Native nephrectomy for autosomal dominant polycystic kidney disease: before or after kidney transplantation?

Abstract

Study Type – Therapy (case series) Level of Evidence 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. OBJECTIVE To analyse indications, timing and outcomes of native nephrectomy in autosomal dominant polycystic kidney disease (ADPKD) patients listed for kidney transplantation. PATIENTS AND METHODS 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. RESULTS 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. CONCLUSION 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.

Tailoring the ‘Perfect Fit’ for Renal Transplant Recipients with End-stage Polycystic Kidney Disease: Indications and Timing of Native Nephrectomy

“…On the other hand, there are many authors who hold that it is wise to avoid any pre-transplant or simultaneous procedures (17,18). According to the retrospective analysis of these studies' outcomes, the estimated percentage of the patients with in vivo 31: 307-312 (2017) 310 (20) + ADPKD that needed NN was relatively low (around 20%) and the majority of complications that led to NN occurred during the post-transplant period (11,(15)(16)(17).…”

Laparoscopic pretransplant nephrectomy with morcellation in autosomic-dominant polycystic kidney disease patients with end-stage renal disease

“…Some authors suggested that concomitant unilateral or bilateral nephrectomy and transplantation are feasible and safe [18][19][20][21], while others preferred to perform NN in a pretransplant setting in order to increase the available space for the transplant, reduce the risk of post-transplant graft loses, and obtain a relief of the symptoms [3]. Moreover, Kirkman suggests a post-transplant unilateral nephrectomy due to the significant morbidity after pretransplant native nephrectomy in ADPKD patients [22].…”

La néphrectomie laparoscopique pour rein polykystique est faisable et reproductible

“…Néanmoins, cette voie d'abord requiert une large incision sous-costale ou une lombotomie qui entraînent une morbidité significative : Bennett rapporte un taux de 38 % de complications et une mortalité de 3 % sur une série de 31 patients traités par néphrectomie ouverte [3]. Des publications plus récentes rapportent des taux de complication entre 36 et 40 % [4,5,10,11]. C'est pour diminuer la morbidité que la voie laparoscopique a été décrite dans quelques séries pionnières [4,8].…”