- Email: [email protected]
Outcome of Renal Transplantation in Adult Patients With Augmented Bladders
Outcome of Renal Transplantation in Adult Patients With Augmented Bladders M. Blanco, J. Medina, M. Pamplona, N. Miranda, E. Gonzalez, J.F. Aguirre, A. Andres, O. Leiva, and J.M. Morales ABSTRACT Objective. We studied the long-term renal graft functions, survivals, and complications among patients with augmented bladders. Patients and Methods. Between 1976 and 2008, we performed 6/2600 renal transplantations in patients with augmented bladders. The mean patient age was 52 years. The cause of end-stage renal disease was chronic interstitial kidney disease in all patients, being secondary to lower urinary tract dysfunction. The etiology of bladder dysfunction was tuberculosis in 4 cases, bladder exstrophy in 1, and myelomeningocele in 1. Enterocystoplasty had been performed at a mean of 19 years prior to transplantation. The ureter was implanted into the native ureter in 5 cases and the bowel segment in 1 case. Results. With a mean follow-up of 56 months (range, 20 –100 months), the overall graft survival was 50%. Three grafts were lost due to venous thrombosis (n ⫽ 1), and chronic allograft nephropathy (n ⫽ 2) at 37 and 100 months posttransplantation. No patient died during follow-up. Mean serum creatinine was 1.44 mg/dL with Modification of Diet in Renal Disease (MDRD) clearance of 76 mL/min/1.73 m2. One fistula that caused obstructive uropathy and 2 cases of migration of a double J catheter were among the surgical complications. These patients showed a mean of 7 episodes of uncomplicated urinary infections. Only 1 patient was rehospitalized due to a complicated urinary tract infection. Conclusions. Patients with enterocystoplasty and renal transplantation show a greater risk of urinary tract infections, albeit mostly uncomplicated. Despite this, the long-term results are acceptable. rinary tract conditions that entail decreased bladder capacity may require surgical reconstruction in order to preserve renal function or to improve associated symptoms of frequency of micturition, pain, and urgency. An augmentation cystoplasty may be performed for some patients prior to kidney transplantation. Data in the literature on adult patients with augmented bladders on the waiting list are scarce. Herein we have reported our experience with adult patients with severe bladder dysfunction who underwent prior augmentation cystoplasty.
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PATIENTS AND METHODS Only 6/2600 transplantations (0.2%) performed since the onset of our program were performed using augmented bladders. The patients were 4 women and 2 men of overall mean age of 52 years (range, 22–72 years). The procedures were performed between
1976 and 2008. The causes of end-stage renal disease (ESRD) were chronic interstitial kidney disease secondary to vesicoureteric tuberculosis (n ⫽ 4), bladder exstrophy (n ⫽ 1), and myelomeningocele (n ⫽ 1). All patients had previously been operated to stop the progression of their kidney failure at a mean of 19 years earlier (range, 5.7–26.6 years). The enterocystoplasty had been performed with an ileal segment in 5 cases and with sigmoid colon in 1. The clinical characteristics of the patients are summarized in Table 1. All the transplants were from cadaveric donors. The ureteral anastomosis was performed to the native ureter in 5 cases and to From the Departments of Urology (M.B., J.M., M.P., N.M., J.F.A., O.L.) and Nephrology (E.G., A.A., J.M.M.), Doce de Octubre University Hospital, Madrid, Spain. Address reprint requests to Maria Blanco Alvarez, Department of Urology, Doce de Octubre University Hospital, Avda de Córdoba s/n 28041, Madrid, Spain. E-mail: [email protected]
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.106
© 2009 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
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Transplantation Proceedings, 41, 2382–2384 (2009)
KIDNEY RECIPIENTS WITH AUGMENTED BLADDERS
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Table 1. Patient Demographics Patient No. Characteristics
1
Sex Age at transplantation (y) Cause of bladder dysfunction Year of bladder augmentation Bowel segment used Year of transplantation Time on dialysis (mos) Urinary diversion Immunosuppression Surgical complication UTI episodes Voiding problems
Female 22 Spina bifida 1990 Sigmoid 1995 5 Native ureter C, P None — Permanent catheter Functioning
Cause of graft loss Follow-up (mos) Serum creatinine (mg/dL)
88 1.2
2
Female 63 Tbc 1971 Ileum 1997 28 Native ureter C, M, P None 0 None
3
Male
4
Male
5
6
Female 27 Tbc Tbc Tbc Bladder exstrophy 1983 Unknown 1979 1985 Ileum Ileum Ileum Ileum 2000 2000 2004 2005 21 14 22 34 Native ureter Native ureter Bowel segment Native ureter T, M, P T, M, P Basiliximab, M, P T, M, P Stent migration Ureteral stenosis Venous thrombosis Stent migration 0 9 — 12 None None None Intermittent catheterization Chronic Functioning Chronic Venous thrombosis Functioning nephropathy nephropathy 100 41 37 1 20 — 2.3 — — 0.82 72
Female
70
59
Abbreviations: Tbc, tuberculosis; C, cyclosporine; P, prednisolone; M, mycophenolate mofetil; T, tacrolimus.
the bowel segment in 1 case. A double J catheter was left in for 3 weeks in all cases.
RESULTS
The mean follow-up was 56 months (range, 20 –100 months). Three grafts were lost due to causes not related to the ureteral anastomosis: venous thrombosis (n ⫽ 1), and chronic allograft nephropathy (CAN; n ⫽ 2) at 37 and 100 months posttransplantation yielding an overall graft survival of 50%. No patient died during the follow-up. Among the surgical complications, there was only 1 case of fistula in the third month posttransplantation that caused obstructive uropathy. This problem was solved with a definitive nephrostomy in which, due to the patient’s express wish, no reintervention was performed. Surgical complications also occurred in 2 cases of migration of a double J catheter; the catheters were removed by an anterograde approach. No patient developed any episode of acute rejection. Regarding renal function, the mean serum creatinine at the end of follow-up was 1.44 mg/dL with Modification of Diet in Renal Disease (MDRD) clearance of 76 mL/min/1.73 m2. These patients showed a mean of 7 urinary tract infections (UTI). Only 1 patient was rehospitalized due to UTI and high fever. The mean number of readmissions was 5 per patient. The 2 patients with congenital conditions (spina bifida and bladder exstrophy) did not have normal voiding, so they required a urinary catheter for micturition. However, this did not lead to a greater number of posttransplantation UTIs (Table 1). DISCUSSION
It is advisable for transplant candidates with small, contracted bladders who have had multiple lower urinary tract
operations to undergo a complete study for a likely voiding problem. If necessary, an augmentation cystoplasty may be performed before transplantation, or afterward if satisfactory bladder function does not return within a few months.1 In this way, the bladder becomes a low-pressure reservoir. Although there are few reports of adult patients who have undergone bladder augmentation, it is well known that it is a safe procedure.2– 6 We therefore consider our work to be relevant. Functionalized augmentation is preferable to dry augmentation because it permits continence and bladder compliance to be documented before transplantation.7 The main problems described in kidney transplant patients with enterocystoplasty are the difficulty for complete voiding and UTI. Patients with augmented bladders usually require clean intermittent catheterization after transplantation. The patient should be trained in this technique well in advance of the transplantation procedure. Clean intermittent self-catheterization (CISC) has been used successfully in transplant recipients for almost 2 decades for patients with neuropathic bladders or transient bladder outlet obstruction.8 In our study, 1 of 6 patients needed CISC before and after transplantation, and another patient used permanent bladder catheterization (Table 1). Regarding UTIs, good graft survival at the expense of relatively poor kidney function has been described.9 In our experience, 1 graft was lost at 3 years after displaying a considerable number of UTIs. However, the other patient with CAN (patient 2) had no UTIs. The renal function was good; however, there are not enough data to draw conclusions due to the limited number of patients. Some authors have preferred sigmoid segments for patients with tuberculosis because of the minimal bladder capacity.10 Nevertheless, we have not observed any difference in our experience, as we had only 1 case with a sigmoid bowel segment.
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The double J catheter migration has already been described in transplant patients11 and was resolved without complications by percutaneous access. In the case of ureteral stenosis, a ureteral reimplantation can be performed.12 In the case of the fistula that caused an obstructive uropathy, a nephrostomy was placed with good evolution and the patient subsequently refused another surgical procedure. In conclusion, kidney transplantation in patients with augmented bladders is rare, even among transplant units with extensive experience. Patients with enterocystoplasty and kidney transplantation have a greater risk of UTIs, mostly uncomplicated, despite acceptable long-term kidney function.
REFERENCES 1. Sheldon CA, Gonzalez R, Burns MW, et al: Renal transplantation into the dysfunctional bladder: the role of adjunctive bladder reconstruction. J Urol 152:972, 1994 2. Power RE, O’Malley KJ, Khan MS, et al: Renal transplantation in patients with an augmentation cystoplasty. BJU Int 86:28, 2000
BLANCO, MEDINA, PAMPLONA ET AL 3. Alapont Alacreu JM, Pacheco Bru JJ, Pontones Moreno JL, et al: [Renal transplantation in patients with enterocystoplasty]. Actas Urol Esp 27:281, 2003 4. Martin MG, Castro SN, Castelo LA, et al: Enterocystoplasty and renal transplantation. J Urol 165:393, 2001 5. Barry JM: Kidney transplantation into patients with abnormal bladders. Transplantation 77:1120, 2004 6. Neild GH, Dakmish A, Wood S, et al: Renal transplantation in adults with abnormal bladders. Transplantation 77:1123, 2004 7. Gonzalez R: Renal transplantation into abnormal bladders. J Urol 158:895, 1997 8. Shneidman RJ, Pulliam JP, Barry JM: Clean, intermittent self-catheterization in renal transplant recipients. Transplantation 38:312, 1984 9. Crowe A, Cairns HS, Wood S, et al: Renal transplantation following renal failure due to urological disorders. Nephrol Dial Transplant 13:2065, 1998 10. Nahas WC, Mazzucchi E, Arap MA, et al: Augmentation cystoplasty in renal transplantation: a good and safe option— experience with 25 cases. Urology 60:770, 2002 11. Surange RS, Johnson RW, Tavakoli A, et al: Kidney transplantation into an ileal conduit: a single center experience of 59 cases. J Urol 170:1727, 2003 12. Arguelles SE, Barrero CR, Torrubia Romero FJ, et al: [Bladder augmentation and urinary diversion in kidney transplant candidates]. Arch Esp Urol 57:699, 2004
U
PATIENTS AND METHODS Only 6/2600 transplantations (0.2%) performed since the onset of our program were performed using augmented bladders. The patients were 4 women and 2 men of overall mean age of 52 years (range, 22–72 years). The procedures were performed between
1976 and 2008. The causes of end-stage renal disease (ESRD) were chronic interstitial kidney disease secondary to vesicoureteric tuberculosis (n ⫽ 4), bladder exstrophy (n ⫽ 1), and myelomeningocele (n ⫽ 1). All patients had previously been operated to stop the progression of their kidney failure at a mean of 19 years earlier (range, 5.7–26.6 years). The enterocystoplasty had been performed with an ileal segment in 5 cases and with sigmoid colon in 1. The clinical characteristics of the patients are summarized in Table 1. All the transplants were from cadaveric donors. The ureteral anastomosis was performed to the native ureter in 5 cases and to From the Departments of Urology (M.B., J.M., M.P., N.M., J.F.A., O.L.) and Nephrology (E.G., A.A., J.M.M.), Doce de Octubre University Hospital, Madrid, Spain. Address reprint requests to Maria Blanco Alvarez, Department of Urology, Doce de Octubre University Hospital, Avda de Córdoba s/n 28041, Madrid, Spain. E-mail: [email protected]
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.106
© 2009 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
2382
Transplantation Proceedings, 41, 2382–2384 (2009)
KIDNEY RECIPIENTS WITH AUGMENTED BLADDERS
2383
Table 1. Patient Demographics Patient No. Characteristics
1
Sex Age at transplantation (y) Cause of bladder dysfunction Year of bladder augmentation Bowel segment used Year of transplantation Time on dialysis (mos) Urinary diversion Immunosuppression Surgical complication UTI episodes Voiding problems
Female 22 Spina bifida 1990 Sigmoid 1995 5 Native ureter C, P None — Permanent catheter Functioning
Cause of graft loss Follow-up (mos) Serum creatinine (mg/dL)
88 1.2
2
Female 63 Tbc 1971 Ileum 1997 28 Native ureter C, M, P None 0 None
3
Male
4
Male
5
6
Female 27 Tbc Tbc Tbc Bladder exstrophy 1983 Unknown 1979 1985 Ileum Ileum Ileum Ileum 2000 2000 2004 2005 21 14 22 34 Native ureter Native ureter Bowel segment Native ureter T, M, P T, M, P Basiliximab, M, P T, M, P Stent migration Ureteral stenosis Venous thrombosis Stent migration 0 9 — 12 None None None Intermittent catheterization Chronic Functioning Chronic Venous thrombosis Functioning nephropathy nephropathy 100 41 37 1 20 — 2.3 — — 0.82 72
Female
70
59
Abbreviations: Tbc, tuberculosis; C, cyclosporine; P, prednisolone; M, mycophenolate mofetil; T, tacrolimus.
the bowel segment in 1 case. A double J catheter was left in for 3 weeks in all cases.
RESULTS
The mean follow-up was 56 months (range, 20 –100 months). Three grafts were lost due to causes not related to the ureteral anastomosis: venous thrombosis (n ⫽ 1), and chronic allograft nephropathy (CAN; n ⫽ 2) at 37 and 100 months posttransplantation yielding an overall graft survival of 50%. No patient died during the follow-up. Among the surgical complications, there was only 1 case of fistula in the third month posttransplantation that caused obstructive uropathy. This problem was solved with a definitive nephrostomy in which, due to the patient’s express wish, no reintervention was performed. Surgical complications also occurred in 2 cases of migration of a double J catheter; the catheters were removed by an anterograde approach. No patient developed any episode of acute rejection. Regarding renal function, the mean serum creatinine at the end of follow-up was 1.44 mg/dL with Modification of Diet in Renal Disease (MDRD) clearance of 76 mL/min/1.73 m2. These patients showed a mean of 7 urinary tract infections (UTI). Only 1 patient was rehospitalized due to UTI and high fever. The mean number of readmissions was 5 per patient. The 2 patients with congenital conditions (spina bifida and bladder exstrophy) did not have normal voiding, so they required a urinary catheter for micturition. However, this did not lead to a greater number of posttransplantation UTIs (Table 1). DISCUSSION
It is advisable for transplant candidates with small, contracted bladders who have had multiple lower urinary tract
operations to undergo a complete study for a likely voiding problem. If necessary, an augmentation cystoplasty may be performed before transplantation, or afterward if satisfactory bladder function does not return within a few months.1 In this way, the bladder becomes a low-pressure reservoir. Although there are few reports of adult patients who have undergone bladder augmentation, it is well known that it is a safe procedure.2– 6 We therefore consider our work to be relevant. Functionalized augmentation is preferable to dry augmentation because it permits continence and bladder compliance to be documented before transplantation.7 The main problems described in kidney transplant patients with enterocystoplasty are the difficulty for complete voiding and UTI. Patients with augmented bladders usually require clean intermittent catheterization after transplantation. The patient should be trained in this technique well in advance of the transplantation procedure. Clean intermittent self-catheterization (CISC) has been used successfully in transplant recipients for almost 2 decades for patients with neuropathic bladders or transient bladder outlet obstruction.8 In our study, 1 of 6 patients needed CISC before and after transplantation, and another patient used permanent bladder catheterization (Table 1). Regarding UTIs, good graft survival at the expense of relatively poor kidney function has been described.9 In our experience, 1 graft was lost at 3 years after displaying a considerable number of UTIs. However, the other patient with CAN (patient 2) had no UTIs. The renal function was good; however, there are not enough data to draw conclusions due to the limited number of patients. Some authors have preferred sigmoid segments for patients with tuberculosis because of the minimal bladder capacity.10 Nevertheless, we have not observed any difference in our experience, as we had only 1 case with a sigmoid bowel segment.
2384
The double J catheter migration has already been described in transplant patients11 and was resolved without complications by percutaneous access. In the case of ureteral stenosis, a ureteral reimplantation can be performed.12 In the case of the fistula that caused an obstructive uropathy, a nephrostomy was placed with good evolution and the patient subsequently refused another surgical procedure. In conclusion, kidney transplantation in patients with augmented bladders is rare, even among transplant units with extensive experience. Patients with enterocystoplasty and kidney transplantation have a greater risk of UTIs, mostly uncomplicated, despite acceptable long-term kidney function.
REFERENCES 1. Sheldon CA, Gonzalez R, Burns MW, et al: Renal transplantation into the dysfunctional bladder: the role of adjunctive bladder reconstruction. J Urol 152:972, 1994 2. Power RE, O’Malley KJ, Khan MS, et al: Renal transplantation in patients with an augmentation cystoplasty. BJU Int 86:28, 2000
BLANCO, MEDINA, PAMPLONA ET AL 3. Alapont Alacreu JM, Pacheco Bru JJ, Pontones Moreno JL, et al: [Renal transplantation in patients with enterocystoplasty]. Actas Urol Esp 27:281, 2003 4. Martin MG, Castro SN, Castelo LA, et al: Enterocystoplasty and renal transplantation. J Urol 165:393, 2001 5. Barry JM: Kidney transplantation into patients with abnormal bladders. Transplantation 77:1120, 2004 6. Neild GH, Dakmish A, Wood S, et al: Renal transplantation in adults with abnormal bladders. Transplantation 77:1123, 2004 7. Gonzalez R: Renal transplantation into abnormal bladders. J Urol 158:895, 1997 8. Shneidman RJ, Pulliam JP, Barry JM: Clean, intermittent self-catheterization in renal transplant recipients. Transplantation 38:312, 1984 9. Crowe A, Cairns HS, Wood S, et al: Renal transplantation following renal failure due to urological disorders. Nephrol Dial Transplant 13:2065, 1998 10. Nahas WC, Mazzucchi E, Arap MA, et al: Augmentation cystoplasty in renal transplantation: a good and safe option— experience with 25 cases. Urology 60:770, 2002 11. Surange RS, Johnson RW, Tavakoli A, et al: Kidney transplantation into an ileal conduit: a single center experience of 59 cases. J Urol 170:1727, 2003 12. Arguelles SE, Barrero CR, Torrubia Romero FJ, et al: [Bladder augmentation and urinary diversion in kidney transplant candidates]. Arch Esp Urol 57:699, 2004