Successful control of heavy proteinuria and return of renal function after bilateral renal artery embolization in focal segmental glomerulosclerosis

Percutaneous bilateral renal arterial occlusion is of value in the management of various nephrourological conditions, including severe nephrotic syndrome unresponsive to medical therapy [1,2] and drug resistant hypertension, either in dialysis patients [3] or where renin secretion from native kidneys remains excessive following transplantation [4]. In patients with end-stage renal disease (ESRD) the indications for bilateral surgical or 'catheter' nephrectomy are the same, (with the exception of chronic pyelonephritis or bilateral renal malignancy), yet morbidity and mortality of transcatheter renal ablation is lower [5]. In an analysis of embolization procedures performed for various renal and non-renal indications, the post-embolization syndrome (malaise, fever, local pain, and leukocytosis) occurred after 42.7% of procedures and was a self-limiting benign phenomenon [6]. Although recorded complications include sepsis, incomplete ablation, and embolization of distal sites, the risks from this procedure in experienced hands are modest [5-7]. Bilateral surgical nephrectomy in patients with ESRD carries a mortality of 3-11%, morbidity may be as high as 87%, and hospitalization ranges from 6 to 21 days [8,9]. Focal segmental glomerulosclerosis (FSGS) is often associated with nephrotic-range proteinuria, and it is only in the minority of patients that the proteinuria remits with systemic corticosteroid and other immunosuppressive therapy. Severe uncontrolled proteinuria and progression of renal impairment toward end-stage are well recognized in this condition [10,11]. We report two patients with 'malignant' nephrotic syndrome due to FSGS. In both cases proteinuria remained excessive in spite of all medical attempts to control it, resulting in cachexia and malnutrition despite nutritional supplementation. Bilateral transcatheter renal artery embolization was eventually considered necessary to sacrifice renal function and therefore prevent further proteinuria.