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Mekahli D, Müller RU, Marlais M, Wlodkowski T, Haeberle S, de Argumedo ML, Bergmann C, Breysem L, Fladrowski C, Henske EP, Janssens P, Jouret F, Kingswood JC, Lattouf JB, Lilien M, Maleux G, Rozenberg M, Siemer S, Devuyst O, Schaefer F, Kwiatkowski DJ, Rouvière O, Bissler J. Clinical practice recommendations for kidney involvement in tuberous sclerosis complex: a consensus statement by the ERKNet Working Group for Autosomal Dominant Structural Kidney Disorders and the ERA Genes & Kidney Working Group. Nat Rev Nephrol 2024; 20:402-420. [PMID: 38443710 DOI: 10.1038/s41581-024-00818-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/07/2024]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by the presence of proliferative lesions throughout the body. Management of TSC is challenging because patients have a multifaceted systemic illness with prominent neurological and developmental impact as well as potentially severe kidney, heart and lung phenotypes; however, every organ system can be involved. Adequate care for patients with TSC requires a coordinated effort involving a multidisciplinary team of clinicians and support staff. This clinical practice recommendation was developed by nephrologists, urologists, paediatric radiologists, interventional radiologists, geneticists, pathologists, and patient and family group representatives, with a focus on TSC-associated kidney manifestations. Careful monitoring of kidney function and assessment of kidney structural lesions by imaging enable early interventions that can preserve kidney function through targeted approaches. Here, we summarize the current evidence and present recommendations for the multidisciplinary management of kidney involvement in TSC.
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Affiliation(s)
- Djalila Mekahli
- PKD Research Group, Laboratory of Ion Channel Research, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
- Department of Paediatric Nephrology, University Hospitals Leuven, Leuven, Belgium.
| | - Roman-Ulrich Müller
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Center for Rare Diseases Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Matko Marlais
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Tanja Wlodkowski
- Division of Paediatric Nephrology, Center for Paediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - Stefanie Haeberle
- Division of Paediatric Nephrology, Center for Paediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - Marta López de Argumedo
- Basque Office for Health Technology Assessment, (OSTEBA), Basque Government, Vitoria-Gasteiz, Spain
| | - Carsten Bergmann
- Department of Medicine IV, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Medizinische Genetik Mainz, Limbach Genetics, Mainz, Germany
| | - Luc Breysem
- Department of Radiology, University Hospital of Leuven, Leuven, Belgium
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ASP, Rome, Italy
- European Tuberous Sclerosis Complex Association (ETSC), Oestrich-Winkel, Germany
| | - Elizabeth P Henske
- Center for LAM Research and Clinical Care, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Janssens
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | - François Jouret
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital, Liège, Belgium
- Interdisciplinary Group of Applied Genoproteomics, Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - John Christopher Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St Georges University of London, London, UK
| | - Jean-Baptiste Lattouf
- Department of Surgery-Urology, CHUM-Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marc Lilien
- Department of Paediatric Nephrology, Wilhelmina Children´s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Micaela Rozenberg
- European Tuberous Sclerosis Complex Association (ETSC), Oestrich-Winkel, Germany
- Associação de Esclerose Tuberosa em Portugal, Lisbon, Portugal
| | - Stefan Siemer
- Department of Urology and Paediatric Urology, Saarland University, Homburg, Germany
| | - Olivier Devuyst
- Department of Physiology, Mechanisms of Inherited Kidney Disorders, University of Zurich, Zurich, Switzerland
- Institute for Rare Diseases, Saint-Luc Academic Hospital, UC Louvain, Brussels, Belgium
| | - Franz Schaefer
- Division of Paediatric Nephrology, Center for Paediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - David J Kwiatkowski
- Cancer Genetics Laboratory, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Rouvière
- Department of Radiology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Lyon, France, Faculté de médecine Lyon Est, Lyon, France
| | - John Bissler
- Department of Paediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN, USA.
- Children's Foundation Research Institute (CFRI), Le Bonheur Children's Hospital, Memphis, TN, USA.
- Paediatric Medicine Department, St. Jude Children's Research Hospital, Memphis, TN, USA.
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陈 克, 邓 绍, 刘 茁, 张 洪, 马 潞, 张 树. [Discussion on the surgical timing of rupture and hemorrhage of renal angiomyolipoma]. Beijing Da Xue Xue Bao Yi Xue Ban 2024; 56:326-331. [PMID: 38595253 PMCID: PMC11004956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To investigate the effect of different surgical timing on the surgical treatment of renal angiomyolipoma (RAML) with rupture and hemorrhage. METHODS The demographic data and perioperative data of 31 patients with rupture and hemorrhage of RAML admitted to our medical center from June 2013 to February 2023 were collected. The surgery within 7 days after hemorrhage was defined as a short-term surgery group, the surgery between 7 days and 6 months after hemorrhage was defined as a medium-term surgery group, and the surgery beyond 6 months after hemorrhage was defined as a long-term surgery group. The perioperative related indicators among the three groups were compared. RESULTS This study collected 31 patients who underwent surgical treatment for RAML rupture and hemorrhage, of whom 13 were males and 18 were females, with an average age of (46.2±11.3) years. The short-term surgery group included 7 patients, the medium-term surgery group included 12 patients and the long-term surgery group included 12 patients. In terms of tumor diameter, the patients in the long-term surgery group were significantly lower than those in the recent surgery group [(6.6±2.4) cm vs. (10.0±3.0) cm, P=0.039]. In terms of operation time, the long-term surgery group was significantly shorter than the mid-term surgery group [(157.5±56.8) min vs. (254.8±80.1) min, P=0.006], and there was no significant difference between other groups. In terms of estimated blood loss during surgery, the long-term surgery group was significantly lower than the mid-term surgery group [35 (10, 100) mL vs. 650 (300, 1 200) mL, P < 0.001], and there was no significant difference between other groups. In terms of intraoperative blood transfusion, the long-term surgery group was significantly lower than the mid-term surgery group [0 (0, 0) mL vs. 200 (0, 700) mL, P=0.014], and there was no significant difference between other groups. In terms of postoperative hospitalization days, the long-term surgery group was significantly lower than the mid-term surgery group [5 (4, 7) d vs. 7 (6, 10) d, P=0.011], and there was no significant difference between other groups. CONCLUSION We believe that for patients with RAML rupture and hemorrhage, reoperation for more than 6 months is a relatively safe time range, with minimal intraoperative bleeding. Therefore, it is more recommended to undergo surgical treatment after the hematoma is systematized through conservative treatment.
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Affiliation(s)
- 克伟 陈
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 绍晖 邓
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 茁 刘
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 洪宪 张
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 潞林 马
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 树栋 张
- />北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
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Combes A, McQueen S, Palma CA, Benz D, Leslie S, Sved P, Boulas J, Vasilaras A, Rogan C, Drivas I, Eisinger DR, Waugh R. Is Size All That Matters? New Predictors of Complications and Bleeding in Renal Angiomyolipoma. Res Rep Urol 2023; 15:113-121. [PMID: 36968628 PMCID: PMC10038158 DOI: 10.2147/rru.s400730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/04/2023] [Indexed: 03/22/2023] Open
Abstract
Purpose Renal angiomyolipoma (AML) is the most common benign renal tumor. Whilst generally asymptomatic, they can cause life-threatening bleeding. Selective angioembolization (SAE) may be used to treat large symptomatic and asymptomatic AMLs. We aimed to evaluate the efficacy of SAE for symptomatic and asymptomatic renal AMLs and determine characteristics that predict spontaneous bleeding. Patients and Methods Data were retrospectively collected from a prospectively maintained database from July 2011 to April 2022. Patients were included if AML was >4cm and they underwent subsequent SAE. Follow-up imaging was analyzed to calculate mean reduction in AML size. Clinical notes were reviewed to analyze lesion characteristics including vascularity, fat content and presence of aneurysm as well as post-procedural complications. Results 26 patients with 30 AMLs were identified. Interval of follow-up imaging ranged from 1 to 60 months. 25 AMLs were embolized electively with 5 emergency embolizations performed for bleeding. Mean reduction in AML volume was 41% at 3 months (p=0.013) and 63% at 12 months (p=0.007). All 5 bleeding AMLs had a rich vascularity with 60% also having either aneurysms or a low fat content. Complications included post-embolic syndrome (n=9), segmental renal parenchyma devascularization (n=3), acute bleeding requiring re-embolization (n=2), nephrectomy for ongoing bleeding (n=1) and delayed bleeding managed conservatively (n=1). No deterioration in renal function was observed. Conclusion SAE is an effective procedure for managing symptomatic and asymptomatic renal AML, with minimal significant complications. AML vascularity, fat content and aneurysms may be useful characteristics to assess future risk of bleeding in patients with renal AML.
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Affiliation(s)
- Alexander Combes
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
- Correspondence: Alexander Combes, Department of Urology, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia, Tel +612 9515 7773, Fax +612 9515 7774, Email
| | - Simon McQueen
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | | | - David Benz
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Scott Leslie
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
- RPA Institute of Academic Surgery, Sydney, NSW, Australia
- Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
- Department of Urology, Chris O’Brien Lifehouse, Sydney, NSW, Australia
| | - Paul Sved
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
- Department of Urology, Chris O’Brien Lifehouse, Sydney, NSW, Australia
| | - John Boulas
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
- Department of Urology, Chris O’Brien Lifehouse, Sydney, NSW, Australia
| | - Arthur Vasilaras
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
- Department of Urology, Chris O’Brien Lifehouse, Sydney, NSW, Australia
| | - Chris Rogan
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
- Department of Urology, Chris O’Brien Lifehouse, Sydney, NSW, Australia
| | - Ilias Drivas
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - David Robert Eisinger
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Richard Waugh
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
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Neela N, Taha H, Kala J. Spontaneous Page kidney from ruptured renal angiomyolipoma. Proc (Bayl Univ Med Cent) 2021; 34:689-690. [PMID: 34732988 DOI: 10.1080/08998280.2021.1948736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Renal angiomyolipomas are the most common benign tumors of the kidneys. They are prone to rupture, which may result in massive hemorrhage and often requires lifesaving nephrectomy. Delay in treatment is likely to result in death. We report two cases of ruptured angiomyolipoma compressing the renal parenchyma, causing secondary hypertension (Page kidney). Both patients presented with abdominal pain, hypertension, and reduced or dropping hemoglobin counts. The delay in diagnosis and treatment resulted in their adverse outcomes. We highlight the need to promptly diagnose and treat symptomatic renal hematomas to avoid subsequent morbidity and mortality.
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Affiliation(s)
- Niharika Neela
- Department of Internal Medicine, University of Texas Health Science Center-McGovern Medical School, Houston, Texas
| | - Hula Taha
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center-McGovern Medical School, Houston, Texas
| | - Jaya Kala
- Department of Internal Medicine, University of Texas Health Science Center-McGovern Medical School, Houston, Texas
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Young J, Kalczynski J, Emerling A, Bianchi W. Renal angiomyolipoma rupture in a young female with COVID-19. Am J Emerg Med 2021; 47:316.e1-316.e3. [PMID: 33741199 PMCID: PMC7879133 DOI: 10.1016/j.ajem.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/28/2021] [Accepted: 02/06/2021] [Indexed: 11/29/2022] Open
Abstract
While primarily a respiratory illness, infection with the novel coronavirus (COVID-19) is associated with pathologic changes in coagulation, characterized by both thromboembolic and bleeding events. We present the case of a 22-year-old female diagnosed with renal angiomyolipoma (AML) rupture 2 weeks after COVID-19 infection, ultimately requiring admission for hemorrhage control via endovascular embolization. Emergency medicine physicians should maintain a high index of suspicion for renal AML rupture and other spontaneous bleeding events in patients with recent COVID-19 infection due to a possible correlation between the two.
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Affiliation(s)
- Jocelyn Young
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States.
| | - Jeffrey Kalczynski
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States
| | - Alec Emerling
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States
| | - William Bianchi
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, United States
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Fuse H, Ito M, Takemura K, Ikuta S, Motoi T, Okuma T, Kataoka M, Koga F. Renal Angiomyolipoma Mimicking a Well-Differentiated Retroperitoneal Liposarcoma. Case Rep Urol 2020; 2020:8812057. [PMID: 33029444 DOI: 10.1155/2020/8812057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 02/07/2023] Open
Abstract
A 37-year-old Burmese woman presented with an incidentally found retroperitoneal fat-containing tumor. The tumor was 9 cm in the longest diameter, surrounding the right kidney, and composed of homogenous adipose tissue with thickened septum-like structures and spotty nonadipose structures, which were enhanced on contrast-enhanced computed tomography and magnetic resonance imaging. The tumor did not show either a beak sign or synchronous angiomyolipoma-like lesion in the kidneys. The tumor had irregular septa, thin blood vessels, and spotty small soft-tissue nodules. The tumor did not contain any heterogeneously enhanced solid lesions suspicious for dedifferentiated liposarcomas. Based on these imaging findings, a clinical diagnosis of a well-differentiated liposarcoma was made. Under the consensus of a multidisciplinary cancer board, she was recommended to undergo core-needle biopsy to confirm the clinical diagnosis. However, she declined to undergo biopsy for financial reasons. She underwent kidney-sparing retroperitoneal tumor resection. Histopathologically, the tumor was an angiomyolipoma with positive immunostaining for HMB45 and Melan A. The present case suggests the importance of core-needle biopsy prior to surgical intervention for retroperitoneal fat-containing tumors.
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