Urological Complications Following Live Donor Kidney Transplantation: Effect of Urinary Schistosomiasis A.A. SHOKEIR, M. A. BAKR,T. A. EL-DIASTY, M. A. SOBH, F. E. MOUSTAFA,A. E. ELA G R O U D I and M. A. GHONEIM Urology a,id Nephrology Centre, Mansoura University, Mansoura, Egypt
Summar\/- Urological complications were studied in 310 live donor kidney transplants. All recipients and donors were investigated for urinary schistosomiasis by examining tissue obtained intra-operatively from the donor's ureter or the patient's bladder. Schistosomiasis was histologically documented in 76 cases (patient's bladder (46), donor's ureter (9), both (21)). The incidence of urological complications was 11/76 (1 5%)in the schistosomal group and 14/234 (6%) in the nonschistosomal group; this was statistically significant. Among the schistosomal patients, the site of infestation had no statistically significant effect on the incidence of urological complications. No deaths or graft losses were directly attributable either to these complications or to their surgical correction.
The frequency, aetiology and management of urological complications following renal transplantation have been reported by Malek et al. (1973) anti Mut~dyr t al. (1981). Schistosomiasis affects approxiniately 200 million people in Africa, the Middlc f.ast, South-East Asia and South America (Wecdcn et d., 1982).It can lead to the development of' irreversible pathological changes in the urinary tract (Ghoneim, 1984). Information on the effect of urinary schistosomiasison the frequency and nature of urological complications following renal transplantation is limited. We present our experience with urological complications that developed among 3 1 0 consecutive live donor renal transplants. Special emphasis is placed on the potential impact of urinat y schistosomiasis on the incidence, type and methods ofmanagement ofsuchcomplications.
Patients and Methods Between March 1976 and March 1991, 480 renal tr,in\pldiitations were carried out in this Centre. Of thew, the last consecutive 310 cases were studied 4 ~ ~ e p r lor e d publication 20 September 1991
for evidence of urinary schistosomiasis by examination of tissue obtained intra-operatively from the donor's ureter and the recipient's bladder. Paraffin blocks were prepared and sections were stained by haematoxylin and eosin for examination by light microscopy. A diagnosis of schistosomiasis was established when Schistosoma eggs were seen in either specimen. The patients were followed up for a mean period of 33 months (range 6-168). In addition to clinical examination and routine assessment of the graft function, isotope renography and ultrasonography were of particular help in the diagnosis of urological complications. The latter provided evidence of perirenal collection or obstruction of the pelvicaliceal system. It was also indispensable for diagnostic aspiration of a suspected collection to determine its chemical nature by quantitative estimation of creatinine content. Intravenous urography (IVU) was considered if renal function was not markedly impaired. More invasive procedures such as ascending cystography, retrograde ureterography, graft percutaneous nephrostomy (PCN) and antegrade study were used as necessary. Statistical analyses were performed with an
247
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BRITISH JOURNAL OF UROLOGY
urinary tract continuity had no impact on the incidence of urological complications (Table 3). The various approaches used for the correction of these complications are summarised in Table 4. Two patients developed a urinary leak from the cystostomy incision. One was treated successfully by an indwelling urethral catheter for 1 week while the other required an open repair. Ureteric fistulae developed in 6 patients. In all but 1 case a graft PCN was initially inserted for adequate drainage and prevention of wound sepsis. In 1 patient drainage was sufficient for prompt healing without stricture formation (Fig. 1). In the remainder, surgical intervention was necessary, the nature of which was based on the length and viability of the ureter as judged during exploration. A ureterovesical reimplantation was feasible in 2 patients, a Boari flap was necessary in 2 (Fig. 2) and a ureteroureteric anastomosis was employed in 1. In the latter case, however, the repair was complicated by urinary leakage and fistula formation and an ileal replacement of the ureter was carried out. Intrinsic ureteric obstruction was seen in 4 patients. The obstruction was due to axial rotation of the ureter in 1 patient (Fig. 3); this was successfully corrected and reimplanted into the bladder. Three patients developed distal ureteric strictures, of whom 2 were treated by ureteroureteric anastomosis and the third by a Boari flap. These latter 3 patients developed recurrent obstruction
independent t test, chi-squared and Fisher’s exact tests.
Results Patients were stratified into 2 groups according to the histopathological findings : schistosomal group (76 patients; 25%) and non-schistosomal group (234 patients ; 75%). Schistosoma eggs were detected in the bladders of 46 recipients, in the ureters of 9 donors and in both in 21 cases. All patients had received live related donor kidneys and the majority had one-haplotype HLA match. Table 1 summarises the demographic characteristics of donors and recipients of the 2 groups. Both were comparable regarding age and sex of donors and recipients, duration of pre-transplant dialysis and prior blood transfusions. The immunosuppressive regimens and the techniques employed for the re-establishment of urinary continuity were also essentially similar. The urological complications are listed in Table 2: 25 were recorded, an incidence of 8%. Eleven complications (15%) were seen among the schistosomal group and 14 (6%) among the nonschistosomal group ;this was statistically significant ( P < 0.05). It was observed that the site of schistosoma1 infestation did not affect either the incidence or the type of urological complications. Furthermore, the surgical techniques used to re-establish
Table 1 Characteristics of Donors and Recipients of Schistosomal and non-Schistosomal Renal Transplants (n = 310) Factors analysed
Donor’s age (years) Donor’s sex (male to female ratio) Recipient’s age (years) Recipient’s sex (male to female ratio) Duration of pre-transplant dialysis (months) Prior transfusions (units)
Schistosmal group ( n = 76)
Non-schistosomal group ( n = 234)
42+5
41 + 6
40136 29+8
1201114 30k7
57/19
170164
35+8 3.2 f2
33k6 3.1 +2.5
Immunosuppression Azathioprine corticosteroids Cyclosporin corticosteroids Triple immunosuppression
No. 45 23 8
%
No. 133 72 29
%
59 31 10
Primary urinary tract procedures Leadbetter-Politano Lich-Gregoir Ureteroureteric
28 44 4
37 58 5
51 160 17
24 69 7
+ +
57 31 12
249
'WFECTOF URINARY SCHISTOSOMIASIS FOLLOWING LIVE DONOR KIDNEY TRANSPLANTS
Table 2 Urological Complications
-~ Schistosomal group (n = 76) No. ofpatients
Complications
Bladder leak Ureteric fistula Intrinsic ureteric obstruction Stone in the graft Bladder stone Urethral stricture Lymphocele
Non-schistosomal group ( n = 234) No. of patients
1
1
4
2 2 1
2 -
2 6 4 1 1 2 9
-
I 1 2
Total
Total
1 I
*11 (15%)
*14 (6%)
25 (8%)
*(x2=4.5, P
Summar\/- Urological complications were studied in 310 live donor kidney transplants. All recipients and donors were investigated for urinary schistosomiasis by examining tissue obtained intra-operatively from the donor's ureter or the patient's bladder. Schistosomiasis was histologically documented in 76 cases (patient's bladder (46), donor's ureter (9), both (21)). The incidence of urological complications was 11/76 (1 5%)in the schistosomal group and 14/234 (6%) in the nonschistosomal group; this was statistically significant. Among the schistosomal patients, the site of infestation had no statistically significant effect on the incidence of urological complications. No deaths or graft losses were directly attributable either to these complications or to their surgical correction.
The frequency, aetiology and management of urological complications following renal transplantation have been reported by Malek et al. (1973) anti Mut~dyr t al. (1981). Schistosomiasis affects approxiniately 200 million people in Africa, the Middlc f.ast, South-East Asia and South America (Wecdcn et d., 1982).It can lead to the development of' irreversible pathological changes in the urinary tract (Ghoneim, 1984). Information on the effect of urinary schistosomiasison the frequency and nature of urological complications following renal transplantation is limited. We present our experience with urological complications that developed among 3 1 0 consecutive live donor renal transplants. Special emphasis is placed on the potential impact of urinat y schistosomiasis on the incidence, type and methods ofmanagement ofsuchcomplications.
Patients and Methods Between March 1976 and March 1991, 480 renal tr,in\pldiitations were carried out in this Centre. Of thew, the last consecutive 310 cases were studied 4 ~ ~ e p r lor e d publication 20 September 1991
for evidence of urinary schistosomiasis by examination of tissue obtained intra-operatively from the donor's ureter and the recipient's bladder. Paraffin blocks were prepared and sections were stained by haematoxylin and eosin for examination by light microscopy. A diagnosis of schistosomiasis was established when Schistosoma eggs were seen in either specimen. The patients were followed up for a mean period of 33 months (range 6-168). In addition to clinical examination and routine assessment of the graft function, isotope renography and ultrasonography were of particular help in the diagnosis of urological complications. The latter provided evidence of perirenal collection or obstruction of the pelvicaliceal system. It was also indispensable for diagnostic aspiration of a suspected collection to determine its chemical nature by quantitative estimation of creatinine content. Intravenous urography (IVU) was considered if renal function was not markedly impaired. More invasive procedures such as ascending cystography, retrograde ureterography, graft percutaneous nephrostomy (PCN) and antegrade study were used as necessary. Statistical analyses were performed with an
247
248
BRITISH JOURNAL OF UROLOGY
urinary tract continuity had no impact on the incidence of urological complications (Table 3). The various approaches used for the correction of these complications are summarised in Table 4. Two patients developed a urinary leak from the cystostomy incision. One was treated successfully by an indwelling urethral catheter for 1 week while the other required an open repair. Ureteric fistulae developed in 6 patients. In all but 1 case a graft PCN was initially inserted for adequate drainage and prevention of wound sepsis. In 1 patient drainage was sufficient for prompt healing without stricture formation (Fig. 1). In the remainder, surgical intervention was necessary, the nature of which was based on the length and viability of the ureter as judged during exploration. A ureterovesical reimplantation was feasible in 2 patients, a Boari flap was necessary in 2 (Fig. 2) and a ureteroureteric anastomosis was employed in 1. In the latter case, however, the repair was complicated by urinary leakage and fistula formation and an ileal replacement of the ureter was carried out. Intrinsic ureteric obstruction was seen in 4 patients. The obstruction was due to axial rotation of the ureter in 1 patient (Fig. 3); this was successfully corrected and reimplanted into the bladder. Three patients developed distal ureteric strictures, of whom 2 were treated by ureteroureteric anastomosis and the third by a Boari flap. These latter 3 patients developed recurrent obstruction
independent t test, chi-squared and Fisher’s exact tests.
Results Patients were stratified into 2 groups according to the histopathological findings : schistosomal group (76 patients; 25%) and non-schistosomal group (234 patients ; 75%). Schistosoma eggs were detected in the bladders of 46 recipients, in the ureters of 9 donors and in both in 21 cases. All patients had received live related donor kidneys and the majority had one-haplotype HLA match. Table 1 summarises the demographic characteristics of donors and recipients of the 2 groups. Both were comparable regarding age and sex of donors and recipients, duration of pre-transplant dialysis and prior blood transfusions. The immunosuppressive regimens and the techniques employed for the re-establishment of urinary continuity were also essentially similar. The urological complications are listed in Table 2: 25 were recorded, an incidence of 8%. Eleven complications (15%) were seen among the schistosomal group and 14 (6%) among the nonschistosomal group ;this was statistically significant ( P < 0.05). It was observed that the site of schistosoma1 infestation did not affect either the incidence or the type of urological complications. Furthermore, the surgical techniques used to re-establish
Table 1 Characteristics of Donors and Recipients of Schistosomal and non-Schistosomal Renal Transplants (n = 310) Factors analysed
Donor’s age (years) Donor’s sex (male to female ratio) Recipient’s age (years) Recipient’s sex (male to female ratio) Duration of pre-transplant dialysis (months) Prior transfusions (units)
Schistosmal group ( n = 76)
Non-schistosomal group ( n = 234)
42+5
41 + 6
40136 29+8
1201114 30k7
57/19
170164
35+8 3.2 f2
33k6 3.1 +2.5
Immunosuppression Azathioprine corticosteroids Cyclosporin corticosteroids Triple immunosuppression
No. 45 23 8
%
No. 133 72 29
%
59 31 10
Primary urinary tract procedures Leadbetter-Politano Lich-Gregoir Ureteroureteric
28 44 4
37 58 5
51 160 17
24 69 7
+ +
57 31 12
249
'WFECTOF URINARY SCHISTOSOMIASIS FOLLOWING LIVE DONOR KIDNEY TRANSPLANTS
Table 2 Urological Complications
-~ Schistosomal group (n = 76) No. ofpatients
Complications
Bladder leak Ureteric fistula Intrinsic ureteric obstruction Stone in the graft Bladder stone Urethral stricture Lymphocele
Non-schistosomal group ( n = 234) No. of patients
1
1
4
2 2 1
2 -
2 6 4 1 1 2 9
-
I 1 2
Total
Total
1 I
*11 (15%)
*14 (6%)
25 (8%)
*(x2=4.5, P
