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  • Review Article
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Vascular complications in autosomal dominant polycystic kidney disease

Nature Reviews Nephrology volume 11, pages 589–598 (2015)Cite this article

Subjects

Key Points

  • Intracranial aneurysms (IAs) are the most common vascular manifestation of autosomal dominant polycystic kidney disease (ADPKD)

  • Individuals with ADPKD and increased risk of IA—including those with a family or personal history of IA or subarachnoid haemorrhage—should undergo screening

  • Other vascular abnormalities in ADPKD include aneurysms and dissections of the thoracic aorta, coronary arteries and cervicocephalic arteries, aortic root dilatation and cerebral dolichoectasia; screening is not usually indicated

  • Asymptomatic IAs detected by screening are frequently small and have a low risk of rupture

  • Intervention, either surgical or endovascular, is indicated based on the size and location of the aneurysm

  • The relationship between PKD1 and PKD2 mutations and the development of vascular abnormalities is undefined; modifier genes that increase TGF-β signalling might increase the risk of vascular complications in ADPKD

Abstract

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease. Relentless cyst growth substantially enlarges both kidneys and culminates in renal failure. Patients with ADPKD also have vascular abnormalities; intracranial aneurysms (IAs) are found in ∼10% of asymptomatic patients during screening and in up to 25% of those with a family history of IA or subarachnoid haemorrhage. As the genes responsible for ADPKD—PKD1 and PKD2—have complex integrative roles in mechanotransduction and intracellular calcium signalling, the molecular basis of IA formation might involve focal haemodynamic conditions exacerbated by hypertension and altered flow sensing. IA rupture results in substantial mortality, morbidity and poor long-term outcomes. In this Review, we focus mainly on strategies for screening, diagnosis and treatment of IAs in patients with ADPKD. Other vascular aneurysms and anomalies—including aneurysms of the aorta and coronary arteries, cervicocephalic and thoracic aortic dissections, aortic root dilatation and cerebral dolichoectasia—are less common in this population, and the available data are insufficient to recommend screening strategies. Treatment decisions should be made with expert consultation and be based on a risk–benefit analysis that takes into account aneurysm location and morphology as well as patient age and comorbidities.

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Figure 1: An aortic aneurysm in a 19-year-old patient with ADPKD.
Figure 2: Right vertebral artery dissection in a 47-year-old patient with ADPKD.
Figure 3: An unruptured intracranial aneurysm in a 47-year-old patient with ADPKD and distant smoking history.
Figure 4: Pkd1 deletion in VSMCs results in abnormal proximal ascending aortic architecture.
Figure 5: A ruptured intracranial aneurysm in a 46-year-old patient with ADPKD.
Figure 6: Surgical and endovascular techniques for the treatment of intracranial aneurysms.

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Acknowledgements

T.W.'s work is supported in part by grants from the National Institute of Diabetes and Digestive and Kidney Diseases (P30DK090868, DK076017 and DK095036). R.D.P.'s work is supported in part by grants from the National Institute of Diabetes and Digestive and Kidney Diseases (DK62411), and from the National Center for Advancing Translational Sciences Clinical and Translational Science Awards (UL1TR001064 awarded to Tufts University).

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Authors and Affiliations

  1. Department of Medicine, Division of Nephrology, Tufts Medical Center, 800 Washington Street, Boston, 02111, MA, USA

    Ronald D. Perrone

  2. Department of Neurosurgery, Cerebrovascular and Endovascular Division, Tufts Medical Center, 800 Washington Street, Boston, 02111, MA, USA

    Adel M. Malek

  3. Department of Medicine, Division of Nephrology, University of Maryland, 720 Rutland Avenue, Baltimore, 21205, MD, USA

    Terry Watnick

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R.D.P. has received research funding from Sanofi–Genzyme and is a consultant for Otsuka and Vertex. T.W. has received research funding from Otsuka. A.M.M. declares no competing interests.

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Perrone, R., Malek, A. & Watnick, T. Vascular complications in autosomal dominant polycystic kidney disease. Nat Rev Nephrol 11, 589–598 (2015). https://doi.org/10.1038/nrneph.2015.128

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