percutaneous reduct10n of cyst kidney disease:effects on volume of
Transcription
percutaneous reduct10n of cyst kidney disease:effects on volume of
0022-5347/92/1476‐ 1482$03.00/0 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 Froれι んaD∞ α″ ι れο れιof」rO疇 、Facaι θ rsj″or To机 Taり Q Japα れ ″ OFMοdたjれ α じれJυ 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. /° 0 0 0 5 ′′ 0 0 0 0 0 0 0 0 0 4 3 2 ― ― 0 0 4 ― 汗―一 ラ ヘて三́ 0 0 3 0 0 2 `______ I -Mo After ← ヽ ヽ 、 __、 _ヽ ヽ … 10.0 . j=--========A t-/--tt ′ ′ ′ ″ 0 0 1 3-Days After oCO匡 ︵ゝ ︶ く ∽ 巨 0 ︲o卜 E8 一o Φ〓 一Q⊃ 一 。 0 3-Days Before 15.0 む 1000 1‐Mo Before ′ ° ヽ 0 0 5 Φ一0﹄L >﹄∞C 〓 ⊃ E ︶ CO 一 一●﹄OX Ш E 一 。 、 . → E朽卜 T >●一 ′/′ ヽ ´ ヽ /′ ′ 、 __ν ´ ミ :/ /年´ :ミ 、 「― ヽ ■ 、さ ミ` `弓 ― ′′ ■ _ _ _ _ _ _ ―● F ■〔 ′ ′ ゝ` ` 月ヽ ′ 、 ′ ′′ 5.0 `ヽ 【〔 「 、 . 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. ;_--------a >-------__a