Long-term results of pediatric renal transplantation into a dysfunctional lower urinary tract

A systematic review of kidney transplantation outcomes in patients with end-stage renal disease due to childhood lower urinary tract malformations

PURPOSE

Patients with lower urinary tract malformations (LUTM) were suspended from kidney transplantation (KT) programs in the past due to various concerns. Consequently, only a limited number of studies have explored this topic at hand. In this study, our objective was to perform a systematic review (SR) to evaluate the current evidence regarding KT outcomes as well as patient survival (PS), postoperative complications and urinary tract infections (UTI) in individuals with childhood LUTM.

METHODS

The search encompassed databases of Web of Science, Medline (via PubMed), and Embase (via Scopus) to identify all studies reporting outcomes on KT for patients with LUTM. The research included articles published in English from January 1995 till September 2023.

RESULTS

Of the 2634 yielded articles, 15 met the inclusion criteria, enrolling a total of 284,866 KT patients. There was significantly better 5-year graft survival (GS) in recipients with LUTM compared to the control group (RR, 1.04; 95% CI 1.02-1.06); while GS at 1-year and 10-year, and PS at 1-year, 5-year and 10-year were similar between groups. On the other hand, the postoperative UTI rate was significantly higher in the LUTM group (RR: 4.46; 95% CI 1.89-10.51). However, data on serum creatinine and estimated glomerular filtration rate on follow-up were insufficient.

CONCLUSION

GS and PS rates appear to be similar in patients with childhood LUTM and those with normal lower urinary tract functions. Despite a higher postoperative UTI rate within this patient group, it appears that this has no effect on GS rates.

[Kidney transplantation in children with complex urogenital malformations-what should be considered?]

BACKGROUND

Congenital anomalies of the kidneys and urinary tract (CAKUT) are the most common cause of end-stage renal disease (ESRD) in children. Approximately one third of children with CAKUT have lower urinary tract dysfunction (LUTD).

AIM

This article highlights the important aspects that need to be considered in kidney transplantation of children with complex urogenital malformations.

MATERIALS AND METHODS

The paper reviews the existing literature regarding the evaluation, preparation, perioperative management, and follow-up of children with complex urogenital malformations and ESRD undergoing renal transplantation.

RESULTS

Comprehensive diagnostics are required before any pediatric kidney transplantation. If LUTD is suspected, voiding cystourethrography and a urodynamic examination should be performed. Treatment of symptomatic vesicoureterorenal reflux and LUTD is mandatory prior to pediatric kidney transplantation. Following successful kidney transplantation of children with congenital urogenital malformations, lifelong follow-up is required. Regular reevaluations of the bladder by means of urodynamic examinations are necessary. In patients following bladder augmentation with intestinal segments or urinary diversions in childhood, regular endoscopic examinations of the urinary tract are recommended to rule out secondary malignancy.

CONCLUSION

Treatment of children with complex urogenital malformations should be carried out in centers with appropriate expertise.

Clean Intermittent Catheterization in Children under 12 Years Does Not Have a Negative Impact on Long-Term Graft Survival following Pediatric Kidney Transplantation

BACKGROUND

Congenital anomalies of the kidneys and urinary tract (CAKUTs) are one of the most prevalent primary causes of end-stage renal disease (ESRD) in young children, and approximately one-third of these children present with lower urinary tract dysfunction (LUTD). Many children with LUTD require therapy with clean intermittent catheterization (CIC). CIC commonly leads to bacteriuria, and considerations have arisen regarding whether CIC in immunosuppressed children is safe or whether repeated febrile urinary tract infections (UTIs) may lead to the deterioration of kidney graft function.

MATERIAL AND METHODS

We retrospectively reviewed all cases of primary kidney transplantation performed in our center between 2001 and 2020 in recipients aged less than twelve years. The number of episodes of febrile UTIs as well as the long-term kidney graft survival of children undergoing CIC were compared to those of children with urological causes of ESRD not undergoing CIC, as well as to those of children with nonurological causes of ESRD.

RESULTS

Following successful kidney transplantation in 41 children, CIC was needed in 8 of these patients. These 8 children undergoing CIC had significantly more episodes of febrile UTIs than did the 18 children with a nonurological cause of ESRD (p = 0.04) but not the 15 children with a urological cause of ESRD who did not need to undergo CIC (p = 0.19). Despite being associated with a higher rate of febrile UTIs, CIC was not identified as a risk factor for long-term kidney graft survival, and long-term graft survival did not significantly differ between the three groups at a median follow-up of 124 months.

CONCLUSIONS

Our study demonstrates that, under regular medical care, CIC following pediatric transplantation is safe and is not associated with a higher rate of long-term graft loss.

MEDIUM AND LONG-TERM CLINICAL OUTCOMES OF KIDNEY TRANSPLANTATION IN PATIENTS WITH PRUNE BELLY SYNDROME: A SINGLE-CENTRE EXPERIENCE

OBJECTIVES

To present the medium and long-term outcomes of kidney transplantation performed in patients with Prune Belly Syndrome (PBS) which is one of the congenital anomalies of the kidney and urinary tract (CAKUT).

METHODS

Thirteen kidney transplantations were performed in nine patients with PBS from January 1994 to December 2020. Demographics, surgical features, graft and patient survival rates were analysed. Survival outcomes was compared with 106 age- and donor-type matched controls who underwent transplantation because of non-urological causes.

RESULTS

The median ages of PBS patients at the time of first and second transplantation were 19 and 34 years old, respectively. One patient had postoperative Clavien grade 3a complication. Eight of 13 transplants are still functional at the last follow-up. Eight patients underwent pre-transplant urological operations in preparation for kidney transplantation, while four patients underwent urological operations in the post-transplant period. Graft survival for PBS transplants at 5, 10 and 15 years were 90.9%, 57.7% and 38.5%, respectively. Graft survival for control cohort at 5, 10 and 15 years were 89.9%, 80% and 74%, respectively. The patient and graft survival rates were similar between PBS and control groups (p=0.449, p=0.134, respectively).

CONCLUSION

This single-centre study showed that the medium term graft survival rates in patients with PBS are encouraging and comparible to non-CAKUT transplant patients, however long-term graft survival rates were found to be proportionally inferior. To help determine the reasons for long-term transplant kidney function deterioration and how to improve them we suggest that multi-centre international collaboration will be needed.

The causes and consequences of paediatric kidney disease on adult nephrology care

Adult nephrologists often look after patients who have been diagnosed with kidney disease in childhood. This does present unique challenges to the adult nephrologist, who may be unfamiliar with the underlying cause of kidney disease as well as the complications of chronic kidney disease (CKD) that may have accumulated during childhood. This review discusses common causes of childhood CKD, in particular congenital anomalies of the kidney and urinary tract (CAKUT), autosomal dominant tubulointerstitial kidney disease (ADTKD), polycystic kidney disease, hereditary stone disease, nephrotic syndrome and atypical haemolytic uraemic syndrome. The long-term consequences of childhood CKD, such as the cardiovascular consequences, cognition and education as well as bone health, nutrition and growth are also discussed.

Surgical considerations in paediatric kidney transplantation: an update

Background

Kidney transplantation has established itself as the most appropriate mode of renal replacement therapy for the majority with end-stage kidney disease. Although at present this is applicable for children as well as adults, a few decades back kidney transplantation was not considered a first-line option in children. This was due to inferior outcomes following transplantation in this age group compared to that of adults. These poor results were attributed to challenges in paediatric transplantation such as the shortage of suitable donors, technical difficulties in performing a sound vascular anastomosis and the adverse effects of immunosuppressive medication on growth and development. However, current patient and graft-centred outcomes after paediatric transplantation equal or surpass that of adults. The advances in evaluation and management of specific surgical concerns in children who undergo transplantation, such as pre-transplant native nephrectomy, correction of congenital anomalies of the urinary tract, placement of an adult-sized kidney in a small child and minimizing the risk of allograft thrombosis, have contributed immensely for these remarkable outcomes.

Conclusions

In this review, we aim to discuss surgical factors that can be considered unique for children undergoing kidney transplantation. We believe that an updated knowledge on these issues will be invaluable for transplant clinicians, who are dealing with paediatric kidney transplantation.

Long-term outcome of transplant ureterostomy in children: A National Review

BACKGROUND

CAKUT are the most common cause of end-stage renal failure in children (Pediatr Nephrol. 24, 2009, 1719). Many children with CAKUT have poor urinary drainage which can compromise post-transplant outcome. Identifying safe ways to manage anatomical abnormalities and provide effective urinary drainage is key to transplant success. Much debate exists regarding optimum urinary diversion techniques. The definitive formation of a continent urinary diversion is always preferable but may not always be possible. We explore the role of ureterostomy formation at transplantation in a complex pediatric group.

METHODS

We report six pediatric patients who had ureterostomy formation at the time of transplantation at the National Paediatric Transplant Centre in Dublin, Ireland. We compared renal function and burden of urinary tract infection to a group with alternative urinary diversion procedures and a group with normal bladders over a 5-year period.

RESULTS

There was no demonstrable difference in estimated glomerular filtration rate between the groups at 5-year follow-up. The overall burden of UTI was low and similar in frequency between the three groups.

CONCLUSIONS

Ureterostomy formation is a safe and effective option for temporary urinary diversion in children with complex abdominal anatomy facilitating transplantation; it is, however, important to consider the implications and risk of ureterostomy for definitive surgery after transplantation.

5-Year Long-Term Outcome of Live-Donor Renal Transplant Recipients With Enterocystoplasty and Ureterocystoplasty: An Age- and Sex-Matched Pair Analysis

OBJECTIVE

To assess surgical complications, febrile UTI, graft function and 5-year graft survival after renal transplantation (RT) in patients with augmentation cytsoplasty (AC) and to compare them to RT patients with normal lower urinary tract.

MATERIALS AND METHODS

A case-control study of 34 RT patients with AC including 23 patients with enterocystoplasty (EC) and 11 patients with ureterocystoplasty (UC) was performed. The primary outcome was to determine the difference between both groups regarding postoperative surgical complications and febrile UTI episodes. Graft function was compared at 1, 3, and 5 years and 5-year graft survival was determined. The secondary outcome was to compare them to an age- and gender-matched control group (122 patients) with normal lower urinary tract.

RESULTS

There was no significant difference regarding surgical complications or rates of hospital readmission between AC groups. Seventeen (73.9%) and 5 (45.5%) patients developed 33 and 14 episodes of febrile UTI in EC and UC groups, respectively (P= .5). Control group had shown lower incidence surgical complications (P = .001) and febrile UTIs (P = .02) compared to AC groups. At 3 and 5 years, UC had higher median eGFR than EC (P = .08, 0.008, respectively). The 5-year graft survival was 32 (94.1%) with no statistically significant difference between EC (95.7%) and UC (90.9%) (P = .5) or between AC and control (85.2%, P = .3).

CONCLUSION

Although RT after AC was associated with higher surgical complications and UTI episodes, they had comparable 5-year graft survival to their control. When indicated, UC should be the preferred choice of AC whenever possible.

Does renal transplant in children with LUTD improve their bladder function?

Much is still unknown about LUT function after receiving renal graft. Graft function was the main focus of different studies discussing the same issue. However, these studies ignored the effects of the graft on lower tract function and more demand for bladder cycling and growth of the child. Therefore, we aimed at evaluating the LUT function after RT into patients with LUTD. We enrolled a retrospective cohort of 83 live renal transplant children with LUTD. The 44 patients in Group (A) had a defunctionalized bladder, and the 39 patients in Group (B) had underlying LUT pathology. All patients had clinical and urodynamic evaluation of LUT functions at least 1 year after RT. We found that the improvement in patients with impaired bladder compliance was 73% in Group (A) and 60% in Group (B), with no statistically significant difference between the study groups. In Group (B), there was statistically significant worsening of MFP (8.4%) and mean PVR (79.9%) after RT. In Group (A), mild but stable significant improvement of all clinical and urodynamic parameters was observed. Serum creatinine was significantly worse in patients with pathological LUTD compared with those with defunctionalized bladder but without significant effect on graft survival. All LUT variables seemed to have no adverse effect on graft survival except for use of CIC and augmented bladder. Incident UTI independent of LUT variables accounted for 20% of graft creatinine change.

Pediatric kidney transplantation in Egypt: Results of 10-year single-center experience

Pediatric kidney transplantation is a multidisciplinary therapy that needs special consideration and experience. In this study, we aimed to present CUCH experience; over a 10-year period, as a specialized center of kidney transplantation in children. We studied 148 transplantations performed at a single center from 2009 to 2018. Pretransplant and follow-up data were collected and graft/patient survival rates were evaluated. A total of 48 patients developed at least one rejection episode during 688 patient-years of follow-up. Infections, recurrence of original disease, and malignancy were the most important encountered medical complications (20%, 2%, and 1.4%, respectively). One-year patient survival was 94.1%, while graft and patient survival was 91.9%. Graft/patient survival at 5, 7, and 9 years was 90%, 77%, and 58%, respectively. Infections were the main cause (69%) of mortality. Death with a functioning graft and CR were the main causes of graft loss (48% and 33%, respectively). Pediatric kidney transplantation in Egypt is still a challenging yet successful experience. Rejections and infections are the most frequent complications. Short-term outcomes surpass long-term ones and graft survival rates are similar to the international standard.

Increasing bladder capacity and vesicoureteral reflux in pediatric kidney transplant patients

OBJECTIVES

To investigate the frequency of vesicoureteral reflux, and the relationship of pretransplant decreased bladder capacity and post-transplant vesicoureteral reflux in children undergoing kidney transplantation.

METHODS

A voiding cystourethrography was carried out in 172 pediatric kidney transplantation recipients before, and 4 months after, transplantation to evaluate bladder capacity and vesicoureteral reflux. The correlation of post-transplant vesicoureteral reflux with pretransplant bladder capacity, vesicoureteral reflux in the native kidney and the method of ureteral reimplantation (intravesical/extravesical) was analyzed. Atrophic bladder was defined as having ≤50% functional bladder capacity (age in years + 2) × 25 (mL) or ≤150 mL in patients aged >10 years.

RESULTS

Bladder capacity increased remarkably after transplantation in both post-transplant vesicoureteral reflux- group (from 180 to 253 mL) and vesicoureteral reflux+ group (from 82 to 171 mL). Voiding cystourethrography showed vesicoureteral reflux in 12 cases of kidney transplantation (7%; grade 1: 2, grade 2: 3, grade 3: 7). Pretransplant atrophic bladder was an independent risk factor of post-transplant vesicoureteral reflux (P = 0.004, hazard ratio 9.5). There was no difference in renal function between the vesicoureteral reflux- group and vesicoureteral reflux+ group at 4 months to 5 years post-transplantation.

CONCLUSIONS

Pretransplant atrophic bladder is a risk factor of post-transplant vesicoureteral reflux in pediatric patients. However, bladder capacity can remarkably increase after transplantation, and kidney function in the post-transplant vesicoureteral reflux+ group is stable.

The history of renal transplantation in Canada: A urologic perspective

While the urologist's involvement in kidney transplantation varies from center to center and country to country, urologists remain integral to many programs across Canada. From the early days of kidney transplant to contemporary times, the leadership, vision, and skillset of Canadian urologists have helped progress the field. In this review of Canadian urologists' role in kidney transplantation, the achievements of this professional group are highlighted and celebrated. Original contributors to the field, as well as notable achievements are highlighted, with a focus on the impact of Canadian urologists.

Long-Term Outcomes of Kidney Transplantation in Children

Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD) in children and confers improved survival, skeletal growth, heath-related quality of life, and neuropsychological development compared with dialysis. Kidney transplantation in children with ESRD results in 10-year patient survival exceeding 90%. Therefore, the long-term management of these patients is focused on maintaining quality of life and minimizing long-term side effects of immunosuppression. Optimal management of pediatric kidney transplant recipients includes preventing rejection and infection, identifying and reducing the cardiovascular and metabolic effects of long-term immunosuppressive therapy, supporting normal growth and development, and managing a smooth transition into adulthood.

Outcome of pediatric renal transplantation in urological versus non-urological causes of end stage renal disease: Does it matter?

INTRODUCTION

Causes for end stage renal disease (ESRD) in children can be categorized into urological causes or non-urological causes. We sought to compare the outcomes of urological and non-urological causes of ESRD in children.

METHODS

Patients were divided into two groups: urological causes of ESRD versus non-urological causes of ESRD. All patients and donors had at least 6 months of follow-up. The main outcomes included the effect on complications and renal function. Comparisons were carried out using the chi-square test or the Student t-test. Multivariate logistic regression analysis was used to define the effect of different variables on the outcome of renal transplantation (Table).

RESULTS

Our study included 123 patients, 91 males. The mean age was 9 years and mean follow up was 46 months. Two-thirds of the patients had non-urological causes of ESRD. Overall survival was 100%, and only one patient needed a graft nephrectomy 3 months after the transplant. The mean estimated glomerular filtration rate was 117 mL/min, and did not differ significantly between the two groups (p = 0.13). Multivariable regression showed that female gender (OR 8.7, 95% CI 2.9-26, p = 0 0.0001) was associated with better renal function, while having a urological cause of ESRD (OR 0.28, CI 0.08-0.98, p = 0 0.05) was associated with worse renal function. Non-urological causes of ESRD were significantly less likely to develop complications following renal transplantation (OR 0.28, CI 0.09-0.89, p = 0 0.03).

CONCLUSION

Female patients with non-urological causes of ESRD are more likely to have better long-term renal functions, and less liable to develop complications following renal transplant.

Long-term Outcome of 1-step Kidney Transplantation and Bladder Augmentation Procedure in Pediatric Patients

BACKGROUND

Guidelines for bladder augmentation (BA) in kidney transplantation (KT) recipients are not well-defined. In our center, simultaneous BA with KT (BA-KT) is performed. We assessed transplantation outcomes of this unique extensive procedure.

METHODS

A case-control single center retrospective study. Transplantation outcomes were compared with those of KT recipients who did not need BA.

RESULTS

Compared with 22 patients who underwent KT only, for 9 who underwent BA-KT, surgical complications and the need for revision in the early posttransplantation period were similar; early graft function was better: estimated glomerular filtration rate, 96.5 ± 17.1 versus 79.4 ± 16.6 mL/min at 0 to 6 months (P = 0.02); posttransplantation clean intermittent catheterization was more often needed: by 78% (7/9) versus 13% (3/22); and asymptomatic bacteriuria was more common: 100% versus 9% during the first 6 months (P < 0.001), 55% versus 9% (P = 0.02) and 66.6% versus 9% during the first and second years, respectively (P = 0.004). Urinary tract infection (UTI) incidence was also higher: 100% versus 23% during the first 6 months and 44% versus 9% during the second year posttransplantation. Graft function deteriorated significantly in the BA-KT group by the fifth posttransplantation year: estimated glomerular filtration rate was 47.7 ± 39.7 mL/min versus 69 ± 21.3 mL/min, with only 6 (66%) of 9 functioning grafts versus 100% in the KT only group. Causes of graft loss were noncompliance with drug therapy in 2 patients and recurrent UTIs in 2 patients.

CONCLUSIONS

Excellent short-term outcome for simultaneous BA-KT is threatened by graft loss due to a high prevalence of UTIs and patient noncompliance with the demanding complex posttransplantation therapy.

Renal Transplant in the Abnormal Bladder: Long-Term Follow-Up

OBJECTIVES

Normal urinary bladder stores urine at low pressure, does not leak, and completely empties by natural voiding. An abnormal bladder may be due to neurologic or urologic disorders that render the bladder of small capacity, of high storage pressure, or of poor compliance. The aim of this study was to determine the long-term outcomes of renal transplant in patients with abnormal bladders.

MATERIALS AND METHODS

We retrospectively compared 30 transplanted kidneys in 25 patients with abnormal bladders with a control group comprising 30 grafts transplanted simultaneously during the same period of time (1990-2014) in 30 patients without bladder abnormality. Patient demographics, graft function, survival, and postoperative complications were compared.

RESULTS

Patients with abnormal bladders received transplants at a younger age than the control group (32 ± 17 vs 47 ± 12 y; P <. 001). Graft survival was not significantly different between the study and the control groups at 1 (90% vs 97%; P = .30), 3 (88% vs 91%; P = .67), and 5 years (82% vs 87%; P = .68). On long-term follow-up (20 years), 19 grafts (63%) were functioning in the study group compared with 25 grafts (83%) in the control group, suggesting inferior survival in those with an abnormal bladder after the first 10 years of transplant. In the abnormal bladder group, there was higher incidence of urologic complications (93% vs 50%; P<.001).

CONCLUSIONS

Despite the earlier age at transplant, the previous urologic operations, and the high incidence of urinary tract infection after renal transplant, graft survival and functions after renal transplant were not significantly different between patients with abnormal and normal bladders over at least the first 10 years. Therefore, it is safe to transplant into abnormal bladders once they have been assessed, reconstructed if necessary, and managed appropriately.

Favorable Outcomes of Renal Transplant in Children With Abnormal Lower Urinary Tract

OBJECTIVES

Chronic kidney disease caused by lower urinary tract abnormalities is a significant complication in pediatric care. Although there are conflicting reports about clinical outcomes in the past, favorable outcomes have been reported in recent years. Despite this, many centers still refrain from performing renal transplant in these patients. Here, we compared clinical outcomes of renal transplant recipients with and without lower urinary tract abnormalities.

MATERIALS AND METHODS

Our study included 71 renal transplant recipients who were divided into 3 groups: 17 patients with abnormal lower urinary tracts having vesicoureteral reflux (group 1), 7 patients with abnormal lower urinary tracts having bladder dysfunction (group 2), and 47 patients with anatomically and functionally normal lower urinary tracts (group 3). We retrospectively compared demographic features, clinical course, graft survival, pre- and posttransplant incidence of urinary tract infections, and final graft function among the groups.

RESULTS

There were no statistically significant differences among groups regarding median age at time of transplant, graft survival, median creatinine level, and median glomerular filtration rate (P > .05). Significant differences were shown in incidence of urinary tract infections between patients in groups 1 and 2 (abnormal lower urinary tracts) and group 3 (normal lower urinary tracts) before transplant (P < .05). Although frequency of urinary tract infections in groups 1 and 2 were moderately higher than shown in group 3 after transplant, this difference was not statistically significant.

CONCLUSIONS

Although the children with abnormal lower urinary tracts had slightly higher incidence of urinary tract infections, there were no differences between patients with abnormal and normal lower urinary tracts regarding allograft survival and function. In addition, proper follow-up of patients before and after transplant, based on our experience, should include educating patients and their parents about potential complications after transplant for the best outcome of renal transplant.

Pre-transplant management of valve bladder: a critical literature review

OBJECTIVE

Indications, timing and problems related to augmentation cystoplasty (AC), in the context of posterior urethral valves (PUV) and renal transplantation (RT) are ill defined. Associated bladder dysfunction (BD) is not a stable condition and may cause the loss of the renal graft. Polyuria, accentuates BD and seems to improve after RT. The objective of this research is to critically review the available literature, aiming to rationalize the treatment of PUV with BD in the context of end stage renal disease (ESRD).

MATERIALS AND METHODS

A thorough literature review was performed. Pertinent papers were, critically analyzed and classified according to the level of evidence.

RESULTS

Data relating to PUV, RT and AC showed low levels of evidence. Results of RT in PUV cases with adequate management of BD were comparable to those suffering from other causes of ESRD. Bladder function can recover spontaneously after urinary undiversion. There were no established criteria to indicate AC in the context of ESRD and PUV or to define the ideal protocol to treat associated vesicoureteral reflux (VUR). Urinary tract infections (UTIs) were more frequent in transplanted PUV patients; this is possibly related to the inadequate control of BD, especially after AC. AC is feasible after RT with outcomes comparable to preemptive ones.

CONCLUSION

AC increases the risk of UTI after RT. Preemptive AC should be constructed only if the risks associated with increased bladder pressures exceed those associated with AC. Adequate management of BD is essential to improve bladder function and to minimize UTIs. AC is feasible after RT, with complication rates similar to the ones performed beforehand. Since a considerable number of PUV patients with high-pressure bladders eventually develop myogenic failure, it seems logical to postponing AC in this population, as long as they are under close surveillance.

Characteristics and survival of patients with end stage renal disease and spina bifida in the United States renal data system

PURPOSE

We describe the characteristics, treatments and survival of patients with spina bifida in whom end stage renal disease developed from 2004 through 2008 in the United States Renal Data System.

MATERIALS AND METHODS

We used ICD-9-CM code 741.* to identify individuals with spina bifida using hospital inpatient data from 1977 to 2010, and physician and facility claims from 2004 to 2008. We constructed a 5:1 comparison group of patients with end stage renal disease without spina bifida matched by age at first end stage renal disease service, gender and race/ethnicity. We assessed the risk of mortality and of renal transplantation while on dialysis using multivariate cause specific proportional hazards survival analysis. We also compared survival after the first renal transplant from the first end stage renal disease service to August 2011.

RESULTS

We identified 439 patients with end stage renal disease and spina bifida in whom end stage renal disease developed at an average younger age than in patients without spina bifida (41 vs 62 years, p <0.001) and in whom urological issues were the most common primary cause of end stage renal disease. Compared to patients with end stage renal disease without spina bifida those who had spina bifida showed a similar mortality hazard on dialysis and after transplantation. However, patients with end stage renal disease without spina bifida were more likely to undergo renal transplantation than patients with spina bifida (HR 1.51, 95% CI 1.13-2.03). Hospitalizations related to urinary tract infections were positively associated with the risk of death on dialysis in patients with end stage renal disease and spina bifida (HR 1.42, 95% CI 1.33-1.53).

CONCLUSIONS

Spina bifida was not associated with increased mortality in patients with end stage renal disease on dialysis or after renal transplantation. Proper urological and bladder management is imperative in patients with spina bifida, particularly in adults.

Long-term outcome of simultaneous or staged urinary diversion and kidney transplantation

OBJECTIVES

We retrospectively analyzed the long-term outcomes of simultaneous or staged urinary diversion and kidney transplantation.

PATIENTS AND METHODS

Between June 2001 and December 2012, 4 patients with dysfunctional bladder resulting from spina bifida (n = 3) or bladder contraction following urologic tuberculosis (n = 1) underwent cadaveric kidney transplantation and urinary diversion simultaneously (n = 3) or 6 months post-transplantation (n = 1). Urinary diversion consisted of cutaneous ureterostomy in 1 patient and ileal conduits in 3 patients. All patients were followed prospectively.

RESULTS

All 4 patients received deceased donor transplants. Median follow-up was 110.5 months (range 50-120). At the last follow-up, serum creatinine levels ranged from 1.1 to 1.8 mg/dl. One patient with a functioning graft died of severe cirrhosis 105 months following transplantation. Graft function remained stable without any severe complications in 3 patients. Hematoma (Clavien-Dindo grade IIIa) and urinary leakage (grade II) occurred in 1 patient in the early postoperative period, but no surgical revision was required. Two patients developed cytomegalovirus pneumonia. Urinary tract infection was a common problem in all patients.

CONCLUSIONS

For patients with lower urinary tract dysfunction, simultaneous kidney transplantation and urinary diversion with an ileal conduit may be a safe, feasible approach, with a satisfactory long-term outcome.

What has changed in pediatric kidney transplantation in Turkey? Experience of an evolving center

INTRODUCTION

Reluctance to perform kidney transplantations on children is an ongoing problem in Turkey. Moreover, urological pathologies still constitute the largest portion of the underlying etiologies in chronic renal failure patients. Herein, we retrospective analyzed the data acquired from our pediatric renal transplantation patients and reviewed the registry of dialysis and transplantation data prepared by the Turkish Society of Nephrology.

MATERIAL AND METHODS

Forty-six living donor kidney transplantations were performed in children between 2008 and 2012. Seventeen of 46 (37%) transplantations were preemptive. The mean age at operation time was 10.8 ± 5 years. The mean patient weight was 31.3 ± 15.8 kg (range, 9.4 to 66.4 kg). A detailed urologic evaluation was performed for every child with an underlying lower urinary tract disease. One enterocystoplasty and 2 ureterocystoplasties were performed for augmentation of the bladder, simultaneously.

RESULTS

One-year death-censored graft survival and patient survival rates were 100% and 97.8%, respectively. The mean serum creatinine level was 0.86 ± 0.32 mg/dL (range, 0.3 to 1.8 mg/dL). None of the patients had vascular complications or acute tubular necrosis. One patient suffered graft-versus-host disease during the second month after renal transplantation and died with a functioning graft. In one patient with massive proteinuria detected after transplantation, recurrence of primary disease (focal segmental glomerulosclerosis) was considered and the patient was treated successfully with plasmapheresis. One child had an acute cellular rejection and was administered pulse steroid treatment.

CONCLUSION

Although challenging, all patients in all pediatric age groups can successfully be operated and managed. With careful surgical technique, close postoperative follow-up, and efforts by the experienced and respectful surgical teams in this country, we could change the negative trends toward perform kidney transplantation in the Turkish pediatric population.

Long-term outcome of kidney transplantation in patients with a urinary conduit: a case-control study

PURPOSE

To study the short- and long-term outcomes of kidney transplantation in patients with a bladder augmentation or urinary diversion compared to patients with a kidney transplantation in a normal functional bladder.

PATIENTS AND METHODS

Between January 2000 and March 2011, 13 patients received 16 grafts into a reconstructed urinary tract. We performed a retrospective case-control study and matched each patient to 4 controls for donor and recipient gender and year of transplantation.

RESULTS

Short- and long-term complications of kidney transplantation occurred in 12 patients, varying from urinary tract infections to medical hospitalization with or without surgical or radiological intervention. In 5 patients, a percutaneous nephrostomy (PCN) was placed followed by surgical re-intervention. In three patients, the grafts failed as a result of chronic rejection and were re-transplanted. There was no graft loss as a result of surgical complications or the reconstructed urinary tract. One-year patient and graft survival was 100 %. After five years, all patients were alive and seven of nine grafts (77.8 %) were functioning. Mean follow-up time was 4.3 years. Among the controls, 55 grafts were transplanted in 52 patients. Ten patients received a PCN. Five patients needed surgical re-intervention. In three patients, transplantectomy was performed for ongoing rejection. Three patients were re-transplanted. One patient had a failing graft 7.5 years post-transplantation and became dialysis dependent.

CONCLUSION

Kidney transplantation in patients with a reconstructed urinary tract has an increased complication rate. Nevertheless, the long-term results are comparable to patients with a normal urinary bladder.

Non-viral infections in children after renal transplantation

Renal transplantation has long been recognised as the gold standard treatment for children with end-stage renal failure. There has been an improvement over the years in patient and renal allograft survival because of improved immunosuppression, surgical techniques and living kidney donation. Despite reduced acute allograft rejection rates, non-viral infections continue to be a serious complication for paediatric renal transplant recipients (RTR). The risk of infections in RTR is determined by the pre-transplantation immunisation status, post-transplant exposure to potential pathogens and the amount of immunosuppression. The greatest risk of life-threatening and Cytomegalovirus infections is during the first 6 months post-transplant owing to a high immunosuppressive burden. The potential sources of bacterial infections are donor derived, transplant medium fluid, peritoneal and haemodialysis catheter and transplant ureteric stent. Urinary tract infections are frequent in patients with lower urinary tract dysfunction and can result in renal allograft damage. This review outlines the incidence, timing, risk factors, prevention and treatment of non-viral infections in paediatric RTR by critically reviewing current immunosuppressive regimens, their risk-benefit ratio in order to optimise renal allograft survival with reduced rates of rejection and infectious complications.

[Outcomes of pediatric renal transplantation in France]

Significant progress has been observed in pediatric renal transplantation over the last 20 years, leading to an increase in graft and patient survival. Mortality is low and is mainly due to infections, neoplasias and complications related to the initial disease. Graft survival is 67% at 10 years. Factors which influence graft survival are: donor type (results are better with a live donor), donor age, recipient age (with 2 periods at risk:<2 years old and teenagers), HLA incompatibilities, and recurrence of the initial disease. Chronic allograft nephropathy (CAN) is the major cause of late graft loss. Poor compliance, especially in teenagers, may lead to late rejections and graft loss. Calcineurin inhibitors nephrotoxicity is in part responsible for the development of CAN, thus treatments and the role of mTOR inhibitors will probably evolve. These different factors are discussed in this article.

Outcome of renal transplant in patients with abnormal urinary tract

PURPOSE

To determine whether surgical procedures of the lower urinary tract in patients with uropathies affect evolution of the graft in renal transplantation.

METHODS

156 kidney transplantations were performed in 150 patients with end-stage renal failure due to urologic disorders. The patients were classified into three groups: A, patients who did not require surgery in the lower urinary tract; B, required surgery and preserved adequate bladder function, and C, required surgery due to vesical dysfunction.

RESULTS

Graft survival rates at 1 year were 93.38% in group A, 95.45% in group B and 93% in group C. Rates at 5 years post-transplantation were 82.45, 79.85 and 86.58% for each group, respectively (not significant). Complications were vesicoureteral stenosis: 2 in group A, 3 in B and 1 in C; vesicoureteral reflux: 1 in group A, 1 in B and 10 in C; distal ureteral necrosis: 2 cases in group A, 2 in B and 1 in C; upper urinary tract infection: 12, 23.1 and 42.2% in each group, respectively.

CONCLUSION

Children with reconstructed urinary tract may be good candidates for kidney transplantation despite the higher frequency of urinary infections. Thus, careful and strict post-surgical urologic follow-up is mandatory.

Pediatric kidney recipients with small capacity, defunctionalized urinary bladders receiving adult-sized kidney without prior bladder augmentation

BACKGROUND

Children with small capacity, defunctionalized urinary bladders present unique operative challenges. Thus, traditional practice has included pretransplant bladder augmentation, but this has several adverse consequences.

METHODS

A single-institutional, retrospective review from January 1, 2004 to December 31, 2008 was conducted. Twelve pediatric patients, whom had not undergone pretransplant bladder augmentation, did not have neurogenic bladders or require preoperative catheterization, and a small capacity defunctionalized bladders were included. All were managed by the same surgeon with a previously described ureteral implantation, and a 7F ureteral stent attached to a large diameter suprapubic catheter was removed in a joint manner without cystoscopy at 2 weeks. Data were collected on patient and graft survival, rejection episodes, urinary tract infection (UTI) requiring antibiotics, grade of vesicoureteral reflux, and posttransplant bladder capacity.

RESULTS

One-year patient and graft survival rates were 100%. One patient experienced a clinical rejection episode, which was successfully treated. Five patients (41.7%) had a UTI requiring abx treatment within the first postoperative year, but at 1 year, all patients had sterile urinary tracts. After removal of suprapubic catheters and ureteral stents, all patients were able to void spontaneously. Seven patients had no posttransplant ureteral reflux, three had grade 1 reflux, and two had grade 3 reflux (both successfully treated). The average age estimated pretransplant bladder and 1 year posttransplant bladder capacity was 14.5% and 84% of expected, respectively.

CONCLUSIONS

In pediatric end-stage renal disease patients with a small capacity defunctionalized bladder, it is reasonable to proceed with kidney transplantation without pretransplant bladder augmentation, thus avoiding an unnecessary surgery.

Treatment strategies to minimize or prevent chronic allograft dysfunction in pediatric renal transplant recipients: an overview

Long-term allograft survival poses a major problem in pediatric renal transplantation, with allograft nephropathy being the principal cause of graft failure after the first post-transplant year. The mechanisms of nephron loss resulting in graft dysfunction are multiple, comprising both immunologic factors such as acute and chronic antibody- or T-cell-mediated rejection and non-immunologic components. The latter include peri-transplant injuries and renovascular lesions (renal artery stenosis, thrombosis) as well as cardiovascular risk factors such as arterial hypertension and hyperlipidemia. Another relevant issue leading to progressive nephron loss and declining kidney transplant function is acute and chronic nephrotoxicity induced by the calcineurin inhibitors (CNIs) ciclosporin (cyclosporine microemulsion) and tacrolimus. Furthermore, the presence of an abnormal lower urinary tract as well as bacterial (recurrent pyelonephritis) and viral (cytomegalovirus [CMV], polyomavirus [BK virus; BKV]) infections are crucial factors involved in the incidence of chronic allograft dysfunction and graft failure. Renovascular lesions and lower urinary tract obstruction are typical indicators for surgical intervention. The aim of treatment in pediatric patients with renal failure secondary to a dysfunctional lower urinary tract is to create a sterile, continent, and nonrefluxive reservoir. Surgical techniques such as bladder augmentation and the introduction of intermittent catheterization and anticholinergic therapy have significantly improved graft outcome. Arterial hypertension, another factor responsible for graft function deterioration in pediatric renal transplant recipients, is controlled preferably by the use of angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists, which are known to possess nephroprotective properties in addition to their potent antihypertensive effects. Although treatment of subclinical rejection with augmented immunosuppression has been associated with better graft survival, an increase of the immunosuppressive level to avoid subclinical rejection should be weighed against the risk of infection. The majority of viral infections affecting kidney allografts are caused by CMV and BKV. Antiviral CMV prophylaxis or pre-emptive therapy with ganciclovir has been shown to have beneficial effects in the pediatric renal transplant population. Treatment of BKV-induced nephropathy is based on reduction of the immunosuppressant therapy, although specific antiviral agents such as cidofovir and leflunomide are known to inhibit BKV. However, cidofovir itself is nephrotoxic and should therefore be administered cautiously to pediatric renal transplant patients. Since CNIs are likewise known for their nephrotoxic effects, especially with long-term use, alteration of the immunosuppressant regimen is necessary in case of deteriorating graft function due to CNI-induced histopathologic changes. Complete CNI avoidance seems inappropriate because, in this situation in pediatric renal transplant recipients, other relatively potent immunosuppressant agents such as lymphocyte-depleting antibodies, which are frequently accompanied by a higher incidence of infections, are needed for rejection prophylaxis. CNI withdrawal and switching of the immunosuppressant regimen from CNI therapy to sirolimus may be an option for some pediatric renal transplant patients with less advanced graft function deterioration. Nevertheless, potential adverse events such as aggravation of proteinuria, hyperlipidemia, myelosuppression, and hypergonadotropic hypogonadism have to be considered, and controlled studies are lacking. At present, an immunosuppressant maintenance therapy composed of low-dose tacrolimus or ciclosporin (CNI minimization) and mycophenolate mofetil with low-dose corticosteroids appears to be the most promising strategy to adopt in pediatric renal transplant recipients at low or normal immunologic risk.

Lower urinary tract symptoms in children and adolescents with chronic renal failure

PURPOSE

Lower urinary tract symptoms are common in children after renal transplantation. However, it is unclear whether lower urinary tract symptoms are present before transplantation or appear postoperatively. We sought to evaluate bladder function in children before renal transplantation.

MATERIALS AND METHODS

A total of 40 children 5 to 18 years old with a glomerular filtration rate of less than 50 ml per minute per 1.73 m(2) were consecutively enrolled in the study from 2006 to 2008. Bladder function was assessed by a comprehensive history, bladder diary, uroflowmetry and bladder ultrasound.

RESULTS

Of the patients 20% suffered from incontinence, 47.5% had bladder capacity larger than expected for age, 20% had discontinuous flow and 15% had residual urine 20 ml or greater. Signs consistent with bladder dysfunction (incontinence, abnormal bladder capacity, discontinuous urinary flow and/or residual urine) were observed in 13 of 13 children (100%) with urological disorders and 16 of 27 (59%) with nonurological disorders. Polyuria was present in 39% of the patients. Prior febrile urinary tract infection was significantly more common in children with vs without signs of bladder dysfunction.

CONCLUSIONS

Lower urinary tract symptoms are common in children with chronic renal failure. Screening for bladder dysfunction is important not only in children with urological disorders, but also in those with nonurological disorders, so that dysfunction can be corrected before transplantation.

Strategies to treat children with end-stage renal dysfunction and severe lower urinary tract anomalies for receiving a kidney transplant

Dealing with children with bladder dysfunction and kidney transplant is certainly not a new issue. Nevertheless, it is still a matter of discussion and dilemma, based on few, not standardized, institutional center experiences. The authors perform a review of the techniques employed to restore the bladder condition in terms of storage and drainage of urine to receive a kidney transplant in a safer condition. Aspects of the etiology and the way of evaluation of such a group of patients are discussed. The strategies and individualized therapeutic options are presented and compared with the author's experience based upon 25 children with urinary anomalies who received 28 kidney transplants. Nevertheless, the number of complications, mainly UTI, graft and patient survival rates are equivalent to the group of children with non-urological causes of ESRD. Patients with severe lower urinary tract abnormalities and ESRD may receive a kidney transplant with comparable success.

Long-term outcome after renal transplantation in childhood

The purpose of this article is to review: 1. Factors influencing long-term outcome data after transplantation 2. Patient survival overall, the effect of recipient age and donor type, causes of death, comparison of mortality after transplantation with that on dialysis, and effect of pre-emptive transplantation and race 3. Transplant survival overall, and the effect of recipient and donor age, donor type, pre-emptive transplantation, recurrent diseases, human leukocyte antigen (HLA) matching, immunosuppression, concordance, hypertension, bladder dynamics and type of donor nephrectomy 4. Final height and obesity 5. Psycho-social outcome.

Urinary tract infections in children after renal transplantation

Urinary tract infections (UTI) after pediatric kidney transplantation (KTX) are an important clinical problem and occur in 15-33% of patients. Febrile UTI, whether occurring in the transplanted kidney or the native kidney, should be differentiated from afebrile UTI. The latter may cause significant morbidity and is usually associated with acute graft dysfunction. Risk factors for (febrile) UTI include anatomical, functional, and demographic factors as well as baseline immunosuppression and foreign material, such as catheters and stents. Meticulous surveillance, diagnosis, and treatment of UTI is important to minimize acute morbidity and compromise of long-term graft function. In febrile UTI, parenteral antibiotics are usually indicated, although controlled data are not available. As most data concerning UTI have been accumulated retrospectively, future prospective studies have to be performed to clarify pathogenetic mechanisms and risk factors, improve prophylaxis and treatment, and ultimately optimize long-term renal graft survival.

Kidney transplantation in children with posterior urethral valves

There is controversy about the outcome of renal transplantation in patients with PUV. The objective of this study was to analyze the outcome of renal transplantation in children with PUV. Fifteen patients had a history of PUV as the etiology of their ESRD. Forty-five patients comprised a control group without lower urinary tract anomalies. Mean age and follow-up duration were not significantly different between the case and the control group (p = 0.1). The immunosuppressive protocol and the year of transplantation were similar in these two groups (p = 0.2, 0.4, respectively). Among patients with PUV, 37.5% had acute rejection; and 56.2% had chronic rejection. Among the controls, 22.2% had acute rejection and 28.8% had chronic rejection. None of these differences was significant. Mean survival time was seven yr in affected patients and 6.2 yr in the control group (p = 0.9). Among patients with PUV, the rate of graft survival in the first year after transplantation was 95%; and those in the third, fifth, and seventh yr, 91%, 65%, and 50%, respectively. For the controls, the graft survival was 83% at one yr; 80% at three yr; 71% at five yr; and 60% at seven yr after transplantation (p = 0.9). Conclusively, this study showed that a history of PUV had no effect on graft function. Graft survival was not different among these patients compared with patients free of these anomalies. We also showed that urological complications were few in these patients.

Renal transplantation in children with lower urinary tract dysfunction of different origin: a single-center experience

INTRODUCTION

Renal transplantation in patients with lower urinary tract dysfunction (LUTD) of various origins is a challenging issue in the field of pediatric transplantation. We report our single-center experience to evaluate patient and graft survivals as well as the risks of the surgery and immunosuppressive therapy.

PATIENTS AND METHODS

Among 70 pediatric transplant patients, 11 displayed severe LUTD. Videourodynamic tests were performed on all patients preoperatively as well as postoperatively if required. The cause of urologic disorders were neurogenic bladder (n = 5) and urethral valves (n = 6). Clean intermittent catheterization (CIC) was needed in six patients to empty the bladder. To achieve a low-pressure reservoir with adequate capacity pretransplantation augmentation ileocystoplasty was created in four patients and gastrocystoplasty in one patient. Three of the patients received kidneys from cadaveric and eight from living donors. All patients were treated with calcineurin-based immunosuppressive therapy.

RESULTS

The mean age at transplantation was 15 +/- 4.7 years. The median follow-up after transplantation was 36 months (6 to 62 months). At their last visit the median creatinine level was 0.95 mg/dL (0.8 to 2.4 mg/dL). Three patients had recurrent symptomatic urinary tract infections who had augmented bladder on CIC. One patient with ileocystoplasty who developed urinary leak and ureteral stricture in the early postoperative period was treated by an antegrade J stent.

CONCLUSION

Severe LUTD carried high risks for the grafted kidney. However, our data suggested that renal transplantation is a safe and effective treatment modality, if the underlying urologic diseases properly managed during the transplantation course. Since surgery and follow-up is more complicated, patient compliance and experience of transplantation team have significant impacts on outcomes.

Comparison of renal transplantation outcomes in children with and without bladder dysfunction. A customized approach equals the difference

PURPOSE

We examined the development of urological abnormalities in a group of pediatric renal transplant recipients.

MATERIALS AND METHODS

We reviewed 211 patients younger than 19 years who underwent 226 renal transplants. Three groups of patients were studied-136 children with end stage renal disease due to a nonurological cause (group 1), 56 children with a urological disorder but with an adequate bladder (group 2a) and 19 children with lower urinary tract dysfunction and/or inadequate bladder drainage (group 2b). A total of 15 children in group 2b underwent bladder augmentation (ureterocystoplasty in 6, enterocystoplasty in 9), 2 underwent continent urinary diversion, 1 underwent autoaugmentation and 1 underwent a Mitrofanoff procedure at the bladder for easier drainage. Kidney transplantation was performed in the classic manner by extraperitoneal access, and whenever possible the ureter was reimplanted using an antireflux procedure.

RESULTS

At a mean followup of 75 months 13 children had died, 59 grafts were lost and 15 children had received a second transplant. Two patients in group 2a required a complementary urological procedure to preserve renal function (1 enterocystoplasty, 1 vesicostomy). A total of 12 major surgical complications occurred in 226 kidney transplants (5.3%), with a similar incidence in all groups. The overall graft survival at 5 years was 75%, 74% and 84%, respectively, in groups 1, 2a and 2b.

CONCLUSIONS

With individualized treatment children with severely inferior lower urinary tract function may undergo renal transplantation with a safe and adequate outcome.

Increased urologic complications in children after kidney transplants for obstructive and reflux uropathy

In the cyclosporine era, reports on pediatric kidney transplant (KTx) patients with obstructive and reflux uropathy are limited by small numbers, short follow-up, and/or lack of control groups. Our single-center study evaluated long-term outcomes (patient and graft survival, urinary tract infections [UTIs], urologic complications) in a large cohort of KTx recipients (<20 years old). We matched our 117 study patients with obstructive and reflux uropathy with 117 controls whose KTx was needed for other reasons; all 234 underwent their KTx between April 25, 1984, and October 23, 2002. The mean age was 8.0 +/- 6.2 years; mean follow-up, 133 +/- 67 months. The urologic complication rate was higher in study patients (43%) than in controls (11%) (p < 0.0001), as was the UTI rate (45% vs. 2%; p < 0.0001). The metabolic acidosis and UTI rates were higher in study patients who did (vs. did not) undergo bladder augmentation (p < 0.0001). We found no significant difference between study patients and controls in patient or graft survival, acute or chronic rejection, or mean estimated glomerular filtration rates. Unique to our study is the finding of higher metabolic acidosis and UTI rates in study patients who underwent bladder augmentation.

Kidney transplantation in abnormal bladder

Structural urologic abnormalities resulting in dysfunctional lower urinary tract leading to end stage renal disease may constitute 15% patients in the adult population and up to 20-30% in the pediatric population. A patient with an abnormal bladder, who is approaching end stage renal disease, needs careful evaluation of the lower urinary tract to plan the most satisfactory technical approach to the transplant procedure. Past experience of different authors can give an insight into the management and outcome of these patients. This review revisits the current literature available on transplantation in abnormal bladder and summarizes the clinical approach towards handling this group of difficult transplant patients. We add on our experience as we discuss the various issues. The outcome of renal transplant in abnormal bladder is not adversely affected when done in a reconstructed bladder. Correct preoperative evaluation, certain technical modification during transplant and postoperative care is mandatory to avoid complications. Knowledge of the abnormal bladder should allow successful transplantation with good outcome.

Simultaneous pediatric kidney transplantation and ureterocystoplasty in a 20-month-old boy

Kidney transplantation (KT) in children with end-stage renal disease and an abnormal bladder poses a complex management challenge. Ureterocystoplasty (UC) has been previously reported in older children with non-compliant bladders, but the timing and technique of repair are controversial. This case reports the youngest patient, a 20-month-old boy to undergo successful single-stage UC and living-related KT. UC was performed because of a fibrotic, non-compliant bladder. A temporary vesicostomy was placed to provide adequate drainage in the presence of urethral stenosis. The patient developed a single episode of pyelonephritis within the first six months post-operatively, but there were no other urologic complications. At 13 months, the renal function is excellent with a mean glomerular filtration rate of 100 mL/min/1.73 m(2) and no clinical evidence of rejection. This case demonstrates that simultaneous UC and KT can be safely performed even in infants with non-compliant bladders and renal failure.

Deceased-donor kidney transplantation in prune belly syndrome

OBJECTIVES

To present the long-term outcome of deceased-donor kidney transplantation in prune belly syndrome (PBS). All the PBS transplant patients had undergone extensive pretransplant urologic tract preparation. We also compared the patient and graft survival in an age-matched control group who underwent transplantation for end-stage renal disease due to a nonposterior urethral valve in our urology department.

METHODS

From 1988 to 2003, 11 kidneys were transplanted in 8 male patients with PBS. The mean age was 13.5 years (range 4 to 32). Patient and graft survival were assessed and compared with that of a group of 103 deceased-donor kidney transplantations performed in 86 age-matched controls who underwent transplantation because of end-stage renal disease due a nonposterior urethral valve (mean age 13.9 years, range 1.7 to 20).

RESULTS

In the PBS group, a total of 23 pretransplant urologic procedures were performed. One operation was performed in 1 patient, two in 2, three in 2, and four in 3 patients. In the PBS group, after transplantation, adequate bladder function was maintained by intermittent catheterization in 4 patients and timed voiding in 3; 1 patient had undergone pretransplant ileal conduit formation. Up to 10 years after transplantation, we found no difference in patient and graft survival between the two groups (P = 0.466 and P = 0.838, respectively).

CONCLUSIONS

Aggressive pretransplant urologic tract preparation and keeping the postvoid residual urine volume to a minimum are needed in patients with PBS. With such management, the outcome of kidney transplantation in our patients with PBS was not different from that of other patients who underwent transplantation for other causes of end-stage renal disease in our department.

Kidney transplants in patients with bladder augmentation: correlation and evolution

OBJECTIVE

To review the literature, analyse the evolution of kidney transplants (KT) in patients with bladder augmentation (BA) and investigate the relation between BA and KT.

MATERIALS AND METHODS

Six patients with a history of severe lower urinary tract dysfunction and BA, received a KT at our Unit between 1993 and 2003. Three had moderate renal failure at the moment of the BA. The remaining three had end stage renal failure.

RESULTS

With a follow-up of 7 years (mean) we have a patient survival of 100% and a graft survival of 83%. No complications occurred between the BA and the KT. The few KT complications were not related to BA.

CONCLUSION

When a bladder dysfunction is present, it should be treated before KT. In noncompliant bladders, BA is the best treatment. This can be done to try to avoid end stage renal failure or only to prepare the lower urinary tract for reception of the transplant. The presence of a BA did not worsen the evolution of the KT.

Dilemmas in Pediatric Renal Transplantation

Solid organ transplantation, which began in adults in the 1950s, was extended to the pediatric population in the mid 1960s. Advances in immunosuppression and in surgical and medical skills have led to improving results in all types of organ transplantation. This success has now created many dilemmas especially in pediatric transplantation. In a field where the demands are high and resources limited, the distribution and allocation of resources becomes difficult. Complex decisions must be made with respect to who should be transplanted, when the transplant should occur, and where it should be performed. Of particular concern is the use of powerful immunosuppressive agents that may affect renal function and equally compromise patient's health with the potential for infection and malignancy. The various side effects of immunosuppressive agents may also cause difficulties in management. Decisions whether to retransplant habitual noncompliers are difficult. Diseases such as focal sclerosis and oxalosis, which recur in transplants, may affect decisions in selecting suitable recipients. The skills, experience, and resources of various multidisciplinary teams who manage these patients are often stretched to the utmost in their endeavors to achieve successful outcomes.

Dysfunction of lower urinary tract in renal transplant children with nephrologic disease

OBJECTIVES

To investigate the relationship between dysfunction of the lower urinary tract after renal transplantation and renal transplant function in children with an underlying nephrologic disease.

METHODS

The research group consisted of 21 renal transplant children (12 girls and 9 boys, mean age 13.5 years, range 6 to 18) with an underlying nephrologic disease. To indicate renal transplant function, the calculated creatinine clearance rate (Ccr) according to Schwartz was used. The Ccr was measured at two points, 2 months after transplantation and at the moment of study. The average graft age was 34 months (range 5 to 85). The data on dysfunction of the lower urinary tract were gathered using a written questionnaire, frequency volume chart, free uroflowmetry, transabdominal ultrasonography, and medical records. To determine the relationship between the symptoms of dysfunction of the lower urinary tract and Ccr at the moment of study, we computed bivariate correlations and performed multivariate regression analyses in which the associations were studied while controlling for the Ccr 2 months after transplantation and graft age.

RESULTS

A sensation of incomplete emptying (P = 0.03), postvoid residual urine volume (P = 0.06), and urinary tract infection (P = 0.004) correlated negatively with the Ccr at the moment of study. These effects remained present (P = 0.07, P = 0.03, and P = 0.003, respectively) while controlling for graft age and the Ccr at 2 months after transplantation in the regression analysis.

CONCLUSIONS

The results of our study have shown that a postvoid residual urine volume and urinary tract infections after renal transplantation may result in renal transplant deterioration in children with an underlying nephrologic disease.

Bladder dysfunction in children and adolescents after renal transplantation

The underlying mechanisms of urinary-tract infections (UTI) in renal transplant recipients are still not fully understood. In otherwise healthy children, bladder dysfunction increases the susceptibility to UTI. The aim of this study was to evaluate lower-urinary-tract function in children and adolescents after renal transplantation. Sixty-eight recipients of renal transplants, 5-20 years of age and 1-15 years after transplantation, were evaluated for their bladder function with a questionnaire, uroflowmetry and bladder ultrasound, and for renal function (glomerular filtration rate) by measuring clearance of inulin or iohexol. Forty-nine patients (72%) had some type of abnormality of bladder function. Abnormal bladder capacity was found in 26%, abnormal urinary flow in 50% and residual urine in 32% of the patients. There was no significant difference in bladder or renal function in children with urinary-tract malformations compared with those with normal urinary tract. Furthermore, there was no significant difference in renal function in patients with bladder dysfunction compared with those without. The incidence of bladder dysfunction is high in children and adolescents after renal transplantation, but the clinical significance of this finding and whether there is a correlation between bladder dysfunction and UTI in these patients need to be clarified further.