Tom Darius, FRCS, MD, PhD

Tom Darius, FRCS, MD, PhD,
Surgical and Abdominal Transplantation Unit,
University Clinics Saint Luc,
Brussels, Belgium

In clinical discourse, the application of native unilateral nephrectomy to prepare the interior cavity for a kidney transplant remains controversial—even in the absence of other autosomal dominant polycystic kidney disease (ADPKD)-related symptoms. Evidence indicates that concern exists in performing this procedure simultaneously with isolated kidney transplantation in patients with ADPKD and whether this could impact the graft survival or introduce surgical comorbidities.

 

Confronting the Controversy

Tom Darius, FRCS, MD, PhD, and colleagues conducted a retrospective study to evaluate this surgical procedure in patients with ADPKD. “We agree that a simultaneous ipsilateral nephrectomy to create space during isolated kidney transplantation can be technically challenging, even in the hands of an experienced surgeon,” wrote Dr. Darius and colleagues in World Journal of Transplantation. However, “a review of the literature… does not show a significant negative impact.” The study team sough to clarify this.

Among 1,026 kidney transplantations performed at the University Clinics Saint-Luc in Brussels, Belgium, 154 patients were identified as undergoing isolated kidney transplantation for ADPKD. Of them, 77 underwent kidney transplantation alone (KTA) and 77 underwent kidney transplantation with associated native ipsilateral nephrectomy (KTIN).

The surgical technique used in the 154 observed patients was a standard kidney transplant procedure with a “hockey stick” incision and classical vascular reconstruction. A baseline ultrasound was performed on each patient before hospital discharge, unless primary nonfunction (PNF), delayed graft function (DGF), or vascular problems of the kidney graft were suspected.

The primary endpoint of the study was postoperative surgical comorbidities, including lymphocele, wound infection, incisional hernia, wound hematoma, urinary infection, need for blood transfusion during or after the transplant, pulmonary embolism, total hospital stay, readmission rate, and other complications. Secondary endpoints included PNG, DGF, venous or arterial kidney graft thrombosis, kidney rejection during the first post-transplant year, 1- and 5-year patient survival rate, and 1- and 5-year kidney graft survival rate.

 

No Significant Difference

No significant difference in surgical comorbidities was observed between the two study groups. The occurrence of PNF and DGF was comparable in both study groups, with PNF occurring in 0% of the KTA group vs 2.6% of the KTIN group (P=0.497) and DGF occurring in 9.1% of the KTA group vs 16.9% of the KTIN group (P=0.230). No significant difference was observed between the two groups in renal artery and vein thrombosis of the kidney graft, nor in acute rejection within 1 year of transplantation.

In the KTA group, the 1-year graft survival rate was 94.8%, and the 5-year graft survival rate was 90.3% (P=0.774). In the KTIN group, the 1-year graft survival rate was 100%, and the 5-year graft survival rate was 93.8% (P=0.774). In the KTA group the 1-year patient survival rate was 96.1%, and the 5-year patient survival rate was 90.3% (P=0.168). In the KTIN group the 1-year patient survival rate was 100%, and the 5-year patient survival rate was 100% (P=0.168).

The research team noted that clear indications must be observed before unilateral or bilateral native nephrectomy is performed prior to transplantation. These include symptoms like invalidating pain and discomfort, ongoing hematuria, and recurrent renal cyst infections. “The advantage of performing the nephrectomy simultaneous with the transplantation is the avoidance of an extra anesthetic/surgical procedure and possible oliguria when performed before transplantation during the time on the waiting list,” wrote Dr. Darius and colleagues.