Urinary tract infection requiring nephrectomy in a patient with autosomal dominant polycystic kidney disease despite ciprofloxacin therapy

Simultaneous transabdominal bilateral nephrectomy in potential kidney transplant recipients

BACKGROUND

Bilateral nephrectomy of potential kidney graft recipients is indicated for patients with recurrent infections in the polycystic kidneys or chronic pyelonephritis resulting from vesicoureteric reflux. The aim of this study was to analyze the frequency of complications after simultaneous bilateral transperitoneal nephrectomy.

PATIENTS AND METHODS

Twenty hemodialysis patients (age 28 to 55 years) were referred for simultaneous bilateral nephrectomy between 1996 and 2004. Among the 18 patients with autosomal-dominant polycystic kidney disease, 11 experienced recurrent cysts or urinary tract infections and two, episodes of disabling flank pain. Five patients with extremely enlarged kidneys were asymptomatic. Two patients presented vesicoureteric reflux with chronic pyelonephritis. In all cases the kidneys were removed transperitoneally via a transverse or midline incision.

RESULTS

Although no fatal outcome was recorded, three patients required brief hospitalizations in the intensive care unit. The only intraoperative complication was spleen injury in five patients. Surgical postoperative complications developed in nine patients (45%) including: extended drainage and delayed wound healing (n = 4), postoperative hernia (n = 3), prolonged abdominal pain (n = 3), perihepatic hematoma (n = 2), stress duodenal ulceration (n = 1), and subileus (n = 1). Five patients displayed thrombosis of their dialysis access, probably as a consequence of low blood pressure. After surgery 15 patients were placed on the waiting list and 10, successfully transplanted.

CONCLUSION

Simultaneous transabdominal bilateral nephrectomy was associated with a high risk of postoperative complications, but may save the suffering associated with a repeated operation in potential kidney graft recipients who have an indication for bilateral nephrectomy.

Polycystic kidney disease: etiology, pathogenesis, and treatment

Once viewed as hopelessly incurable disorders and the dustbin for careers in academic medicine, the polycystic kidney diseases have emerged as prime targets of pathophysiologic study and palliative and definitive treatment in the era of molecular medicine. Polycystic kidney disease (PKD) may be hereditary or acquired. The major inherited types are autosomal dominant (AD) and autosomal recessive (AR). ADPKD is caused by at least two (and possibly three) genes located on separate chromosomes, while ADPKD-1 is due to a 14 kb transcript in a duplicated region on the short arm of chromosome 16 very near the alpha-globin gene cluster and the gene for one form of tuberous sclerosis. ADPKD-2 has been assigned to the long arm of chromosome 4. ARPKD is due to a mutated gene on both copies of the long arm of chromosome 6. Cysts originate in renal tubules. Proliferation of tubule epithelial cells modulated by endocrine, paracrine, and autocrine factors is a major element in the pathogenesis of renal cystic diseases. In addition, fluid that is abnormally accumulated within the cysts is derived from glomerular filtrate and, to a greater extent, by transepithelial fluid secretion. Abnormal synthesis and degradation of matrix components associated with interstitial inflammation are additional features in the pathogenesis of renal cystic diseases. The ADPKD genotypes are characterized by bilateral kidney cysts, hypertension, hematuria, renal infection, stones, and renal insufficiency. ADPKD is a systemic disorder; cysts appear with decreasing frequency in the kidneys, liver, pancreas, brain, spleen, ovaries, and testis. Cardiac valvular disorders, abdominal and inguinal hernias, and aneurysms of cerebral and coronary arteries and aorta are also associated with ADPKD. Treatment is supportive: dietary regulation of salt and protein intake, control of hypertension and renal stones, and dialysis and transplantation at the end stage. ARPKD is a relatively rare disease that causes clinical symptoms at birth, with significant mortality in the first month of life. The cysts develop primarily in the collecting ducts because of a failure in the maturation process. Early complications include Potter's syndrome; excessive size of the kidneys, causing respiratory dysfunction; hypertension; and renal insufficiency. Hepatic fibrosis is an associated extrarenal problem that results in significant morbidity in young children and adolescents. Treatment includes supportive care, dialysis, and renal transplantation. Acquired cysts (solitary/simple) are commonplace in older persons. Multiple cysts may be seen in association with potassium deficiency, congenital disorders, metabolic diseases, and toxic renal injury.(ABSTRACT TRUNCATED AT 400 WORDS)