Transcatheter arterial embolization: an underappreciated alternative to nephrectomy in autosomal dominant polycystic kidney disease?

Autosomal dominant polycystic kidney disease (ADPKD) is well-known for its association with renal function decline that is caused by cyst formation in both kidneys. The majority of patients also have liver cysts (94%) [1]. However, due to enlargement of the kidneys or liver, these patients can also develop symptoms associated with abdominal distension, such as abdominal fullness, dyspepsia, and early satiety [2, 3]. Treatment for these symptoms is limited to either cyst aspiration or fenestration, which in most cases will not provide significant volume reduction, or a nephrectomy, with all its associated risks [4]. An alternative may be renal transcatheter arterial embolization (TAE). In renal TAE, coils are placed into the main renal arteries to obstruct blood flow, resulting in renal ischaemia and shrinkage of the kidney. Renal TAE has been used for certain indications, including gross haematuria, renal trauma and tumours. Reduction of kidney volume in ADPKD is a relatively novel indication. This procedure was first introduced in Japan in the late 1990s [5] and some experience has recently been obtained in France [6, 7]. In this issue of Nephrology Dialysis Transplantation, Suwabe et al. [8] analysed the effect of bilateral renal TAE on quality of life (QoL) in ADPKD patients. To our knowledge, this is the first study to report on this issue. In their observational study in 188 ADPKD patients on haemodialysis with a residual volume <500 mL, bilateral renal TAE was performed when patients reported pain and gastrointestinal complaints that affected their QoL. The authors assessed QoL with the 36-item Short Form Health Survey and also with a 15-item questionnaire that they developed themselves and that assesses organ enlargement– related complaints, such as abdominal fullness, pain, sleep disorder and heartburn. QoL was assessed at 1, 3, 6 and 12 months after the intervention. Their results indicate that even within 1 month after TAE, QoL improves significantly. In addition, several complaints, including abdominal fullness, poor appetite and heartburn, were reduced. This study performed by Suwabe et al. [8] gives us a unique data set of a well-characterized, large cohort of ADPKD patients who underwent TAE. Since TAE is a relatively novel procedure in ADPKD, what is known concerning its safety, efficacy and side effects? TAE has proven to be relatively safe and effective in the treatment of recurrent and resistant renal haematuria, renal trauma and renal cell carcinoma [9–11]. Several complications have been reported with TAE, the most notable being transient postembolization syndrome. Post-embolization syndrome is described as severe flank pain, fever and elevation of inflammatory markers that lasts in general 3 days [12]. In the majority of patients, no residual pain was reported after 2 weeks [7]. To reduce the severity of post-embolization syndrome, corticosteroids, analgesics, antibiotics and a proton pump inhibitor are administered before the procedure. In some centres, the procedure is performed under spinal analgesic therapy and after the procedure patients temporarily require opioids and sometimes prolongation of spinal analgesic therapy. Concerning major complications, in one cohort of 449 patients in Japan, 3 deaths were reported that were thought to be associated with TAE [12]. One patient died of severe arrhythmia and acute heart failure on the third day after TAE, which might have been related to inflammation and rapid accumulation of fluid or to toxicity of a renally excreted antiarrhythmic agent, of which the serum concentration increased rapidly after TAE. The second patient had a history of bladder cancer with complete resection, but there might have been renal metastasis; the patient died on the eighth day after renal TAE with features of tumour lysis syndrome. The third patient developed