Pretransplant Nephrectomy for Large Polycystic Kidneys in ADPKD (Autosomal Dominant Polycystic Kidney Disease) Patients

Abstract

Introduction and Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is characterized by relentless development and growth of cysts causing progressive kidney enlargement and progressive renal failure. Diuresis and fluid volume control is often preserved also during the dialytic period. Some recent studies have proposed peritoneal dialysis (PD) as a valid alternative even for ADPKD, which was once considered a relative contraindication because of the possible limited intraperitoneal space and the risk of hernia. Native kidneys are not routinely removed before transplantation in consideration of the significant morbidity and mortality associated to the procedure. Indications for nephrectomy include recurrent or severe infection, symptomatic nephrolithiasis, recurrent or severe bleeding, intractable pain, suspicion of renal cancer and space restrictions prior to transplantation. Considering that after a trans-peritoneal nephrectomy the peritoneum often results damaged and unsuitable for PD, the aim of this study is to assess if and how long after nephrectomy PD may be effectively resumed. Materials and Method A retrospective analysis of ADPKD patients in waiting list for kidney transplant which underwent nephrectomy in our trasplant surgery department between December 2012 and October 2017 was carried out. All patients were included, male and female, and the indications for nephrectomy were symptoms (pain, urinary tract infections or hematuria) or steric hindrance. In all cases the surgical procedure was performed with meticoulus technique by laparotomic access with subcostal incision with recostruction of the posterior peritoneal flap in order to preserve peritoneal cavity avoiding visceral adhesions and for future peritoneal dialysis recovery. Results and Discussion From December 2012 to October 2017 30 ADPKD patients underwent nephrectomy in our transplant surgery department. The patients were 18 (63%) males and 12 (37%) females, with a mean age of 54±8. 9 patients were in peritoneal dialysis, 19 in hemodialysis and 2 were affected by stage 5 chronic renal failure. 4 patients underwent nephrectomy after trasplantation. The indication for nephrectomy was steric hindrance in 43,3% of cases, while 56,6% of patients had symptoms (52,9% UTI, 35,3% haematuria and 11,7% pain). No complications were reported after surgery. Among patients treated with peritoneal dialysis before nephrectomy 3 underwent nephrectomy after trasplantation, 3 started hemodialysis and 3 resumed peritoneal dialysis 30 days after surgery. Conclusions Monolateral nephrectomy with a laparotomic approach seems to be a safe and feasible procedure also for very large kidneys. A meticulous technique with accurate peritoneal preservation avoids commons postsurgical complications and may allow a rapid peritoneal dialysis resume.