Questioning the efficacy of unilateral nephrectomy in the pediatric hypertensive patient
Kunj R. Sheth, MD, Shiv Patel, BS, Jeffrey T. White, MD, Abhishek Seth, MD.
Texas Children's Hospital - Baylor College of Medicine, Houston, TX, USA.
Background: Secondary hypertension due to a poorly functioning or nonfunctional kidney may be refractory to medical management. In such cases nephrectomy can improve or cure hypertension. With the routine use of laparoscopy, nephrectomy can be performed in a minimally invasive manner, but surgery still carries inherent risks and complications. We evaluate the outcomes of laparoscopic nephrectomy performed for secondary hypertension with the hypothesis that it is effect in at least 60% of cases as previously reported in the literature.
Methods: After obtaining IRB-approval, patients from Oct 2011 to March 2018 who underwent laparoscopic nephrectomy were identified using CPT codes. All charts were then manually reviewed to isolate those patients with secondary hypertension present preoperatively. Patient demographics (age, sex, ethnicity, insurance, and comorbidities) and urologic history were recorded for all patients. Serial blood pressures were recorded at all renal visits along with any antihypertensive medication changes. Postoperative outcomes and complications were also noted for all patients.
Results: Over the 7-year period, 14 patients (4 girls, 10 boys) underwent laparoscopic nephrectomy to treat hypertension at an average age of 11.5 years (range 1.7 – 17.0 years). Fifty percent of the patient cohort was Hispanic, 58% had private insurance and 42% had Medicaid coverage. Etiology of a solitary nonfunctional kidney was vesicoureteral reflux in 8/14 patients, multicystic dysplastic kidney in 4/14 patients, ureteropelvic junction obstruction in 1/14 patients and renal artery stenosis in 1/14 patients. At time of surgery, 3/14 patients were on two antihypertensives, 7/14 were on one antihypertensive, and 4/14 proceeded to surgery with no medical management. In the 30-day postoperative period, no complications were noted. Hypertension improved in 5/14 (38%) patients, all of whom have remained off any antihypertensive medications after surgery. Hypertension persisted in 4/14 (29%) patients, requiring the same antihypertensive regimen and worsened in 5/14 (38%) patients, requiring increased doses and/or additional antihypertensives. Average follow-up time was 1.6 years. No patients had contralateral renal scarring, but one patient with renal artery stenosis did have mild renal artery stenosis of the contralateral kidney that required stent placement to normalize blood pressure.
Conclusions: While laparoscopic nephrectomy for a nonfunctioning kidney in the setting of hypertension is a safe procedure, the cure rate for hypertension in our cohort appears to be lower than previously reported. Patients should be carefully counseled on the risks and benefits of nephrectomy to treat hypertension, the importance of continued follow-up post-nephrectomy and the possible need for chronic medical management with antihypertensives.
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