New therapeutic option for autosomal dominant polycystic kidney disease patients with enlarged kidney and liver

Transcatheter arterial embolization therapy in patients with polycystic kidney disease and liver disease: review from case series

We have achieved good results of renal transarterial embolization (TAE) therapy as an alternative to surgical nephrectomy to decrease renal size in autosomal polycystic kidney disease (ADPKD) patients with enlarged kidneys, but only in patients on dialysis. Renal transplantation is another treatment option, and patients who receive a donor kidney have achieved a reduction in kidney size after surgery. TAE has also been used in polycystic liver disease (PCLD), an extrarenal lesion of ADPKD. Although TAE is effective in some PCLD patients, others develop hepatomegaly, which leads to liver cyst infection and liver failure. Recently, liver transplantation has started to be performed in such patients. Initially, living donor liver transplants were performed from family members, but in 2010, deceased donor liver transplantation became available. This article gives an overview of the history of TAE for ADPKD and PCLD on the basis of our experience.

Incidental renal cell carcinoma post bilateral nephrectomy in autosomal dominant polycystic kidney disease

BACKGROUND

Renal cell carcinoma (RCC) is more common in patients with autosomal dominant polycystic kidney disease (ADPKD) than in the general population. Diagnosing RCC in ADPKD is challenging due to the presence of multiple renal cysts, often leading to delays and difficulties in distinguishing RCC from cyst infection or hemorrhage.

AIM

To analyze the prevalence and characterize the clinical features of RCC in patients with ADPKD undergoing simultaneous bilateral native nephrectomy.

METHODS

Between May 2017 and April 2024, 19 ADPKD patients undergoing hemodialysis and awaiting kidney transplantation due to end-stage renal disease (ESRD) underwent bilateral nephrectomies in a single center. Parameters such as patient characteristics, intraoperative blood loss, blood transfusion volume, length of hospital stay, and postoperative complications were documented. Pathological findings for RCC were reviewed.

RESULTS

A total of 38 kidneys were excised from 19 patients, with a mean age of 56.8 years and an average hemodialysis duration of 84.2 months. Eight patients underwent open nephrectomies, and 11 underwent hand-assisted laparoscopic nephrectomies. RCC was detected in 15.8% of kidneys, affecting 21.1% of patients. Two patients had multifocal RCC in both kidneys. All RCC cases were pT1 stage, with the largest lesion averaging 16.5 mm in diameter. The average operative duration was 120 minutes, with intraoperative blood loss averaging 184.2 mL. Five patients required blood transfusions. Postoperative complications occurred in five patients, with a mean hospital stay of 17.1 days. The mean follow-up period was 28.1 months.

CONCLUSION

The prevalence of RCC is higher in patients with ADPKD with ESRD than in those with ESRD alone. Thus, clinicians should be cautious and implement surveillance programs to monitor the development of RCC in patients with ADPKD, particularly those on dialysis.

A Case of Autosomal Dominant Polycystic Kidney Disease With Resolution of Massive Pericardial Effusion After Renal Transcatheter Artery Embolization

A 68-year-old woman being treated with hemodialysis for autosomal dominant polycystic kidney disease was admitted for progressive dyspnea over 6 months. On chest radiography, her cardiothoracic ratio had increased from 52.2% 6 months prior, to 71%, and echocardiography revealed diffuse pericardial effusion and right ventricular diastolic insufficiency. A resultant pericardial tamponade was thought to be the cause of the patient's dyspnea, and therefore a pericardiocentesis was performed, with a total of 2,000mL of fluid removed. However, 21 days later the same amount of pericardial fluid had reaccumulated. The second pericardiocentesis was performed, followed by transcatheter renal artery embolization (TAE). The kidneys, which were hard on palpation before TAE, softened immediately after TAE. After resolution of the pericardial effusion was confirmed, the patient was discharged after 24 days in hospital. Twelve months later, the patient was asymptomatic, the cardiothoracic ratio decreased to 48% on chest radiography and computed tomography revealed no reaccumulation of pericardial effusion. This case illustrates a potential relationship between enlarged kidneys in autosomal dominant polycystic kidney disease and pericardial effusion.

Development of an enterocutaneous fistula from an intestinal perforation in a patient with autosomal dominant polycystic kidney disease

We herein report a case of enterocutaneous fistula in a patient with autosomal dominant polycystic kidney disease (ADPKD). A 37-year-old Japanese man was admitted to our hospital. Three months prior to transfer to our hospital, he developed intense flank pain with gross hematuria. His serum creatinine had decreased to 7.8 mg/dL and hemodialysis was started, but gross hematuria persisted and he developed hypotension. Upon admission, plain chest radiography did not reveal any free air, but computed tomography (CT) showed generalized ventral subcutaneous air from the head to the lower extremities and enlarged kidneys. Enterography showed leakage of contrast medium from the descending colon into the subcutaneous area. C-reactive protein was 23.1 mg/dL. A colostomy was placed in the transverse colon proximal to the perforation, and systemic subcutaneous drainage was performed. The fever subsequently resolved, and the C-reactive protein test became negative. Three months later, renal artery embolization was performed, and 12 months thereafter, CT showed a marked decrease in kidney size. We assume that a markedly enlarged kidney leaded to intestinal perforation, which developed into an enterocutaneous fistula. Consequently, intestinal fluid leaked into the subcutaneous cavity of the abdominal wall and spread systemically, resulting in extensive subcutaneous abscesses.

The Safety and Efficacy of Hepatic Transarterial Embolization Using Microspheres and Microcoils in Patients with Symptomatic Polycystic Liver Disease

Purpose: We investigated the long-term safety and efficacy of hepatic transarterial embolization (TAE) in patients with symptomatic polycystic liver disease (PLD). Materials and Methods: A total of 26 patients were included, mean age of 52.3 years (range: 33−78 years), undergoing 32 TAE procedures between January 2012 and December 2019 were included in this retrospective study. Distal embolization of the segmental hepatic artery was performed with 300−500 µm embolic microspheres associated with proximal embolization using microcoils. The primary endpoint was clinical efficacy, defined by an improvement in health-related quality of life using a modified Short Form-36 Health Survey and improvement in symptoms (digestive or respiratory symptoms and chronic abdominal pain), without invasive therapy during the follow-up period. Secondary endpoints were a decrease in total liver volume and treated liver volume and complications. Results: Hepatic embolization was performed successfully in 30 of 32 procedures with no major adverse events. Clinical efficacy was 73% (19/26). The mean reduction in hepatic volume was −12.6% at 3 months and −27.8% at the last follow-up 51 ± 15.2 months after TAE (range: 30−81 months; both ps < 0.01). The mean visual analog scale pain score was 5.4 ± 2.8 before TAE and decreased to 2.7 ± 1.9 after treatment. Three patients had minor adverse events, and one patient had an adverse event of moderate severity. Conclusion: Hepatic embolization using microspheres and microcoils is a safe and effective treatment for PLD that improves symptoms and reduces the volume of hepatic cysts.

Polycystic liver disease: Classification, diagnosis, treatment process, and clinical management

Polycystic liver disease (PLD) is a rare hereditary disease that independently exists in isolated PLD, or as an accompanying symptom of autosomal dominant polycystic kidney disease and autosomal recessive polycystic kidney disease with complicated mechanisms. PLD currently lacks a unified diagnostic standard. The diagnosis of PLD is usually made when the number of hepatic cysts is more than 20. Gigot classification and Schnelldorfer classification are now commonly used to define severity in PLD. Most PLD patients have no clinical symptoms, and minority with severe complications need treatments. Somatostatin analogues, mammalian target of rapamycin inhibitor, ursodeoxycholic acid and vasopressin-2 receptor antagonist are the potentially effective medical therapies, while cyst aspiration and sclerosis, transcatheter arterial embolization, fenestration, hepatic resection and liver transplantation are the options of invasion therapies. However, the effectiveness of these therapies except liver transplantation are still uncertain. Furthermore, there is no unified strategy to treat PLD between medical centers at present. In order to better understand recent study progresses on PLD for clinical practice and obtain potential directions for future researches, this review mainly focuses on the recent progress in PLD classification, clinical manifestation, diagnosis and treatment. For information, we also provided medical treatment processes of PLD in our medical center.

Transcatheter Arterial Embolization Therapy for Huge Renal Cysts: Two Case Reports

We encountered 2 patients with symptomatic huge simple renal cysts. In case 1, 4,000 mL of cyst fluid was drained via a catheter, but intracystic bleeding occurred immediately afterwards. Transcatheter arterial embolization (TAE) was performed, after which the bleeding stopped, and cyst drainage was repeated successfully. After 2 years, the total cyst volume was reduced from 11,775 mL to 75.4 mL. In case 2, TAE was performed prophylactically before drainage. Subsequently, 9,400 mL of fluid was removed from multiple cysts. After 1 year, the total cyst volume was reduced from 9,215 mL to 633 mL without bleeding. Based on these 2 cases, prophylactic TAE before drainage may be useful in patients with huge renal cysts.

Suitability of Patients with Autosomal Dominant Polycystic Kidney Disease for Renal Transcatheter Arterial Embolization

In patients with autosomal dominant polycystic kidney disease (ADPKD), massive renal enlargement is a serious problem. Renal transcatheter arterial embolization (TAE) can reduce renal volume (RV), but effectiveness varies widely, and the reasons remain unclear. We investigated factors affecting renal volume reduction rate (RVRR) after renal TAE in all 449 patients with ADPKD who received renal TAE at Toranomon Hospital from January of 2006 to July of 2013, including 228 men and 221 women (mean age =57.0±9.1 years old). One year after renal TAE, the RVRR ranged from 3.9% to 84.8%, and the least squares mean RVRR calculated using a linear mixed model was 45.5% (95% confidence interval [95% CI], 44.2% to 46.8%). Multivariate analysis using the linear mixed model revealed that RVRR was affected by the presence of large cysts with wall thickening (regression coefficient [RC], -6.10; 95% CI, -9.04 to -3.16; P<0.001), age (RC, -0.82; 95% CI, -1.03 to -0.60; P<0.001), dialysis duration (RC, -0.10; 95% CI, -0.18 to -0.03; P<0.01), systolic BP (RC, 0.39; 95% CI, 0.19 to 0.59; P<0.001), and the number of microcoils used for renal TAE (RC, 1.35; 95% CI, 0.83 to 1.86; P<0.001). Significantly more microcoils were needed to achieve renal TAE in patients with younger age and shorter dialysis duration. In conclusion, cyst wall thickening had an important effect on cyst volume reduction. Renal TAE was more effective in patients who were younger, had shorter dialysis duration, or had hypertension, parameters that might associate with cyst wall stiffness and renal artery blood flow.

Renal artery embolization-indications, technical approaches and outcomes

Owing to improvements in catheters and embolic agents, renal artery embolization (RAE) is increasingly used to treat nephrological and urological disease. RAE has become a useful adjunct to medical resuscitation in severe penetrating, iatrogenic or blunt renal traumatisms with active bleeding, and might avoid surgical intervention, particularly among patients that are haemodynamically stable. The role of RAE in pre-operative or palliative management of advanced malignant renal tumours remains debated; however, RAE is recommended as a first-line therapy for bleeding angiomyolipomas and can be used as a preventative treatment for angiomyolipomas at risk of bleeding. RAE represents an alternative to nephrectomy in various medical conditions, including severe uncontrolled hypertension among patients with end-stage renal disease, renal graft intolerance syndrome or autosomal dominant polycystic kidney disease. RAE is increasingly used to treat renal artery aneurysms or symptomatic renal arteriovenous malformations, with a low complication rate as compared with surgical alternatives. This Review highlights the potential use of RAE as an adjunct in the management of renal disease. We first compare and contrast the technical approaches of RAE associated with the various available embolization agents and then discuss the complications associated with RAE and alternative procedures.

Management of pain in autosomal dominant polycystic kidney disease and anatomy of renal innervation

PURPOSE

Chronic pain is a prominent feature of autosomal dominant polycystic kidney disease that is difficult to treat and manage, often resulting in a decrease in quality of life. Understanding the underlying anatomy of renal innervation and the various etiologies of pain that occur in autosomal dominant polycystic kidney disease can help guide proper treatments to manage pain. Reviewing previously studied treatments for pain in autosomal dominant polycystic kidney disease can help characterize treatment in a stepwise fashion.

MATERIALS AND METHODS

We performed a literature search of the etiology and management of pain in autosomal dominant polycystic kidney disease and the anatomy of renal innervation using PubMed® and Embase® from January 1985 to April 2014 with limitations to human studies and English language.

RESULTS

Pain occurs in the majority of patients with autosomal dominant polycystic kidney disease due to renal, hepatic and mechanical origins. Patients may experience different types of pain which can make it difficult to clinically confirm its etiology. An anatomical and histological evaluation of the complex renal innervation helps in understanding the mechanisms that can lead to renal pain. Understanding the complex nature of renal innervation is essential for surgeons to perform renal denervation. The management of pain in autosomal dominant polycystic kidney disease should be approached in a stepwise fashion. Acute causes of renal pain must first be ruled out due to the high incidence in autosomal dominant polycystic kidney disease. For chronic pain, nonopioid analgesics and conservative interventions can be used first, before opioid analgesics are considered. If pain continues there are surgical interventions such as renal cyst decortication, renal denervation and nephrectomy that can target pain produced by renal or hepatic cysts.

CONCLUSIONS

Chronic pain in patients with autosomal dominant polycystic kidney disease is often refractory to conservative, medical and other noninvasive treatments. There are effective surgical procedures that can be performed when more conservative treatments fail. Laparoscopic cyst decortication has been well studied and results in the relief of chronic renal pain in the majority of patients. In addition, renal denervation has been used successfully and could be performed concurrently with cyst decortication. Nephrectomy should be reserved for patients with intractable pain and renal failure when other modalities have failed.

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.

Transperitoneal laparoscopic nephrectomy for autosomal dominant polycystic kidney disease

Compared to open surgery, laparoscopic nephrectomy for autosomal dominant polycystic kidney disease appears to be a feasible and safe approach.

Objective:

This study focuses on laparoscopic nephrectomy for autosomal dominant polycystic kidney disease (ADPKD).

Material and Methods:

We retrospectively reviewed 21 consecutive patients who had previously undergone laparoscopy between 2007 and 2010. Data were compared to that obtained from 19 consecutive patients who had open surgery between 2004 and 2007. Clinical parameters, operative data, perioperative mortality, postoperative complications, and length of hospital stay were compared using χ² and Student t tests for qualitative and quantitative variables, respectively.

Results:

Nephrectomy is usually performed to create space for renal transplantation (81% and 79%, respectively). Operating time was longer with the laparoscopic approach (180 min vs. 128 min, P = .001). Blood loss was comparable in the 2 groups (154 vs. 222 ml, P = .359) but 3 patients were transfused in the open surgery group as compared with 1 patient in the laparoscopic group. No conversion was needed. There was a trend in the laparoscopic group with respect to lower consumption of analgesics in the postoperative period (P = .06). Delay to transit recovery (2.1 d vs 4.1 d, P < .001) and hospital stay (5.2 d vs. 8.28 d, P = .002) were significantly decreased in the laparoscopic group. The interval from surgery to renal transplantation was lower in patients operated on laparoscopically (3.1 vs. 12 mo). Complications occurred in 33% of the patients in the laparoscopic group as compared with 68% in the open surgery group (P = .22). Severe complications were less frequent in the laparoscopic group (9.5% vs. 37%, P = .04).

Conclusion:

Laparoscopic nephrectomy is a feasible and safe procedure for ADPKD. Morbidity is significantly reduced compared with the open approach.

Incidental renal cell carcinoma presenting in a renal transplant recipient with autosomal dominant polycystic kidney disease: a case report

Introduction

We report an instructive case of incidental renal cell carcinoma in a patient with autosomal dominant polycystic kidney disease who underwent simultaneous bilateral native nephrectomy and living donor renal transplantation.

Case presentation

A 57-year-old Asian man with end-stage kidney disease due to autosomal dominant polycystic kidney disease received a living kidney graft from his brother. Because of recurrent infection, chronic pain and enlarged kidneys, he underwent a bilateral nephrectomy with concomitant renal transplantation. The total weight of the removed kidneys was 6kg; the maximal diameter of the larger kidney was 28cm. His left kidney had a 1cm diameter tumor. Pathology indicated papillary renal cell carcinoma. At the time of this report, the transplant kidney function was normal with no evidence of local recurrence or distant metastasis.

Conclusion

This case shows and reinforces the importance of considering the possibility of an occult malignancy in the native kidneys of patients with autosomal dominant polycystic kidney disease. Simultaneous bilateral native nephrectomy should be considered in these renal transplant recipients not only for preventing the development of adverse symptoms but also for detecting an occult malignancy.

Transcatheter renal artery embolization improves lung function in patients with autosomal dominant polycystic kidney disease on hemodialysis

BACKGROUND

Since 1996, transcatheter renal artery embolization (renal TAE) has been performed to reduce the volume of the kidneys in patients with autosomal dominant polycystic kidney disease (ADPKD) and complications of nephromegaly at our hospital. Respiratory dysfunction is often a serious problem in these patients before TAE.

PATIENTS AND METHODS

Between January 2006 and October 2008, renal TAE was performed and lung function testing [percent vital capacity (%VC) and percent forced expiratory volume in 1 s (%FEV(1.0))] was done by spirometry in 28 patients on maintenance hemodialysis who had respiratory symptoms.

RESULTS

Renal volume was 6,330.5 ± 3,126.5 cm(3) (range 1,771-12,761 cm(3)) before TAE, and decreased significantly to 2,892.2 ± 1,841.7 cm(3) (range 622-6,961 cm(3)) by 12 months after TAE (p = 0.0001). The percent decrease of renal volume at 12 months after TAE versus baseline was 45.6 ± 14.6% (range 6.6-67.3%). %VC showed a significant increase from 95.9 ± 14.8% (range 63-127%) before renal TAE to 100.1 ± 11.7% (range 78-120%) at 12 months after TAE (p < 0.01). %FEV(1.0) was also significantly increased from 87.9 ± 15.0% (range 55-110%) before renal TAE to 92.5 ± 14.4% (range 58.0-115.0%) at 12 months after TAE (p < 0.01). The changes of VC (ΔVC%) and FEV(1.0) (ΔFEV(1.0)%) both showed a significant positive correlation with the reduction of renal volume (Δ renal volume) (p = 0.001 and p = 0.004, respectively).

CONCLUSION

Since TAE not only led to a significant decrease of renal volume in ADPKD patients with nephromegaly, but also improved lung function (both %VC and %FEV(1.0)), pulmonary dysfunction should be recognized as one of the extrarenal complications of ADPKD.

Transcatheter arterial embolization using ethanol in a dialysis patient for contracting enlarged polycystic kidneys

The mass effect of nephromegaly in patients with autosomal dominant polycystic kidney disease may cause pain and symptoms by compressing the alimentary tract, lungs, and heart. Conventional therapies exist to contract enlarged polycystic kidneys including surgical and interventional procedures. A surgical nephrectomy is often difficult to perform in dialysis patients due to the associated risks related to surgery. In contrast, renal transcatheter arterial embolization (TAE) with metallic coils, which is a less invasive interventional procedure, can also be utilized to contract enlarged kidneys in dialysis patients as an effective treatment. However, metallic coils present the possibility of recanalization and cost issues. Thus, we used ethanol instead of coils in renal TAE to resolve these issues. We report a dialysis patient with enlarged polycystic kidneys and poor oral intake due to abdominal distention that was successfully treated by TAE with absolute ethanol.

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.

Isolated polycystic liver disease

Isolated polycystic liver disease (PCLD) is an autosomal dominant disease with genetic and clinical heterogeneity. Apart from liver cysts, it exhibits few extrahepatic manifestations, and the majority of patients with this condition are asymptomatic or subclinical. However, a small fraction of these patients develop acute liver cyst-related complications and/or massive cystic liver enlargement, causing morbidity and mortality. Currently, the management for symptomatic PCLD is centered on palliating symptoms and treating complications.

Refractory Ascites Due to Portal Hypertension in Autosomal Dominant Polycystic Kidney Disease (ADPKD) Patients Successfully Treated with Peritoneal Dialysis

Refractory ascites is uncommon in autosomal dominant polycystic kidney disease (ADPKD) but it usually makes the patient physically and psychologically handicapped. Two uremic ADPKD patients in our hospital developed refractory ascites after 1 year on hemodialysis. The refractory ascites was due to portal hypertension, which was caused primarily by portal outflow obstruction due to the numerous enlarged cysts in the liver and secondarily by increased portal inflow. We attempted continuous ambulatory peritoneal dialysis (CAPD) to treat the 2 patients and obtained satisfactory results. Not only was the refractory ascites well controlled, but also the portal hypertension disappeared. Based on our experience, we think CAPD could serve as a very effective therapy to treat the refractory ascites of portal hypertension due to polycystic liver in uremic ADPKD patients.

Autosomal dominant polycystic kidney disease: the last 3 years

Autosomal dominant polycystic kidney disease is the most prevalent, potentially lethal monogenic disorder. It has large inter- and intra-familial variability explained to a large extent by its genetic heterogeneity and modifier genes. An increased understanding of its 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 therapies. The purpose of this review is to update the core of knowledge in this area with recent publications that have appeared during 2006-2009.

Transcatheter arterial embolization therapy for a massive polycystic liver in autosomal dominant polycystic kidney disease patients

Polycystic liver is the most common extra-renal manifestation associated with autosomal dominant polycystic kidney disease (ADPKD), comprising up to 80% of all features. Patients with polycystic liver often suffer from abdominal discomfort, dyspepsia, or dyspnea; however, there have been few ways to relieve their symptoms effectively and safely. Therefore, we tried transcatheter arterial embolization (TAE), which has been used in treating hepatocellular carcinoma. We enrolled four patients with ADPKD in Seoul National University Hospital, suffering from enlarged polycystic liver. We embolized the hepatic arteries supplying the dominant hepatic segments replaced by cysts using polyvinyl alcohol particles and micro-coils. The patients were evaluated 12 months after embolization for the change in both liver and cyst volumes. Among four patients, one patient was lost in follow up and 3 patients were included in the analysis. Both liver (33%; 10%) and cyst volume (47.7%; 11.4%) substantially decreased in two patients. Common adverse events were fever, epigastric pain, nausea, and vomiting. We suggest that TAE is effective and safe in treating symptomatic polycystic liver in selected ADPKD patients.

Transcatheter arterial embolization with absolute ethanol injection for enlarged polycystic kidneys after failed metallic coil embolization

Kidney enlargement in autosomal-dominant polycystic kidney disease (ADPKD) may cause symptoms by compressing the alimentary tract, lungs, and heart. The clinical symptoms may be progressive, may markedly decrease quality of life, and may even be life-threatening. Although treatment of this disease is often difficult, transcatheter arterial embolization (TAE) with metallic coils has been reported as a renal contraction therapy that is less invasive than surgery. The present report describes a case of ADPKD successfully treated by TAE with absolute ethanol after a previous TAE procedure with metallic coils failed to contract the affected kidneys because of recanalization.

Inferior vena cava stenting: a safe and effective treatment for intractable ascites in patients with polycystic liver disease

We performed a retrospective study of seven patients with polycystic liver disease who underwent stenting of the inferior vena cava for intractable ascites. All patients had symptomatic ascites and inferior vena cava stenosis demonstrable by venography. The mean pressure gradient across the inferior vena cava stenosis before stenting was 14.5 mm Hg (range 6-25 mm Hg) and significantly decreased to a mean pressure gradient of 2.8 mm Hg (range 0-6 mm Hg, p = 0.008) after stenting. Two patients also had stenting of hepatic venous stenoses after unsuccessful inferior vena cava stenting. After a mean follow-up of 12.2 months (range 0.5-39.1 months), five of the seven patients have had maintained clinical improvement, defined as decreased symptoms, diuretic requirements, and frequency of paracentesis. Four patients have required no further intervention. The other patient was lost in follow-up. Patients with clinical improvement had an overall larger mean pressure gradient before stenting (19.2 vs. 9.8 mm Hg) and a larger Delta pressure gradient (15.8 vs. 7.8 mm Hg) compared to those in whom stenting was unsuccessful. These results suggest inferior vena cava stenting is safe and effective and should be considered as a first-line intervention in the treatment of medically intractable ascites in select patients with polycystic liver disease.