Percutaneous renal artery embolization in a patient with severe nephrotic syndrome which continued after the introduction of hemodialysis

Preparing for a kidney transplant: Medical nephrectomy in children with nephrotic syndrome

Nephrotic syndrome is characterized by proteinuria, hypoalbuminemia, and general edema. These symptoms may persist in children who reach ESRD, which is unfavorable for the patient's allograft outcome. In addition, this may hamper early diagnosis of a relapse after transplantation. Surgical bilateral nephrectomy is often considered for that reason, but medical nephrectomy may be a less invasive alternative. In this retrospective single-center case series, we identified all children on dialysis with ESRD due to nephrotic syndrome in which a medical nephrectomy was attempted before kidney transplantation between 2013 and 2018. Outcome was measured by urine output and serum albumin levels. Eight patients with either congenital nephrotic syndrome or focal segmental glomerular sclerosis were included in the study. All patients received an ACE inhibitor as drug of first choice for medical nephrectomy, to which 5 patients responded with oligoanuria and a significant rise in serum albumin, and 3 patients responded insufficiently. In 1 of these 3 patients, diclofenac was added to the ACE inhibitor, with good result. In the other 2 patients, indomethacin was initiated without success, and surgical bilateral nephrectomy was performed. Overall, 6/8 patients had a successful medical nephrectomy and did not need surgical nephrectomy. No recurrence of nephrotic syndrome was found after kidney transplantation in all but one. Medical nephrectomy with ACE inhibitors and/or non-steroidal anti-inflammatory drugs is a safe and non-invasive therapy to minimize proteinuria in children with ESRD due to nephrotic syndrome before kidney transplantation. We suggest that this strategy should be considered as therapy before proceeding with surgical nephrectomy.

Radiologically Guided Renal Artery Embolization with an Amplatzer Vascular Plug as a Rescue Therapy for Refractory Nephrotic Syndrome in AL-Amyloidosis

Nephrotic syndrome is common in immunoglobulin light-chain (AL) amyloidosis and successful therapy may pose a challenge. We report the case of a 63-year-old patient with severe nephrotic syndrome due to primary renal AL-amyloidosis with well-preserved renal function at first presentation. Therapy with high dose steroids, loop diuretics, and ACE-inhibitors did not affect his proteinuria and he was seriously disabled because of symptomatic orthostatic hypotension and anasarca. With the patient's informed consent, medical nephrectomy was tried with nonsteroidal-anti-inflammatory drugs (NSAIDs), cyclosporine, and aminoglycosides, with significant deterioration of his renal function, but without relevant effect on his proteinuria. Despite adequate anticoagulation life threatening thrombotic and bleeding complications occurred. Total renal ablation was finally achieved using an Amplatzer vascular plug Typ IV (AVP 4) with a self-expanding Nitinol mesh design, which was placed in both main renal arteries in the same intervention. The patient became completely anuric, protein loss stopped, and serum albumin slowly rose to normal levels. The patient's clinical condition dramatically improved and he regained his full mobility at the price of a lifelong renal replacement therapy. To our knowledge, this is the first reported usage of such a vascular occluder in the setting of refractory nephrotic syndrome with normal kidney function at the time of first presentation.

Safety and efficacy of transarterial nephrectomy as an alternative to surgical nephrectomy

OBJECTIVE

To evaluate the safety and efficacy of transarterial nephrectomy, i.e., complete renal artery embolization, as an alternative to surgical nephrectomy.

MATERIALS AND METHODS

This retrospective study included 11 patients who underwent transarterial nephrectomy due to a high risk of surgical nephrectomy or their refusal to undergo surgery during the period from April 2002 to February 2013. Medical records and radiographic images were reviewed retrospectively to collect information regarding underlying etiologies, clinical presentations and embolization outcomes.

RESULTS

The underlying etiologies for transarterial nephrectomy included recurrent hematuria (chronic transplant rejection [n = 3], arteriovenous malformation or fistula [n = 3], angiomyolipoma [n = 1], or end-stage renal disease [n = 1]), inoperable renal or ureteral injury (n = 2), and ectopic kidney with urinary incontinence (n = 1). The technical success rate was 100%, while clinical success was achieved in eight patients (72.7%). Subsequent surgical nephrectomy was required for three patients due to an incomplete nephrectomy effect (n = 2) or necrotic pyelonephritis (n = 1). Procedure-related complications were post-infarction syndrome in one patient and necrotic pyelonephritis in another patient. Of four patients with follow-up CT, four showed renal atrophy and two showed partial renal enhancement. No patient developed a procedure-related hypertension.

CONCLUSION

Transarterial nephrectomy may be a safe and effective alternative to surgical nephrectomy in patients with high operative risks.