Acquired renal cystic disease in children and young adults on maintenance dialysis

Acquired renal cystic disease (ARCD) is a well-known complication of end-stage renal disease (ESRD). We studied 24 patients, aged 8 – 27 years (mean 19.8±5.3 years), on chronic maintenance dialysis in our service. The duration of dialysis ranged between 13 and 192 months (mean 77.8±44.3 months). High-resolution ultrasonography revealed ARCD in 11 (45.8%) patients. No cysts were seen in 7 (29.1%) patients and solitary cysts in one or both kidneys were seen in 6 (25%) patients. Renal malignancy was diagnosed in 2 patients. One, 15 years old, had renal cell carcinoma after being on dialysis for 6 years. She did well after bilateral nephrectomy, left salpingo-oophorectomy, and regional lymphadenectomy. The second patient, 23 years old, had been on dialysis for 16 years when she developed renal oncocytoma. She died of congestive cardiomyopathy 6 months later. We conclude that ARCD is common in children and young adults with ESRD. Neoplastic transformation, although rare, is a potential complication. Annual follow-up with ultrasonography with selective use of computed tomography or magnetic resonance imaging is advised. Received July 29, 1996; received in revised form and accepted November 15, 1996     

Acquired renal cystic disease mimicking adult polycystic kidney disease in a patient undergoing long-term hemodialysis.

Acquired renal cystic disease (ARCD) is defined as the development of multiple cysts in the renal cortex and medulla in patients with chronic renal failure who are free from congenital polycystic kidney disease. ARCD develops generally in contracted kidneys. We report a case of grotesque enlargement of a single kidney in a patient who had been receiving hemodialysis for 18 years. Although the exact causes of ARCD are not known, 3 factors may contribute to the development of nephromegaly; the sex, the duration of hemodialysis and previous unilateral nephrectomy. As in polycystic disease, when the involved kidney reaches considerable size, ARCD may have a favorable effect on anemia caused by chronic renal failure.     

Acquired renal cystic disease in children prior to the start of dialysis

This report describes the clinical course and serial sonographic findings in three children who developed acquired renal cystic disease (ARCD) prior to the institution of dialysis. The children were aged from 3 years to 13 years and their estimated glomerular filtration rate varied from 8 to 13 ml/min per 1.73 m² when ARCD was diagnosed. Their primary renal disorders, which included hemolytic-uremic syndrome and focal segmental glomerulosclerosis, had been present for 1.5–11.5 years prior to the cysts being discovered. These patients show that ARCD may develop in children with chronic progressive renal parenchymal disease prior to the institution of specific therapy for end-stage renal disease.     

Acquired renal cystic disease in HD: a study of 82 nephrectomies in young patients.

In order to study the development of acquired renal cystic disease (ARCD) and its potential complications, we studied, macro- and microscopically, 82 surgical specimens of nephrectomy carried out on young patients with chronic renal failure previous to renal transplantation. Statistical correlation of pathological findings with age, sex and time on hemodialysis (HD) have been done. There were 72 cases of ARCD (87.8%). It was statistically correlated with male sex (p less than 0.02) and prolonged time on HD (p less than 0.001) as has been previously reported. Hyperplasia of the cystic epithelium was found in 42 cases (52%), with 18 (22%) showing marked papillary proliferation. Also, there were 22 cases (27%) with renal adenomas. This incidence of hyperplastic and neoplastic proliferations, more than would be common in such a young population (males: 33.5 +/- 9.3 years; females: 35.4 +/- 11.7 years), suggests the potential of patients affected by ARCD to develop neoplasms. Thus, we consider that these patients must be checked periodically to detect possible malignant neoplasms.     

Prevalence of renal cell carcinoma in patients with ESRD pre-transplantation: a pathologic analysis

BACKGROUND: Acquired renal cystic disease (ARCD), renal adenoma (AD), and renal cell carcinoma (RCC) are more common in patients with end-stage renal disease (ESRD). However, the prevalence of these conditions in patients undergoing transplantation, and the clinical characteristics associated with their occurrence are unclear. METHODS: At our institution, the majority of patients undergo an ipsilateral native nephrectomy at the time of transplantation, providing a unique opportunity to study the prevalence and pathology of ARCD, AD and RCC in ESRD. We retrospectively reviewed all consecutive nephrectomy pathology reports over a six year period. Demographic and clinical characteristics associated with these lesions were identified. RESULTS: Two hundred and sixty nephrectomy reports were reviewed: ARCD, AD, RCC and oncocytoma were found in 33%, 14%, 4.2% and 0.6% of cases, respectively. On multivariable analysis, ARCD was positively associated with male sex and longer dialysis duration and negatively associated with peritoneal dialysis. Similarly, AD was positively associated with male sex, longer dialysis duration and greater age. There was a trend for RCC cases to share similar associations although the small total number of cases precluded findings of statistical significance. CONCLUSION: By pathologic analysis, renal tumors are more common in the pre-transplant ESRD population than previously reported (using radiologic methods). Our study also identifies risk factors for their occurrence. This may prove useful in designing screening studies for renal tumors in this patient population.     

Acquired cystic disease of the kidneys in chronic hemodialyzed and renal transplant patients

In this study, the appearance of renal cysts in 43 chronic hemodialyzed patients (mean duration of dialysis treatment: 26.3 months) was investigated by sonography with a high resolution (3.5 MHz) sector scanner. In an investigation of the patients' own kidneys, 23 renal transplant patients (mean observation time: 51.3 months after transplantation; mean dialysis treatment before transplantation: 22.8 months) were also studied by sonography. Cysts could be demonstrated in 21 of 43 (49%) patients on maintenance hemodialysis. In 10 of these patients a previous investigation at the beginning of dialysis did not demonstrate any cysts. The diameter of the cysts varied between 5 and 30 mm. With regard to the duration of dialysis, cysts could be demonstrated by sonography in 9 of 23 (39%) dialyzed patients, with a maximum dialysis duration of 2 years, and in 12 of 20 (60%) patients who had been dialyzed for more than 2 years. The development of acquired cystic disease of the kidneys in dialysis patients seems to be promoted by the longer survival of uremic patients. Cysts could be found in the patients' own kidneys in only 4 of 23 (17%) renal transplant patients. The difference in the demonstration of cysts between patients on maintenance hemodialysis and renal transplant patients was statistically significant. This suggests that cystic transformation may possibly be a reversible process.     

Dialysis-associated renal cystic disease resembling autosomal dominant polycystic kidney disease: a report of two cases.

Acquired renal cystic disease is common in patients receiving dialysis. Characteristically, the kidneys are small or, less often, normal in size, and the cysts are usually less than 0.6 cm in diameter. We present here 2 patients who, after 5 and 7 years on hemodialysis, developed marked renal enlargement, with large cysts in the kidneys and, in 1 patient, in the liver as well; the appearance on ultrasonography and computed tomography was indistinguishable from autosomal dominant polycystic kidney disease. Before starting dialysis the first patient was a 19-year-old man who developed renal shutdown from crescentic glomerulonephritis, and the second patient was a 33-year-old man who developed end-stage renal failure from malignant hypertension. Neither patient had renal cysts at the onset of end-stage renal failure.     

Acquired cystic kidney disease in children undergoing long-term dialysis

Acquired cystic kidney disease (ACKD) occurs in adult patients undergoing long-term dialysis. Early detection is important because clinically significant hematuria and malignancies are associated with ACKD. We evaluated by magnetic resonance imaging (MRI) and ultrasonography (US) the incidence of ACKD in 15 patients aged 7.3–21.6 years (mean 15.9 years) with non-cystic primary renal disease. Nine patients had been treated with peritoneal dialysis only, and 6 with both hemodialysis and peritoneal dialysis for 24–73 months (mean 37 months). Three patients (20%) had no cysts. In 5 patients (33%) with bilateral multiple cysts, the diagnosis of ACKD was made by MRI and US. In another 5 patients, solitary cysts were localized to one kidney by MRI, and in 2 patients solitary cysts were seen in both kidneys. This study documents that ACKD is not limited to older patients with end-stage renal disease. Early detection of these cysts can be accomplished by MRI and is warranted since 1 patient developed neoplastic tubular changes which can precede tumor formation.     

Patient and technique survival on peritoneal dialysis in patients with failed renal allograft: a case-control study

Failed renal allograft is becoming one of the most frequent causes of dialysis initiation in countries with developed transplant programs. The majority of patients initiate hemodialysis (HD) as their next renal replacement modality and concerns about the success of peritoneal dialysis (PD) in this patient population has been expressed. We evaluated patient and technique outcome in a cohort of 494 patients in the United States who initiated PD after a failed renal allograft in the years 2000-2003, and compared the outcomes to those of two case-matched groups: patients new to dialysis or patients transferred from HD who started PD during the same period. Patients starting PD after a failed allograft had patient survival and technique survival similar to case-matched controls. Transplantation was lower in patients with failed allograft than controls. The high success of PD in patients with failed allograft suggests that it is beneficial to utilize this modality more frequently in this patient group than current practice.     

Ethylene oxide allergy in a dialysis center: prevalence in hemodialysis and peritoneal dialysis populations

Chronic hemodialysis (HD) and peritoneal dialysis (PD) patients in one dialysis center were examined for (EO)-related sensitization. Five of 56 (8.9%) HD patients and 0 of 30 PD patients skin tested with a conjugate of human serum albumin (HSA) and EO had positive skin prick tests. The sera of 13 of 107 (12.1%) HD patients including sera from 5 patients with negative skin tests were positive in an EO-HSA radioallergosorbent test (RAST). Sensitized patients in this population did not experience allergic-type reactions during hemodialysis. There were no positive EO-HSA RAST results which could be ascribed to PD. Non-specific cutaneous responsiveness of the renal failure patients was compared with that of normal adult subjects by the use of skin prick tests with codeine phosphate and histamine phosphate. A significantly reduced responsiveness is present in chronic renal failure patients which would be expected to lower the sensitivity of the diagnostic skin test by comparison with the RAST.     

Clinical outcomes after failed renal transplantation-does dialysis modality matter?

Patients returning to dialysis after graft loss (DAGL) are an increasing segment of the end-stage renal disease (ESRD) population. It is unclear whether patients with previous graft loss have equivalent or reduced survival from the time of restarting dialysis when compared with ESRD patients initiating dialysis for the first time. Moreover, the impact of dialysis modality on the survival of patients returning to DAGL is not known. Studies of patients with transplant graft failure returning to hemodialysis (HD) have suggested decreased survival when compared with transplant-na?ve dialysis patients, yet some studies of patients with graft failure returning to peritoneal dialysis (PD) have demonstrated equivalent survival. Based on these data, it is unclear whether survival differences may exist between the dialysis modalities, and if they do, whether they can be attributed to either differences in patient characteristics or to factors related to the dialysis modalities. For patients starting back onto dialysis, in whom preservation of residual renal function is important, it is also unclear how immunosuppression reduction or transplant nephrectomy may affect survival. In this review, we will summarize the available literature on survival rates of patients returning to DAGL; compare and contrast survival after initiation of HD and PD and discuss what is known about the impact of transplant nephrectomy and the different approaches to immunosuppression reduction. Practical considerations will be discussed with a specific emphasis on patients treated by PD.     

Health-related quality of life in different stages of renal failure

Measures of health-related quality of life (HRQoL) have a significant predictive value on patient survival and hospitalizations, especially in patients with chronic kidney disease (CKD). In this review, some of the major studies performed in patients with different stages of renal failure are presented. The most used instrument for measuring HRQoL is the Short form health survey questionnaire (SF-36). Patients with predialysis CKD had higher SF-36 scores than a large cohort of hemodialysis (HD) or peritoneal dialysis (PD) patients, but lower scores than those reported for the adult population. Kidney transplantation offers better HRQoL than dialysis. Hemoglobin level predicted both physical and mental domain scores of the SF-36. HRQoL of HD and PD patients were compared in only a few studies, mostly because these studies are difficult to interpret. PD patients generally have lower comorbidity scores at the onset of end-stage renal disease (ESRD), independent of other factors influencing modality selection. Comorbid medical conditions are common in patients with ESRD, and are an important contributing factor to clinical outcomes and quality of life. Depression occurs in about 20-30% of dialysis patients. This is important because of the negative impact depression has on quality of life, but also because depression is now established as a factor that can significantly affect morbidity and mortality in ESRD patients. Sexual life satisfaction showed marked deterioration in all age groups. Patients aged over 65 scored significantly better than younger patients on dialysis stress scales, and were generally more satisfied with life. Longitudinal studies are needed to define periods at risk for decline in HRQoL during progression of CKD.     

A study of the native kidneys in patients with chronic renal failure. Report 1: Morphological changes and occurrence of acquired cysts of the native kidneys in patients with chronic renal failure

As morphological changes of the native kidneys, the presence of acquired cysts, intra-renal calcification and renal tumor was investigated mainly by ultrasonography and computed tomography in 151 patients with chronic renal failure. 1) Among 140 uremic patients caused by medical diseases. 40 patients had simple cysts, and 37 had acquired cystic disease of the kidneys (ACDK). However 4, uremic patients caused by urological diseases were not seen to be with an acquired cysts. 2) The patients with ACDK were with significantly longer durations of dialysis therapy than those with simple cysts or no cysts. Furthermore, the patients with ACDK were younger than those of the other groups. 3) Intra-renal calcification was more frequently found in patients with cystic disease (simple cyst, ACDK and polycystic disease) than in those without cystic disease with statistic significance. 4) Native kidneys became larger after the occurrence of ACDK. 5) Three cases of renal tumor were found.     

Bilateral renal cell carcinoma in a patient receiving long-term dialysis

Bilateral renal cell carcinoma developing in a 55-year-old male receiving long-term dialysis is reported. The patient, who had undergone maintenance hemodialysis for 12 years, was admitted in July, 1986 for the purpose of extensive examination of a right renal mass. CT scan and ultrasonography demonstrated an enlarged bilateral kidney associated with multiple cysts, containing a solid mass in the right upper pole. The patients underwent right nephrectomy under the diagnosis of right renal tumor. The solid tumor 4 x 3 cm in size revealed a grade 1 to 2 renal cell carcinoma pathologically. Two small tumors were recognized in other portions of the kidney. Multiple cysts of varying sizes, the largest 2 cm in diameter, replaced the renal parenchyma. The cyst walls frequently contained hyperplastic changes. The patient has been subsequently followed up for 2 years and 9 months and underwent left nephrectomy for suspected left renal tumor. The surface of the left kidney was covered by numerous cysts. The result of pathological examination was renal cell carcinoma, which was recognized in a total of 7 regions of the left kidney. The patient remains well on hemodialysis, with no evidence of recurrence or metastasis.     

Acquired renal cystic disease

In 1977, Dunnill et al. described a new disorder, bilateral multiple renal cystic disease. It occurred among hemodialysis patients whose original illness had not been cyst-related. Acquired cystic disease of the kidney (ACDK) is commonly observed in patients undergoing hemodialysis. The incidence of ACDK is 40-50% in reports of autopsy and surgical specimens, rising to more than 90% after 5-10 years of dialysis. The volume of the kidneys decreases in the first 3 years of dialysis and then increases as the rate of cyst formation increases. In male patients undergoing long-term hemodialysis the incidence of ACDK is markedly high. ACDK is also found in patients before hemodialysis. The primary concern in patients with ACDK is the increased incidence (5-19%) of renal cell carcinoma (RCC). The incidence is about twelve to eighteen times higher than that in the general population and the cancers may be asymptomatic. Therefore, screening is essential if carcinomas are to be detected early. Regular screening by ultrasonic examination or CT scan is needed. A patient requires nephrectomy when the kidney cancer exists or is suspected by dynamic CT scan. Nephrectomy is performed only on the side with renal mass. It has been argued that RCC associated with ACDK are innocuous and do not predispose the patient to an increased risk of death from RCC. RCC arising from ACDK is considered to be a tumor of low malignant potential, compared with classic RCC. However, RCC has been reported to metastasize in 16% of the patients on dialysis and to be the cause of death in 2% of the kidney transplant recipients. The etiology of ACDK is unclear and its incidence increases with the duration of dialysis. ACDK patients have a propensity to develop adenocarcinoma. The increased incidence of RCC in ACDK patients warrants careful radiologic monitoring of end-stage kidneys in selected patients.     

Home dialysis as a first option: a new paradigm

Traditionally, the initial choice of dialysis for patients with end stage renal disease (ESRD) has been in-center hemodialysis (HD) or peritoneal dialysis (PD). Usually, the choice between these (PD vs. HD) has been based on the characteristics of the dialysis techniques. Obviously the choice of peritoneal dialysis implied dialysis at home, but its geographic location has been only a secondary consideration. Peritoneal dialysis has evolved as a dependable mode that gives good outcomes. This method has become more attractive with the option of overnight cyclers and the recent use of home helpers in some jurisdictions. At the same time the interest in home hemodialysis was rekindled by reports of good outcomes with short daily or nocturnal hemodialysis. Home dialysis (PD or HD) offers high quality of treatment, a high degree of patient independence, and is financially attractive. Therefore, we propose a change in our approach to the choice of the initial form of dialysis for patients with ESRD. Instead of choosing between HD and PD we should present the new patients the advantage of dialysis at home and instead of asking them to choose between peritoneal dialysis or hemodialysis, they should be offered the option to choose between dialysis at home (PD or HD) or in-hospital. This paper will review the advantages of the home-based dialysis methods and the arguments for this simple but vital change in the process of choosing the method of dialysis.     

Vancomycin-resistant enterococcus in end-stage renal disease

The percentage of nosocomial vancomycin-resistant enterococci (VRE) has been increasing rapidly in the United States. This has recently resulted in recommendations to reserve vancomycin use for cases with proven resistance to other antimicrobials. We prospectively investigated the incidence of VRE in our dialysis population and compared it with a control group of 40 clinic patients with chronic renal insufficiency (CRI) who had a serum creatinine level greater than 1.5 mg/dL, but were not undergoing dialysis. The incidence of VRE on our campus is almost 10%, which is similar to US data. We studied 50 chronic hemodialysis (HD) patients and 50 peritoneal dialysis (PD) patients. Each patient had a rectal swab test performed and cultured for the presence of enterococci. Antimicrobial exposures over the 6 months before the initial swab test were reviewed in each patient. At least one repeated swab test was performed in 30 CRI, 45 HD, and 37 PD patients. From the initial swab culture, vancomycin-sensitive enterococci (VSE) were isolated in 65% of CRI, 54% of HD, and 70% of PD patients. No CRI or HD patients had VRE isolated and 2% (1 of 50) of PD patients had VRE isolated. The remaining patients had no enterococci isolated. Review of antimicrobial exposures in the 6 months before the initial swab test showed 0% of CRI, 32% of HD, and 36% of PD patients received vancomycin. Other antimicrobials were administered to 40% of CRI, 46% of HD, and 78% of PD patients in the same time period. In the month immediately preceding the initial swab test, 0% of CRI, 12% of HD, and 22% of PD patients received vancomycin and 18% of CRI, 20% of HD, and 36% of PD patients received other antimicrobials. Results from repeated cultures showed that 57% of CRI, 40% of HD, and 38% of PD patients changed their culture status related to VSE, VRE, or no enterococci present. Cultures of 342 swabs from 140 patients yielded three VRE isolates in two patients. We conclude that despite the frequent use of vancomycin and other antimicrobials, the incidence of VRE in our renal population is less than the reported incidence. Given this lack of VRE isolates, we recommend the continued judicious use of vancomycin in treating renal patients and continued enterococcal sensitivity surveillance.     

Acquired renal cysts in maintenance dialysis patients

Ultrasonographic examination of the kidneys of 111 patients on long term maintenance hemodialysis was performed. None of the patients had genuine polycystic kidney disease. In many patients acquired cysts were found. Frequency and volume of these cysts were the same on the right and left side. There was no correlation between the age of the patients and the number of cysts. There were no differences concerning sex and type of primary renal disease. There was a significant positive correlation between time on maintenance hemodialysis and number of cysts but no correlation between number of cysts and hemoglobin concentration. This is in contrast to data in the literature. Clinical relevance of acquired kidney cysts in dialysis patients concerns hematuria, retroperitoneal bleeding, kidney stone formation, septicemia and malignancy.     

Effect of peritoneal dialysis versus hemodialysis on renal anemia in renal in end-stage disease patients: a meta-analysis

The aim of this meta-analysis was to evaluate the effect of peritoneal dialysis (PD) and hemodialysis (HD) on renal anemia (RA) in renal disease patients by a meta-analysis. Relevant studies published before June 2015 were searched. Pooled odds ratio (OR) with 95% confidence interval (CI) was used to evaluate the effect of HD and PD on RA based on five indexes: hemoglobin, ferritin, transferrin saturation index, serum albumin, and parathyroid hormone. Sensitivity analysis and publication bias assessment were conducted to evaluate the stability and reliability of our results. A total of fourteen eligible studies with 1103 cases underwent HD and 625 cases underwent PD were used for this meta-analysis. There were no significant difference for levels of hemoglobin (SMD?=??0.23, 95% CI: ?0.74 to 0.28), ferritin (SMD?=?0.01, 95% CI: ?0.59 to 0.62), parathyroid hormone (SMD?=?0.11, 95% CI: ?1.53 to 1.75) and transferrin saturation index (SMD?=??0.06, 95% CI: ?0.67 to 0.56) between HD and PD group. However, the content of serum albumin in HD group was much more than that in PD group (SMD?=?1.58, 95% CI: 0.35 to 2.81). Neither of the included studies could reverse the pooled side effect and Egger’s test demonstrated no publication bias. Both of the two dialysis strategies have a similar effect on RA in renal disease patients.     

Atherosclerosis in patients with end-stage renal failure prior to initiation of hemodialysis

BACKGROUND: In dialysis patients cardiovascular mortality is 10 to 20 times higher than in general population. It remains uncertain whether atherosclerosis of dialysis patients is effectively accelerated because many of dialysis patients have more or less marked vascular lesions already at the start of dialysis treatment. SUBJECTS AND METHODS. Using B-mode ultrasonography (ATL HDI 3000), we compared intima-media thickness (IMT) and plaque occurrence (indicators of atherosclerosis) in the common carotid arteries (CC), in the area of bifurcation (CB) and in the proximal part of internal carotid arteries (CI) in 28 hemodialysis patients (14 men and 14 women; mean age 49.4 years; mean duration of HD treatment 66.6 months) with that in 28 age-sex matched patients prior to initiation of hemodialysis. We also investigated possible differences in atherosclerotic risk factors in both groups. RESULTS: The IMT values of CC (0.71 vs. 0.70 mm; p = 0.937), CB (0.81 vs. 0.77 mm; p = 0,423) and CI (0.72 vs. 0.71 mm; p = 0.935) were not significantly different in dialysis patients and patients starting dialysis treatment. We also found no difference in plaque occurrence (61% vs. 54%; p = 0.787) and in atherosclerotic risk factors (hypertension, smoking, lipids) between both groups. CONCLUSIONS: In our study we found no difference in atherosclerotic lesions in carotid arteries between dialysis patients and patients with end-stage renal failure starting dialysis treatment. Patients with chronic renal failure are at high risk for cardiovascular diseases so we should intervene earlier and more actively long before dialysis treatment in order to reduce the atherosclerotic risk factors.