|Year : 1997 | Volume
| Issue : 2 | Page : 105-112
|Acquired Cystic Renal Disease
Christopher R Blagg
Department of Medicine, Northwest Kidney Centers, Washington, USA
Click here for correspondence address and email
|How to cite this article:|
Blagg CR. Acquired Cystic Renal Disease. Saudi J Kidney Dis Transpl 1997;8:105-12
| Introduction|| |
Acquired cystic renal disease (ACRD) was first described in the kidneys of patients dying from Brights disease by John Simon in 1847  , and again by Frerichs in 1851  and by Piepers in 1894  . It was rediscovered and reported in 1977 in a study of kidneys in hemodialysis patients  . While sometimes thought of as a complication occurring in dialysis patients, ACRD occurs as a consequence of damage produced by the underlying chronic kidney disease ,, ; dialysis merely lengthens the time over which cyst formation can occur.
Acquired cystic renal disease must be distinguished from other acquired renal cystic diseases such as the simple renal cysts that develop with advancing age, and the cystic changes found with primary hyperaldosteronism that are probably related to hypokalemia. It also must be distinguished from hereditary autosomal-dominant polycystic disease, and from rare causes of cystic kidneys such as tuberous sclerosis, Von-Hipple-Lindau disease, autosomalrecessive polycystic disease, medullary cystic disease and medullary sponge kidney  .
Acquired renal cysts have been reported in some 7% to 22% of patients with chronic renal failure prior to starting on dialysis, and serial computerized tomography (CT) scans suggest that cysts start to develop when the serum creatinine level exceeds 365 µmol/L  . Cysts are found with increasing frequency as time on dialysis increases , , and more than 80% of patients on dialysis for more than four years have developed cystic changes , . Increasing numbers of cysts and enlarging kidney volume reflect the severity of ACRD  . Thus, the extent of cystic disease appears to relate to the duration and degree of uremia.
Acquired cystic renal disease is not specifically related to any one of the causes of chronic renal failure  , and may be commoner in males ,, and in black patients  . It also occurs in the kidneys of children on long-term dialysis ,,, at a frequency comparable to that seen in the adult patient population , . While ACRD is often thought of as a complication found in hemodialysis patients, the incidence is similar in patients treated by long-term continuous ambulatory peritoneal dialysis (CAPD) ,, .
After successful kidney transplantation, ACRD may regress and the native kidneys atrophy, supporting the hypothesis that factors not removed by dialysis may be involved in its genesis  . However, in some cases presence of a functioning renal transplant may only slow progression of existing ACRD ,, , and as many as 18% of patients with a functioning transplant continue to show an increase in renal volume and number of cysts in their native kidneys despite good renal function  . In other cases, continuing increase in cysts may be related to poor function of the transplanted kidney and continuance of the cystogenic state  . Acquired renal cystic disease may occur more frequently in transplant recipients treated with cyclosporin  , and renal cell cancer, if it develops in such patients, may progress more rapidly, although this has not been the experience of others  .
| Pathology|| |
Acquired cystic renal disease is characterized by development of fluid-filled cysts in the kidneys of patients with chronic renal failure due to non-cystic renal diseases. The cysts, usually between 3 mm and 5 cm in diameter, are lined with flattened/ cuboidal tubular epithelium and are mainly derived from the proximal tubules  . In the early stages of their development, the cysts are connected to an afferent and an efferent tubular segment through which a derivative of glomerular filtrate enters and leaves the cavity  . Once the cysts exceed some 2 millimeters in diameter, most detach from both portions of the renal tubule from which they are derived, and then the major source of cyst fluid is probably transepithelial secretion of sodium chloride and water. This may be stimulated by parathyroid hormone and possibly by other hormones. One or more retained uremic toxins also may act as growth factors that stimulate cystic transformation in the kidney  . Non-dialyzable mitogenic and cystogenic substances may accumulate, causing hypertrophy, hyperplasia and proliferation of renal tubular epithelial cells in the surviving nephrons , . The tubules are distorted by interstitial fibrosis  , and obstructed by hyperplastic epithelium and deposition of oxalate crystals, resulting in accumulation of fluid. At the same time, ischemia-induced parenchymal fibrosis results from occlusion of small blood vessels. The tubules dilate to form cysts, leading to an increase in kidney volume. In some patients the multifocal epithelial hyperplasia may progress to adenoma formation and eventually to renal cell carcinoma, presumable by activation of certain oncogenes  .
| Etiopathogenesis|| |
Cysts are found in a number of renal diseases, suggesting that their formation can result from both inherited and acquired defects rather than being due to a single pathogenetic mechanism. Nevertheless, there is remarkable similarity of structure among cysts resulting from hereditary and acquired renal diseases. At least three components appear to be involved in cyst formation: increased epithelial cellular proliferation possibly resulting in intratubular obstruction, increased transepithelial fluid secretion, and abnormalities in the extracellular matrix  . In ACRD these may result from an insult to the mature kidney that results in de-differentiation  . Thus, cyst development in the scarred kidney of a patient with chronic renal failure resembles an extreme result of the intact nephron hypothesis as the tubules that survive the primary insult undergo hypertrophy and hyperplasia to form the cysts  .
There is also altered expression of various proto-oncogenes, growth factors and growth factor receptors such as c-myc, c-fos, c-Kiras, c-erb-B2, c-jun, transforming growth factor alpha, epidermal growth factor and epidermal growth factor receptor  , and epidermal growth factor precursor is found in the fluid of many varieties of renal cysts  . Increased sensitivity to epithelial growth factor and other mitogens found in the cyst fluid may be pathogenic for the development of progressive renal cystic disease.
Other suggested etiologic factors for ACRD include exposure to chemicals such as di-2-ethylhexylphthalate leached from the dialysis equipment, carcinogens in the dialysate water, formaldehyde, and accumulation of biologically active agents such as spermine, spermidine or putrescine in uremic plasma  . A possible role for chronic renal ischemia is suggested by a patient with a 13-year history of renal artery stenosis and a contracted left kidney who developed ACRD and renal cell carcinoma in the left kidney despite a serum creatinine level of only 168 µmol/L  .
| Clinical Manifestations and Diagnosis|| |
Diagnostic screening for ACRD involves the use of renal ultrasonography and CT scanning. The former may be more helpful in the later stages, but CT scanning may be more sensitive when the kidneys and cysts are small ,, . The definitive imaging procedure after screening is contrastenhanced CT scanning  or magnetic resonance imaging. Typically ACRD is bilateral, may begin before end-stage renal disease develops, and is usually asymptomatic and found accidentally during abdominal imaging.
If symptoms do occur, the most likely is pain due to hemorrhage into a cyst. This is more frequent in hemodialysis patients than in CAPD patients because of the repeated heparinization during dialysis , . Retroperitoneal hemorrhages and infections of the cysts can also occur. Sometimes the kidneys enlarge sufficiently to resemble autosomal-dominant polycystic kidney disease  , especially if one kidney has been removed previously  . Improvement of anemia in dialysis patients has been described in association with development of ACRD ,,, . This may be due to production of erythropoietin as a result of ischemia and interstitial hypoxemia from tissue compression. Significantly higher hematocrits have been found in patients with ACRD who have particularly large kidneys, although their erythropoietin levels were not different from those of patients with ACRD who had smaller kidneys and a lower hematocrit  .
| Renal Cell Carcinoma and ACRD|| |
The most serious complication of ACRD is development of renal cell carcinoma ,,,,,,, , although the risk of developing this is present in dialysis patients both with and without ACRD  . In ACRD, the multifocal hyperplasia can lead to adenoma formation and thence to adenocarcinoma  . Parathyroid hormone is thought by some to stimulate neoplasia in association with both primary and secondary hyperparathyroidism  by activating adenylate cyclase and so, promoting sustained activation or mutation of one or more proto-oncogenes. This could result in transformation of cells and the development of malignancy. A proto-oncogene, C-erb B2, that has been associated with breast and ovarian cancers is over-expressed in patients with end-stage renal disease, patients with ACRD, and patients with renal cell carcinoma. Other factors almost certainly also play a role in the development of neoplasia. For example, arginine vasopressin, VIP and adrenergic compounds may also increase the rate of fluid secretion by cysts.
A histopathologic and molecular genetic study of 21 renal cell carcinomas from dialysis patients found a preponderance of chromophilic renal cell carcinomas. Only a small number of these tumors showed the deletion of gene sequences in the short arm of chromosome 3 (3p), seen in almost all cases of the clear cell carcinoma that is the predominant type of renal cancer in the general population  . Thus, the genetic changes underlying development of renal tumors in patients with end-stage renal disease differ from those occurring with sporadic clear cell renal cell carcinoma. Chronic renal failure appears to promote structural chromosomal abnormalities including trisomy, and in a recently reported case, karyotype analysis showed trisomy of chromosomes 5,16 and 20 and deletion of chromosome Y. These cytogenetic changes are similar to those found in sporadic cases of renal cell carcinoma in the general population  . Perhaps, a genetic factor modulating tubular cell growth is affected by uremia, and this could account for a linkage between papillary hyperplasia and development of renal cell carcinoma  .
Renal cell carcinoma in a patient with ACRD may be asymptomatic in as many as 86% of cases, although in many of these the tumor is small and may still be considered an adenoma  . In those patients who develop symptoms, the commonest are due to bleeding into the tissue of the tumor  , into the renal parenchyma with rapid swelling of the kidney, into the subcapsular or retroperitoneal space with flank pain, or into the pyelocalyceal system resulting in gross hematuria. In some cases, persistent hematuria may be the only symptom and the cancer may not be detectable by the usual imaging procedures.
Screening by ultrasonography is useful and readily available, but small cysts and tumors may not be seen. Contrast-enhanced CT scanning shows the renal outlines and content more clearly. Especially with solid tumors, CT scanning may need to be supplemented with arteriography or magnetic resonance imaging  . Nevertheless, ACRDrelated renal cell carcinomas may not be detected by imaging techniques and may manifest themselves only by kidney enlargement , . The development of renal cancer appears to be correlated with kidney size, reflecting the volume of cysts and epithelial cell proliferation. Kidneys with ACRD weighing more than 150 gm are six-times more likely to contain cancer (56%) than are smaller kidneys (11%)  . This is in keeping with the view that the development of malignancy in patients with ACRD is a progressive process that starts in terminally differentiated renal tubules and progresses through adenoma to adenocarcinoma ,, . Even so, as many as 17% of the renal cancers found in dialysis patients occur in the absence of ACRD ,, .
The reported frequency of renal cancer in dialysis patients varies widely and a recent review suggested a prevalence of 1.3 % in patients with ACRD . A Japanese study found two cases of renal cell carcinoma in 57 patients over a ten-year period  , and a study in the United States found two cases of renal cell carcinoma in 30 patients over seven years  . This suggests the annual incidence of renal cell carcinoma in dialysis patients is some three to six times that in the general population ,, . Others have reported an incidence as high as 57 to 134 times that in the general population  .
A nationwide Japanese survey covering some 57,500 dialysis patients over a twoyear period, found that renal carcinomas had been detected in 112 male and 18 female patients. Their average age was 52.6 years, and the mean duration on dialysis was 106 months  . The incidence rate was 125 cases per 100,000 patients, compared with 3 cases per 100,000 in the general population over a similar time period. Diagnosis was based on CT scan or renal ultrasonography in 83.6% of the affected patients; CT scan in 59 cases and ultrasonography in 48 cases. Acquired cystic renal disease was present in 82.3% of the cases, bilateral renal cell carcinomas were found in 11 patients, and 19 patients (15.1%) had metastases. Curative nephrectomy was performed in 99 of 129 patients, the mean tumor diameter being 4.2 + 2.5 cm (range 0.5 to 15.0 cm). Perhaps this high incidence of tumors reflected the frequency of small (3 cm or less) renal tubular neoplasms that were adenomatous and might never have developed into clinically significant malignant lesions.
The incidence of tumors increases with time on dialysis and the severity of ACRD. They are four to seven times more common in males than in females ,, , and this compares with the two-fold greater risk of renal cancers in males compared with females in the general population of the United States. In general, ACRD-associated renal cell carcinoma occurs some 13 to 20 years earlier in dialysis patients than in the general population (45 ± 18 years vs. 64 ± 12 years) , and has also been reported in association with ACRD in peritoneal dialysis patients ,, . Renal cell carcinoma in association with ACRD occasionally develops in pediatric dialysis patients  , in one case in a 13-year-old boy who had been on dialysis for nine years  . Whether there is a racial difference in the incidence of ACRD-associated renal cell carcinoma is unknown, although this may be more common in black patients in the United States. In Japanese patients the incidence resembles that in white patients  .
In as many as 86% of cases, renal cell carcinoma is asymptomatic, and it metastasizes in 20% or less of cases ,, . Annual CT screening of dialysis patients has been suggested  , but death from renal cell carcinoma is relatively rare in dialysis patients, most dying from cardiovascular causes. In fact, the 5-year survival rate for patients diagnosed as having cancer of the end-stage kidney is about 35%, similar to the 42% survival for the general population with renal cancer  . The major differences are that renal cancer associated with ACRD is more often bilateral and multifocal, and that non-papillary renal cell carcinomas are the common type in the general population, while papillary renal cell tumors are much more frequent in dialysis patients.
Long-term dialysis patients frequently have severe cardiovascular disease and are poor surgical risks for radical nephrectomy. Because a tumor found by screening may be small and asymptomatic  , routine screening of all dialysis patients might have little impact on patient survival  . Also, based on 1987 cost data, annual CT screening of dialysis patients in the United States beginning three years after they start on dialysis would add at least 36 million US dollars to the Medicare budget  . With the increasing numbers of dialysis patients each year and the increasing costs of health care, this figure would be much higher today.
The effects of screening have been examined by decision analysis modeling using a tumor growth model to provide estimates of the relationship between tumor size, clinical stage and patient survival. Three strategies were assessed; no screening until patients develop symptomatic cysts and/or cancer; CT screening or ultrasound screening starting three years after starting dialysis and annually thereafter in those found to have cysts; and every three years in patients without cysts. The benefit of screening was found to depend critically on the life expectancy of the patient  . For example, for a 20-year old non-diabetic patient starting dialysis with a 25-year life expectancy, screening could increase this by about 1.6 years (6%). By comparison, for a 58 year-old patient starting dialysis with a life expectancy of five years, screening would only prolong life by four or five days (0.3%). Perhaps the best compromise is to screen young male dialysis patients who have been on dialysis for several years, are known to have ACRD, and have large kidneys ,, . The median age of patients starting dialysis in the United States is now more than 60 years, and diabetes is the cause of renal failure in more than one third of patients, suggesting that less than half the patients would benefit from screening. Sensitivity analysis also shows that if the false positive rate with screening techniques is 10%, this would result in an actual shortening of life expectancy for dialysis patients aged 64 and older. If this not unreasonable false positive rate applies, screening would actually shorten survival for almost half the dialysis patients in the United States.
The occurrence of hematuria, flank pain, unexplained fever or systemic illness in a dialysis patient is an indication for renal imaging. Until a subset of dialysis patients is identified for whom annual imaging is cost effective, the main consideration should be the general medical condition and life expectancy of the individual patient. Finding a renal carcinoma in an elderly patient with significant cardiovascular or other disease may have no effect on patient care and prognosis. On the other hand, a young, relatively fit dialysis patient may benefit greatly if renal imaging finds a renal tumor that is still localized to the kidney and is easily resectable. It may also be possible to assess prognosis by DNA flow cytometric analysis of the cellular DNA content and Sphase fraction. There appears to be a close relationship between DNA aneuploidy and high S-phase fraction and the tendency to metastasize or to develop recurrence  . There are also some differences in the DNA content profile of renal cancers in patients with ACRD compared with that in such tumors arising in the general population, perhaps reflecting differences in the biological nature of these neoplasms.
Renal cell carcinoma can also occur in the native kidneys of a patient some two to fifteen years after successful kidney transplantation , . Most of these patients have metastases at the time of diagnosis and also have evidence of ACRD. Thus, the malignant potential of the proliferative changes of ACRD is not removed by transplantation, and immunosuppressive treatment, especially with cyclosporin  , may activate occult renal cancers. In one study, metastatic renal carcinoma accounted for 2% of deaths in kidney transplant recipients  . Consequently, the native kidneys of potential transplant recipients should be imaged by CT or ultrasound to exclude tumors as part of the pre-transplant work up  . It has also been suggested that screening be done annually in transplant recipients, as the malignant potential associated with ACRD persists even after many years of normal renal function  . Certainly, if a transplanted patient develops high risk factors such as gross hematuria, flank pain, fever or a puzzling systemic illness, their native kidneys should be imaged to exclude tumors. Screening should also be used in patients with any two of the following moderate risk factors: ACRD, more than four years on dialysis, male sex, and a history of a questionable renal mass  . If questionable renal masses are seen with CT scanning, serial examinations at regular intervals are indicated, and any renal tumor should be removed ,,,, .
In the United States there are now more than 250,000 dialysis patients, more than 60,000 new patients start treatment for endstage renal disease each year, and more and more patients are living longer on dialysis  . More than 80% of dialysis patients have developed ACRD after four years on dialysis, and by 10 years this is present in all patients  . Consequently, the development of ACRD-associated renal cancers will become an ever-larger problem in future years.
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Christopher R Blagg
Executive Director, Northwest Kidney centers, Seattle WA 98122
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