Selective Pre-Transplant Nephrectomy: Indications and Perioperative Management

Abstract

From May 1977 to June 1983, 198 patients were accepted as candidates for renal transplantation at our university. We review our experience with 14 consecutive patients who underwent selective pre-transplant nephrectomy during this interval. Indications for this procedure included recurrent or chronic pyelonephritis, structural abnormalities of the urinary tract predisposing the patient to infection, malignant or renin-dependent hypertension, Goodpasture's disease, certain cases of rapidly progressive glomerulonephritis and selected patients with polycystic kidneys. All patients underwent dialysis 1 day preoperatively. Perioperative fluid losses were measured carefully with prompt and vigorous replacement therapy. Patients received an average of 5,890 cc fluid replacement before postoperative dialysis. All patients underwent dialysis within 29 hours postoperatively. There were no postoperative deaths and 8 complications. Selective pre-transplant nephrectomy has spared 93 per cent of potential renal transplant candidates from a major surgical procedure. No patient has required removal of the original kidneys during the post-transplant period. Our experience has shown that the reluctance to hydrate these patients is unwarranted and that prompt postoperative dialysis, if required, is safe. Since some end stage kidneys are physiologically active and the associated surgical risk is high, pre-transplant nephrectomy should be performed only in carefully selected patients. In contrast to previous reports, which advocated minimal fluid administration and delayed postoperative dialysis, our recent experience indicates that vigorous fluid replacement therapy, carefully monitored with serial vital signs, weights, serum electrolytes and central venous pressure readings, will avert many of the complications encountered previously.

Kidney Transplantation with Concomitant Unilateral Nephrectomy: A Matched-Pair Analysis on Complications and Outcome

“…Indication for nephrectomy in non-PKD patients was based on widely accepted criteria such as recurrent or chronic pyelonephritis, structural abnormalities of the urinary tract predisposing the patient to infection, pharmaco-resistant hypertension and major vesicoureteral reflux (3,26,27). In all patients undergoing concomitant nephrectomy, major concern was taken to prevent infection caused by potentially infected native kidneys.…”

Transplantation in Autosomal Dominant Polycystic Kidney Disease without Nephrectomy

“…Uncontrollable arterial hypertension, recurrent infec tious disease due to peristent bacterial focus, intractable bleeding, and excessive size of the cysts are described as the main reasons for pretransplantation nephrectomy in patients with ADPKD [6,8,[10][11][12], Bilateral nephrecto my, however, is associated with a high rate of morbidity (18.7-58.7%) and mortality (exceeding 10% in one series) [6][7][8][9], Improvements in pharmacologic management of arterial hypertension and substitution of cyclosporine for azathioprine in immunosuppression have prompted us to change our policy in patients with ADPKD. Starting in 1985, all ADPKD patients with end-stage renal disease received their transplants without prior nephrectomy.…”

“…Screening for urinary tract infection in our patients was careful, and some received low-dose antibiotic prophylaxis during the first months, which were known to be the period of high est risk for infection. Modern antibiotic treatment, in cluding ciprofloxacin, seems to make intractable infection in ADPKD patients who require nephrectomy an excep tional case [14], However, recurrent cyst infection, intrac table pain, and recurrent bleeding remain conditions, requiring pretransplantation nephrectomy in some cases [ 11,12].…”

Retroperitoneoscopic pre‐transplant native kidney nephrectomy

“…1,2 Laparoscopic nephrectomy has become a routine procedure at specialized centers. The advantages of lower postoperative pain, minimal scars, rapid recovery and short convalescence period have offset the marginal increase in instrumentation costs and longer training periods of the surgeons.…”