percutaneous reduct10n of cyst kidney disease:effects on volume of

percutaneous reduct10n of cyst kidney disease:effects on volume of

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THE」
OURNAL OF UROLOGY
Vol.147,1482-1484,」uno 1992
P五れ″djル じ S■
Copyright()1992 by AMERICAN UROLOGICAL AssocIATlON,INC
PERCUTANEOUS REDUCT10N OF CYST
KIDNEY DISEASE:EFFECTS ON
VOLUME OF POLYCYSTIC
RENAL FUNCT10N
EIJI HIGASHIHARA,KIKUO NUTAHARA,SHIGERU MINOWADA,
YUK10 HOMMA AND YOSH10 AS0
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ABSTRACT
Percutaneousreduction of cyst volume was performed in 10 patients with autosomal dominant
polycystic kidney disease and its effects on renal function were studied. Although creatinine
clearance,^grinaryexcretion of B2-microglobulinand N-acetyl-B-D-glucosaminidase,
and renal
uptake of ee*technetium-dimercaptosuccinicacid did not changb signifilantly, a transient increase
in urinary protein and a decrease in inulin clearance were observed. Complications, such as
hematuria, fever and decreasesin hematocrit, were slight and transient in most patients. This
procedureholds little promise for altering the courseof polycystic kidney disease.
Kuv Wonos: kidney, polycystic; kidney failure, chronic
Percutaneouspuncture of renal cysts has becomea common
procedureto treat simple renal cysts.l Recently, percutaneous
or surgical decompressionwas performed for the treatment of
symptomatic patients with polycystic kidney diseasewithout
any deleteriouseffectson renal function.2'3In the 1960ssurgical
decompressionwas abandonedfor the treatment of polycystic
kidney disease.aHowever, the effect of percutaneouscyst aspiration on renal function remains to be clarified. Since renal
function was shown to correlate inversely with the total renal
volume,s reduction of the cyst volume might improve renal
function if it is done as a minimally invasive procedure.Therefore, we examinedthe effect of percutaneouscyst aspiration on
renal function in autosomal dominant polycystic kidney
disease.
ment. The diagnosisof autosomaldominant polycystic kidney
diseasewas confirmed in all patients by computerizedtomography and ultrasonography.6
After informed consent was obtained, the renal uptake of
ee-technetium-dimercaptosuccinicacid (se-Tc-DMSA)
was
measuredand urine was collectedduring a24-hour period. The
urine was usually collectedon a nonworking but otherwisefully
ambulant day. A blood sample was obtained at the completion
of the 24-hour urine collection. Approximately 1 month after
ambulatory examination of renal function the patients were
hospitalized. Urine was collected for 24 hours, and inulin and
paraaminohippurate clearancewere determined during hospitalization before and after the cyst puncture.
The cysts were punctured while the patients were under
epidural anesthesia.Puncture and aspiration ofcyst fluids with
MATERIALS AND METHODS
a 23 gaugeIong needle guided by ultrasonographywere termiA total of 7 men and 3 women between 20 and 66 years old nated when large cystsbecameindistinct on the ultrasonogram.
(mean age 45.6 + 15.8 years, standard deviation) with autoso- The patients were dischargedfrom the hospital 5 days after the
mal dominant polycystic kidney diseaseunderwenr percuta- puncture and after complications,such as fever and hematuria,
neous aspiration of renal cysts. The patients with polycystic had been adequatelycontrolled.
Approximately 1 month after the patient was discharged
kidney diseasewere identified from the registry of our departhome the renal uptake of ee*Tc-DMSA and a 24-hour clearance
publication
Accepted
for
November
15,1991.
Supportedin part by a grant on progressive
renal failurefrom the study were repeated.TBlood pressure was measured during
Ministry of Health and Welfareand a srant on cvsticrenal disease severalvisits and 3 times a day during hospitalization without
fromthe Ministry of Educationof Japan.
atry change in medical treatment of hypertension. The blood
Changesin uariousparameters after percutaneous decompressionof renal cyst in patients with polycystichidney disease
a
1 Mo. Before
Puncture
Serum creatinine (mg./dl.)
Serum urea (mg./dl.)
Serum uric acid (mg./dl.)
Hemoglobin (gm./dl.)
Hematocrit (%)
Creatinine clearance(ml./
m l n . / r ./ d m . - J
Urinary excretion of:
Protein (mg./day/1.73 m.2)
B2-microglobulin(me./ dav/
1.73m.'?)
N-acetyl-B-D-glucosaminidase(U./day/l.73 m.'?)
Mean arterial blood pressure
(mm. Hg)
bc
3 Days Before
Puncture
3 . 2 4 ±2 . 7 2
3.43±
328± 17.0
361±
6.40± 1.33
667±
1 1 . 8 2 ±2 9 1 1 1 . 6 0 ±
3505± 8.21
3456±
405± 277
409±
3 Days After
Puncture
3.02
3.59± 319
229
36.1± 253
158
6.69± 168
271 1040±
324
840
3067± 960
323
419± 328
Paired t Test
d
1 Mo. After
Puncture
3.43±
340±
602±
1080±
3243±
397±
2.86
18 4
1 09
3.08
9 17
30 3
a Versusd
Not
Not
Not
Not
Not
Not
Normal Laboratory Values'
b Versus c
signiicant
signiicant
signiflcant
signiflcant
significant
signiflcant
Not signiflcant
Not signi■cant
Not signiflcant
pく 001
p<0.01
Not signiflcant
07∼ 13
8∼ 21
2.3∼ 73
12∼
18
34∼
48
92±
21.8+
1 , 2 3 4 ±1 , 2 4 0
166± 24.0
728± 634
185± 23.7
1,667± 1,371
201± 19.7
l,826± 2,909
24.3± 30.2
Not signiflcant
Not signiflcant
pく 005
Not signiflcant
8.08± 2.90
676± 231
8.36± 257
764± 2 35
Not signiflcant
Not signiicant
l.8∼ 6.8
Not significant
Not signiflcant
Less than l10
1163± 13.6
1112±
101
106.8±
114
l102± 14 4
44∼
295
0 03∼ 037
Data are mean t standard deviation.
* Normal laboratory valuesare those report€d at the
Hospitel of Faculty of Medicine, tle University of Tokyo, except for creatinine clearance.
t Creatinine clearancewas obtained on 38 healthv controls.
1482
POLYCYSTIC KIDNEY
PERCUTANEOUS PUNCTURE OF
1483
DISEASE
N.S.
P<0.05
N.S.
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PUNCTURE
FIc. 1. Effect of percutaneous
decompression
on urinary protein
excretionin patientswith polycystickidneydisease.
Dottedline representseachvalue and solid line representsmeanvalue.N.S., not
signifrcant.
and urine samples were analyzed by an autoanalyzer. Urine
protein was measuredwith a pyrogallol red-molybdatecomplex
method. Urine N-acetyl-B-D-glucosaminidasewas determined
with a chromogenic substrate method. B2-Microglobulin was
determined by double-antibodyradioimmunoassay.The inulin
concentration was determined by the anthrone method and
paraaminohippurate by the method of Smith et al.7 All data
are expressedas the mean + standard deviation. The multiple
comparisoncorrectedby Bonferroni's method and paired t test
were used.
RESULTS
The aspirated fluid volumes ranged from 112 to 968 ml. per
kidney (mean 467.7 + 342.8 ml.) and numbers of punctured
cystsrangedfrom 4 to 17 per kidney (mean8.8 + 3.2).Changes
in the pertinent parameters are shown in the table. Serum
creatinine, blood urea nitrogen and uric acid did not change
significantly. Hemoglobin and hematocrit decreasedsignificantly in the short-term comparison (b versus c in table) but
not in the 2-month comparison (a versus d). Urine protein
increasedsignificantly in the short-term comparisonbut not in
the 2-month comparison (fig. 1). Urinary excretion of 92microglobulin and N-acetyl-B-D-glucosaminidase
as well as
renal uptake of ee'Tc-DMSA (6.45versus6.82%, fig.2) did not
change significantly. Inulin clearance decreasedsignificantly
from 35.2+ 27.lto 32.0+ 26.4ml. per minute per 1.73m.2but
paraaminohippurate clearancedid not (fig. 3).
Among the complications, gross hematuria was observedin
N.S.
Before
After
FIc. 2. Effect of percutaneous
decompression
on renal uptakeof
$'Tc-DMSA in patientswith polycystii kidney disease.Salid line
represents
meanvalue.Normalvalueat Universityof TokyoHospital
is 20 to 25Vo.
N.5., not significant.
7 patients and transfusion of 600 ml. was required in 1. Hematuria spontaneouslyregressedwithin a few daysin all except
the patient who neededa transfusion. In this patient hematuria
continued for 10 days. Fever greater than 38.0C was observed
in 1 patient and greaterthan 37.5Cin 4. Feverwas controlled
in every patient with intravenous antibiotic administration for
2 or 3 days.
D IS C U S S ION
Surgical decompression (Rovsing's operation) was abandoned in the 1960sbecauseof the report by Bricker et al who
showeddeteriorated renal function after the procedure.nHowever, in this widely cited article only 2 patients were studied
and the natural courseof proglessiverenal failure in polycystic
kidney diseasewas not considered.More recent studies show
that renal function of polycystic kidney diseaseremains well
preservedfor many yearsbut decreasesrapidly at a later stage.s
Thus, the renal function of 2 patients might become worse
irrespective of the surgical procedure.Following the report of
Bricker and Patton,aend stagerenal failure has been attributed
to surgical decompressionwhen Rovsing's operation had been
1484
m1/min・
:73m:
HIGASHIHARA
Cprx
m1/min・
1.73m2
C:N
400
G - - - ___* __-
- - - "' t
l'-'l-------
80
=こ
― ――
a
ヽ
=F=
AND ASSOCIATES
diseasemakes it difficult to examine the long-term effect of
percutaneouslypuncturing cysts on renal function. Therefore,
in our study renal function was evaluatedfor 1 month after the
puncture. More prolonged followup might be biased by the
natural courseof deterioration in renal function and interpretation becomescomplex. The decreasein hematocrit and hemoglobin, and the increasein proteinuria were observedafter
puncture but these changeswere transient. This procedure is
not recommendedto improve renal function but it might be
performed without a seriousadverseeffect on renal function if
the procedureis indicatedfor reliefofpain2 or infection.3
REFERENCES
1. Stables,D. P.: Percutaneousnephrostomy:techniques,indications,
and results. Urol. Clin. N. Amer., 9: 15, 1982.
2. Bennett, W. M., Elzinga, L., Golper, T. A. and Barry, J. M.:
G---------a
_=8
F_-_-______==:_a
81==‐――
Reduction of cyst volume for symptomatic managementof autosomal dominant polycystic kidney disease.J. Urol., 137: 620,
P<0.05
N.S.
1987.
Before
After
Before
After
3. Chapman, A. 8., Thickman, D. and Gabow, P. A.: Percutaneous
cyst puncture in the treatment of cyst infection in autosomal
FIc. 3. Effectof percutaneous
decompression
on renal functionin
patientswith polycystickidney disease.Solid line representsmean
dominant polycystic kidney disease.Amer. J. Kidney Dis., 16:
value.Normalvalueof paraaminohippurate
clearance(Cpaa)is 423t
252,1990.
45 ml. per minuteper i.?3 m.' and ihat of inulin clearinie(Crv)is
4. Bricker, N. S. and Patton, J. F.: Renal-function studiesin polycys105t 11ml. per minuteper 1.73m.2.N.S.,not significant.
tic diseaseof the kidneys with observations on the effects of
surgical decompression.New Engl. J. Med., 258:212, t957.
5. Thomsen, H. S., Madsen, J. K., Thaysen, J. H. and Damgaarddone.e'loNone of these reports, however, examined the actual
Petersen,K.: Volume of polycystic kidneys during reduction of
courseof renal function after Rovsing's operation.
renal function. Urol. Rad., 3: 85, 1981.
Our study attempted to examine these issues and showed 6. Grantham, J. J. and Gabow, P. A.: Polycystic kidney
diseases.In:
percutaneous
that
decompressiondoes not causea significant
Diseasesof the Kidney, 4th ed. Edited by R. W. Schrier and C.
alteration in renal function. The inulin clearance decreased
W. Gottschalk. Boston: Little, Brown & Co., vol. 1, chapt. 18,
when measured shortly after the procedure but the decrease
pp. 583-615,1988.
was only marginal and creatinine clearance,although it is of
7. Higashihara, E., Okada, Y., Tokuda, H., Nishikawa, J., Kishi, H.,
Iio, M. and Niijima, T.: Technetium-99m dimercaptosuccinic
limited value in assessingrenal function,ll remained stable
acid uptake in long-term catheterizedkidney. Comparisonwith
during a 2-month interval. In the polycystic kidney the cysts
renal function. Urology, 31: 327, 1988.
are scatteredthroughout the parenchyma ofboth kidneys. The
8. Franz, K. A. and Reubi, F. C.: Rate of functional deterioration in
decompressionof a relatively limited number of cysts would
polycystic kidney disease.Kidney Int., 23: 526, 1983.
not have a substantial effect on overall renal function.
9. Mitcheson, H. D., Williams, G. and Castro, J. E.: Clinical aspects
Franz and Reubi reported that renal function did not deofpolycystic diseaseofthe kidneys. Brit. Med. J., 1: 1196,1977.
creaseat a constant rate in polycystic kidney disease.8The rate 10. Suki, W. N.: Polycystic kidney disease.Kidney lnt.,22: 57I, 1982.
of functional deterioration becomesrapid at a later stage.This 11. Walser, M.: Progression.of chronic renal failure in man. Kidney
characteristic progressionof renal failure in polycystic kidney
Int.,37: 1195,1990.
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