From the Guidelines
The most appropriate management of this patient's acquired kidney cysts is no intervention, as the cysts are asymptomatic and do not have any solid components or evidence of vascular flow within the cysts, and the patient is on the kidney transplant list. According to the KDIGO 2025 clinical practice guideline for the evaluation, management, and treatment of autosomal dominant polycystic kidney disease (ADPKD) 1, native nephrectomy should be performed only for specific indications and when the benefit outweighs the risk, and there is no indication for intervention in this case. The guideline also recommends that imaging of the kidneys should be performed within 1 year prior to the anticipated timing of transplantation to rule out solid or complex cystic lesions, but this does not necessarily imply annual surveillance imaging for asymptomatic cysts.
The patient's current management with regular hemodialysis and medications such as amlodipine, calcitriol, lisinopril, and sevelamer carbonate should continue, with monitoring of blood pressure and renal function. The use of tolvaptan therapy is not indicated in this case, as it is primarily used for the treatment of autosomal dominant polycystic kidney disease (ADPKD) and not for acquired kidney cysts. Bilateral nephrectomy is also not indicated, as it is a major surgical procedure with significant risks and is not necessary for asymptomatic cysts.
In terms of surveillance imaging, the KDIGO guideline does not provide specific recommendations for the frequency of imaging for asymptomatic acquired kidney cysts, but it does recommend that imaging should be performed within 1 year prior to the anticipated timing of transplantation 1. However, another study recommends that patients with chronic kidney disease should undergo renal assessment at least annually by estimated or measured GFR and albuminuria (or proteinuria) measurement 1.
Overall, the best approach for this patient is to continue current management and monitoring, with no intervention for the asymptomatic acquired kidney cysts, and to coordinate care with the transplant team.
From the Research
Management of Acquired Kidney Cysts
The patient in question has acquired kidney cysts due to congenital reflux nephropathy and is on the kidney transplant list. The management of acquired kidney cysts in this context is crucial for the patient's overall health and transplant eligibility.
- The patient's kidney ultrasound shows small kidneys with multiple cysts bilaterally, and a few cysts have internal septations, but there are no solid components or evidence of vascular flow within the cysts.
- According to 2, acquired cystic kidney disease (ACKD) is characterized by the development of many fluid-filled renal cysts and sometimes neoplasms in the kidneys of individuals with chronic renal failure but without a history of hereditary cystic disease.
- The study 2 also mentions that most patients with ACKD are asymptomatic, but the disorder may be associated with serious complications such as retroperitoneal hemorrhage and metastatic renal cell carcinoma.
- Screening for renal cell carcinoma in dialysis patients or transplant recipients is not generally recommended unless they have specific risk factors, as stated in 2.
- There is no evidence to suggest that the patient's current condition requires immediate intervention such as surgery or medication specifically for the acquired kidney cysts.
- Given the patient's stable condition and the absence of symptoms or complications related to the cysts, the most appropriate management approach would be to monitor the patient's condition without immediate intervention.
Recommended Course of Action
Based on the available evidence, the recommended course of action for this patient would be:
- No intervention is necessary for the acquired kidney cysts at this time, as stated in option D.
- The patient should continue to be monitored for any changes in their condition or the development of complications related to the cysts.
- Annual kidney ultrasonography, as mentioned in option A, may be considered to monitor the size and characteristics of the cysts, but it is not explicitly recommended in the provided studies for asymptomatic patients with ACKD.