Live Donor Renal Transplant With Simultaneous Bilateral Nephrectomy for APKD: 10-Year Experience.

Abstract

Bilateral native nephrectomy (BNx) is indicated in patients with autosomal dominant polycystic kidney disease (APKD) with medically refractory symptoms and ESRD. However, timing of BNx is controversial. We report the largest study to date examining outcomes for patients with ESRD secondary to APKD who have undergone simultaneous BNx and live donor renal transplant (LRT). Methods: A retrospective review for all adults who underwent simultaneous BNx and LRT from August 2003 to August 2013 at a single, high volume transplant center yielded 66 patients, who were compared to 52 APKD patients who underwent LRT without BNx. Results: Mean age was 50 yrs. There were no differences for age, race, sex, BMI, ASA class, and dialysis status. As expected, simultaneous BNx increased operative duration, EBL, transfusion requirements, fluid administration, and hospital LOS (6.6 vs. 4.8 d). Six patients had staged BNx, of which 4 had BNx prior to LRT (mean 13 mo interval) and required a mean 37 sessions of HD vs 0 for simultaneous BNx. All 6 staged operations required additional hospital stays (mean 9.3 d). Most common indications for BNx were pain, loss of abdominal domain, and early satiety. Simultaneous BNx group had 6 vs 0 (p=.03) intraoperative complications, specifically 2 vascular, 2 splenic, and 1 liver injury, plus 1 immediate re-exploration to adjust graft positioning, Using the Clavien-Dindo classification for postoperative events, there were no significant differences in Grade I or II (pharmacologic intervention or transfusion; 39% vs 25%, p=.12) or Grade III or IV (life or graft-threatening, requiring surgery; 7.5% vs 5.7%, p=1.0) complications. There were no surgery related mortalities. There were no significant differences in general readmission rates (68% vs. 48%, p=.19) or those requiring additional procedure (25% vs. 20%, p=.51) over 12 months. In the BNx group, 100% of allografts functioned at >1 month follow-up and > 1 year for all patients available for 1 year follow-up. Conclusions: The excellent outcomes for patient and graft survival and incidence of morbidities suggest that the simultaneous approach be preferred for patients with symptomatic APKD to avoid multiple operative procedures, dialysis, and costs related to staged operations.