Year : 2000 | Volume
: 16 | Issue : 2 | Page : 157--160
Renal failure following unilateral nephrectomy in Wilms' tumour
KL Narasimhan, Sujit Kumar Chowdhary, RK Marwaha, KLN Rao
Departments of Paediatric Sugery & Paediatrics, Chandigarh, India
K L Narasimhan
Dept. of Paediatric Surgery, PGIMER, Chandigarh - 160 012
A 3-year-old male child with (L) sided Wilms«SQ» 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.
|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;16:157-160
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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 2020 Jan 24 ];16:157-160
Available from: http://www.indianjurol.com/text.asp?2000/16/2/157/22220
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.
Renal vein and inferior vena caval involvement is reported in around 17% and 10% of cases of Wilms' tumour.  Malignant vena caval thrombosis is unaccompanied by symptoms or signs in half of the patients.  Albuminuria, hematuria or presence of hypertension, penile, genital or leg edema or a varicocele should alert the physician of an underlying caval obstruction.  Magnetic resonance imaging, ultrasound and inferior vena cavogram are very accurate and specific in the diagnosis of caval involvement in Wilms' tumour.  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. , 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. ,
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  [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. 
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.  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. 
Preoperative accurate assessment of caval invasion is a must before surgery. ,, 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.  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. , 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.
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