Bilateral nephrectomy concomitantly with renal transplantation

Simultaneous Native Nephrectomy and Kidney Transplantation in Patients With Autosomal Dominant Polycystic Kidney Disease

Introduction

To evaluate the feasibility of simultaneous unilateral nephrectomy with kidney transplantation and to determine the effect of this procedure on perioperative morbidity and mortality and graft and patient survival.

Methods

Between January 2000 and May 2015, 145 patients with autosomal dominant polycystic kidney disease (ADPKD) underwent kidney transplantation. Of those, 40 (27.5%) underwent concurrent ipsilateral native nephrectomy (group NT). Patients in group NT were compared with patients with ADPKD not undergoing concurrent nephrectomy (group NT-) and asymptomatic patients undergoing pretransplant nephrectomy (group PNT).

Results

The average follow-up was 66 months. The graft survival rate at 1 and 5 years was 95% and 87.5% versus 93% and 76.2% in the NT and NT- groups, respectively (P = .903 and P = .544, respectively); 1-year patient survival was 100% for NT and 97% for NT- patients (P = .288), whereas 5-year patient survival was 100% and 92% for NT and NT- groups, respectively (P = .128). After propensity score matching (34 patients per group) no significant differences were observed in 1-year (97.1% in NT and 94.1%; P = 1) and 5-year (88.2% in NT and 91.2% in NT-; P = 1) graft survival, and in 1-year (100% for both groups; P = 1) and 5-year (100% in NT and 94.1% in NT-; P = 1) patient survival. Perioperative mortality was 0% among NT and 1.2% among NT- patients, whereas perioperative surgical complications were similar in both groups. One- and 5-year graft and patient survival were similar between the NT and PNT groups, but patients in the PNT group had significantly lower levels of hemoglobin and residual diuresis volumes at the time of transplant. Moreover, PNT patients had a longer pretransplant dialysis and a longer time on the waiting list.

Conclusions

Simultaneous unilateral nephrectomy does not have a negative effect on patient and graft survival in patients with ADPKD and is associated with low morbidity. Pretransplant nephrectomy should be restricted only to highly symptomatic patients, whereas unilateral nephrectomy in asymptomatic patients should be performed during kidney transplantation only if massive kidney size precludes graft positioning.

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 Transplantation with Concomitant Unilateral Nephrectomy: A Matched-Pair Analysis on Complications and Outcome

BACKGROUND

We sought to determine the impact of kidney transplantation with simultaneous unilateral nephrectomy on perioperative morbidity and patient and graft survival.

METHODS

From January 1990 to May 2004, 75 kidney transplantations with simultaneous unilateral nephrectomy (group NE+) were performed at the University of Freiburg. Of these, 49 had polycystic kidney disease. Patients of group NE+ were matched with 75 kidney transplants without nephrectomy (group NE-). Immunosuppressive maintenance therapy in both groups was based on cyclosporine A, mycophenolate mofetil or azathioprine, and prednisone. Mean follow up was 4.1 yrs (range 0.3-11.7 yrs).

RESULTS

Patient survival rate at 1 and 5 yrs was 95% and 84% versus 95% and 93% in group NE+ and NE-, resp. (P=0.56). Accordingly, kidney function rate was 85% and 74% in group NE+ versus 89% and 79% in group NE- (P=0.89). Perioperative (90 days) mortality rate in group NE+ was 1.3% and 2.7% in group NE- (P=0.56). Perioperative surgical complications were similar in both groups.

CONCLUSIONS

Kidney transplantation with concomitant unilateral nephrectomy has no negative impact on patient or graft survival and is associated with a reasonable morbidity rate.

Simultaneous vs. Sequential Laparoscopic Bilateral Native Nephrectomy and Renal Transplantation

We reviewed our experience with simultaneous single incision bilateral native nephrectomy and renal transplantation in 11 patients (Group 1), compared to seven recipients who underwent staged laparoscopic bilateral nephrectomy followed by kidney transplantation (Group 2). Mean age, donor source, sex, cause of ESRD, and specimen size were similar in both groups (P=0.1). All Group 2 patients and 9 of 11 Group 1 patients had autosomal-dominant polycystic kidney disease. Perioperative Group 1 complications included: bowel injury, transplant urine leak, necrotic pancreatitis, delayed bowel movement, and severe shoulder pain secondary to diaphragmatic irritation. Seven (63.6%) Group 1 patients required an additional surgical procedure: midline incisional hernia, repair ureteral fistula, and repair enterocutaneous fistula. One Group 1 patient lost his graft secondary to bowel injury and intra-abdominal sepsis. No major complications, reoperations, or graft loss occurred in Group 2. For simultaneous bilateral native nephrectomy and kidney transplantation, over 60% of patients required an additional surgical procedure. Laparoscopic bilateral nephrectomy followed by kidney transplantation is a safe and feasible alternative.

Bilateral nephrectomy with concomitant renal graft transplantation for autosomal dominant polycystic kidney disease

PURPOSE

There has been controversy about pre-transplant nephrectomy in patients with autosomal dominant polycystic kidney disease. Kidneys may be removed in these patients when they cause respiratory compromise, early satiety, increased abdominal girth, pain, hematuria or recurrent infection. We determined whether concomitant bilateral nephrectomy at renal transplantation is safe and efficacious.

MATERIALS AND METHODS

Between December 1996 and January 1999, 10 patients with autosomal dominant polycystic kidney disease underwent bilateral nephrectomy with concomitant renal grafting (group 1). We compared these patients to 9 with autosomal dominant polycystic kidney disease matched for age and gender who underwent transplantation only (group 2) and 4 with the same condition who underwent bilateral nephrectomy and renal transplantation as staged procedures (group 3).

RESULTS

No patients died perioperatively. There was a lower rate of complications in group 1 than in groups 2 or 3. The only significant differences in intraoperative and perioperative parameters were operative time and intraoperative blood loss, which were greater in group 1 than in group 2. We noted no significant differences in groups 1 and 3. Patient satisfaction analyzed by a survey revealed that the 70% of group 1 patients who responded were satisfied with kidney removal and 7 of the 9 in group 2 desired native kidney removal. All group 3 patients already had a functioning renal graft but were satisfied with native kidney removal, although they would rather have undergone bilateral nephrectomy at transplantation.

CONCLUSIONS

Our data imply that there is no higher morbidity or mortality when performing concomitant bilateral nephrectomy at renal transplantation in patients with renal failure due to autosomal dominant polycystic kidney disease. There was a higher rate of satisfaction in patients who underwent nephrectomy and transplantation simultaneously, while those who did not undergo concomitant procedures strongly desired to have had that option. Bilateral nephrectomy may alleviate symptoms while providing greater room for renal graft placement. When done without transplantation, bilateral nephrectomy resulted in the highest number of complications. Our data indicate that if bilateral nephrectomy is performed as an adjunct to transplantation, it should be done at renal grafting.

Pyeloureterostomy or ureteroneocystostomy in renal transplantation?

A retrospective comparison of pyeloureterostomy and external ureteroneocystostomy as methods of reconstructing the urinary tract in 128 renal transplants is presented. There was one urological complication in 52 pyeloureterostomies (1.9%) compared with 4 in the 76 ureteroneocystostomies (5.3%). 6/0 Polydioxanone (PDS) is preferred to Prolene for the anastomosis because of possible calculus formation on the latter. Wound sepsis is commoner in pyeloureterostomies undergoing concomitant nephrectomy, despite prophylactic antibiotics, though this is not statistically significant and the overall sepsis rate is higher for ureteroneocystostomy. Nephrectomy was avoided in 17 selected cases by simply ligating the recipient ureter where the pre-transplant urine output was low. Two of these patients developed hydronephrosis in the isolated kidney and required later nephrectomy.