Patel P, Horsfield C, Compton F, Taylor J, Koffman G, Olsburgh J
Guy's Hospital, London, UK.
Ann R Coll Surg Engl. 2011 Jul;93(5):391-5. doi: 10.1308/003588411X582690.
This study examined the clinical indications and timing for native nephrectomy (NN), together with the associated pathological findings in transplant patients with autosomal dominant polycystic kidney disease (ADPKD) at our institute over a period of 20 years.
A retrospective review was performed of ADPKD patients who had undergone both kidney transplantation and NN. Patients were identified from the kidney transplant database between 1988 and 2008 at Guy's and St Thomas' Hospital and the notes reviewed. All NN specimens were re-reviewed and reported according to current guidelines.
There were 157 kidney transplants performed for ADPKD (114 cadaveric and 43 living donor). Of these, 31 required NN (28 bilateral). The timing of NN was pre-transplant in 10 cases, at the time of the transplant in 1 case and post-transplant in 20 cases. The indications for NN were urinary tract infection (n=14, 45%), pain (n=12, 39%), tumour suspicion (n=3, 10%), haematuria (n=1, 3%) and space (n=1, 3%). Mortality in this NN series was 3%, with a 65% surgical morbidity rate. The length of hospital stay post-NN was significantly longer with open compared with laparoscopic techniques (p=0.003). There were two renal cell carcinomas (RCCs) in this series. Both patients presented with macroscopic haematuria (bilateral pT1a papillary RCCs in one case and a pT3b clear cell RCC in the other case). The incidence of RCC in this series of ADPKD transplant patients was 1.3%.
We have demonstrated that the majority of ADPKD patients do not require NN, with only 20% of our series undergoing this procedure. The timing of NN is variable and dictated by indication. NN was only required to make space for transplantation in one case (combined kidney and pancreas transplant). The main indications for NN were recurrent infection and pain, where NN can provide a successful outcome. Laparoscopic NN can be performed safely in patients with ADPKD. Haematuria in such patients should not be assumed to be of benign origin and requires exclusion of urinary tract malignancy as the incidence of RCC in this population is at least as common as in the general population.
本研究调查了我院20年间常染色体显性遗传性多囊肾病（ADPKD）移植患者行自体肾切除术（NN）的临床指征、时机及相关病理结果。
对接受过肾移植及NN的ADPKD患者进行回顾性研究。从盖伊和圣托马斯医院1988年至2008年的肾移植数据库中识别出患者，并查阅病历。所有NN标本均重新按照现行指南进行复查并报告。
共为ADPKD患者实施了157例肾移植手术（114例尸体供肾，43例活体供肾）。其中，31例需要行NN（28例双侧）。NN的时机为移植前10例，移植时1例，移植后20例。NN的指征包括尿路感染（n = 14，45%）、疼痛（n = 12，39%）、怀疑肿瘤（n = 3，10%）、血尿（n = 1，3%）和占位（n = 1，3%）。该NN系列患者的死亡率为3%，手术发病率为65%。与腹腔镜技术相比，开放手术NN术后住院时间显著更长（p = 0.003）。该系列中有2例肾细胞癌（RCC）。两名患者均表现为肉眼血尿（1例为双侧pT1a乳头状RCC，另1例为pT3b透明细胞RCC）。该系列ADPKD移植患者中RCC的发病率为1.3%。
我们证明了大多数ADPKD患者不需要行NN，本系列中仅20%的患者接受了该手术。NN的时机各异，取决于指征。仅1例（肾胰联合移植）需要NN为移植创造空间。NN的主要指征是反复感染和疼痛，此时NN可取得成功结果。ADPKD患者可安全地进行腹腔镜NN。此类患者的血尿不应被认为是良性的，需要排除尿路恶性肿瘤，因为该人群中RCC的发病率至少与普通人群一样常见。
