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CASE REPORT
Year : 2000  |  Volume : 16  |  Issue : 2  |  Page : 157-160
 

Renal failure following unilateral nephrectomy in Wilms' tumour


Departments of Paediatric Sugery & Paediatrics, Chandigarh, India

Correspondence Address:
K L Narasimhan
Dept. of Paediatric Surgery, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

A 3-year-old male child with (L) sided Wilms' tumour with extensive vena caval thrombus developed acute re­nal failure following (L) nephrectomy.
In kidney tumours with inferior vena caval (IVC) in­volvement the difference in the venous drainage of the right and left kidneys makes the (R) kidney more vulner­able to venous hypertension and renal failure following a left nephrectomy. The likely etiology of acute renal shut­down of the opposite kidney in the index case is discussed and preventive measures suggested.


Keywords: Caval Thrombrosis; Wilms′ Tumour; Renal Failure.


How to cite this article:
Narasimhan K L, Chowdhary SK, Marwaha R K, Rao K. Renal failure following unilateral nephrectomy in Wilms' tumour. Indian J Urol 2000;16:157-60

How to cite this URL:
Narasimhan K L, Chowdhary SK, Marwaha R K, Rao K. Renal failure following unilateral nephrectomy in Wilms' tumour. Indian J Urol [serial online] 2000 [cited 2019 Dec 6];16:157-60. Available from: http://www.indianjurol.com/text.asp?2000/16/2/157/22220



   Case Report Top


A 3-year-old male child presented with history of fe­ver, hematuria and vomiting of 2 weeks' duration. On ex­amination he was poorly nourished. The pulse rate was 140/minute and blood pressure 190/140 mmHg. There was no pedal edema. There was no dilated veins in the ab­dominal wall. There was a large lump in the (L) hypo­chondrium with restricted mobility extending into lumbar and umbilical regions and was 15 cm below the (L) costal margin in the mid clavicular region. Medially it was cross­ing the midline. Urine microscopy showed many RBCs. Ultrasound of the abdomen showed a huge mass arising from the left kidney with multiple retroperitoneal lymph nodes. The caval invasion by the tumour was missed on sonography. IVP showed a (L) intrarenal space occupy­ing lesion with gross distortion of pelvic calyceal system on (L) side. The (R) kidney was normal. Fine needle aspi­ration cytology (FNAC) of the mass was suggestive of a Anaplastic nephroblastoma.

The child was started on preoperative chemotherapy with three weekly doses of vincristine and one dose of actinomycin D. There was regression of the tumour to chemotherapy. The child was explored by a transabdomi­nal incision after 4 weeks. The (R) kidney was inspected after opening the capsule and found to be normal. A 12 x 15 cm mass occupying the entire (L) kidney was found. The (L) renal vein and the IVC upto the diaphragm was thick and cordlike, being replaced by tumour infiltrating the IVC. (L) Nephrectomy with lymph node sampling was done. No attempt to remove the tumour from IVC was made.

The child developed oliguria in first 24 hours in spite of adequate hydration. The urine output fell down to less than 1 ml/kg/hr and the urea and S. creatinine rose to 60 mg and 2 mg respectively. Subsequently, the child progressed to frank renal failure. He was treated with restricted I.V. fluids. Antibiotic dosages were adjusted to S. creatinine values. The child developed intractable generalised clonic tonic seizures and was treated with intravenous diazepam drip. A peritoneal dialysis was in progress when the pa­tient had cardiorespiratory arrest from which he could not be revived despite adequate resuscitative measures.


   Discussion Top


Renal vein and inferior vena caval involvement is re­ported in around 17% and 10% of cases of Wilms' tu­mour. [1] Malignant vena caval thrombosis is unaccompanied by symptoms or signs in half of the patients. [1] Albuminu­ria, hematuria or presence of hypertension, penile, genital or leg edema or a varicocele should alert the physician of an underlying caval obstruction. [1] Magnetic resonance imaging, ultrasound and inferior vena cavogram are very accurate and specific in the diagnosis of caval involvement in Wilms' tumour. [2] Preoperative ultrasound abdo­men missed the caval invasion in the index case.

The pathophysiology of caval involvement and the likely cause of renal failure in this situation is briefly discussed. The collateral venous drainage of the left kidney is better than right kidney and the left kidney is better protected against venous hypertension in the event of caval involve­ment by tumour. [1],[3] A sustained increase of venous pres­sure of the inferior vena cava can cause atrophy of the proximal convoluted tubules, glomerulus and distal tubules and result in renal failure. [1],[3]

The collateral veins draining the kidney in case of ob­struction of inferior vena cava are via the intercostal veins, vertebral veins, hemorrhoidal veins and superficial epi­gastric vessels. The (L) renal vein has a better collateral venous drainage and receives the ascending lumbar vein which connects it with hemiazygos and the azygos sys­tem of veins. Others, viz., the adrenal, inferior phrenic, gonadal, ureteric also contribute to the collateral circula­tion. The collateral venous drainage of the right side is limited to capsular, adrenal and ureteric veins [4] [Figure 1]. In the patient described the (R) kidney venous drainage was precariously in balance as the inferior vena cava was blocked. Following (L) nephrectomy the venous drainage to the (R) kidney which was precariously balanced pre­operatively got compromised presumably because the collateral venous drainage of right kidney was damaged when the capsule of the right kidney was opened. This lead to increased venous pressure in the right kidney re­sulting in acute renal shutdown [Figure 1]. A mechanism simi­lar to the renal failure following aortic surgery due to stimulation of Renin Angiotensin system producing de­creased renal blood flow could also be responsible or could aggravate the shutdown. [5]

Anticipation of this problem preoperatively could have averted the renal failure. Intraoperative injection of 10 ml of indigocarmine intravenously after (L) nephrectomy could be used to check the renal reserve. If the urine bag did not turn blue in 12-15 minutes then renal reserve was a suspect. [7] Study of (R) renal vein pressure would have also helped. A pressure below 30-35 cms of water is com­patible with adequate renal functions. If any of these tests was unfavourable, the (R) renal vein should have been anastomosed to the portal vein or suprahepatic inferior vena cava by a venous graft to reduce the venous pres­sure. [1]

Preoperative accurate assessment of caval invasion is a must before surgery. [2],[6],[7] In National Wilms' Tumour study where prenephrectomy chemotherapy is not employed. It will be necessary to accurately stage the disease and re­move the entire involved segment. [2] The knowledge of the venous anatomy and pathophysiology of renal shutdown is a must before surgery. In International Society of Pediatric Oncology Group where presurgery chemotherapy is used, a longer course of chemotherapy can clear the infe­rior vena cava of the tumour before surgery. [6],[7] Caval in­volvement of Wilms' tumour must be adequately treated with chemotherapy and the integrity of the renal reserve assessed intraoperatively to prevent renal failure in the postoperative period. When the left kidney is affected by the tumour with caval thrombosis it may be prudent not to disturb the capsule of right kidney.

 
   References Top

1.Clayman RV, Sheldon CA, Gonzalez R. Wilms' Tumour: An ap­proach to vena caval intrusion. Prog Pediatr Surg 1983; 15: 285-305.  Back to cited text no. 1    
2.Green DM, Finklestein JZ, Breslow NE et al. Remaining problems in the treatment of patients with Wilms' tumour. Pediatr Clin North Am 1991; 38: 475-488.  Back to cited text no. 2    
3.Gonzalez R. Clayman RV, Sheldon CA. Management of intravas­cular nephroblastoma to avoid complications. Urol Clin North Am 1983; 10: 407-415.  Back to cited text no. 3    
4.Clayman RV, Gonzalez R, Fraley EE. Renal cell cancer invading the inferior vena cava: Clinical review and anatomical approach. J Urol 1980; 123: 157-163.  Back to cited text no. 4    
5.Miranda JV, Grissom TE. Anesthetic implications of the Renin An­giotensin system and Angiotensin converting enzyme inhibitors. Anaesth Analg 1991; 72: 667-683.  Back to cited text no. 5    
6.Gouch DCS. Wilms' tumor and genitourinary Rhabdomyosarcoma. Br J Urol 1989; 63: 109-116.  Back to cited text no. 6    
7.Kogan SJ, Marans H, Santorineau M et al. Successful treatment of renal vein and vena caval extension of nephroblastoma by pre­operative chemotherapy, J Urol 1986; 136: 312-317.  Back to cited text no. 7    


    Figures

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