Is bilateral nephrectomy (surgical removal of both kidneys) a recommended treatment for resistant hypertension in patients with end-stage renal disease (ESRD)?

Bilateral Nephrectomy for Resistant Hypertension in ESRD

Bilateral nephrectomy should be considered as a rescue therapy for ESRD patients with truly resistant hypertension only after optimizing volume status through dialysis and failing maximal medical therapy with at least three antihypertensive agents from different classes. 1

When to Consider Bilateral Nephrectomy

Consider bilateral nephrectomy in ESRD patients who meet ALL of the following criteria:

• Blood pressure remains >140/90 mmHg despite achieving dry weight through adequate dialysis 1
• Failure of appropriate triple-drug regimen at near-maximal doses (including ACE inhibitors/ARBs, calcium channel blockers, beta-blockers, antiadrenergic agents, or direct vasodilators like minoxidil) 1
• Patient compliance confirmed 1
• Secondary causes of hypertension have been excluded 1

The Algorithmic Approach

Step 1: Optimize volume status

• Achieve dry weight through dialysis with emphasis on salt restriction and extracellular fluid volume reduction 1

Step 2: Maximize medical therapy

• Start with ACE inhibitors or ARBs as first-line agents 1
• Add beta-blockers (especially if prior MI or coronary disease) 1
• Add calcium channel blockers and anti-alpha-adrenergic drugs as needed 1
• Progress to minoxidil for severe cases 1

Step 3: Consider alternative dialysis modality

• Trial of continuous ambulatory peritoneal dialysis (CAPD) if three-drug regimen plus minoxidil fails 1

Step 4: Bilateral nephrectomy

• If CAPD proves ineffective, surgical or embolic nephrectomy should be considered 1

Evidence Supporting Bilateral Nephrectomy

The American Journal of Transplantation guidelines acknowledge that bilateral nephrectomy can improve blood pressure control in transplant candidates, though they note the procedure carries morbidity and mortality risks 1. The key caveat is that more recent data from the cyclosporine era showed conflicting results, with one study reporting no differences in blood pressure control compared to patients not undergoing nephrectomy 1.

However, multiple case series demonstrate effectiveness:

• Patients requiring 3.6 antihypertensive drugs pre-nephrectomy reduced to 1.4 drugs at 3 years post-procedure 2
• The blood pressure improvement takes time—starting at 3 months and continuing for a year or more 2
• Case reports document successful rescue of refractory hypertension with multiple life-threatening hypertensive crises 3, 4
• Laparoscopic bilateral nephrectomy has proven feasible with patients becoming normotensive within 1 month 5, 6

Critical Caveats and Pitfalls

Loss of residual renal function may be detrimental for some patients 1. This is particularly important because:

• Any remaining native kidney function contributes to volume management
• Residual function may provide some metabolic benefits
• Once removed, this function cannot be restored

Prior angioembolization can make subsequent laparoscopic surgery difficult or impossible due to dense perirenal reactions 6. Therefore, if considering nephrectomy, proceed directly to surgical approach rather than attempting embolization first.

The procedure is not without morbidity and mortality 1, so patient selection is critical. Reserve this intervention for truly refractory cases where medical management has definitively failed.

Practical Considerations

For transplant candidates specifically, the guidelines suggest bilateral nephrectomy may reduce the number of post-transplant antihypertensive medications needed, potentially improving compliance and reducing costs 1. However, this should be weighed against surgical risks and the loss of any residual renal function 1.

The laparoscopic approach is preferred when feasible, offering reduced morbidity compared to open surgery 5, 6. Simultaneous bilateral laparoscopic nephrectomy can be performed with operating times of 260-280 minutes 6.