Vessel malformation in a patient with ADPKD: megadolichobasilar artery, abdominal aortic and iliac aneurysms

Cysts and swellings: a systematic review of the association between polycystic kidney disease and abdominal aortic aneurysm

BACKGROUND

Whether abdominal aortic aneurysm (AAA) forms part of the extrarenal manifestations of autosomal-dominant polycystic kidney disease (ADPKD) is unclear. We set out to review the evidence for an association.

MATERIALS AND METHODS

PubMed, Medline, Embase, and Web of Science databases 1960-2011 were searched [abdominal aortic aneurysm OR AAA OR triple A] AND [polycystic kidney disease OR PKD OR ADPKD OR Renal Cysts]. No limitations were placed on article type or language. Reference lists were recursively searched as were pertinent journal contents.

RESULTS

Eighteen papers were included. Since the first documented case of ADPKD and AAA in 1980, there have been 23 case reports. The voluminous kidneys make AAA diagnosis challenging and surgical exposure difficult. Two studies have assessed aortic diameter in patients with ADPKD and controls, one finding increased aortic diameter in ADPKD (2.7 cm vs. 2.3 cm, P < 0.02) and the other finding no difference. A further study identified a higher incidence of renal cysts in patients with AAA compared to controls (54% vs. 30%, P = 0.0006).

CONCLUSION

There is not enough clinical evidence to determine if ADPKD and AAA share a common pathology. Larger multicenter trials are required to determine if a link exists.

Polycystic kidney disease: inheritance, pathophysiology, prognosis, and treatment

Both autosomal dominant and recessive polycystic kidney disease are conditions with severe associated morbidity and mortality. Recent advances in the understanding of the genetic and molecular pathogenesis of both ADPKD and ARPKD have resulted in new, targeted therapies designed to disrupt cell signaling pathways responsible for the abnormal cell proliferation, dedifferentiation, apoptosis, and fluid secretion characteristic of the disease. Herein we review the current understanding of the pathophysiology of these conditions, as well as the current treatments derived from our understanding of the mechanisms of these diseases.

[Pitfalls and outcome of nephrectomy for patients with polycystic kidney disease: Peri- and postoperative results]

BACKGROUND

There are several indications to perform nephrectomy in patients with polycystic kidney disease (PCKD), including pain, hematuria, hypertension, and infections. Operative access and time to surgery are discussed controversially in the literature. We retrospectively reviewed our peri- and postoperative experiences in the surgical management of patients with PCKD and compared them to minimally invasive procedures.

MATERIAL AND METHOD

Between January 2003 and January 2010, 40 patients with PCKD underwent simple (n=25) or radical nephrectomy (n=4). In 11 patients a bilateral nephrectomy was performed. The mean patient age was 59 (45-69) years. Indications for nephrectomy were flank/abdominal pain (n=19); gross recurrent hematuria (n=9), septic constellation (n=8), and suspected malignancy (n=4). There were 26 male and 14 female patients. All procedures were performed with a retroperitoneal approach or a chevron incision.

RESULTS

A total of 51 nephrectomies were performed on 40 patients with a mean surgical time of 115 (60-310) min. There was one significant intraoperative complication. The mean length of the specimens was 45 (20-87) cm and mean weight was 3.5 (0.8-22.3) kg. Histological examination of the specimens identified renal cell carcinoma (RCC) in three of the four cases. In the other kidneys the pathologists described a polycystic kidney disease. Two significant complications (5%) occurred in the postoperative period: bleeding from an intercostal artery and nonocclusive mesenteric ischemia (NOMI).

CONCLUSION

Although technically demanding due to size and weight, retroperitoneal nephrectomy can be performed safely in patients with PCKD. However, surgery might be associated with unusual complications such as NOMI due to nephrectomy. Compared to minimally invasive procedures there is reduced morbidity, so at least in larger specimens we recommend open surgery.

Matrix metalloproteinases synthesized in autosomal dominant polycystic kidney disease play a role in development of a concurrent abdominal aortic aneurysm

Abdominal aortic aneurysm is well known to be associated with autosomal dominant polycystic kidney disease. Kidney tubules of autosomal dominant polycystic kidney disease synthesize and secrete high levels of matrix metalloproteinase 2, 3, and 9, especially matrix metalloproteinase 2, and serum matrix metalloproteinase 1 and plasma matrix metalloproteinase 9 concentrations in the disease are significantly higher than those in healthy controls. On the other hand, matrix metalloproteinases play a crucial role in the pathogenesis of abdominal aortic aneurysm. Inflammatory cell expression of matrix metalloproteinase 9 plays a critical role in an experimental model of aortic aneurysm disease. Macrophage-derived matrix metalloproteinase 9 and mesenchymal cell matrix metalloproteinase 2 are both required and work in concert to produce abdominal aortic aneurysm. The plasma matrix metalloproteinase 9 levels are significantly higher in the patients with abdominal aortic aneurysm than in the patients with aortoiliac occlusive disease or the healthy patients. Remarkably elevated matrix metalloproteinase 2 mRNA and protein levels in abdominal aortic aneurysm tissues as compared with normal and atherosclerotic aortic tissues are detected, and matrix metalloproteinase 2 proteolytic activity is several-fold higher in abdominal aortic aneurysms than in other pathological or normal states. Patients with abdominal aortic aneurysm elevate matrix metalloproteinase 2 levels in the vasculature remote from the aorta, supporting both the systemic nature of aneurysmal disease and a primary role of matrix metalloproteinase 2 in aneurysm formation. The authors propose a novel hypothesis that matrix metalloproteinases, synthesized and secreted by kidney tubules of autosomal dominant polycystic kidney disease, play a critical role in development of a concurrent abdominal aortic aneurysm.

Survival after end-stage renal disease in autosomal dominant polycystic kidney disease: contribution of extrarenal complications to mortality

Autosomal dominant polycystic kidney disease (ADPKD) accounts for 8% to 10% of patients with end-stage renal disease (ESRD) in the United States and Europe. Progressive expansion of multiple bilateral renal cysts leads to massive enlargement of the kidneys and progressive renal failure. Extrarenal manifestations of ADPKD, such as liver cysts, intracranial aneurysms, cardiac valvular disease, and perhaps diverticulosis, have been documented extensively in cross-sectional studies, but little is known about their natural history. It is thought that extrarenal aspects of ADPKD contribute to increased mortality, yet survival on dialysis of the ADPKD population surpasses that of the general dialysis population. To address this issue, we analyzed the relative risk and causes of death after ESRD in ADPKD versus nondiabetic controls using data from the United States Renal Data System. Relative risk of death from any cause, including the major extrarenal manifestations of ADPKD, was determined as a function of ESRD treatment modality (dialysis or transplantation). We found a lower total mortality rate in ADPKD ESRD patients compared with nondiabetic control ESRD patients (relative risk of death in ADPKD = 0.57; P < 0.001). Mortality rates of extrarenal complications except for polycystic liver disease were similar or lower in ADPKD patients than in nondiabetic controls. Mortality secondary to extrarenal complications was substantially lower than that secondary to cardiovascular or cerebrovascular disease.

[Abdominal aortic aneurysm and autosomal dominant polycystic kidney disease]

AIM

The aim of this study was to report a series of patients with autosomal dominant polycystic kidney disease operated for abdominal aortic aneurysm.

PATIENTS AND METHODS

From 1986 to 1999, seven patients with this pathologic association were operated for aneurysm by the same surgeon. All were males, 47 to 69 years old (mean: 57.7). All were hypertensive and heavy smokers. Four were treated by hemodialysis. In five patients, the aneurysm was an incidental discovery, while two patients presented signs of obstructive arterial disease of the lower limbs. Ultrasound was the routine screening investigation, completed by aortography in all patients and by computed tomography in 2 patients. Surgical treatment consisted of intrasaccular repair of the aneurysm with a straight aortic tube (n = 5), a bifurcated prosthesis from the aorta to both common iliac arteries (n = 1) and a bifurcated prosthesis from the aorta to both common femoral arteries (n = 1).

RESULTS

There was no postoperative mortality or morbidity. Two late deaths (at 5 and 8 years) occurred from myocardial infarction. Only one patient subsequently received a kidney transplant. Repairs were verified by postoperative angiography: anatomical results were satisfactory in all patients. Only nine similar cases have been published in the literature, including two deaths from ruptured aneurysm.

CONCLUSIONS

The clinical diagnosis of aortic aneurysm is difficult in patients with polycystic kidneys due to renal volume. Ultrasound scan of the aorta is recommended to screen these patients for aneurysm. The data of our series show that the main cause of aortic aneurysms is atheroma and that a pathogenic link between this lesion and polycystic kidney disease is questionable. Elective aortic repair is recommended in order to avoid rupture of the aneurysm.