Massive bilateral polycystic kidneys, successful treatment with embolization and nephrectomy: A case report

Polycystic kidney disease (PKD) is a genetic disorder characterized by the formation of multiple cysts in the kidneys. We present a case of a 47-year-old male with PKD on dialysis who underwent bilateral renal artery embolization followed by bilateral nephrectomy via a median incision. The specimen weight was 5 kg for the left kidney and 8 kg for the right one. Renal artery embolization can be a useful tool in managing polycystic kidney disease in cases where nephrectomy is indicated. This case highlights the importance of timely intervention and the role of minimally invasive techniques in managing this rare condition.

Shift from severe hypotension to salt-dependent hypertension in a child with autosomal recessive polycystic kidney disease after bilateral nephrectomies: a case report

BACKGROUND

Autosomal recessive polycystic kidney disease (ARPKD) is a significant cause of morbidity and mortality in infants and children. In severe cases bilateral nephrectomies are considered but may be associated with significant neurological complications and life-threatening hypotension.

CASE PRESENTATION

We describe a case of a 17 months old boy with genetically confirmed ARPKD who underwent sequential bilateral nephrectomies at the age of 4 and 10 months. Following the second nephrectomy the boy was started on continuous cycling peritoneal dialysis with blood pressure on the lower range. At the age of 12 months after a few days of poor feeding at home the boy experienced a severe episode of hypotension and coma of Glasgow Come Scale of three. Brain magnetic-resonance imaging (MRI) showed signs of hemorrhage, cytotoxic cerebral edema and diffuse cerebral atrophy. During the subsequent 72 h he developed seizures requiring anti-epileptic drug therapy, gradually regained consciousness but remained significantly hypotensive after discontinuation of vasopressors. Thus, he received high doses of sodium chloride orally and intraperitoneally as well as midodrine hydrochloride. His ultrafiltration (UF) was targeted to keep him in mild-to-moderate fluid overload. After two months of stable condition the patient started to develop hypertension requiring four antihypertensive medications. After optimizing peritoneal dialysis to avoid fluid overload and discontinuation of sodium chloride the antihypertensives were discontinued, but hyponatremia with hypotensive episodes reoccurred. Sodium chloride was reintroduced resulting in recurrent salt-dependent hypertension.

CONCLUSIONS

Our case report illustrates an unusual course of blood pressure changes following bilateral nephrectomies in an infant with ARPKD and the particular importance of tight regulation of sodium chloride supplementation. The case adds to the scarce literature about clinical sequences of bilateral nephrectomies in infants, and as well highlights the challenge of managing blood pressure in these patients. Further research on the mechanisms and management of blood pressure control is clearly needed.

Unilateral nephrectomy for young infants with congenital nephrotic syndrome of the Finnish type

BACKGROUND

The management of congenital nephrotic syndrome of the Finnish type (CNF) is challenging. It is difficult to withdraw intravenous albumin infusions, resulting in long-term hospitalization. In addition, fatal hypotension after bilateral nephrectomy has been reported. In our center, we have performed unilateral nephrectomy during early infancy.

METHODS

Infants diagnosed with CNF between 2011 and 2020 in our institution were enrolled. We examined the clinical course before and after unilateral nephrectomy and evaluated the effectiveness of this strategy.

RESULTS

Seven patients (all showing NPHS1 mutations) were enrolled. All required daily intravenous albumin infusion via central venous catheter (CVC). Unilateral nephrectomy was performed at a median of 76 days of age (59-208 days). Surgical complications did not occur in any of patients. The mean albumin dose was decreased after unilateral nephrectomy (2.0 vs 0.4 g/kg/day; p = 0.02). Intravenous albumin infusion could be withdrawn at a median of 17 days, the CVC removed at a median of 21 days, and they discharged at a median of 82 days after unilateral nephrectomy. Although bacterial infections were noted seven times before unilateral nephrectomy, only one episode occurred after surgery. Four patients initiated peritoneal dialysis at two to three years of age and all of them underwent kidney transplantation thereafter.

CONCLUSIONS

Unilateral nephrectomy during early infancy may be an effective treatment allowing for withdrawal from albumin infusion, prevention of complications, withdrawal from CVCs and shortening hospital stay for patients with CNF.

Laparoscopic Nephrectomy for Massive Kidneys in Polycystic Kidney Disease

Background and Objectives:

Laparoscopic nephrectomy is now considered a feasible surgical approach, even for large kidneys. In the case of massive kidneys, laparoscopy can be problematic, so that some authors suggest an open approach. However, previous studies have shown that hand-assisted laparoscopic nephrectomy (HALN) may represent a useful compromise.

We describe our hand-assisted laparoscopic technique for nephrectomy of large kidneys (> 2500 g) to encourage the use of laparoscopy for nephrectomy in autosomal dominant polycystic kidney disease.

Methods:

We retrospectively analyzed data from 26 nephrectomies in 17 patients who underwent HALN for ADPKD and compared them to a group of 22 nephrectomies in 18 patients with open surgical technique.

Results:

The duration of the procedure was significantly longer in the laparoscopic group, with a median of 180 minutes versus 90 minutes for the unilateral nephrectomies, and 240 minutes versus 122 minutes for the bilateral procedures. The median kidney weight in the open group was 2500 g (range 1300 – 4500 g), while the median weight in the HALN group was 2375 g (range 1000 – 4700 g). The median hospital stay was comparable. No significant differences were recorded in the intra- and postoperative complication rate.

Conclusion:

Hand-assisted laparoscopic nephrectomy can be considered a technique of choice for patients suffering from ADPKD requiring nephrectomy, also with massive kidneys weighing more than 3500 g. Compared to open nephrectomy, HALN can be performed safely, with reasonably longer operating times and without major complications, and offers a significant reduction in hospitalization time, pain and postoperative discomfort.

Bilateral Nephrectomy in Patients with Autosomal Dominant Polycystic Kidney Disease and End-Stage Chronic Renal Failure

BACKGROUND

In patients with autosomal dominant polycystic kidney disease (ADPKD) and end-stage kidney disease, bilateral nephrectomy (BN) is currently performed predominantly via the laparoscopic approach. We analysed the results of BN depending on the approach and preoperative and perioperative factors.

PATIENTS AND METHODS

This was a single-centre retrospective study carried out from April 2010 to March 2020, including a total of 142 patients presenting with ADPKD who were treated by BN. Of these, 108 patients meeting the inclusion criteria were selected to analyse the results. We compared therapeutic outcomes depending on the surgical approach (laparotomy or laparoscopy) and the type of the operation (emergent or elective).

RESULTS

Of the 108 eligible patients, 36 (group I) underwent laparoscopic BN and the remaining 72 patients (group II) were subjected to midline laparotomy. Sixty-nine patients underwent elective surgery and 39 endured emergent operations. The most frequent indications (87 patients, 80.6%) for surgical treatment were urinary tract infection and infected cysts. The median length of hospital stay for group I and group II patients amounted to 8 days (IQR: 7.5-9) and 12.5 days (IQR: 9-16.5), respectively (p < 0.001). However, comparing the patients operated on electively, the actual difference in the length of hospital stay was inconsiderable: median 8 days (IQR: 7-9) in group I and 9 days (IQR: 9-11.5) in group II. The median duration of the operation was significantly (p < 0.001) longer in group I amounting to 217.5 min (IQR: 197.5-305) than in group II equalling 115 min (IQR: 107.5-145). The frequency of postoperative complications, lethal outcomes, and blood loss volume did not statistically significantly differ depending on the surgical approach. Only patients operated on emergency underwent releparotomy due to intraoperative large bowel injury. Lethal outcomes (n = 18, 16.7%) after surgery were observed only in emergent patients. Sepsis prior to surgery, systemic inflammation response syndrome (SIRS) with the CRP level above 173 mg/mL, prolonged preoperative antibacterial therapy, and undiagnosed large bowel injury were associated with a lethal outcome after BN.

CONCLUSION

The results of open and laparoscopic BN in elective surgery were comparable. Emergency operations for infected renal cysts and SIRS were associated with increased incidence of large bowel injury and lethal outcomes.

Effects of acute kidney dysfunction on hypothalamic arginine vasopressin synthesis in transgenic rats

Acute loss of kidney function is a critical internal stressor. Arginine vasopressin (AVP) present in the parvocellular division of the paraventricular nucleus (PVN) plays a key role in the regulation of stress responses. However, hypothalamic AVP dynamics during acute kidney dysfunction remain unclear. In this study, we investigated the effects of bilateral nephrectomy on AVP, using a transgenic rat line that expressed the AVP-enhanced green fluorescent protein (eGFP). The eGFP fluorescent intensities in the PVN were dramatically increased after bilateral nephrectomy. The mRNA levels of eGFP, AVP, and corticotrophin-releasing hormone in the PVN were dramatically increased after bilateral nephrectomy. Bilateral nephrectomy also increased the levels of Fos-like immunoreactive cells in brainstem neurons. These results indicate that bilateral nephrectomy upregulates the AVP-eGFP synthesis. Further studies are needed to identify the neural and/or humoral factors that activate AVP synthesis and regulate neuronal circuits during acute kidney dysfunction.

Pfannenstiel laparoendoscopic reduced-port bilateral radical nephrectomy for a patient with renal cell carcinoma undergoing hemodialysis

We performed Pfannenstiel laparoendoscopic reduced-port bilateral radical nephrectomy on a patient with renal cell carcinoma undergoing hemodialysis. A 4-cm Pfannenstiel incision was made, and a GelPOINT access was inserted. Three trocars were placed through the access platform, and additional 5- and 3-mm trocars were inserted in the umbilicus and paraumbilical area, respectively. After left nephrectomy, right nephrectomy was successfully completed in 401 min, with an estimated blood loss of 70 mL. There were no intraoperative or postoperative complications, and the patient was discharged 10 days postoperatively. The umbilical scar was concealed within the umbilical fold, and the scar from the 3-mm trocar was almost invisible. The Pfannenstiel scar was minimal and concealed by the patient's underwear. Pfannenstiel laparoendoscopic reduced-port simultaneous bilateral radical nephrectomy is a safe and technically feasible procedure that offers great cosmesis for patients with bilateral renal tumors and end-stage renal disease.

Paradoxical increase in blood pressure following bilateral native nephrectomy

Hypertension with Chronic kidney disease is often difficult to control medically. In such patients, nephrectomy can help to control blood pressure (BP). We describe a case of a 6-year-old boy with autosomal recessive polycystic kidney disease who showed a paradoxical increase in BP following bilateral nephrectomy.

Bilateral nephrectomy for uncontrolled hypertension in hemodialysis patient: a forgotten option?

Resistant arterial hypertension in chronic hemodialysis patients is still a therapeutical challenge despite the development of modern antihypertensive drugs and dialysis procedures. Bilateral nephrectomy seems to be a forgotten option, although it has given good results. We present a case of a 39-year-old female chronic hemodialysis patient, in whom the problem of uncontrolled renal parenchymal hypertension remained despite multiple drug therapy and the ultrafiltration intensification. The problem was solved by bilateral nephrectomy. We discuss the role of bilateral nephrectomy for arterial hypertension control in chronic hemodialysis patients and the surgical and non-surgical options of nephrectomy.

Bilateral nephrectomy as a rescue therapy for hemodialyzed patient with malignant hypertension - case report

We present the case of a 64-year-old male patient in whom malignant phase of hypertension developed during dialysis therapy. Hypertension was resistant to pharmacological therapy with seven antihypertensive drugs and dialysis therapy with ultrafiltration. In this patient bilateral nephrectomy was performed as a rescue therapy. It led to better control of blood pressure and allowed to reduce the number and dosage of antihypertensive medications.