Diagnostic Management of Suspected Acute Cyst Complication in Patients with Autosomal Dominant Polycystic Kidney Disease

(1)

• Retrospective identification of ADPKD patients presenting with abdominal pain and/or fever between January 2005 and June 2015 in a prospective computerized database

• Stepwise and systematic review of all medical files • Diagnostic criteria:

 CyH: intracystic density above 50 Hounsfield units on CT  CyI:

~ “definite” by cyst fluid analysis showing bacteria or neutrophils ~ “probable” in case of concomitant presence of:

1. temperature >38°C for 3 days 2. loin or liver tenderness

3. CRP plasma level >50 mg/L 4. no CT evidence for CyH

 IUO: episodes out of criteria for CyH or CyI

Diagnostic Management of Suspected Acute Cyst Complication

in Patients with Autosomal Dominant Polycystic Kidney Disease

Marie Neuville

1

_{, Roland Hustinx}

2

_{, Jessica Jacques}

3

_{, Jean-Marie Krzesinski}

1

_{and François Jouret}

1

Divisions of (1) Nephrology, (2) Nuclear Medicine and (3) Medico-Economic Information, University of Liège Hospital (ULg CHU), Liège, Belgium

• Two main types of acute cyst complication in patients with autosomal dominant polycystic kidney disease (ADPKD):  cyst infection (CyI)

 cyst hemorrhage (CyH) • Double diagnostic challenge :

 differentiating acute cystic from non-cystic diseases  distinguishing CyI from CyH

• Prominence of an accurate diagnosis to target the treatment:  CyI: 6-week antibiotic therapy (and cyst puncture)

 CyH: antalgics and watchful waiting

• Recent suggestion of diagnostic criteria, with unknown sensibility and specificity

This monocentric 10-year retrospective study aims at challenging clinical, biological and imaging criteria in order to propose a diagnostic algorithm in the management of suspected acute cyst complication

Background and Objectives

Demographics of the Cohort

Bacteriological Documentation

Diagnostic Algorithm

Discussion

This monocentric 10-year retrospective study including 88 episodes of suspected acute cyst complication in 53 ADPKD patients highlights:

• _{the usefulness of clinical, i.e. fever, and biological, i.e. CRP levels, criteria to distinguish CyI from CyH;} • _{the limitations of bacteriological and conventional radiological investigations;}

• _{the yield of}18_{FDG-PET/CT imaging in the diagnosis of CyI.}

Table 1. Clinical and biological characteristics of the cohort

KTR, kidney transplant recipients; eGFR, estimated glomerular filtration rate; WBC, white blood cells at admission; CRP, C-reactive protein level at admission; ID, identification; IUO, inflammation of unknown origin. Mean +/- Standard Deviation.

n Age Gender Dialysis KTR eGFR* T°>38°C Pain WBC CRP Hematuria Leucocyturia Germ ID PET/CT

(years) (male, %) (%) (%) (ml/min) (%) (%) (106_/mm³) _(mg/L) _(%) _(%) _Urine

(%) Blood (%) (+, %)

Hemorrhage 30 46 ± 13 50 0 17 77 ± 49 7 97 9.7 ± 3.3 13 ± 14 23 10 10 7 0/1, 0

Renal cyst infection

Definite 7 52 ± 11 70 15 43 39 ± 16 100 86 11.3 ± 3.9 163 ± 98 29 43 15 57 3/3, 100

Probable 10 48 ± 14 30 20 30 61 ± 43 100 100 10.8 ± 3.1 252 ± 204 40 40 40 20 3/4, 75

Liver cyst infection

Definite 4 63 ± 5 50 25 75 29 ± 14 100 100 12.1 ± 2.6 230 ± 87 50 1/1, 100

Probable 2 [66 ; 66] 50 50 50 38 100 100 [4.2 ; 6.5] [51 ; 342] 50 1/2, 50

IUO 35 55 ± 15 50 6 66 49 ± 31 66 66 11.8 ± 5.6 98 ± 92 37 60 48 23 7/17, 42

Diagnostic yields of conventional imaging techniques in CyI were:

 _{Ultrasounds: 10% (1/10)}

 _{Computed tomography: 26.1% (6/23)}  _{Magnetic resonance imaging: 25% (1/4)}