|Year : 2018 | Volume
| Issue : 3 | Page : 68-72
Native nephrectomy in kidney transplantation, when, why, and how?
Mohamed E Elrggal1, Hoda M.M Abd Elaziz2, Mohammed A Gawad1, Hussein A Sheashaa3
1 Department of Nephrology, Kidney and Urology Center (KUC), Alexandria, Egypt
2 Department of Nephrology, Mansoura Nephrology and Dialysis Unit (MNDU), Mansoura, Egypt
3 Department of Nephrology, Mansoura Urology and Nephrology Center (UNC), Mansoura University, Mansoura, Egypt
|Date of Submission||26-Apr-2018|
|Date of Acceptance||15-Aug-2018|
|Date of Web Publication||09-Nov-2018|
Mohamed E Elrggal
23, Mohamed Safwat Street, Kafr-Abdo, Alexandria, 21529
Source of Support: None, Conflict of Interest: None
Native nephrectomy (NN) is not routinely performed in the context of kidney transplantation. Certain clinical circumstances necessitate performing NN such as large polycystic kidneys impairing patient’s quality of life and hindering graft implantation. NN may be done either before, simultaneously with, or after kidney transplantation. Although several studies have reported the potential benefits of the pretransplantation approach, others defended the simultaneous approach postulating that it is feasible and satisfactory. Nevertheless, still the ideal timing of NN is not settled, and several factors determine the choice of nephrectomy timing, including the presence of pressure symptoms, residual diuresis, and adequate space for the graft and living (not deceased) kidney donation. Answering these questions will help in decision making to attain an individualized approach that would help in achieving optimum timing of NN in relation to kidney transplantation.
Keywords: kidney transplantation, native nephrectomy
|How to cite this article:|
Elrggal ME, Abd Elaziz HM, Gawad MA, Sheashaa HA. Native nephrectomy in kidney transplantation, when, why, and how?. J Egypt Soc Nephrol Transplant 2018;18:68-72
|How to cite this URL:|
Elrggal ME, Abd Elaziz HM, Gawad MA, Sheashaa HA. Native nephrectomy in kidney transplantation, when, why, and how?. J Egypt Soc Nephrol Transplant [serial online] 2018 [cited 2018 Dec 11];18:68-72. Available from: http://www.jesnt.eg.net/text.asp?2018/18/3/68/245128
| Introduction|| |
Pretransplant recipient native nephrectomy (NN) is not the standard practice in kidney transplantation and usually both native kidneys are left in place. In some circumstances, NN may be beneficial and indicated in certain circumstances ([Table 1]); however, data to support or discourage are limited. The loss of residual excretory function and erythropoietin production are the main concerns should the graft fail, especially in pre-emptive transplantation.
| Why?|| |
Several indications exist for NN either unilateral or bilateral ,,.
For patients with recurrent infection associated with nephrolithiasis, pre-transplant nephrectomy of native kidneys seems a reasonable therapeutic option. Stones requiring nephrectomy are usually complicated (stag-horn stone) or infected (struvite stone) .
For vesicoureteral reflux, the presence of recurrent pyelonephritis − especially when accompanied by a nonfunctioning kidney − is considered an indication for pretransplant nephrectomy despite paucity of evidence .
Regarding blood pressure control, benefits of NN have been reported from retrospective observations. Hypertension is very common after kidney transplantation and is one of the non-immunological causes of graft failure. Theoretically, NN is thought to ameliorate hypertension by removing the renin-secreting native kidneys. However, old reports from Norway did not find any significant improvement of blood pressure after NN as compared with a non-nephrectomized control group in a retrospective evaluation of 158 patients . Nevertheless, another research group explored the outcomes of NN for a prolonged period after transplant and concluded that NN is effective to help blood pressure control, in resistant hypertension in renal transplant patients, but it starts to show up 3 months after surgery, and continues to work for a year and more . Moreover, kidney transplant recipients with pre-transplant bilateral NN were found to have lower blood pressure and lower ventricular mass index compared with controls without nephrectomy . Patients with autosomal dominant polycystic kidney disease (ADPKD) who had ipsilateral nephrectomy concomitantly with transplantation required less hypertensive medications after transplantation than controls . A delayed contralateral nephrectomy for the same group improved blood pressure control to a greater extent . Bilateral NN also helped in controlling resistant hypertension in five patients after kidney transplantation . Thus, it seems that NN works for resistant hypertension, and the old reports about its poor results may ensue from multiple perioperative complications at that time.
Patients with massive proteinuria may benefit from pretransplant nephrectomy. Nephrectomy decreases mortality, allows for growth (in children), and protects against renal graft thrombosis ,.
Moreover, there may be other special indications for NN in pediatric population with genetic disorders including Denys–Drash syndrome and patients with primary hyperoxaluria.
Denys–Drash syndrome is a rare genetic disorder consisting of pseudohermaphroditism, Wilms’ tumor, and progressive glomerulopathy. Native bilateral nephrectomy is advised in patients with this syndrome, because the risk of developing Wilms’ tumor is very high if native kidneys are left in place even if it was absent at the time of diagnosis .
In patients with primary hyperoxaluria, combined liver and kidney transplantation (CLKT) is the treatment of choice when the patient reaches end-stage kidney disease. However, plasma oxalate levels remain high several months after transplantation owing to slow excretion of the residual body oxalate. Those patients often require dialysis after transplantation to protect the graft. Recently, bilateral NN was performed at the time of CLKT in a child with primary hyperoxaluria . This led to drastic decrease of oxalate levels eight-fold within hours after the operation then continued to decrease thereafter till reaching normal levels in less than 20 days (reported in the literature to occur within several months up to 3 years with some patients still having high oxalate levels even after 3 years of CLKT ). This can decrease the need for hemodialysis after transplantation and help protect the kidney against graft dysfunction from persistent hyperoxaluria.
Native nephrectomy and autosomal dominant polycystic kidney disease
In ADPKD, NN is a controversial issue ,,. Native polycystic kidneys tend to regress in volume after kidney transplantation, which supports the opinion of leaving native kidneys in place . Pretransplant nephrectomy is commonly reserved only for those with certain indications (see [Table 2]) ,,.
|Table 2 Indications for native nephrectomy in autosomal dominant polycystic kidney disease|
Click here to view
When? (simultaneous or sequential in autosomal dominant polycystic kidney disease)
Timing of nephrectomy relative to graft placement is controversial and yet there is no consensus regarding the optimal timing in relation to transplantation. Although some studies reported similar outcomes when nephrectomy was performed before, during, or after kidney transplantation , a considerable number of other studies favor simultaneous NN ,.
When comparing nephrectomy timing either before, during, or after kidney transplantation, blood loss, operative time, and hospitalization length were nonsignificantly greater for the concomitant nephrectomy group; however, kidney allograft function and patient survival did not differ between the three groups . Patient satisfaction was better with concomitant nephrectomy and kidney transplantation ,. Another study reported excellent graft and patient survival with low morbidity with simultaneous ipsilateral nephrectomy and graft transplantation . One more advantage of the simultaneous approach is that it allows for pre-emptive transplantation especially in the presence of well-planned living donor . Despite all these advantages, a recent study reported an increased incidence of renal vascular thrombosis with the simultaneous bilateral nephrectomy approach in patients with ADPKD .
Regarding pretransplant NN, one study reported safer results with sequential laparoscopic bilateral NN followed by kidney transplantation than simultaneous nephrectomy and transplantation . However, many drawbacks of this approach should be considered, notably the increased number of procedures to which the patient is exposed before kidney transplantation with risk of sensitization to human leukocyte antigen (HLA) antigens . A recent retrospective report noted that the mean panel-reactive antibodies significantly increased after pretransplant NN was performed . Moreover, rapid loss of residual kidney function with pretransplant NN leaves predialysis patients anuric, thus losing the advantage of pre-emptive transplantation  (see [Table 3]).
|Table 3 Benefits and drawbacks of pretransplant and simultaneous native nephrectomy|
Click here to view
A third group of studies compared pre-kidney and post-kidney transplant NN. In their cohort, post-transplant nephrectomy, especially when laparoscopically done, was very safe procedure with excellent comparable patient and graft outcomes plus a lower complication rate than pretransplant nephrectomy .
How? (laparoscopic or open − unilateral or bilateral)
The choice of surgical technique is still a controversial issue. Laparoscopic removal of cystic kidneys is increasingly used and is gaining more popularity rather than open nephrectomy. Many studies had shown the safety of performing laparoscopic nephrectomy with comparable results and better patient satisfaction than open nephrectomy ,,.
Ipsilateral nephrectomy was chosen as the standard procedure for kidney transplantation in one hundred consecutive patients with ADPKD, with excellent graft and patient survival. In this study, simultaneous ipsilateral nephrectomy with kidney transplantation had lower surgical complications and less added time to the standard transplantation compared with bilateral nephrectomy .
An individualized approach for autosomal dominant polycystic kidney disease
Finally, as discussed before, no consensus is there regarding the optimal timing for NN relative to kidney transplantation especially in patients with ADPKD. An algorithm was recently proposed which can assist in choosing the best time and technique for NN in kidney transplantation . This algorithm can be modified for optimum decision making (see [Figure 1]) considering the following points: the presence of residual kidney function, the presence of adequate site for graft placement, the higher complication rate of the simultaneous approach, the potential hazards of the remaining kidney in cases when the unilateral approach is chosen, the presence of experienced surgeons for laparoscopic approaches, and the degree of patient satisfaction.
|Figure 1 a proposed algorithm for decision making regarding the optimum timing and technique for native nephrectomy in ADPKD (modified from reference number ).|
Click here to view
Alternative options to native nephrectomy
Indeed, when NN is indicated, surgery remains the gold standard but transcatheter renal arterial embolization may be a safer alternative option owing to its low morbidity . However, it may not be a suitable option in the context of pre-emptive living donor kidney transplantation, as it takes as long as 6 months to achieve sufficient kidney volume reduction before grafting can be performed .
| Conclusion|| |
NN has several indications with kidney transplantation. Timing of NN is still a matter of debate. Each approach for NN has its benefits and drawbacks. Therefore, decision making should be individualized for each patient to reach the best clinical outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Knoll G, Cockfield S, Blydt-Hansen T, Baran D, Kiberd B, Landsberg D et al.
Canadian Society of Transplantation consensus guidelines on eligibility for kidney transplantation. CMAJ 2005; 173:1181–1184.
Ghane Sharbaf F, Bitzan M, Szymanski KM, Bell LE, Gupta I, Tchervenkov J et al.
Native nephrectomy prior to pediatric kidney transplantation: biological and clinical aspects. Pediatr Nephrol 2012; 27:1179–1188.
Rosenberg JC, Azcarate J, Fleischmann LE, McDonald FD, Menendez M, Pierce JM et al.
Indications for pretransplant nephrectomy. Arch Surg 1973; 107:233.
Abramowicz D, Cochat P, Claas FHJ, Heemann U, Pascua J, Dudley C et al.
European Renal Best Practice Guideline on kidney donor and recipient evaluation and perioperative care. Nephrol Dial Transplant 2015; 30:1790–1797.
Erturk E, Burzon DT, Orloff M, Rabinowitz R. Outcome of patients with vesicoureteral reflux after renal transplantation: the effect of pretransplantation surgery on posttransplant urinary tract infections. Urology 1998; 51(5A Suppl):27–30.
Midtvedt K, Hartmann A, Bentdal O, Brekke IB, Fauchald P. Bilateral nephrectomy simultaneously with renal allografting does not alleviate hypertension 3 months following living-donor transplantation. Nephrol Dial Transplant 1996; 11:2045–2049.
Gawish AEA, Donia F, Fathi T, Al-Mousawi M, Samhan M. It takes time after bilateral nephrectomy for better control of resistant hypertension in renal transplant patients. Transplant Proc 2010; 42:1682–1684.
Obremska M, Boratyńska M, Zyśko D, Szymczak M, Kurcz J, Goździk A et al.
Beneficial effect of bilateral native nephrectomy as complete denervation on left ventricular mass and function in renal transplant recipients. Pol Arch Med Wewn 2016; 126:58–67.
Shumate AM, Bahler CD, Goggins WC, Sharfuddin AA, Sundaram CP. Native nephrectomy with renal transplantation is associated with a decrease in hypertension medication requirements for autosomal dominant polycystic kidney disease. J Urol 2016; 195:141–146.
Lerman MJ, Hinton S, Aronoff R. Bilateral native nephrectomy for refractory hypertension in kidney transplant and kidney pancreas transplant patients. Int J Surg Case Rep 2015; 15:127–129.
Savage JM, Jefferson JA, Maxwell AP, Hughes AE, Shanks JH, Gill D. Improved prognosis for congenital nephrotic syndrome of the Finnish type in Irish families. Arch Dis Child 1999; 80:466–469.
Slaughenhoupt BL, Lohrasbi FF, Harrison HL, Van Savage JG. Urologic management of congenital nephrotic syndrome of the Finnish type. Urology 1998; 51:492–494.
Hu M, Zhang GY, Arbuckle S, Graf N, Shun A, Silink M et al.
Prophylactic bilateral nephrectomies in two paediatric patients with missense mutations in the WT1 gene. Nephrol Dial Transplant 2004; 19:223–226.
Villani V, Gupta N, Elias N, Vagefi PA, Markmann JF, Paul E et al.
Bilateral native nephrectomy reduces systemic oxalate level after combined liver-kidney transplant: a case report. Pediatr Transplant 2017; 21:e 12901.
Duclaux-Loras R, Bacchetta J, Berthiller J, Rivet C, Demède D, Javouhey E et al.
Pediatric combined liver-kidney transplantation: a single-center experience of 18 cases. Pediatr Nephrol 2016; 31:1517–1529.
Wagner MD, Prather JC, Barry JM. Selective, concurrent bilateral nephrectomies at renal transplantation for autosomal dominant polycystic kidney disease. J Urol 2007; 177:2250–2254. Discussion 2254.
Brazda E, Ofner D, Riedmann B, Spechtenhauser B, Margreiter R. The effect of nephrectomy on the outcome of renal transplantation in patients with polycystic kidney disease. Ann Transplant 1996; 1:15–18.
Knispel HH, Klän R, Offermann G, Miller K. Transplantation in autosomal dominant polycystic kidney disease without nephrectomy. Urol Int 1996; 56:75–78.
Jung Y, Irazabal MV, Chebib FT, Harris PC, Dean PG, Prieto M et al.
Volume regression of native polycystic kidneys after renal transplantation. Nephrol Dial Transplant 2016; 31:73–79.
Argyrou C, Moris D, Vernadakis S. Tailoring the ‘perfect fit’ for renal transplant recipients with end-stage polycystic kidney disease: indications and timing of native nephrectomy. In Vivo (Brooklyn) 2017; 31:207–312.
Fuller TF, Brennan TV, Feng S, Kang S-M., Stock PG, Freise CE. End stage polycystic kidney disease: indications and timing of native nephrectomy relative to kidney transplantation. J Urol 2005; 174:2284–2288.
Glassman DT, Nipkow L, Bartlett ST, Jacobs SC. Bilateral nephrectomy with concomitant renal graft transplantation for autosomal dominant polycystic kidney disease. J Urol 2000; 164(3 Pt 1):661–664.
Kim JH, Chae SY, Bae HJ, Kim JI, Moon IS, Choi BS et al.
Clinical outcome of simultaneous native nephrectomy and kidney transplantation in patients with autosomal dominant polycystic kidney disease. Transplant Proc 2016; 48 (3):840–843.
Grodstein EI, Baggett N, Wayne S, Leverson G, D’Alessandro AM, Fernandez LA et al.
An evaluation of the safety and efficacy of simultaneous bilateral nephrectomy and renal transplantation for polycystic kidney disease: a 20-year experience. Transplantation 2017; 101:2774–2779.
Ahmad SB, Inouye B, Phelan MS, Kramer AC, Sulek J, Weir MR et al.
Live donor renal transplant with simultaneous bilateral nephrectomy for autosomal dominant polycystic kidney disease is feasible and satisfactory at long-term follow-up. Transplantation 2016; 100:407–415.
Veroux M, Zerbo D, Basile G, Gozzo C, Sinagra N, Giaquinta A et al.
Simultaneous native nephrectomy and kidney transplantation in patients with autosomal dominant polycystic kidney disease. PLoS One 2016; 11:e0155481.
Cohen D, Timsit M-O, Chrétien Y, Thiounn N, Vassiliu V, Mamzer M-F et al.
Place of nephrectomy in patients with autosomal dominant polycystic kidney disease waiting for renal transplantation. Prog Urol 2008; 18:642–649.
Ismail HR, Flechner SM, Kaouk JH, Derweesh IH, Gill IS, Modlin C et al.
Simultaneous vs. sequential laparoscopic bilateral native nephrectomy and renal transplantation. Transplantation 2005; 80:1124–1127.
Chebib FT, Prieto M, Yeonsoon J, Irazabal MV, Kremers WK, Dean PG et al.
Native nephrectomy in renal transplant recipients with autosomal-dominant polycystic kidney disease. Transplant Direct 2015; 1:e43.
Lipke MC, Bargman V, Milgrom M, Sundaram CP. Limitations of laparoscopy for bilateral nephrectomy for autosomal dominant polycystic kidney disease. J Urol 2007; 177:627–631.
Torres VE, Harris PC. Autosomal dominant polycystic kidney disease: the last 3 years. Kidney Int 2009; 76:149–168.
Whitten MG, Van der Werf W, Belnap L. A novel approach to bilateral hand-assisted laparoscopic nephrectomy for autosomal dominant polycystic kidney disease. Surg Endosc 2006; 20:679–684.
Neeff HP, Pisarski P, Tittelbach-Helmrich D, Karajanev K, Neumann HPH, Hopt UT et al.
One hundred consecutive kidney transplantations with simultaneous ipsilateral nephrectomy in patients with autosomal dominant polycystic kidney disease. Nephrol Dial Transplant 2013; 28:466–471.
Tillou X, Timsit M-O., Sallusto F, Culty T, Verhoest G, Doerfler A et al.
Polycystic kidney disease and kidney transplantation. Prog Urol 2016; 26:993–1000.
Versteeg IB, Casteleijn NF, Gansevoort RT. Transcatheter arterial embolization: an underappreciated alternative to nephrectomy in autosomal dominant polycystic kidney disease?. Nephrol Dial Transplant 2017; 32:1075–1078.
[Table 1], [Table 2], [Table 3]