Value of ultrasound-guided irrigation and drainage of refractory pyocysts in ADPKD
© Saedi et al; licensee BioMed Central Ltd. 2009
Received: 24 December 2008
Accepted: 20 January 2009
Published: 20 January 2009
Cyst infections is not common in the patients with autosomal dominant polycystic kidney disease (ADPKD) however it may pose major problems to the clinicians because the diagnosis is hampered by lack of reliable imaging techniques for identification of the infected cysts and treatment may be difficult due to poor penetration of antibiotics into the cysts.
We present a case of ADPKD and intractable pyocysts that did not respond to standard antibiotic therapy but successfully treated by using ultrasound-guided cyst puncture, and repeated irrigation and drainage.
Where the experienced interventional radiologists are available, this method can rescue these patients from nephrectomy.
Urinary tract infection (UTI) occurs frequently in the patients with autosomal dominant polycystic kidney disease (ADPKD). Among the various forms of UTI, infections involving the cysts are usually diagnostic dilemmas and often refractory to therapy possibly because of poor penetration of antibiotics into the cysts . Herein, we present a case of ADPKD with refractory pyocysts that was successfully treated by using an interventional method. The feasibility and usefulness of interventional radiology in the management of refractory pyocysts in the patients with ADPKD will be discussed.
The prevalence of UTI in the ADPKD is abnormally high. Infections involving the cysts are often refractory to the antibiotic therapy because of limited entry of commonly used antibiotic into the cysts. Treatment of infected cysts in ADPKD should begin with lipophilic compounds such as ciprofloxacin and new quinolones, TMP-SMX, because of their low toxicity and high volume of distribution [1–4]. In the lack of response to the antibiotic therapy, cyst drainage may be a suitable alternative method. The successful use of irrigation drains for the treatment of the cyst infection in ADPKD subjects has been reported scarcely in the literature [1–3]. It should be considered that the identification of infected cysts is essential for imaging-guided diagnostic or therapeutic percutaneous puncture. US may be a feasible method for the evaluation of complicated cysts in ADPKD however it often fails to reliably differentiate benign hemorrhagic cysts from the other complications . Chapman et al.  suggested that percutaneous drainage under fluoroscopic localization should be the treatment of choice for the accessible infected cysts greater than 5 cm in diameter. The interesting point in the management of this case was the effectiveness of repeating this procedure despite the lack of response in the initial stages. We stress that even in severe cases with persistent and refractory pyocysts which shows no response to the initial stages of irrigation and drainage, repeated irrigation and drainage in a logical sequence will be an appropriate method for rescuing the patient from nephrectomy. This observation is in contrast with the former studies which have recommended nephrectomy in the severe cases, or in those with persistent recurrent infections. One problem still to be resolved is the role of intracystic irrigation by using the antibiotics and/or povidone iodine. To our knowledge, no evidence based data about the efficacy of this method in the treatment of intractable pyocysts in ADPKD has been reported in the English literature so far. Povidone iodine as a sclerosing agent was successful in the ablation of giant renal cysts , but no data about the beneficial effects of this agent in the treatment of pyocyst has been mentioned. Clearly, determining the role of irrigation of the infected cysts with the ideal antibiotics such as quinolones and/or povidone iodine requires replication in other studies. Hence, the success of this treatment may be related to the irrigation and drainage with saline solution solely. On the other hand it should be noted that iodine irrigation can increase the blood iodine levels significantly. We used the povidone iodine as an irrigating agent only in the first stage and we didn't measure the level of plasma iodine in the current patient however no aggravation of renal function and another complication was occurred. We emphasize that plasma iodine levels should be monitored in the patients with renal insufficiency; because iodine toxicity can lead to increased morbidity and mortality of these patients. In conclusion, this method is an effective and feasible method for treatment of the patients with ADPKD and intractable pyocysts and therefore, where experienced interventional radiologists are available, this method can rescue these patients from nephrectomy.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Chapman AB, Thickman D, Gabow PA: Percutaneous cyst punctures in the treatment of cyst infection in autosomal dominant polycystic kidney disease. Am J Kidney Dis. 1990, 16 (3): 252-255.View ArticlePubMedGoogle Scholar
- Gibson P, Watson ML: Cyst infection in polycystic kidney disease: a clinical challenge. Nephrol Dialysis Transplant. 1998, 13: 2455-2457. 10.1093/ndt/13.10.2455.View ArticleGoogle Scholar
- Palou J, Monreal F, Caparros J, Marti J, Calero F, Ballarin J: Percutaneous drainage by multiple and bilateral puncture of infected renal cysts in autosomal dominant polycystic kidney disease. Nephrol dialysis transplant. 1998, 13: 1606-1608. 10.1093/ndt/13.6.1606.View ArticleGoogle Scholar
- Frishman E, Orron DE, Heiman Z, Kessler A, Kaver I, Graif M: Infected renal cyst: sonographic diagnosis and management. J Ultrasound Med. 1994, 13 (1): 7-10.PubMedGoogle Scholar
- Peyromaure M, Debre B, Flam TA: Sclerotherapy of a giant renal cyst with Povidone-iodine. J Urol. 2002, 168: 2525-10.1016/S0022-5347(05)64183-3.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.