Does Lower Urinary Tract Status Affect Renal Transplantation Outcomes in Children? F.T. Akia,*, A.M. Aydina, H.S. Dogana, M.I. Donmeza, I. Erkana, A. Duzovab, R. Topaloglub, and S. Tekgula a Department of Urology, School of Medicine, Hacettepe University, Ankara, Turkey; and bDivision of Pediatric Nephrology, Department of Pediatrics, Hacettepe University, School of Medicine, Ankara, Turkey
ABSTRACT Background. Lower urinary tract dysfunction (LUTD), an important cause of end stage renal disease (ESRD) in children, can adversely affect renal graft survival. We compared renal transplant patients with LUTD as primary renal disease to those without LUTD. Methods. The data of 60 children who underwent renal transplantation (RTx) between 2000 and 2012 were retrospectively reviewed. All patients with LUTD were evaluated with urodynamic tests preoperatively; 15 patients required clean intermittent catheterization and 9 patients underwent augmentation cystoplasty before RTx. Results. There were 25 children with LUTD. The mean follow-up for LUTD (þ) and LUTD () groups were 63 (22e155) and 101 months (14e124), and graft survival were 76% for LUTD (þ) and 80% for LUTD (), respectively (P ¼ .711). On the other hand, creatinine levels at last follow-up were significantly higher in the LUTD (þ) group (1.3 0.3 mg/dL vs 0.96 0.57 mg/dL, P < .001). Infectious complications and postoperative urinary tract infection incidences were also higher in the LUTD (þ) group (68% vs 25.7%, P ¼ .002 and 60% vs 11.4%, P < .01). Conclusion. UTI is significantly higher after kidney transplantation in patients with LUTD. Despite the higher risk of UTI, renal transplantation can be performed safely in those patients with careful patient selection, preoperative management, and close postoperative follow-up. Restoration of good bladder function is the key factor in the success of kidney transplantation in those patients.
E
ND STAGE RENAL DISEASE (ESRD) with its unique challenges is a major health problem worldwide. Although generally accepted as the disease of the elderly due to its high prevalence in older ages, the number of pediatric patients having ESRD is not negligible. In the U.S., the incidence rate of ESRD per 1 million population in children aged 0e19 years reached 15.9 in 2011; it was 10.2 in 1980 [1]. In Turkey, the prevalence of chronic kidney disease (CKD) stage 5 per 1 million population in children was found to be 300 in a recent population-based study [2]. In the pediatric age group urological disorders account for 20% to 30% of total ESRD cases. Among the urinary tract malformations, vesicoureteral reflux (VUR) and posterior urethral valve (PUV) are the leading causes of CKD in children [3,4]. Moreover, in the presence of lower urinary tract dysfunction (LUTD), progression of irritative symptoms, recurrent urinary tract infections, refluxes, etc. may be observed
in the postrenal transplantation period. Renal allograft dysfunction and graft loss would be developed secondary to severe LUTD [5]. However, many studies have reported good graft function rates in children with previous lower urinary tract dysfunction with proper management and meticulous followup [6,7]. In this study, we compared renal transplant patients with LUTD as primary renal disease to those without LUTD in terms of graft survival and function, postoperative complications, and urinary tract infections (UTIs). MATERIALS AND METHODS The data of 60 children (36 males and 24 females) who underwent renal transplantation (RTx) between 2000 and 2012 were *Address correspondence to Fazıl Tuncay Aki, Department of Urology, School of Medicine, Hacettepe University, Sihhiye/ Ankara, Turkey 06100. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2014.10.069
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1114
Transplantation Proceedings, 47, 1114e1116 (2015)
LOWER UT STATUS AND RENAL TX IN CHILDREN retrospectively reviewed. Of those, 25 developed ESRD secondary to LUTD while the remaining 35 had no LUTD. Thirty-nine patients received grafts from living donors, and 21 from deceased donors. All patients with prior diagnosis of LUTD were evaluated with urodynamic testing during preoperative evaluation. Volume at first sensation, bladder capacity, mean and peak urinary flow rate, and post-voiding residue were recorded. After accomplishment of low pressure bladder with sufficient drainage either by medical or surgical treatments, patients were approved to undergo renal transplantation. Lich-Gregoir was the technique of choice for ureteral reimplantation in all patients. After RTx, all patients received a combination of immunosuppressive therapy including a corticosteroid, a calcineurin inhibitor (cyclosporine A or tacrolimus), an anti-proliferative agent (mycophenolate mofetil, mycophenolic acid, or azathiopurine,) and were evaluated by urinary system ultrasonography and Tc-99m-DTPA renography when needed. At the end of the follow-up, based on creatinine values and renal biopsies we categorized final states of each patient. UTI was defined as any urinary tract infection sign or symptom such as dysuria, suprapubic pain, and cloudy urine, etc., together any positive urine culture greater than 105 CFU/mL from a midstream voided or catheterized urine, regardless of fever. All infections such as wound infection, pneumonia, and UTI were defined as infectious complications. The same medical team in our university hospital provided management for all patients from preoperative diagnosis to postoperative last visit. Statistical analyses of data were obtained from IBM SPSS version 15.0 for Windows (IBM, Chicago, Ill., United States). We used the c2 test for analysis of proportions, the Mann-Whitney U test for evaluation of median, the Kolmogorov-Smirnov test to test for normality, the log-rank test for survival analysis, and the Student t test when necessary. A P value less than .05 was considered statistically significant.
RESULTS
In our study, there were 19 males and 6 females in the LUTD group, whereas there were 17 males and 18 females in the nonLUTD group. Mean age at transplantation was significantly higher in the LUTD group (13.7 2.9 in the LUTD group and 10.5 3.1 in the non-LUTD group, P ¼ .001). The etiologies of ESRD in the LUTD group were neurogenic bladder in 14 cases and posterior urethral valve in 11. Most PUV patients have small capacity and poor compliant bladders. However there wasn’t any statistically significant difference in renal graft survival between PUV and LUTD () patients. The etiologies in the non-LUTD group were as follows: focal segmental glomerulosclerosis in 12 cases, nephronophthisis in 6, cystinosis in 4, diffuse crescentic glomerulonephritis in 3, nephrolithiasis in 3, polycystic kidney disease in 3, rapidly progressive glomerulonephritis in 2, amyloidosis in 1, and oligomeganephronia in 1. In the non-LUTD group 74% of patients were treated either by hemodialysis or peritoneal dialysis before RTX, compared to 48% in the LUTD (þ) group. Duration of dialysis before RTx also showed extensive variability between each patient. The outcomes and demographics of patients with and without LUTD are summarized in Table 1. In the LUTD group, 15 patients required clean intermittent catheterization and 9 patients underwent augmentation cystoplasty prior to RTx. Ileum was the preferred
1115 Table 1. Outcomes and Demographics of Patients With and Without LUTD LUTD (þ)
Age at RTx (y) 13.7 2.9 Gender (male/female) 19/6 Living/deceased donor 14/11 5eyear graft survival (%) 73 Mean creatinine value 1.3 0.3 Last follow-up graft survival (%) 76 Infectious complications (%) 68 Postoperative UTI incidence (%) 60
LUTD ()
P Value
10.5 3.1 17/18 25/10 75 0.96 0.57 80 25.7 11.4
ABSTRACT Background. Lower urinary tract dysfunction (LUTD), an important cause of end stage renal disease (ESRD) in children, can adversely affect renal graft survival. We compared renal transplant patients with LUTD as primary renal disease to those without LUTD. Methods. The data of 60 children who underwent renal transplantation (RTx) between 2000 and 2012 were retrospectively reviewed. All patients with LUTD were evaluated with urodynamic tests preoperatively; 15 patients required clean intermittent catheterization and 9 patients underwent augmentation cystoplasty before RTx. Results. There were 25 children with LUTD. The mean follow-up for LUTD (þ) and LUTD () groups were 63 (22e155) and 101 months (14e124), and graft survival were 76% for LUTD (þ) and 80% for LUTD (), respectively (P ¼ .711). On the other hand, creatinine levels at last follow-up were significantly higher in the LUTD (þ) group (1.3 0.3 mg/dL vs 0.96 0.57 mg/dL, P < .001). Infectious complications and postoperative urinary tract infection incidences were also higher in the LUTD (þ) group (68% vs 25.7%, P ¼ .002 and 60% vs 11.4%, P < .01). Conclusion. UTI is significantly higher after kidney transplantation in patients with LUTD. Despite the higher risk of UTI, renal transplantation can be performed safely in those patients with careful patient selection, preoperative management, and close postoperative follow-up. Restoration of good bladder function is the key factor in the success of kidney transplantation in those patients.
E
ND STAGE RENAL DISEASE (ESRD) with its unique challenges is a major health problem worldwide. Although generally accepted as the disease of the elderly due to its high prevalence in older ages, the number of pediatric patients having ESRD is not negligible. In the U.S., the incidence rate of ESRD per 1 million population in children aged 0e19 years reached 15.9 in 2011; it was 10.2 in 1980 [1]. In Turkey, the prevalence of chronic kidney disease (CKD) stage 5 per 1 million population in children was found to be 300 in a recent population-based study [2]. In the pediatric age group urological disorders account for 20% to 30% of total ESRD cases. Among the urinary tract malformations, vesicoureteral reflux (VUR) and posterior urethral valve (PUV) are the leading causes of CKD in children [3,4]. Moreover, in the presence of lower urinary tract dysfunction (LUTD), progression of irritative symptoms, recurrent urinary tract infections, refluxes, etc. may be observed
in the postrenal transplantation period. Renal allograft dysfunction and graft loss would be developed secondary to severe LUTD [5]. However, many studies have reported good graft function rates in children with previous lower urinary tract dysfunction with proper management and meticulous followup [6,7]. In this study, we compared renal transplant patients with LUTD as primary renal disease to those without LUTD in terms of graft survival and function, postoperative complications, and urinary tract infections (UTIs). MATERIALS AND METHODS The data of 60 children (36 males and 24 females) who underwent renal transplantation (RTx) between 2000 and 2012 were *Address correspondence to Fazıl Tuncay Aki, Department of Urology, School of Medicine, Hacettepe University, Sihhiye/ Ankara, Turkey 06100. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2014.10.069
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1114
Transplantation Proceedings, 47, 1114e1116 (2015)
LOWER UT STATUS AND RENAL TX IN CHILDREN retrospectively reviewed. Of those, 25 developed ESRD secondary to LUTD while the remaining 35 had no LUTD. Thirty-nine patients received grafts from living donors, and 21 from deceased donors. All patients with prior diagnosis of LUTD were evaluated with urodynamic testing during preoperative evaluation. Volume at first sensation, bladder capacity, mean and peak urinary flow rate, and post-voiding residue were recorded. After accomplishment of low pressure bladder with sufficient drainage either by medical or surgical treatments, patients were approved to undergo renal transplantation. Lich-Gregoir was the technique of choice for ureteral reimplantation in all patients. After RTx, all patients received a combination of immunosuppressive therapy including a corticosteroid, a calcineurin inhibitor (cyclosporine A or tacrolimus), an anti-proliferative agent (mycophenolate mofetil, mycophenolic acid, or azathiopurine,) and were evaluated by urinary system ultrasonography and Tc-99m-DTPA renography when needed. At the end of the follow-up, based on creatinine values and renal biopsies we categorized final states of each patient. UTI was defined as any urinary tract infection sign or symptom such as dysuria, suprapubic pain, and cloudy urine, etc., together any positive urine culture greater than 105 CFU/mL from a midstream voided or catheterized urine, regardless of fever. All infections such as wound infection, pneumonia, and UTI were defined as infectious complications. The same medical team in our university hospital provided management for all patients from preoperative diagnosis to postoperative last visit. Statistical analyses of data were obtained from IBM SPSS version 15.0 for Windows (IBM, Chicago, Ill., United States). We used the c2 test for analysis of proportions, the Mann-Whitney U test for evaluation of median, the Kolmogorov-Smirnov test to test for normality, the log-rank test for survival analysis, and the Student t test when necessary. A P value less than .05 was considered statistically significant.
RESULTS
In our study, there were 19 males and 6 females in the LUTD group, whereas there were 17 males and 18 females in the nonLUTD group. Mean age at transplantation was significantly higher in the LUTD group (13.7 2.9 in the LUTD group and 10.5 3.1 in the non-LUTD group, P ¼ .001). The etiologies of ESRD in the LUTD group were neurogenic bladder in 14 cases and posterior urethral valve in 11. Most PUV patients have small capacity and poor compliant bladders. However there wasn’t any statistically significant difference in renal graft survival between PUV and LUTD () patients. The etiologies in the non-LUTD group were as follows: focal segmental glomerulosclerosis in 12 cases, nephronophthisis in 6, cystinosis in 4, diffuse crescentic glomerulonephritis in 3, nephrolithiasis in 3, polycystic kidney disease in 3, rapidly progressive glomerulonephritis in 2, amyloidosis in 1, and oligomeganephronia in 1. In the non-LUTD group 74% of patients were treated either by hemodialysis or peritoneal dialysis before RTX, compared to 48% in the LUTD (þ) group. Duration of dialysis before RTx also showed extensive variability between each patient. The outcomes and demographics of patients with and without LUTD are summarized in Table 1. In the LUTD group, 15 patients required clean intermittent catheterization and 9 patients underwent augmentation cystoplasty prior to RTx. Ileum was the preferred
1115 Table 1. Outcomes and Demographics of Patients With and Without LUTD LUTD (þ)
Age at RTx (y) 13.7 2.9 Gender (male/female) 19/6 Living/deceased donor 14/11 5eyear graft survival (%) 73 Mean creatinine value 1.3 0.3 Last follow-up graft survival (%) 76 Infectious complications (%) 68 Postoperative UTI incidence (%) 60
LUTD ()
P Value
10.5 3.1 17/18 25/10 75 0.96 0.57 80 25.7 11.4
