Long-term cardiovascular effects of pre-transplant native kidney nephrectomy in children

Abstract

Left ventricular (LV) hypertrophy (H) and hypertension are prevalent in children with end-stage renal disease (ESRD) and after renal transplantation. Severe hypertension prior to renal transplantation has traditionally been an indication for native kidney nephrectomy. The impact of nephrectomy on cardiovascular disease has not been well documented. We retrospectively evaluated echocardiographic and ambulatory blood pressure monitoring (ABPM) data in 67 young adults who had undergone transplantation in the pediatric age with a mean follow-up of 10.4 years. Unilateral or bilateral nephrectomies had been performed in 32 patients. The number of antihypertensive drugs used prior to transplantation was significantly higher in the nephrectomized groups. At follow-up the amount of antihypertensive medications was similar between groups and no significant differences were observed in mean arterial blood pressure (MAP) or LV mass index (LVMi). LVH was observed in 50% of non-nephrectomized patients, 45.4% of patients with unilateral nephrectomy, and 44.4% of patients without native kidneys (p = n.s.). In conclusion, unilateral or bilateral nephrectomies prior to transplantation do not appear to influence blood pressure control or the prevalence of LVH after renal transplantation. Longitudinal studies with repeated assessment of LVMi, before and after renal transplantation, are needed to assess the impact of residual activity of native kidneys on arterial blood pressure and cardiac structural changes, even in normotensive patients, to evaluate cardiovascular morbidity.

Native nephrectomy in pediatric transplantation – Less is more!

“…For some underlying renal diseases there was variation in the management of unilateral PTNN both in our series and other reported series [5]. It is unclear whether unilateral PTNN is adequate, or if bilateral PTNN is performed whether this should be a synchronous or staged procedure.…”

“…Previous studies describing effects of PTNN on children with focal segmental glomerulosclerosis (FSGS) have suggested that bilateral nephrectomy prior to transplant reduces the risk of recurrent disease in the graft, but the controlled data to support this are lacking [4]. In a recent series examining cardiovascular effects of hypertensive children with established renal failure (ERF), almost half of the children had undergone PTNN, and no additional benefit was seen in those undergoing bilateral procedures [5].…”

Hypertension in the Pediatric Kidney Transplant Recipient

“…Occasionally, native nephrectomies are performed prior to or at the time of transplant to help with management of hypertension (22). However, this is becoming an uncommon practice because recent data suggest that the benefit is limited (23). …”

Native Nephrectomy in Relation to Pediatric Renal Transplantation

“…Indications were drug-resistant proteinuria in six children, recurrent upper tract urosepsis in another six children, refractory hypertension in four children, malignancy/ malignant predisposition in four children and concomitant procedure during ureterocystoplasty in one child [8]. [6,[17][18][19][20][21][22][23][24]. Many causes of ESRD are associated with loss of proteins in urine.…”

“…Hypertension is common in patients with chronic kidney disease and may be caused by fluid overload or by increased renin secretion [20]. Cavallini, et al [21] compared retrospectively young adults who had undergone RTx in the pediatric age (with a mean follow-up of 10 years) with or without NN for hypertension. Fourteen patients had undergone a bilateral pre-RTx NN, 18 had undergone a unilateral NN, mostly at the time of transplantation and the native kidneys were left in place in the remaining 35 patients.…”