Embolization in Polycystic Liver and Kidney Disease

Transcription

1 Embolization in Polycystic Liver and Kidney Disease Francois Cornelis, MD, PhD Radiology Department Bordeaux, France

2 Francois Cornelis, MD, PhD No relevant financial relationship reported

3 PKD / PLD Cnossen Wr et al. Orphanet J Rd 2014

4 Interventional Radiology Complications Discomfort Hemorrhage Infection Rupture Portal Hypertension- Hepatic / Renal failure Aneurysms, Hypertension Therapeutic options Ponction Sclerosis Embolization Bajwa WH et al. Kidney Int Rayner BL et al. Clin Nephrol Sakuhara Y et al. J Vasc Interv Radiol Sakuhara Y et al. Radiology 2015

5 Embolization Hepatic/Renal TAE Distal Embolization Proximal Embolization Alcohol (Kidney) Particules ( ) Coils Plug POD

6 Technique Kidney: Petitpierre F. Eur Radiol 2015

7 Embolization Courtesy of Penumbra. Inc

8 Analgesia 3 days hospitalization D0: IV methylprednisolone + paracetamol + ketoprofène + morphin D1-D3: IV methylprednisolone +paracetamol +/- morphin D4-D13: oral prednisolone + paracetamol Pain +++ No Pain D0 D1- D3 >D4

9 1/PKD: Symptoms Sakuhara Y. Radiology 2015

10 1/ PKD: Symptoms Sakuhara Y. Radiology 2015

11 Patient s selection 449 patients with ADPKD from January of 2006 to July of men and 221 women (mean age =57.0±9.1 years old). Reduction from 3.9% to 84.8%, mean: 45.5% [95% CI: 44.2% to 46.8%] Multivariate analysis on volume reduction: presence of large cysts with wall thickening (-6.10 [-9.04 to ]; P<0.001), age (-0.82 [-1.03 to -0.60]; P<0.001) dialysis duration ( -0.10;[-0.18 to -0.03]; P<0.01) systolic Blood Pressure (0.39; [0.19 to 0.59]; P<0.001), number of microcoils used (1.35; [0.83 to 1.86]; P<0.001) Suwabe T et al. J am Soc Nephrol 2015

12 2/ PLD: Symptoms Large Study from June 2001 to December 2012 N=244; age: 55 ± 9 years Mean liver volumes were 8,353 ± 2,807 and 6,626 ± 2,485 cm(3) in men and women. Platinum microcoils Liver/cyst volume decreased to 94.7% (95% CI, 93.5%-95.8%) at 6 months and 90.8% (95% CI, 88.7%-92.9%) at 12 months of pretreatment volumes. Our experience on symptoms: 8 patients; Age : 54 ± 10 [43 ; 76] 5 PKD et 3 PLD Follow-up: 26 months Coils + Particules ( ) Technical eff: 100% Procedure length: 53 min ± 12 min [40 ; 80] 3 days hospitalization Efficacy : 6/8 complete, 1/8 partial, 1 failure Hoshino J et al. Am J Kidney Dis 2014

13

14

15 11/ /2013

16 Comparison of techniques 28 ADPKD patients who underwent TAE, liver resection or liver transplantation 18 TAE: high treatment failure rate (69.6%): 5 repeat TAE 5 rescue liver transplantation or liver resection because of refractory symptoms or hepatic failure 3 died of infections or hepatic failure 9 liver resection volume reduction > TAE group (-52.4% vs -7.6%, P < 0.001) 1 rescue liver transplantation because of hepatic failure. No death 7 liver transplantations 100% success / alive Yang J et al. Hepatol Res 2016

17 Survival n = 1,028 followed until death from October 1996 through March 2013 RENAL TAE 5-year survival: 0.78 [ ] 10-year survival: 0.56 [ ] Factors: age [hazard ratio (HR) 3.02 ( ) for every 10 years albumin [HR 0.70 ( ) per 0.1 g/dl] Kidney volume was not associated with patient death after TA HEPATIC TAE 5-year survival: epatic TAE, 0.69 [ ] 10-year survival: 0.41 [ ] SIGNIFICANT cause is cyst infection (12.5% with PLD and 5.9% with PKD, p < 0.01) DUAL TAE 5-year survival: 0.82 [ ] 5-year survival: 0.45 [ ]. Survival after dialysis initiation after with renal TAE > general PKD patients Hoshino J et al. J Nephrol 2015

18 3/ PKD: Before Transplantation Between January 2008 and November 2013, 82 ERA procedures were performed on 76 kidneys in 73 patients (mean age 53 years, range: 34-72) Terminal-stage PKD under dialysis On the renal transplant waiting list with a temporary contraindication due to excessive renal volume. Petitpierre F. Eur Radiol 2015

19 Results Successful in 89.5% (68/76) of embolized kidneys Temporary contraindication for transplantation withdrawn for 65 patients (on average 5.6 months, range: , after ERA). Mean volume reduction was 40 % (range: 2-69) at 3 months and 59% (35-86) thereafter (both p<0.001). Petitpierre F. Eur Radiol 2015

20 Results

21 Results Post-embolization syndrome occurred after 15 of 82 procedures (18.3 %) Severe complication rate of 4.9% (4 cases): PE, iliac vein thrombosis, pseudoaneurysm, cyst infection Petitpierre F. Eur Radiol 2015

22 Results 43 (67.7 %) transplantation successfully conducted after ERA (to date) After transplantation, mean follow-up of 26.2 months (range: ) Overall MDRD > 30ml/min

23 Conclusion Embolization appears safe and effective in case of symptoms of PKD/PLD or to prepare renal transplantation Careful management of patients is mandatory: analgesia+++ Large multi-institutional study and long-term follow-up are required