Pain management in polycystic kidney disease

Health-related quality of life in patients with autosomal dominant polycystic kidney disease and CKD stages 1-4: a cross-sectional study

BACKGROUND

In people with early autosomal dominant polycystic kidney disease (ADPKD), average total kidney volume (TKV) is 3 times normal and increases by an average of 5% per year despite a seemingly normal glomerular filtration rate (GFR). We hypothesized that increased TKV would be a source of morbidity and diminished quality of life that would be worse in patients with more advanced disease.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

1,043 patients with ADPKD, hypertension, and a baseline estimated GFR (eGFR)> 20mL/min/1.73m(2).

PREDICTORS

(1) eGFR, (2) height-adjusted TKV (htTKV) in patients with eGFR> 60mL/min/1.73m(2).

OUTCOMES

36-Item Short Form Health Survey (SF-36) and the Wisconsin Brief Pain Survey.

MEASUREMENTS

Questionnaires were self-administered. GFR was estimated from serum creatinine using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. htTKV was measured by magnetic resonance imaging.

RESULTS

Back pain was reported by 50% of patients, and 20% experienced it "often, usually, or always." In patients with early disease (eGFR> 60mL/min/1.73m(2)), there was no association between pain and htTKV, except in patients with large kidneys (htTKV> 1,000mL/m). Comparing across eGFR levels and including patients with eGFRs< 60mL/min/1.73m(2), patients with eGFRs of 20-44mL/min/1.73m(2) were significantly more likely to report that pain impacted on their daily lives and had lower SF-36 scores than patients with eGFRs of 45-60 and ≥60mL/min/1.73m(2). Symptoms relating to abdominal fullness were reported by 20% of patients and were related significantly to lower eGFRs in women, but not men.

LIMITATIONS

TKV and liver volume were not measured in patients with eGFR < 60mL/min/1.73m(2). The number of patients with eGFRs< 30mL/min/1.73m(2) is small. Causal inferences are limited by cross-sectional design.

CONCLUSIONS

Pain is a common early symptom in the course of ADPKD, although it is not related to kidney size in early disease (eGFR> 60mL/min/1.73m(2)), except in individuals with large kidneys (htTKV> 1,000 mL/m). Symptoms relating to abdominal fullness and pain are greater in patients with more advanced (eGFR, 20-45mL/min/1.73m(2)) disease and may be due to organ enlargement, especially in women. More research about the role of TKV in quality of life and outcomes of patients with ADPKD is warranted.

Quality of life of patients with ADPKD-Toranomon PKD QOL study: cross-sectional study

Background

The quality of life (QOL) of patients with autosomal dominant polycystic kidney disease (ADPKD) has not been investigated well. This study was performed to clarify the QOL of patients with ADPKD and to identify factors that affected their QOL.

Methods

The present cross-sectional study is part of a prospective observational study on the QOL of ADPKD patients. Patients with ADPKD who were referred to Toranomon Hospital between March 2010 and November 2012 were enrolled. The short form-36 (SF-36) questionnaire and our original 12-item questionnaire were used to evaluate QOL. We analyzed the results of the questionnaire survey and then investigated correlations between QOL and clinical features.

Results

A total of 219 patients (93 men and 126 women) were enrolled and their mean age was 55.1±10.8 years. There were 108 patients on dialysis. The SF-36 scores (PCS, MCS, and RCS) of all patients were significantly lower than the mean scores for the Japanese population. Stepwise multiple regression analysis demonstrated that Hb, serum Alb, ascites, and cerebrovascular disease all had a significant influence on the PCS, while mental disease had a significant influence on the MCS and serum Alb significantly influenced the RCS. The total liver and kidney volume (TLKV) and the dialysis status were not significantly associated with any of the SF-36 scores by multiple regression analysis, but TLKV was closely correlated with abdominal distention and distention had an important influence on QOL. Pain, sleep disturbance, heartburn, fever, gross hematuria, and anorexia also affected QOL, but these variables were not correlated with TLKV.

Conclusions

Several factors influence QOL, so improving symptoms unrelated to TLKV as well as reducing abdominal distention can improve the QOL of ADPKD patients.

Patient-reported outcomes in clinical trials of CKD-related therapies: report of a symposium sponsored by the national kidney foundation and the U.S. Food and Drug Administration

The National Kidney Foundation and the U.S. Food and Drug Administration (FDA) convened a symposium in September 2010, bringing together more than 70 experts, including representatives from the FDA, the National Institutes of Health, the Critical Path Institute, nephrologists, patients, and the pharmaceutical industry to discuss the feasibility and process of developing patient-reported outcome (PRO) measures to access how patients feel or function to be used in clinical trials for regulatory review of treatment benefit. Three disease areas were evaluated for development of end point models in which PRO measures may be useful: anemia secondary to chronic kidney disease, autosomal dominant polycystic kidney disease (ADPKD), and nephrotic syndrome. The participants thought it valuable to use observational data to generate hypotheses regarding patient baseline characteristics that are likely to predict clinically important changes in PROs in response to anemia treatment and to design adequately powered blinded randomized controlled trials of anemia treatment using PROs as primary rather than secondary end points. Validated PRO instruments that reflect the patient experience in ADPKD and nephrotic syndrome are essential to incorporate into clinical trials of new therapeutic interventions because glomerular filtration rate decline may occur late in the disease course, at which point therapeutic benefit is less likely. Conference attendees addressed how PRO measures could be used to evaluate, monitor, provide care, and facilitate the introduction of treatments for patients with these challenging conditions.

Acute abdomen and hemorrhagic shock caused by spontaneous rupture of renal cyst in autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease is an important cause of end stage renal failure. Rarely, these patients may present with hemorrhagic shock caused by rupture of the renal cyst. The aim of this study was to report a rare case of a patient who arrived at the emergency department with autosomal dominant polycystic kidney disease presenting with acute abdominal pain and hemorrhagic shock. A 58-year-old male with chronic renal failure was admitted to the emergency department with acute abdominal pain and hemorrhagic shock. The patient was admitted to the Department of Surgery with diagnosis of acute abdomen and perirenal hematoma. Although the patient was on conservative treatment, his symptoms did not improve and the patient was operated emergently. During exploration, there was bleeding from the right polycystic kidney, which was 30×20 cm in dimension. The patient underwent nephrectomy and drainage of the hematoma, and was discharged on the fifth postoperative day without any problems. Bleeding due to rupture of a cyst in autosomal dominant polycystic kidney disease occurs rarely but it may be life threatening. Although conservative methods are often preferable in treatment, surgery can be life saving for patients in whom the clinical situation does not improve.

One hundred consecutive kidney transplantations with simultaneous ipsilateral nephrectomy in patients with autosomal dominant polycystic kidney disease

PURPOSE

Surgical management of autosomal dominant polycystic kidney disease (ADPKD) in patients awaiting renal transplantation is a challenging task.

METHODS

From 1998 to 2009, a total of 100 consecutive renal transplantations with simultaneous unilateral nephrectomy were performed in 59 men and 41 women with ADPKD and end-stage renal failure. About 38% received kidney allografts from living donors. The ipsilateral polycystic kidney was removed at the time of renal transplantation. Immunosuppressive therapy was not modified. Cold ischaemia time was 155 (38-204 min) versus 910 min (95-2760 min) for living versus deceased donor transplantation. Mean weight of removed kidneys was 2002 g (414-8850 g). Mean follow-up was 3.0 years (0.8-10.0 years).

RESULTS

Overall patient and graft survival were 97 and 96% at 1 year and 93 and 80% at 5 years, respectively. Serum creatinine at current follow-up was 1.49 (0.8-2.8) mg/dL. Surgical complications, which might be associated with simultaneous nephrectomy requiring re-operation, occurred in 12% (lymphocele 4%, hernia 4%, post-operative haematoma or bleeding 4%). None of the patients died peri-operatively.

CONCLUSION

Renal transplantation with simultaneous unilateral nephrectomy in ADPKD is a reasonable procedure for patients suffering from massively enlarged native kidneys.

Kidney volume changes in patients with autosomal dominant polycystic kidney disease after renal transplantation

BACKGROUND

Few studies have investigated whether the volume of native kidney and liver (when combined with polycystic disease) in patients with autosomal dominant polycystic kidney disease (ADPKD) decreases after renal transplantation.

METHODS

Changes in the volume of native kidney (bilateral: n=28; unilateral: n=5) and liver (concomitant polycystic disease: n=18) were analyzed in 33 patients with ADPKD, who underwent renal transplantation. Volumetry was retrospectively conducted using simple computed tomography scan data 6 months before transplantation, at the time of transplantation, and 1, 3, and 5 years after transplantation. Volume change was calculated on the basis of the value at the time of transplantation.

RESULTS

Mean±standard deviation values of bilateral native kidney volume were 3100±1417 (range: 756 to 6525; median: 2499) cm at the time of transplantation. Kidney volumes were significantly reduced in all but one patient after renal transplantation, decreasing by 37.7% and 40.6% at 1 and 3 years, respectively. The major proportion of the decrease was observed within the first year posttransplantation. In contrast, 16 of 18 patients showed significant increase of liver volumes after renal transplantation. The mean rates of increase were 8.6% and 21.4% at 1 and 3 years, respectively.

CONCLUSIONS

As the volume of native polycystic kidneys could be reduced after renal transplantation, resection would be unnecessary if the space for kidney graft is available in the absence of infection, bleeding, or malignancy. When ADPKD is combined with polycystic liver disease, the possibility of intolerable symptoms caused by growing liver cysts should also be taken into account.

Femoral nerve injury as a complication of percutaneous simple renal cyst sclerotherapy with ethanol: a case report

Simple renal cysts are benign, common, and often asymptomatic disease in old age, sometimes treated with ethanol sclerotherapy. We report a case of iatrogenic femoral nerve injury following percutaneous injection of ethanol into a renal cyst under sedation. The percutaneous injection was guided by sonography. At the end of the procedure, the cyst ruptured so the patient progressed to loss of consciousness due to alcohol intoxication. Ethanol was damaged to the femoral nerve, so patient was developed with limping, numbness, and weakness in anteromedial aspect of the right thigh. To the best of our knowledge, this is the first report of femoral nerve injury caused by percutaneous simple renal cyst sclerotherapy with ethanol. This rare event has not been previously described, Physicians should be aware of the possibility of this complication.

Management of chronic pain in a patient with autosomal dominant polycystic kidney disease by sequential celiac plexus blockade, radiofrequency ablation, and spinal cord stimulation

Chronic pain frequently is associated with autosomal dominant polycystic kidney disease and is a significant cause of morbidity. The classic approach to treat pain in patients with this disease starts with nonpharmacologic therapy and progresses to high-dose opioid therapy and more invasive procedures, including surgery. We present the case of a 43-year-old white woman presenting in our clinic with poorly controlled chronic left flank and epigastric pain secondary to autosomal dominant polycystic kidney disease despite high-dose opioids and multiple cyst decompression procedures. After temporarily successful management with celiac plexus neurolysis and intercostal nerve radiofrequency ablations for years, the next more permanent step was dorsal column neurostimulation, affording excellent analgesia with significantly improved quality of life to this day.

Pain in chronic kidney disease: prevalence, cause and management

Pain is an unpleasant sensory and emotional experience and is the most common symptom experienced by renal patients. It can be caused by primary co-morbid diseases, renal replacement therapies, medication or treatment side effects, and its intensity varies from moderate to severe. Pain management in renal patients is difficult, since the distance between pain relief and toxicity is very small. This paper will provide an algorithm for pain management proposed using paracetamol, nonsteroid anti-inflamatory drugs (NSAIDs), mild and stronger opioids as well as complementary techniques. Quality of Life (QoL) and overall enhancement of the patient experience through better pain management are also discussed. To improve pain management it is essential that nurses recognise that they have direct responsibilities related to pain assessment and tailoring of opioid analgesics and better and more detailed education.

Tolvaptan in autosomal dominant polycystic kidney disease: three years' experience

BACKGROUND AND OBJECTIVES

Autosomal dominant polycystic kidney disease (ADPKD), a frequent cause of end-stage renal disease, has no cure. V2-specific vasopressin receptor antagonists delay disease progression in animal models.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

This is a prospectively designed analysis of annual total kidney volume (TKV) and thrice annual estimated GFR (eGFR) measurements, from two 3-year studies of tolvaptan in 63 ADPKD subjects randomly matched 1:2 to historical controls by gender, hypertension, age, and baseline TKV or eGFR. Prespecified end points were group differences in log-TKV (primary) and eGFR (secondary) slopes for month 36 completers, using linear mixed model (LMM) analysis. Sensitivity analyses of primary and secondary end points included LMM using all subject data and mixed model repeated measures (MMRM) of change from baseline at each year. Pearson correlation tested the association between log-TKV and eGFR changes.

RESULTS

Fifty-one subjects (81%) completed 3 years of tolvaptan therapy; all experienced adverse events (AEs), with AEs accounting for six of 12 withdrawals. Baseline TKV (controls 1422, tolvaptan 1635 ml) and eGFR (both 62 ml/min per 1.73 m(2)) were similar. Control TKV increased 5.8% versus 1.7%/yr for tolvaptan (P < 0.001, estimated ratio of geometric mean 0.96 [95% confidence interval 0.95 to 0.97]). Corresponding annualized eGFR declined: -2.1 versus -0.71 ml/min per 1.73 m(2)/yr (P = 0.01, LMM group difference 1.1 ml/min per 1.73 m(2)/yr [95% confidence interval 0.24 to 1.9]). Sensitivity analyses including withdrawn subjects were similar, whereas MMRM analyses were significant at each year for TKV and nonsignificant for eGFR. Increasing TKV correlated with decreasing eGFR (r = -0.21, P < 0.01).

CONCLUSION

ADPKD cyst growth progresses more slowly with tolvaptan than in historical controls, but AEs are common.

TRPP channels and polycystins

The founding member of the TRPP family, TRPP2, was identified as one of the disease genes causing autosomal dominant polycystic kidney disease (ADPKD). ADPKD is the most prevalent, potentially lethal, monogenic disorder in humans, with an average incidence of one in 400 to one in 1,000 individuals worldwide. Here we give an overview of TRPP ion channels and Polycystin-1 receptor proteins focusing on more recent studies. We include the Polycystin-1 family since these proteins are functionally linked to TRPP channels.

Evaluation and management of pain in autosomal dominant polycystic kidney disease

Transient episodes of pain are common in autosomal dominant polycystic kidney disease (ADPKD). A small fraction of patients have disabling chronic pain. In this review, we discuss the etiologies of pain in ADPKD; review how ADPKD patients should be assessed; and discuss medical, surgical, and other management options.

Cyst ablation using a mixture of N-butyl cyanoacrylate and iodized oil in patients with autosomal dominant polycystic kidney disease: the long-term results

Objective

We wanted to assess the long-term results of cyst ablation with using N-butyl cyanoacrylate (NBCA) and iodized oil in patients with autosomal dominant polycystic kidney disease (ADPKD) and symptomatic cysts.

Materials and Methods

Cyst ablation using a mixture of NBCA and iodized oil was performed in 99 cysts from 21 patients who had such symptoms as abdominal distension and pain. The collapse or reaccumulation of the ablated cysts after the procedure was assessed during the follow-up period of 36 to 90 months. The treatment effects, including symptom relief, and the clinical data such as the blood pressure and serum creatinine levels were also assessed, together with the complications.

Results

The procedure was technically successful in all 99 cysts from the 21 patients. Any procedure-related significant complications were not detected. Seventy-seven of 99 cysts (78%) were successfully collapsed on the follow-up CT. Twenty-two cysts showed reaccumulation during long-term follow-up period. The clinical symptoms were relieved in 17 of the 21 patients (76%). Four of 12 patients (33%) with hypertension and two of six patients (33%) with azotemia were improved. End stage renal disease (ESRD) occurred in six of the 21 patients (28%) during the follow-up period. The mean age of ESRD in our patients was 57 years. The mean time interval for the development of ESRD was 19 months.

Conclusion

Ablation using a mixture of NBCA and iodized oil may be an effective, safe method for obtaining symptom relief in patients with ADPKD.

Experience with autosomal dominant polycystic kidney disease in patients before and after renal transplantation: a 7-year observation

OBJECTIVE

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the presence of multiple cysts in both kidneys. Symptoms of the disease may arise either from the presence of cysts or from increasing loss of kidney function. First symptoms usually appear in the third decade of life: lumbar pain, urinary tract infections, arterial hypertension, or renal colic due to cyst rupture or coexistent nephrolithiasis. An early diagnosis, male gender, large kidneys by sonography, arterial hypertension, hematuria, and urinary tract infections are predictive factors of a faster progression of the disease. Our aim was to establish the indications for nephrectomy among symptomatic ADPKD patients before kidney transplantation and to assess the risks of posttransplantation complications among ADPKD patients without nephrectomy.

PATIENTS AND METHODS

The observed group consisted of 183 patients with ADPKD among whom 50 (27.3%) underwent kidney transplantation during a 7-year observation period (2000-2007). Among those subjects were 3 groups: (I) nephrectomy preceding transplantation; (II) nephrectomy during kidney transplantation; and (III) without nephrectomy.

RESULTS

Among group I before transplantation we observed: arterial hemorrhage, wound infections, and splenectomy 4 weeks after ADPKD nephrectomy; afterward we observed: urinary tract infections and contralateral cyst infection. Among group II we only observed 1 case of wound infection. Among group III we observed: ascending urinary tract infections, cyst infections, and cyst hemorrhage. Cyst hemorrhage and cyst infections led mainly to ADPKD kidney nephrectomy. During the observation time, 80.95% of grafts were functioning.

CONCLUSIONS

Unilateral nephrectomy is a well-founded preliminary surgical treatment before kidney transplantation. Bilateral nephrectomy before or during transplantation eliminates ADPKD complications and does not significantly increase general complications. The greatest numbers of complications and of graft losses were observed among the group without pretransplantation nephrectomy.

Quality of life in autosomal dominant polycystic kidney disease patients not yet on dialysis

BACKGROUND AND OBJECTIVES

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited progressive disorder associated with significant pain and discomfort affecting quality of life. This study determined the impact of pain medication use and other clinical, biochemical and genetic characteristics on the physical and mental well being of predialysis ADPKD patients using the Short Form 36 (SF-36) questionnaire.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The authors prospectively evaluated ADPKD patients in the Cohort Study, funded by the Polycystic Kidney Disease Foundation. Data on clinical, biochemical, and radiologic variables were collected in patients who were given the Short Form-36 questionnaire. Variables independently associated with the Physical Component Summary (PCS) and the Mental Component Summary (MCS) scores were identified.

RESULTS

One hundred fifty-two patients had a mean PCS and MCS of 46.9 +/- 11.3 and 51.0 +/- 9.0, similar to the general population and better than the ESRD population. Eleven (7%) reported pain medication intake within 1 mo of evaluation and demonstrated lower PCS than those not taking pain medications. Patients with GFR >or= 80 ml/min/1.73 m(2) had greater PCS than those with GFR < 80 ml/min/1.73 m(2). Age, BMI, pulse pressure, pain medication use, and education level independently associate with PCS and account for 32% of the variability of the measurement. Pulse pressure correlated with MCS.

CONCLUSIONS

Predialysis ADPKD patients assess their quality of life similar to the general population. Age, BMI, pulse pressure, pain medication intake, and education level link to their physical well-being.

Simultaneous bilateral native nephrectomy and living donor renal transplantation are successful for polycystic kidney disease: the University of Maryland experience

PURPOSE

Patients with autosomal dominant polycystic kidney disease have significant morbidity due to large kidney size and the resultant compression of adjacent organs. Surgical extirpation is limited to the most severe cases due to the risk of complications. Typically surgical extirpation of autosomal dominant polycystic kidney disease kidneys and renal transplantation are performed in staged fashion. The additive risks of these 2 procedures have been a barrier to a simultaneous surgical approach. The risks include transplant compromise due to cyst rupture, bleeding, adjacent organ injury and anti-HLA antibody sensitization from transfusion in cases of pretransplant nephrectomy. We reviewed the results of and graft survival data on bilateral nephrectomy for autosomal dominant polycystic kidney disease with simultaneous live donor renal transplantation.

MATERIALS AND METHODS

From August 2003 to November 2007, 20 sets of kidneys were removed in patients with autosomal dominant polycystic kidney disease, followed by simultaneous live donor transplantation. We retrospectively reviewed the outcomes in terms of surgical time, complications, length of stay, transfusion rate and transplant kidney status.

RESULTS

A total of 20 sets of kidneys were removed and these patients then underwent immediate live donor renal transplantation. Mean operative time was 190 minutes for the bilateral nephrectomy portion alone with an average estimated blood loss of 723 cc. Complications were rare and well tolerated. Mean hospital stay was 7.2 days for this procedure. Graft survival was 100% and all patients reported relief of symptoms.

CONCLUSIONS

Bilateral nephrectomy and immediate transplantation in patients with autosomal dominant polycystic kidney disease can be done with minimal morbidity. Preliminary studies show that patients may have significant improvement in quality of life from this procedure and graft viability is not compromised.

Follow-up for laparoscopic renal denervation and nephropexy for autosomal dominant polycystic kidney disease-related pain in pediatrics

PURPOSE

To present our medium-term experience with laparoscopic renal denervation and nephropexy for autosomal dominant polycystic kidney disease (ADPKD)-related pain in the pediatric patient.

MATERIALS AND METHODS

Twelve patients aged 8 to 19 years (mean age 12.4 years) with ADPKD presented with chronic pain refractory to narcotic analgesics. These 12 patients underwent laparoscopic renal denervation of 16 kidneys.

RESULTS

Mean operative time was 152 minutes and mean hospital stay was 2.17 days. All patients were pain-free at discharge and remain pain-free at a mean follow-up of 25.5 months. Three adolescent patients each had an episode of flank pain. One was associated with pyelonephritis, another with stones, and the third with trauma and a hematoma.

CONCLUSIONS

Laparoscopic renal denervation and nephropexy is a promising option for pediatric patients with uncontrolled ADPKD-related pain.

Contribution of renal innervation to hypertension in rat autosomal dominant polycystic kidney disease

The kidney has both afferent (sensory) and efferent (sympathetic) nerves that can influence renal function. Renal innervation has been shown to play a role in the pathogenesis of many forms of hypertension. Hypertension and flank pain are common clinical manifestations of autosomal dominant (AD) polycystic kidney disease (PKD). We hypothesize that renal innervation contributes to the hypertension and progression of cystic change in rodent PKD. In the present study, the contribution of renal innervation to hypertension and progression of renal histopathology and dysfunction was assessed in male Han:SPRD-Cy/+ rats with ADPKD. At 4 weeks of age, male offspring from crosses of heterozygotes (Cy/+) were randomized into either 1) bilateral surgical renal denervation, 2) surgical sham denervation control, or 3) nonoperated control groups. A midline laparotomy was performed to allow the renal denervation (i.e., physical stripping of the nerves and painting the artery with phenol/alcohol). Blood pressure (tail cuff method), renal function (BUN) and histology were assessed at 8 weeks of age. Bilateral renal denervation reduced the cystic kidney size, cyst volume density, systolic blood pressure, and improved renal function (BUN) as compared with nonoperated controls. Operated control cystic rats had kidney weights, cyst volume densities, systolic blood pressures, and plasma BUN levels that were intermediate between those in the denervated animals and the nonoperated controls. The denervated group had a reduced systolic blood pressure compared with the operated control animals, indicating that the renal innervations was a major contributor to the hypertension in this model of ADPKD. Renal denervation was efficacious in reducing some pathology, including hypertension, renal enlargement, and cystic pathology. However, sham operation also affected the cystic disease but to a lesser extent. We hypothesize that the amelioration of hypertension in Cy/+ rats was due to the effects of renal denervation on the renin angiotensin system.

Developments in the management of autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent life- threatening, hereditary disease. ADPKD is more common than sickle cell anemia, cystic fibrosis, muscular dystrophy, hemophilia, Down's syndrome, and Huntington's disease combined. ADPKD is a multisystemic disorder characterized by the progressive development of renal cysts and marked renal enlargement. Structural and functional renal deterioration occurs in ADPKD patients and is the fourth leading cause of end-stage renal disease (ESRD) in adults. Aside from the renal manifestations, extrarenal structural abnormalities, such as liver cysts, cardiovascular abnormalities, and intracranial aneurysms may lead to morbidity and mortality. Recent studies have identified prognostic factors for progressive renal impairment including gender, race, age, proteinuria, hematuria, hypertension and increased left ventricular mass index (LVMI). Early diagnosis and better understanding of the pathophysiology of the disease provides the opportunity to aggressivly treat hypertension with renin-angiotensin-aldosterone system inhibitors and thereby potentially reduce LVMI, prevent cardiovascular morbidity and mortality and slow progression of the renal disease.

The prevalence and management of chronic pain in end-stage renal disease

A growing body of literature has demonstrated that chronic pain is common for patients with end- stage renal disease (ESRD), is typically moderate or severe, and impacts virtually every aspect of health-related quality of life. Unfortunately, there is a lack of clinical and research focus in this area in nephrology and pain in ESRD is undertreated. This paper reviews the epidemiology of chronic pain in ESRD, discusses basic principles of pain assessment and management, and highlights some of the challenges in pain management in ESRD with the hope of guiding health professionals in the effective management of pain in patients with ESRD.

Responding to threats to the kidney

Here's what you need to know about polycystic kidney disease and renal artery stenosis.

Selective, concurrent bilateral nephrectomies at renal transplantation for autosomal dominant polycystic kidney disease

PURPOSE

An algorithm was developed for performing bilateral nephrectomies for specific indications before or at renal transplantation in patients with autosomal dominant polycystic kidney disease. Outcomes for the living donor arm of the algorithm are reported.

MATERIALS AND METHODS

Patients with autosomal dominant polycystic kidney disease and end stage renal disease were evaluated for transplantation. Patients with recurrent pyelonephritis, hemorrhage, pain, early satiety or kidneys that extended into the true pelvis underwent bilateral nephrectomies. Bilateral nephrectomies with concurrent renal transplantation were performed if a living renal donor was identified. If no living donor was identified, pre-transplantation bilateral nephrectomies were done and the patients were listed for cadaveric donor renal transplantation. The living renal donor arm of the algorithm was evaluated by comparing certain parameters for 15 and 17 patients with autosomal dominant polycystic kidney disease who underwent pre-transplantation and concurrent bilateral nephrectomies, respectively, including patient and graft survival, delayed graft function, graft function, length of stay for each surgery, transfusions and complications.

RESULTS

No deaths, graft failures or delayed graft function occurred. In the delayed renal transplant group median time from nephrectomy to living donor transplantation was 124 days. Serum creatinine at discharge home and 1 year after transplantation for the pre-transplantation nephrectomy cohort was 2.0 and 1.3 mg/dl, respectively. Seven of the 17 patients with concurrent nephrectomy underwent transplantation before starting renal replacement therapy. A longer mean total hospital stay in the pre-transplantation nephrectomy cohort was the only statistically significance outcome variable.

CONCLUSIONS

Selective bilateral nephrectomies at living donor renal transplantation results in decreased total length of stay without compromising patient or graft outcomes and it allows preemptive renal transplantation. Concurrent nephrectomy is safe and it further validates the algorithm for selective, concurrent bilateral nephrectomies for patients with autosomal dominant polycystic kidney disease who undergo living donor renal transplantation.

Autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease is the most prevalent, potentially lethal, monogenic disorder. It is associated with large interfamilial and intrafamilial variability, which can be explained to a large extent by its genetic heterogeneity and modifier genes. An increased understanding of the disorder's underlying genetic, molecular, and cellular mechanisms and a better appreciation of its progression and systemic manifestations have laid out the foundation for the development of clinical trials and potentially effective treatments.

Laparoscopic renal denervation and nephropexy for autosomal dominant polycystic kidney disease related pain in adolescents

PURPOSE

We present our initial experience with laparoscopic renal denervation and nephropexy for ADPKD related pain in the adolescent population.

MATERIALS AND METHODS

Four patients 15 to 19 years old previously diagnosed with ADPKD presented with chronic pain refractory to narcotic analgesics. These 4 patients underwent laparoscopic renal denervation of 5 kidneys.

RESULTS

Mean operative time was 136 minutes and mean hospital stay was 2.75 days. All patients were pain-free at discharge home and remained pain-free at a mean followup of 11.5 months.

CONCLUSIONS

We believe that laparoscopic renal denervation plus nephropexy is a promising option for uncontrolled ADPKD related pain in the adolescent population.

Volume progression in polycystic kidney disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by progressive enlargement of cyst-filled kidneys.

METHODS

In a three-year study, we measured the rates of change in total kidney volume, total cyst volume, and iothalamate clearance in patients with ADPKD. Of a total of 241 patients, in 232 patients without azotemia who were 15 to 46 years old at baseline we used magnetic-resonance imaging to correlate the total kidney volume and total cyst volume with iothalamate clearance. Statistical methods included analysis of variance, Pearson correlation, and multivariate regression analysis.

RESULTS

Total kidney volume and total cyst volume increased exponentially, a result consistent with an expansion process dependent on growth. The mean (+/-SD) total kidney volume was 1060+/-642 ml at baseline and increased by a mean of 204+/-246 ml (5.27+/-3.92 percent per year, P<0.001) over a three-year period among 214 patients. Total cyst volume increased by 218+/-263 ml (P<0.001) during the same period among 210 patients. The baseline total kidney volume predicted the subsequent rate of increase in volume, independently of age. A baseline total kidney volume above 1500 ml in 51 patients was associated with a declining glomerular filtration rate (by 4.33+/-8.07 ml per minute per year, P<0.001). Total kidney volume increased more in 135 patients with PKD1 mutations (by 245+/-268 ml) than in 28 patients with PKD2 mutations (by 136+/-100 ml, P=0.03).

CONCLUSIONS

Kidney enlargement resulting from the expansion of cysts in patients with ADPKD is continuous and quantifiable and is associated with the decline of renal function. Higher rates of kidney enlargement are associated with a more rapid decrease in renal function.

Volume Progression in Autosomal Dominant Polycystic Kidney Disease: The Major Factor Determining Clinical Outcomes

Autosomal dominant polycystic kidney disease (PKD) is a hereditary condition characterized by the progressive enlargement of innumerable renal cysts that contribute to life-altering morbidity early in the course of the disease. Evidence indicates that the rate of increase in kidney volume can be reliably measured by magnetic resonance or computed tomography imaging, thus providing objective means to judge the effectiveness of therapies that are targeted to the aberrant growth of renal tubules. It is now possible, therefore, to monitor the effectiveness of potential therapies on the signature abnormality in autosomal dominant PKD before irreversible damage has been done by the cysts. Evidence accumulated from human cross-sectional and longitudinal studies and longitudinal studies of PKD models in animals provide strong support for the view that reducing the rate of kidney volume enlargement will ameliorate the late-stage development of renal insufficiency.

Earlier Diagnosis of Autosomal Dominant Polycystic Kidney Disease: Importance of Family History and Implications for Cardiovascular and Renal Complications

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is a common and serious cause of hereditary renal disease. The emerging possibilities to intervene early in the disease course elevate the importance of both accurate and early diagnosis of ADPKD. Family history analysis is a simple and inexpensive approach to identifying individuals at risk for ADPKD. We hypothesized that advances in knowledge of and potential interventions for ADPKD have led to increased use of family history screening.

METHODS

We distributed surveys to 1,527 subjects from our ADPKD research database to determine the extent to which examination of family history was used to diagnose ADPKD, by birth cohort.

RESULTS

Six hundred thirty-seven subjects with ADPKD (42%) completed and returned surveys. Family history analysis led to the initial ADPKD diagnosis in 49% of all subjects overall. In the birth-cohort analysis, ADPKD was more likely to have been diagnosed in individuals born between 1951 and 1974 because of family history (55% versus 38%; P < 0.0002) and patients were younger at diagnosis (27 versus 39 years; P < 0.0001) than individuals born before 1951.

CONCLUSION

In a large cohort of subjects with ADPKD, we found increased use of family history analysis as a tool for diagnosing ADPKD and earlier age of diagnosis in the more recent birth cohort. This trend may reflect increased overall awareness of ADPKD by physicians, as well as encouraging hypertension and proteinuria treatment outcome data that may depend on intervening early in the course of disease.

Acupuncture and kidney disease

Acupuncture as a complex therapeutic system has been used to treat a variety of diseases and pathological conditions. Although the exact mechanism(s) of acupuncture remains unknown, some evidence suggests a mechanism initially involving signal transduction through connective tissue, with secondary involvement of other systems including the nervous system. Acupuncture has become increasingly popular in the Western countries as a therapy for pain and several chronic disorders difficult to manage with conventional treatments. Acupuncture and acupuncture-like somatic nerve stimulation have been used in different kidney diseases and several complications related to them. The effect of acupuncture techniques in some kidney diseases is reviewed on the basis of clinical reports as well as mechanisms that may possibly explain the beneficial effects mediated by acupressure/acupuncture. The potential effect of acupressure techniques in renal inflammation and whether these effects could be mediated through the newly identified cholinergic anti-inflammatory pathway are discussed.

Pain patterns in patients with polycystic kidney disease

BACKGROUND

Pain is a common problem in patients with polycystic kidney disease (PKD), but patterns have not been characterized as to frequency and severity. Physicians should be aware of pain problems so an approach to chronic pain management can be pursued.

METHODS

One hundred seventy-one completed questionnaires out of 300 distributed to PKD patients whose renal function ranged from normal to end-stage renal disease (ESRD) were analyzed. Age at diagnosis of PKD was documented, and patients noted how the diagnosis was made. Location, severity, and frequency of pain were characterized. The Visual Analogue Scale (VAS) was used to measure pain intensity.

RESULTS

There were 94 females and 77 male respondents, with a mean age of 47.4 years. Initial diagnosis of PKD occurred at a mean age of 31.6 years. Caucasians comprised 92.2% of the respondents. Patients' symptoms, a family history of PKD, and discovery of PKD during evaluation for hypertension or hematuria were the most frequent factors that led to the diagnosis. Order of frequency of pain was: low back pain, abdominal pain, headache, chest pain, and leg pain. Severity of pain, documented by the VAS intensity, was 4 to 5/10 in the majority of patients.

CONCLUSION

Pain, which can be diffuse, is the most frequent symptom that led to the diagnosis of PKD in patients who responded to this questionnaire, and occurs with greater frequency than generally appreciated. Physicians need to obtain a detailed history about pain in their PKD population so as to allow an approach to pain management.

Ablation of symptomatic cysts using absolute ethanol in 11 patients with autosomal-dominant polycystic kidney disease

Objective

To evaluate the effects of cyst ablation with absolute ethanol in autosomal-dominant polycystic kidney disease (ADPKD) patients with symptomatic cysts.

Materials and Methods

Using absolute ethanol, cyst ablation was performed in 11 patients with documented ADPKD who suffered cyst pain refractory to medical treatment. An ethanol solution was instilled into the largest symptomatic cysts through a catheter. We assessed the therapeutic efficacy of the procedure by tracking subjective pain relief during a 3 to 24-month follow-up period after ablation.

Results

At follow-up, we found that the duration of subjective pain relief was 12 to 24 months in seven patients, 4 to11 months in one, and less than 3 months in three.

Conclusion

Selective ablation of a symptomatic cyst may be a valid option in managing chronic pain caused by one or a few large cysts in ADPKD patients.

Thoracoscopic renal denervation for intractable autosomal dominant polycystic kidney disease-related pain

The authors report a case of intractable autosomal dominant polycystic kidney disease-related pain associated with normal renal function, treated with renal denervation. Renal denervation was performed via a thoracoscopic approach. The good medium-term result suggests that thoracoscopic sympatho-splanchnicectomy would be an attractive procedure for pain management in autosomal polycystic kidney disease.

Recent advances in the cell biology of polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is a significant familial disorder, crossing multiple ethnicities as well as organ systems. The goal of understanding and, ultimately, curing ADPKD has fostered collaborative efforts among many laboratories, mustered on by the opportunity to probe fundamental cellular biology. Here we review what is known about ADPKD including well-accepted data such as the identification of the causative genes and the fact that PKD1 and PKD2 act in the same pathway, fairly well-accepted concepts such as the "two-hit hypothesis," and somewhat confusing information regarding polycystin-1 and -2 localization and protein interactions. Special attention is paid to the recently discovered role of the cilium in polycystic kidney disease and the model it suggests. Studying ADPKD is important, not only as an evaluation of a multisystem disorder that spans a lifetime, but as a testament to the achievements of modern biology and medicine.

Renal colic: new concepts related to pathophysiology, diagnosis and treatment

PURPOSE OF REVIEW

To give new insights into the pathophysiology, diagnosis and treatment of acute renal colic caused by a stone disease.

RECENT FINDINGS

Traditional intravenous pyelography is no longer the primary method of investigation in patients with renal colic. If the patient has a history of previous attacks of renal colic and stone disease the recommended diagnostic approach is to start with plain abdominal radiography and ultrasonography together with Doppler ultrasonography. Noncontrast computerized tomography is reserved for unsolved problems. If the patient has no history of stone disease or has atypical clinical presentation it is better to start with noncontrast computerized tomography. Intravenous pyelography is indispensable if an endoscopic or open intervention is required. Magnetic resonance imaging is a promising method of investigation, particularly in pregnant women. Effective pain relief is achieved by the use of opioids, nonsteroidal antiinflammatory drugs or desmopressin.

SUMMARY

The diagnostic approach to renal colic has recently been changed due to the introduction of new, noninvasive radiologic procedures such as Doppler ultrasonography, noncontrast computerized tomography and magnetic resonance imaging.