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Intracranial aneurysms in patients receiving kidney transplantation for autosomal dominant polycystic kidney disease

  • Original Article - Vascular Neurosurgery - Aneurysm
  • Published:
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Abstract

Background

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disease, leading to kidney failure. One of the most serious extrarenal complications of ADPKD is comorbid intracranial aneurysms. The aim of this study is to evaluate the prevalence, rupture rate, and treatment outcomes of intracranial aneurysms in ADPKD.

Methods

Adult patients with a documented diagnosis of ADPKD who received kidney transplantation at our center from January 1994 to December 2018 were included in the study. Medical history, physical examination, laboratory findings, imaging studies, and operation records were collected and analyzed from our database.

Results

Among 154 kidney transplant recipients with ADPKD, 113 (73.4%) patients were screened for intracranial aneurysms preoperatively. Twenty three patients (14.9%) had intracranial aneurysms with mean diameter size of 4.5 ± 2.7 mm. Nine patients (5.8%) experienced aneurysm rupture and the mean age at time of rupture was 34.9 ± 9.3 years. Twelve patients (52.2%) presented with multiple aneurysms. The most common aneurysm location was the bifurcation of the middle cerebral artery (34.9%). Clipping was the most common treatment in both ruptured and unruptured aneurysms.

Conclusions

Intracranial aneurysms are more frequent in patients with ADPKD, and the average age of intracranial artery rupture in patients with ADPKD is earlier than in the general population. It is necessary to consider proper evaluation and management of intracranial aneurysms when counseling ADPKD patients who will undergo kidney transplantation.

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Authors and Affiliations

  1. Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea

    Jee Yeon Kim, Youngmin Ko, Dong Hyun Kim, Ji Yoon Choi, Hyunwook Kwon, Joo Hee Jung, Young Hoon Kim, Duck Jong Han & Sung Shin

  2. Department of Radiology and Research, Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea

    Seung Chai Jung

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. This study received approval from the institutional review board of Asan Medical Center (approval number: 2019-0310).

For this type of study, formal consent is not required.

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Comments

Special high-risk subgroups are always interesting when we look for patients who will benefit from screening and treatment of UIA. This paper adds to our knowledge of the demographics and risk associated with UIA in polycystic kidney disease, ADPKD.

The authors screened with CTA, MRA, or DSA (over a 24 year period) 113 ADPKD patients for intracranial aneurysms prior to scheduled kidney transplantation. Twenty three patients (14.9%) had intracranial aneurysms with mean diameter size of 4.5 ± 2.7 mm. Nine patients (5.8%) experienced aneurysm rupture and the mean age at time of rupture was 34.9 ± 9.3 years. Twelve patients (52.2%) presented with multiple aneurysms. The most common aneurysm location was the bifurcation of the middle cerebral artery (34.9%). More than half of these patients had multiple aneurysms.

Clipping was the most common treatment in both ruptured and unruptured aneurysms, probably because of the years in which the study was done. We do not have data on clipping or endovascular treatment either before or after transplantation, nor what algorithms were used to recommend treatment.

The authors conclude that intracranial aneurysms are more frequent in patients with ADPKD and, important to consider, that the average age of intracranial artery rupture in patients with ADPKD is earlier than in the general population.

In considering this article we would ask the following further questions, with a recommendation that some of these unanswered questions form the basis for future study:

1. Is the rupture rate higher than the general UIA population? Apparently not, although rupture appears to occur at a younger age.

2. Is there a risk to performing transplant with an untreated UIA? Should aneurysms be treated before the renal transplant is done? Not discussed in this article.

3. What size are the ruptured aneurysms? Not discussed in this article.

4. What is the risk of UIA treatment in their group? Not discussed in this article.

In my personal experience unruptured aneurysm surgery in patients on dialysis has a higher risk profile, because of postoperative fluid shifts and the potential for brain edema, than in patients with normal renal function. This is a natural question for these authors to consider in future.

In my opinion this is a good article and I believe we can learn from a further analysis of this compelling group of patients.

Christopher Loftus

PA, USA

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Kim, J.Y., Jung, S.C., Ko, Y. et al. Intracranial aneurysms in patients receiving kidney transplantation for autosomal dominant polycystic kidney disease. Acta Neurochir 161, 2389–2396 (2019). https://doi.org/10.1007/s00701-019-04060-7

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