Native nephrectomy prior to pediatric kidney transplantation: biological and clinical aspects

TLDR

Pre‑transplant nephrectomy is performed to reduce risks to graft and recipient. The study aimed to evaluate indications, surgical approach, morbidity of native nephrectomy, and its effects on clinical and biological parameters in pediatric kidney transplant recipients. The authors conducted a single‑center retrospective cohort study of 49 patients, extracting demographic, clinical, and laboratory data, and performed nephrectomy based on clinical judgment considering physiological and psychosocial factors such as polyuria, proteinuria, recurrent infections, or hypertension. Nephrectomy reduced urine output by 34 % and proteinuria by 40 %, normalized serum albumin, protein, and fibrinogen in 93 %, 73 %, and 55 % of patients, and was associated with clinically relevant complications in five cases.

Abstract

Pre-transplant nephrectomy is performed to reduce risks to graft and recipient. The aims of this study were to evaluate (1) indications, surgical approach, and morbidity of native nephrectomy and (2) the effects of kidney removal on clinical and biological parameters.This study was designed as a single-center retrospective cohort study in which 49 consecutive patients with uni- or bilateral native nephrectomies were identified from a total of 126 consecutive graft recipients in our pediatric kidney transplantation database between 1992 and 2011. Demographic, clinical, and laboratory details were extracted from charts and electronic records, including operation reports and pre- and post-operative clinic notes.Of the 49 nephrectomized patients, 47% had anomalies of the kidneys and urinary tract, 22% had cystinosis, 12% had focal segmental glomerulosclerosis, and 6% had congenital nephrotic syndrome. Nephrectomy decisions were based on clinical judgment, taking physiological and psychosocial aspects into consideration. Nephrectomy was performed in patients with polyuria (>2.5 ml/kg/h) and/or large proteinuria (>40 mg/m(2)/h), recurrent urinary tract infection or (rarely) hypertension. Urine output decreased from (median) 3.79 to 2.32 ml/kg/h (-34%), and proteinuria from 157 to 100 mg/m(2)/h (-40%) after unilateral nephrectomy (p=0.005). After bilateral nephrectomy, serum albumin, protein and fibrinogen concentrations normalized in 93, 73, and 55% of nephrectomized patients, respectively. Clinically relevant procedure-related complications (peritoneal laceration, hematoma) occurred in five patients.In summary, we demonstrate quantitatively that native nephrectomy prior to transplantation improved serum protein levels and anticipated post-transplant fluid intake needs in select children, reducing the risk of graft hypoperfusion and its postulated consequences for graft outcome.