Simultaneous versus Pretransplant Native Nephrectomy in Autosomal Dominant Polycystic Kidney Disease Patients

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Abstract

Introduction

50% of autosomal dominant polycystic kidney disease (ADPKD) patients will develop ESRD. For those patients who undergo renal transplantation (RT) and require a native nephrectomy (NN), the optimal timing of NN in relation to RT remains unknown.

Materials and Methods

We retrospectively reviewed 216 adult patients who underwent RT for ADPKD from 2005 to 2017. Patients were stratified by timing of NN into 2 groups. Group 1 included patients who had simultaneous NN and RT (n=102) & Group 2 underwent NN prior to RT (n=26). Patients with post-transplant NN (n=5) and those not requiring NN (n=83) were excluded, leaving 128 patients for analysis. Data were analyzed with chi-squared or Mann-Whitney U test.

Results

The median age for both groups was 52 (p=0.943) and 55% were male (p=0.095). Regarding co-morbidities, 8/128 (6%) had DM at the time of transplant and 119/128 (93%) had HTN (p=0.696, 0.116, respectively). 36% of patients were symptomatic. The most common symptom was pain (25/46). Non-symptomatic patients underwent NN when the native kidney extended into the pelvis. Group 1 patients were more likely to be preemptive (47% vs. 0% [p<0.0001]) and receive living donors (58% vs 29% [p=0.007]). Median EBL for Group 1 was 500 ml (IQR 300-900) vs 200 (IQR 150-388) for Group 2 (p<0.0001). Median operative time for transplant was 458 min (IQR 351-565) for Group 1 vs. 363 min (IQR 289-410) for Group 2 (p=0.034).

Results

There were no differences in intraoperative complications (total rate 5.5%, p=0.169) or in postoperative complications (20%, p=0.094). The most frequent post-op complication was ileus (28%). Median length of stay was 6 days for both groups (p=0.268) and there was no difference in the readmission rate (p=0.81). The most frequent reason for readmission overall was infection (22%). Median creatinine (Cr) at discharge was 1.7 (IQR 1.2-3.1) for Group 1 vs 2.5 (IQR 1.6-4.6) for Group 2 (p=0.027). Creat one year was 1.6 (IQR 1.3-2.1) for Group 1 vs 1.4 (IQR 1.2-1.8) for Group 2 (p=0.110) for patients transplanted prior to 11/2016.

Conclusions

Patients who underwent simultaneous NN and KT experienced lower immediate post-op Cr which can likely be explained by the increased rate of living donor transplantation in this group. However, the difference in Cr disappeared within 1 year and there were no differences in perioperative complications. Our results indicate that simultaneous surgery is safe despite longer operative times and greater blood loss and that the two approaches have similar 1-year short-term outcomes. Timing decisions should be based on individual patient circumstances and patient & surgeon preference.

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