medicine Department of Medicine IV, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Stefan Fichtner-Feigl
- Faculty of Medicine, Department of General and Digestive Surgery, Section of Transplant Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Oliver Thomusch
- Faculty of Medicine, Department of General and Digestive Surgery, Section of Transplant Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hannes Neeff
- Faculty of Medicine, Department of General and Digestive Surgery, Section of Transplant Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Przemyslaw Pisarski
- Faculty of Medicine, Department of General and Digestive Surgery, Section of Transplant Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Torben Glatz
- Faculty of Medicine, Department of General and Digestive Surgery, Section of Transplant Surgery, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
- Department of Surgery, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
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Change in kidney volume after kidney transplantation in patients with autosomal polycystic kidney disease. PLoS One 2018; 13:e0209332. [PMID: 30589879 PMCID: PMC6307782 DOI: 10.1371/journal.pone.0209332] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/04/2018] [Indexed: 12/16/2022] Open
Abstract
Background The indication to bilateral nephrectomy in patients with autosomal dominant polycystic kidney scheduled for kidney transplantation is controversial. Indeed, the progressive enlargement of cysts may increase the risk of complications and the need for nephrectomy. However, very few studies investigated the change in kidney volume after kidney transplantation. Material and methods In this prospective cohort study, the change in native kidney volume in polycystic patients was evaluated with magnetic resonance imaging. Forty patients were included in the study. Kidney diameters and total kidney volume were evaluated with magnetic resonance imaging in patients who underwent simultaneous nephrectomy and kidney transplantation and in patients with kidney transplant alone, before transplantation and 1 year after transplantation. Results There was a significant reduction of kidney volume after transplantation, with a mean degree of kidney diameters reduction varying from 12.24% to 14.43%. Mean total kidney volume of the 55 kidney considered in the analysis significantly reduced from 1617.94 ± 833.42 ml to 1381.42 ± 1005.73 ml (P<0.05), with a mean rate of 16.44% of volume decrease. More than 80% of patients had a volume reduction in both groups. Conclusions Polycystic kidneys volume significantly reduces after kidney transplantation, and this would reduce the need for prophylactic bilateral nephrectomy in asymptomatic patients.
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Argyrou C, Moris D, Vernadakis S. Tailoring the 'Perfect Fit' for Renal Transplant Recipients with End-stage Polycystic Kidney Disease: Indications and Timing of Native Nephrectomy. ACTA ACUST UNITED AC 2018; 31:307-312. [PMID: 28438856 DOI: 10.21873/invivo.11060] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/20/2017] [Accepted: 03/22/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The ideal timing of native nephrectomy in relation to kidney transplantation in patients with autosomal-dominant polycystic kidney disease (ADPKD) can be a very puzzling decision for transplant surgeons and remains a matter of debate. This review article aims to present current literature regarding this highly controversial issue. MATERIALS AND METHODS The MEDLINE/PubMed database was searched using "polycystic kidney disease", "renal/kidney transplantation" and "native nephrectomy" as key words. Our search was focused on the optimal timing of and indications for native nephrectomy in renal transplant recipients with ADPKD. RESULTS In symptomatic cases, pre-transplant unilateral or bilateral native nephrectomy seems appropriate, in order to alleviate symptoms. In cases that are provided with the option of living-donor transplantation, the performance of the simultaneous procedure could be of benefit. When the principal indication of native nephrectomy is the creation of space for the renal allograft, various studies highlight the safety of the simultaneous approach of either unilateral or bilateral nephrectomy. CONCLUSION No consensus exists on the appropriate timing for native nephrectomy in patients with ADPKD. Several issues to be addressed in the decision-making process are the importance of residual diuresis, the longer operative time along with the associated prolonged ischemia time and higher complication rate of the combined procedure.
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Affiliation(s)
| | - Demetrios Moris
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, U.S.A.
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Live Donor Renal Transplant With Simultaneous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease Is Feasible and Satisfactory at Long-term Follow-up. Transplantation 2016; 100:407-15. [PMID: 26262506 DOI: 10.1097/tp.0000000000000838] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Timing of bilateral nephrectomy (BN) is controversial in patients with refractory symptoms of autosomal dominant polycystic kidney disease (APKD) in need of a renal transplant. METHODS Adults who underwent live donor renal transplant (LRT) + simultaneous BN (SBN) from August 2003 to 2013 at a single transplant center (n = 66) were retrospectively compared to a matched group of APKD patients who underwent LRT alone (n = 52). All patients received general health and polycystic kidney symptom surveys. RESULTS Simultaneous BN increased operative duration, estimated blood loss, transfusions, intravenous fluid, and hospital length of stay. Most common indications for BN were pain, loss of abdominal domain, and early satiety. There were more intraoperative complications for LRT + SBN (6 vs 0, P = 0.03; 2 vascular, 2 splenic, and 1 liver injury; 1 reexploration to adjust graft positioning). There were no differences in Clavien-Dindo grade I or II (39% vs 25%, P = 0.12) or grade III or IV (7.5% vs 5.7%, P = 1.0) complications during the hospital course. There were no surgery-related mortalities. There were no differences in readmission rates (68% vs 48%, P = 0.19) or readmissions requiring procedures (25% vs. 20%, P = 0.51) over 12 months. One hundred percent of LRT + SBN allografts functioned at longer than 1 year for those available for follow-up. Survey response rate was 40% for LRT-alone and 56% for LRT + SBN. One hundred percent of LRT + SBN survey responders were satisfied with their choice of having BN done simultaneously. CONCLUSIONS Excellent outcomes for graft survival, satisfaction, and morbidity suggest that the combined operative approach be preferred for patients with symptomatic APKD to avoid multiple procedures, dialysis, and costs of staged operations.
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Simultaneous Native Nephrectomy and Kidney Transplantation in Patients With Autosomal Dominant Polycystic Kidney Disease. PLoS One 2016; 11:e0155481. [PMID: 27257690 PMCID: PMC4892472 DOI: 10.1371/journal.pone.0155481] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/29/2016] [Indexed: 12/17/2022] Open
Abstract
Introduction To evaluate the feasibility of simultaneous unilateral nephrectomy with kidney transplantation and to determine the effect of this procedure on perioperative morbidity and mortality and graft and patient survival. Methods Between January 2000 and May 2015, 145 patients with autosomal dominant polycystic kidney disease (ADPKD) underwent kidney transplantation. Of those, 40 (27.5%) underwent concurrent ipsilateral native nephrectomy (group NT). Patients in group NT were compared with patients with ADPKD not undergoing concurrent nephrectomy (group NT-) and asymptomatic patients undergoing pretransplant nephrectomy (group PNT). Results The average follow-up was 66 months. The graft survival rate at 1 and 5 years was 95% and 87.5% versus 93% and 76.2% in the NT and NT- groups, respectively (P = .903 and P = .544, respectively); 1-year patient survival was 100% for NT and 97% for NT- patients (P = .288), whereas 5-year patient survival was 100% and 92% for NT and NT- groups, respectively (P = .128). After propensity score matching (34 patients per group) no significant differences were observed in 1-year (97.1% in NT and 94.1%; P = 1) and 5-year (88.2% in NT and 91.2% in NT-; P = 1) graft survival, and in 1-year (100% for both groups; P = 1) and 5-year (100% in NT and 94.1% in NT-; P = 1) patient survival. Perioperative mortality was 0% among NT and 1.2% among NT- patients, whereas perioperative surgical complications were similar in both groups. One- and 5-year graft and patient survival were similar between the NT and PNT groups, but patients in the PNT group had significantly lower levels of hemoglobin and residual diuresis volumes at the time of transplant. Moreover, PNT patients had a longer pretransplant dialysis and a longer time on the waiting list. Conclusions Simultaneous unilateral nephrectomy does not have a negative effect on patient and graft survival in patients with ADPKD and is associated with low morbidity. Pretransplant nephrectomy should be restricted only to highly symptomatic patients, whereas unilateral nephrectomy in asymptomatic patients should be performed during kidney transplantation only if massive kidney size precludes graft positioning.
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Sáez ID, de la Llera JF, Tapia A, Chacón RA, Figueroa PA, Vivaldi BI, Domenech A, Horn CD, Coz F. Pre-transplant treatment of large polycystic kidney. World J Clin Urol 2016; 5:66-71. [DOI: 10.5410/wjcu.v5.i1.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/11/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the indications, optimal timing and outcomes of native nephrectomy and other techniques in pretransplant treatment of autosomal dominant polycystic kidney disease (PKD).
METHODS: A literature review was conducted using the PubMed and Epistemonikos databases. Keywords for pre-transplant surgical management of polycystic kidneys were: Transplant, treatment and PKD. Keywords for pre-treatment embolization of PKD were: Embolization, transplant and polycystic kidney disease. The inclusion criterions were all articles found using this search method. The exclusion criterions were articles found to include bias and not attending pre-transplant treatment options. Fifteen articles were included in our final analysis. Ten articles were found regarding embolization of PKD of which three reviews were selected for final analysis. The reviews were divided into pre transplant and intra transplant treatment for the surgical treatment of PKD. All articles meeting inclusion criteria were thoroughly analyzed by two independent reviewers. A third independent reviewer was consulted if the reviewers did not agree upon the inclusion or exclusion of a specific article. No statistical analysis was performed.
RESULTS: Studies vary regarding the technique used (open or laparoscopic), laterality (single or bilateral) and temporality of nephrectomy with respect to renal transplant (pre-transplant or simultaneous to transplant). Several groups argue in favor of simultaneous nephrectomy and kidney transplant since it avoids the deleterious effects of being anefric. Long-term results and patient satisfaction are acceptable. However, it is associated with increased operative time, transfusion rate, morbidity and length of hospital stay. Based on small sample studies, bilateral nephrectomy prior to transplant has been associated with a higher risk of morbidity and mortality. Studies on laparoscopic approach report it as a feasible and safe alternative to the open surgery approach, highlighting its lower complication rate, transfusions and shorter hospital stay. Arterial embolization of the kidney appears as an effective and low morbid alternative for the management of large native kidneys. The reduction in renal size allow transplant in a significant number of patients, which makes it an appealing alternative to surgery.
CONCLUSION: There is limited evidence regarding best pretrasnplant treatment of large PKD but to date embolization seems an appealing alternative to augment space for renal graft allocation.
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Chebib FT, Prieto M, Jung Y, Irazabal MV, Kremers WK, Dean PG, Rea DJ, Cosio FG, Torres VE, El-Zoghby ZM. Native Nephrectomy in Renal Transplant Recipients with Autosomal Dominant Polycystic Kidney Disease. Transplant Direct 2015; 1:e43. [PMID: 26981586 PMCID: PMC4788702 DOI: 10.1097/txd.0000000000000554] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 10/15/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Native nephrectomy (NNx) is often done in patients with autosomal dominant polycystic kidney disease (ADPKD). Controversy exists concerning the need and timing of nephrectomy in transplant candidates. We hypothesize that post-transplant NNx does not negatively impact patient and graft survival. METHODS Among 470 ADPKD transplant recipients included in the study, 114 (24.3%) underwent pre- (30.7%) or post-transplant (69.3%) NNx. Clinical data was retrieved from electronic records. Follow up was until death, graft loss or June 2014. Perioperative complications were compared between the surgical techniques (open or laparoscopic) and between the pre- and post-transplant nephrectomy groups. The effect of nephrectomy on graft survival was analyzed as a time-dependent covariate when performed post-transplant. RESULTS Mean age at transplant was 52.4 years, 53.8% were male, 93% white, 70% were from living donors and 56.8% were pre-emptive. Nephrectomy was done laparoscopically in 31% and 86% in the pre- and post- transplant nephrectomy groups, respectively. Complications were less common in those who underwent nephrectomy post-transplant (26.6% vs. 48%, p=0.03) but were similar regardless of surgical technique (open, 33.3% vs. laparoscopic 33%, p=0.66). Patient and graft survival were similar between those who underwent pre-transplant nephrectomy and the rest of the recipients. In the post-transplant nephrectomy group, nephrectomy did not affect patient (HR 0.77, CI 0.38-1.54, p=0.45) or graft survival (HR 1.0, CI 0.57-1.76, p=0.1). CONCLUSIONS Nephrectomy does not adversely affect patient or graft survival. Post-transplant nephrectomy is feasible when indicated without compromising long term graft outcome and has fewer complications than pre-transplant nephrectomy.
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Affiliation(s)
- Fouad T Chebib
- Department of Internal Medicine, Division of Nephrology and Hypertension
| | | | - Yeonsoon Jung
- Department of Internal Medicine, Division of Nephrology and Hypertension; Kosin University College of Medicine, Busan, South Korea
| | - Maria V Irazabal
- Department of Internal Medicine, Division of Nephrology and Hypertension
| | - Walter K Kremers
- William von Liebig Transplant Center; Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David J Rea
- Department of Surgery, Southern Illinois University, Springfield, Illinois, USA
| | - Fernando G Cosio
- Department of Internal Medicine, Division of Nephrology and Hypertension; William von Liebig Transplant Center
| | - Vicente E Torres
- Department of Internal Medicine, Division of Nephrology and Hypertension
| | - Ziad M El-Zoghby
- Department of Internal Medicine, Division of Nephrology and Hypertension
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Mehrabi A, Golriz M, Maier J, Fonouni H, Garoussi C, Hafezi M, Fard N, Faridar A, Rezaei N, Wiesel M, Mieth M, Morath C, Büchler MW, Tönshoff B, Zeier M, Schmidt J, Schemmer P. Long-Term Follow-Up of Kidney Transplant Recipients With Polycystic Kidney Disease. EXP CLIN TRANSPLANT 2015; 13:413-420. [PMID: 26450465 DOI: 10.6002/ect.2014.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2025]
Abstract
OBJECTIVES Patients with polycystic kidney disease are candidates for kidney transplant. We report the results of our single center study of 250 first transplant recipients with polycystic kidney disease (autosomal dominant [64%], medullary cystic [16%], autosomal recessive [6%], and nonspecified [14%]). MATERIALS AND METHODS Patient groups were divided and analyzed according to the origin of the graft (deceased donor or living donor). We also analyzed demographic data of donors and recipients, waiting time, duration of dialysis, transfusion, nephrectomy, hospitalization, morbidities, and graft and patient survival. The study was approved by the Ethical Review Committee of the Institute. All of the protocols conformed to the ethical guidelines of the 1975 Helsinki Declaration. RESULTS The deceased-donor group comprised 79% and the living-donor group comprised 21% of the cases. Nephrectomy was performed on 21% of the recipients. The deceased-donor group showed significantly higher values than the living-donor group regarding rate of hemodialysis (82% vs 68%), duration of dialysis (1571 vs 1002 days), waiting time (1129 vs 33 days), and blood transfusions (45% vs 27%). In deceased-donor versus living-donor transplant recipients, surgical complications included arterial stenosis (1% vs 0%), venous thrombosis (1% vs 0%), urine leakage (0.5% vs 1.9%), ureteral stenosis (0.5% vs 0%), reflux (0% vs 1.9%), lymphocele (11.7% vs 8.1%), and hernia (5.2% vs 8.1%), with no statistically significant differences shown between the groups. The living-donor group had graft and patient survival rates as high as the deceased-donor group. CONCLUSIONS The low rate of morbidity and excellent survival rates make kidney transplant an excellent option for patients with polycystic kidney disease. Although fear of future appearance of polycystic kidney disease may reduce the rate of related living donors, our study showed that graft and patient survival rates in the living-donor group were as high as in the deceased-donor group.
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Affiliation(s)
- Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Asimakopoulos AD, Gaston R, Miano R, Annino F, Mugnier C, Dutto L, Vespasiani G, Spera E, Hoepffner JL, Piechaud T. Laparoscopic pretransplant nephrectomy with morcellation in autosomic-dominant polycystic kidney disease patients with end-stage renal disease. Surg Endosc 2014; 29:236-44. [PMID: 25125090 DOI: 10.1007/s00464-014-3663-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 05/31/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic nephrectomy (LN) in end-stage autosomic-dominant polycystic kidney disease (ADPKD) requires a large abdominal incision for the specimen extraction. OBJECTIVE The objective of this study was to describe our technique of LN for end-stage ADPKD followed by morcellation (LNM) of the specimen and extraction through a minimal abdominal incision. METHODS The medical records of 19 consecutive patients who underwent pretransplant LNM between 2008 and 2011 by a single experienced laparoscopic surgeon were analyzed. Morcellation was performed with the Gynecare Morcellex™ Tissue morcellator, Ethicon. RESULTS AND LIMITATIONS All cases but one were completed laparoscopically. Mean specimen weight was 1,026.8 g. Mean duration of the procedure, estimated blood loss, and hospital stay were 131.3 min, 52.1 ml, and 7.9 days, respectively. Specimens were extracted through a 12-mm trocar in 10/18 patients and through a 3-cm incision in 9/18 cases. Postoperatively, three complications were observed (Clavien grades II, I, and II). The only case of incisional hernia was observed in the converted procedure. Major limitation of the study is its retrospective design. CONCLUSIONS In our preliminary series and in the hands of a very experienced laparoscopist, LNM for ADPKD appears as a modern, mini-invasive, and safe technique. Specimen's extraction through a small abdominal incision reduces postoperative pain and incisional hernias and guarantees the final cosmetic result of laparoscopy. The reduced overall morbidity could reduce the period between nephrectomy and transplantation.
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Affiliation(s)
- Anastasios D Asimakopoulos
- UOC of Urology, Department of Surgery, University of Rome Tor Vergata, Policlinico Casilino, Viale Oxford 81, 00133, Rome, Italy,
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Takiar V, Caplan MJ. Polycystic kidney disease: pathogenesis and potential therapies. Biochim Biophys Acta Mol Basis Dis 2010; 1812:1337-43. [PMID: 21146605 DOI: 10.1016/j.bbadis.2010.11.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 11/23/2010] [Accepted: 11/26/2010] [Indexed: 10/18/2022]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is a prevalent, inherited condition for which there is currently no effective specific clinical therapy. The disease is characterized by the progressive development of fluid-filled cysts derived from renal tubular epithelial cells which gradually compress the parenchyma and compromise renal function. Current interests in the field focus on understanding and exploiting signaling mechanisms underlying disease pathogenesis as well as delineating the role of the primary cilium in cystogenesis. This review highlights the pathogenetic pathways underlying renal cyst formation as well as novel therapeutic targets for the treatment of PKD. This article is part of a Special Issue entitled: Polycystic Kidney Disease.
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Affiliation(s)
- Vinita Takiar
- Department of Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT, USA
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Papalia R, Simone G, Guaglianone S, Forastiere E, Gallucci M. Single-setting laparoscopic approach to synchronous urologic tumors. J Endourol 2010; 24:1967-73. [PMID: 20969461 DOI: 10.1089/end.2010.0240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To evaluate the feasibility and safety of two or three concomitant laparoscopic procedures in the same patient in one anesthesia session. PATIENTS AND METHODS Data were reviewed for 32 patients for whom two or three concomitant laparoscopic surgeries at our institution were considered. Preoperative details, port position, surgical time, blood loss, complications, hospital stay, and postoperative recovery were analyzed. RESULTS Thirty-two patients underwent two concomitant laparoscopic procedures and one patient three procedures. Surgical time was increased by 6 minutes because of the repositioning time of the patients. There were no complications during all procedures, and hospital stay was not increased, being limited only by the first procedure. CONCLUSION Planned laparoscopic surgery for two or three urologic malignancies is feasible in one anesthesia session, thereby reducing cost and overall hospital stay for the patient without any increased risk of perioperative morbidity. The decision to continue with the second or the third procedures depends on the successful conclusion of the former procedures in a reasonable time and without any complications.
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Affiliation(s)
- Rocco Papalia
- Regina Elena National Cancer Institute of Rome, Rome, Italy
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Lee DI, Clayman RV. Hand-Assisted Laparoscopic Nephrectomy in Autosomal Dominant Polycystic Kidney Disease. J Endourol 2004; 18:379-82. [PMID: 15253790 DOI: 10.1089/089277904323056942] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Among patients with renal insufficiency secondary to autosomal dominant polycystic kidney disease (ADPKD), the onset of refractory urinary infection, hypertension, pain, or hematuria often necessitates a nephrectomy. However, the huge size of these kidneys makes a standard laparoscopic approach difficult, and the increased fragility of these patients makes an open nephrectomy risky. A compromise position has been found in the realm of hand-assisted laparoscopic techniques, especially for patients in need of a bilateral nephrectomy. TECHNIQUE Hand-assisted laparoscopic nephrectomy (HALN) is performed via a hand-assist device placed in the midline. A subxiphoid midline port and a midclavicular subcostal port are placed on the ipsilateral side. The right hand is inserted for left nephrectomy and the left hand for a right nephrectomy. The laparoscope is introduced into the subxiphoid port, and the surgeon's primary working instrument is passed via the midclavicular port. Occasionally, it is helpful to place a 5-mm subcostal port in the midaxillary line to aid in retracting the kidney. Once the kidney is devascularized, it is removed via the 7- to 8-cm hand-assist incision; drainage of cysts may be necessary during extraction to reduce the kidney size so that it can be withdrawn. If a bilateral approach is to be done, then after the first nephrectomy, the lateral 5-mm port is closed, and the table is rolled such that the contralateral side is elevated about 30 degrees to 45 degrees; a subcostal midclavicular 12-mm port is placed, and, if needed, a 5-mm port is inserted subcostally in the midaxillary line for renal retraction. RESULTS Seven bilateral hand-assisted laparoscopic nephrectomy cases have been reported. In two reports, the mean operating times were 4.8 and 5.5 hours. The mean estimated blood loss was <350 mL. CONCLUSION The hand-assisted laparoscopic approach makes both unilateral and bilateral nephrectomy feasible in ADPKD patients with acceptable morbidity.
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Affiliation(s)
- David I Lee
- Department of Urology, University of California-Irvine, Orange, California, USA
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