- Email: [email protected]
Does Lower Urinary Tract Status Affect Renal Transplantation Outcomes in Children?
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
<.001* .033† .217† .892§ <.001‡ .711§ .002† <.01†
Boldface indicates statistical significance. Abbreviations: RTx, renal transplantation; LUTD, lower urinary tract dysfunction; UTI, lower urinary tract infection. *Student t test. † 2 c test. ‡ Mann-Whitney U test. § Log-rank test.
intestinal segment in all augmented bladders except 1 patient with gastrocystoplasty. Three patients underwent simple native kidney nephrectomy due to recurrent infections. Cadaveric renal transplantation was performed in 11 and 10 patients in LUTD vs non-LUTD group, respectively. Fourteen patients in LUTD group had living donors, compared with 25 patients in the other group (P ¼ .217). Mean follow-up for LUTD (þ) and LUTD () groups were 63 (22e155) and 101 months (14e124), respectively (P ¼ .384, Mann-Whitney U test). At last follow-up graft survivals were comparable (76% and 80%, P ¼ .711). Also, there was no difference in 5-year graft survival (73% and 75%, P ¼ .892). Among patients with functioning graft, creatinine levels at last follow-up were lower for the LUTD () group (0.96 .0.57 vs 1.3 0.3 mg/dL, P < .001). Infectious complications and postoperative UTI incidence were higher in the LUTD (þ) group (68% vs 25.7%, P ¼ .002 and 60% vs 11.4%, P < .01). In LUTD (þ) group, UTI incidence was higher in patients with bladder augmentation (87.5 vs 47%, P ¼ .088). UTI developed in 14 of 16 patients in whom clean intermittent catheterization (CIC) was continued. Bladder augmentation and CIC were significant risk factors to develop UTI. Graft survival at the end of follow-up, and 5-year graft survival rates were 80% and 87% in living kidney recipients and 68% and 68% in cadaveric kidney recipients with and without LUTD, respectively (P ¼ .023, log-rank test). With regard to graft survival, high-grade reflux to native kidneys in the LUTD (þ) group was not found to affect graft survival outcomes. One LUTD (þ) patient who lost a renal graft in the seventh year post-transplantation followup died due to respiratory problems 4 years later while on hemodialysis. DISCUSSION
There are a variety of lower urinary tract abnormalities that can lead to ESRD. However, a low-pressure, good-volume reservoir bladder and adequate urinary drainage must be obtained in all renal transplantation patients. Some studies
1116
reported that patients with LUTD had worse renal graft function compared to others [8,9]. However, other recent studies observed no significant differences in renal transplantation complications or graft survival regarding lower urinary tract status [10,11]. These studies have several differences in patient sampling and matching comparisons. Preoperative evaluations of patients with LUTD must include routine imaging modalities and urodynamic testing. Intervention must be considered when there is no adequate lower urinary tract. Although times of reconstructive surgeries performed in our hospital vary according to patients’ referral to our center, in all patients a properly functioning lower urinary tract was accomplished before RTx and was confirmed by urodynamic testing before RTx. Special attention must be given to oligoanuria patients during interpretation of results. Bladder cycling may increase bladder capacity, and thus may increase the accuracy of urodynamic testing in some patients. CIC is continued in patients with augmented bladder and bladder dysfunction. Postoperative UTIs were significantly higher in this group but there was no statistical difference in graft survival. Patients and their families should be informed and given CIC education by a health care professional. Several studies concluded that the presence of lower urinary tract abnormality is a significant risk factor for posttransplant UTI [12,13]. However the prevalence of UTI in LUTD (þ) patients varies widely in the literature due to many factors, such as differences in the definition of UTI, agents chosen for prophylaxis, etc. We accepted any possible related sign as positive for UTI and treated patients to avoid risks, as the immune response to infections in kidney recipients may be diminished due to immunosuppression. These may cause overestimation of UTI in our patients. In our study we found that the incidence of at least 1 UTI was 11.4% in the non-LUTD group, whereas it was 60% in the LUTD group. In subgroup analysis, UTI incidence was higher in patients with bladder augmentation (87.5 vs 47%, P ¼ .088). Antibiotic prophylaxis may be considered or meticulous follow up may be indicated in this special subgroup to reduce the incidence of UTI. Our policy of strict adherence to routine use of CIC in LUTD (þ) patients seems to prevent UTI from threatening graft survival. Higher risk of stone diseases, metabolic bone complications, and malignancy also should be borne in mind while managing patients with bladder augmentation. UTI after RTx is common. There is also additional high risk for LUTD recipients. Although augmentation enterocystoplasty and CIC increase infection incidence, achieving a highly compliant, low pressure, and effectively drained bladder minimizes risk of bladder dysfunction and UTI on graft functions. Low compliant, high-pressure bladders, and
AKI, AYDIN, DOGAN ET AL
infected urine may cause severe deterioration of graft function. Restoration of good bladder function is the key factor in the success of kidney transplantation in patients with LUTD. In conclusion, all ESRD patients with severe LUTD should be investigated as renal transplantation candidates and their bladders must be rehabilitated. Although at higher risk of UTI, renal transplantation can be performed safely in these patients with careful patient selection, preoperative management, and close postoperative follow-up.
REFERENCES [1] U.S. Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013. Available at: http://www.usrds.org/atlas.aspx. Accessed September 3, 2014. [2] Soylemezoglu O, Duzova A, Yalcinkaya F, Arinsoy T, Suleymanlar G. Chronic renal disease in children aged 5-18 years: a population-based survey in Turkey, the CREDIT-C study. Nephrol Dial Transplant 2012;27:146e51. [3] Ardissino G, Dacco V, Testa S, Bonaudo R, ClarisAppiani A, Taioli E, et al. Epidemiology of chronic renal failure in children: data from the ItalKid Project. Pediatrics 2003;111:382e7. [4] Bek K, Akman S, Bilge I, Topaloglu R, Caliskan S, Peru H, et al. Chronic kidney disease in children in Turkey. Pediatr Nephrol 2009;24:797e806. [5] Adams J, Mehls O, Wiesel M. Pediatric renal transplantation and the dysfunctional bladder. Transpl Int 2004;17:596e602. [6] Broniszczak D, Ismail H, Nachulewicz P, Szymczak M, Drewniak T, Markiewicz-Kijewska M, et al. Kidney transplantation in children with bladder augmentation or ileal conduit diversion. Eur J Pediatr Surg 2010;20:5e10. [7] Bilginer Y, Aki FT, Topaloglu R, Tekgul S, Demirkaya E, Duzova A, et al. Renal transplantation in children with lower urinary tract dysfunction of different origin: a single-center experience. Transplant Proc 2008;40:85e6. [8] Crowe A, Cairns HS, Wood S, Rudge CJ, Woodhouse CR, Neild GH. Renal transplantation following renal failure due to urological disorders. Nephrol Dial Transplant 1998;13:2065e9. [9] Churchill BM, Sheldon CA, McLorie GA, Arbus GS. Factors influencing patient and graft survival in 300 cadaveric pediatric renal transplants. J Urol 1988;140:1129e33. [10] Mendizabal S, Estornell F, Zamora I, Sabater A, Ibarra FG, Simon J. Renal transplantation in children with severe bladder dysfunction. J Urol 2005;173:226e9. [11] Nahas WC, Antonopoulos IM, Piovesan AC, Pereira LM, Kanashiro H, David-Neto E, et al. Comparison of transplantation outcomes in children with and without bladder dysfunction. A customized approach equals the difference. J Urol 2008;179:712e6. [12] Esezobor CI, Nourse P, Gajjar P. Urinary tract infection following kidney transplantation: frequency, risk factors and graft function. Pediatr Nephrol 2012;27:651e7. [13] Silva A, Rodig N, Passerotti CP, Recabal P, Borer JG, Retik AB, et al. Risk factors for urinary tract infection after renal transplantation and its impact on graft function in children and young adults. J Urol 2010;184:1462e8.
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
<.001* .033† .217† .892§ <.001‡ .711§ .002† <.01†
Boldface indicates statistical significance. Abbreviations: RTx, renal transplantation; LUTD, lower urinary tract dysfunction; UTI, lower urinary tract infection. *Student t test. † 2 c test. ‡ Mann-Whitney U test. § Log-rank test.
intestinal segment in all augmented bladders except 1 patient with gastrocystoplasty. Three patients underwent simple native kidney nephrectomy due to recurrent infections. Cadaveric renal transplantation was performed in 11 and 10 patients in LUTD vs non-LUTD group, respectively. Fourteen patients in LUTD group had living donors, compared with 25 patients in the other group (P ¼ .217). Mean follow-up for LUTD (þ) and LUTD () groups were 63 (22e155) and 101 months (14e124), respectively (P ¼ .384, Mann-Whitney U test). At last follow-up graft survivals were comparable (76% and 80%, P ¼ .711). Also, there was no difference in 5-year graft survival (73% and 75%, P ¼ .892). Among patients with functioning graft, creatinine levels at last follow-up were lower for the LUTD () group (0.96 .0.57 vs 1.3 0.3 mg/dL, P < .001). Infectious complications and postoperative UTI incidence were higher in the LUTD (þ) group (68% vs 25.7%, P ¼ .002 and 60% vs 11.4%, P < .01). In LUTD (þ) group, UTI incidence was higher in patients with bladder augmentation (87.5 vs 47%, P ¼ .088). UTI developed in 14 of 16 patients in whom clean intermittent catheterization (CIC) was continued. Bladder augmentation and CIC were significant risk factors to develop UTI. Graft survival at the end of follow-up, and 5-year graft survival rates were 80% and 87% in living kidney recipients and 68% and 68% in cadaveric kidney recipients with and without LUTD, respectively (P ¼ .023, log-rank test). With regard to graft survival, high-grade reflux to native kidneys in the LUTD (þ) group was not found to affect graft survival outcomes. One LUTD (þ) patient who lost a renal graft in the seventh year post-transplantation followup died due to respiratory problems 4 years later while on hemodialysis. DISCUSSION
There are a variety of lower urinary tract abnormalities that can lead to ESRD. However, a low-pressure, good-volume reservoir bladder and adequate urinary drainage must be obtained in all renal transplantation patients. Some studies
1116
reported that patients with LUTD had worse renal graft function compared to others [8,9]. However, other recent studies observed no significant differences in renal transplantation complications or graft survival regarding lower urinary tract status [10,11]. These studies have several differences in patient sampling and matching comparisons. Preoperative evaluations of patients with LUTD must include routine imaging modalities and urodynamic testing. Intervention must be considered when there is no adequate lower urinary tract. Although times of reconstructive surgeries performed in our hospital vary according to patients’ referral to our center, in all patients a properly functioning lower urinary tract was accomplished before RTx and was confirmed by urodynamic testing before RTx. Special attention must be given to oligoanuria patients during interpretation of results. Bladder cycling may increase bladder capacity, and thus may increase the accuracy of urodynamic testing in some patients. CIC is continued in patients with augmented bladder and bladder dysfunction. Postoperative UTIs were significantly higher in this group but there was no statistical difference in graft survival. Patients and their families should be informed and given CIC education by a health care professional. Several studies concluded that the presence of lower urinary tract abnormality is a significant risk factor for posttransplant UTI [12,13]. However the prevalence of UTI in LUTD (þ) patients varies widely in the literature due to many factors, such as differences in the definition of UTI, agents chosen for prophylaxis, etc. We accepted any possible related sign as positive for UTI and treated patients to avoid risks, as the immune response to infections in kidney recipients may be diminished due to immunosuppression. These may cause overestimation of UTI in our patients. In our study we found that the incidence of at least 1 UTI was 11.4% in the non-LUTD group, whereas it was 60% in the LUTD group. In subgroup analysis, UTI incidence was higher in patients with bladder augmentation (87.5 vs 47%, P ¼ .088). Antibiotic prophylaxis may be considered or meticulous follow up may be indicated in this special subgroup to reduce the incidence of UTI. Our policy of strict adherence to routine use of CIC in LUTD (þ) patients seems to prevent UTI from threatening graft survival. Higher risk of stone diseases, metabolic bone complications, and malignancy also should be borne in mind while managing patients with bladder augmentation. UTI after RTx is common. There is also additional high risk for LUTD recipients. Although augmentation enterocystoplasty and CIC increase infection incidence, achieving a highly compliant, low pressure, and effectively drained bladder minimizes risk of bladder dysfunction and UTI on graft functions. Low compliant, high-pressure bladders, and
AKI, AYDIN, DOGAN ET AL
infected urine may cause severe deterioration of graft function. Restoration of good bladder function is the key factor in the success of kidney transplantation in patients with LUTD. In conclusion, all ESRD patients with severe LUTD should be investigated as renal transplantation candidates and their bladders must be rehabilitated. Although at higher risk of UTI, renal transplantation can be performed safely in these patients with careful patient selection, preoperative management, and close postoperative follow-up.
REFERENCES [1] U.S. Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013. Available at: http://www.usrds.org/atlas.aspx. Accessed September 3, 2014. [2] Soylemezoglu O, Duzova A, Yalcinkaya F, Arinsoy T, Suleymanlar G. Chronic renal disease in children aged 5-18 years: a population-based survey in Turkey, the CREDIT-C study. Nephrol Dial Transplant 2012;27:146e51. [3] Ardissino G, Dacco V, Testa S, Bonaudo R, ClarisAppiani A, Taioli E, et al. Epidemiology of chronic renal failure in children: data from the ItalKid Project. Pediatrics 2003;111:382e7. [4] Bek K, Akman S, Bilge I, Topaloglu R, Caliskan S, Peru H, et al. Chronic kidney disease in children in Turkey. Pediatr Nephrol 2009;24:797e806. [5] Adams J, Mehls O, Wiesel M. Pediatric renal transplantation and the dysfunctional bladder. Transpl Int 2004;17:596e602. [6] Broniszczak D, Ismail H, Nachulewicz P, Szymczak M, Drewniak T, Markiewicz-Kijewska M, et al. Kidney transplantation in children with bladder augmentation or ileal conduit diversion. Eur J Pediatr Surg 2010;20:5e10. [7] Bilginer Y, Aki FT, Topaloglu R, Tekgul S, Demirkaya E, Duzova A, et al. Renal transplantation in children with lower urinary tract dysfunction of different origin: a single-center experience. Transplant Proc 2008;40:85e6. [8] Crowe A, Cairns HS, Wood S, Rudge CJ, Woodhouse CR, Neild GH. Renal transplantation following renal failure due to urological disorders. Nephrol Dial Transplant 1998;13:2065e9. [9] Churchill BM, Sheldon CA, McLorie GA, Arbus GS. Factors influencing patient and graft survival in 300 cadaveric pediatric renal transplants. J Urol 1988;140:1129e33. [10] Mendizabal S, Estornell F, Zamora I, Sabater A, Ibarra FG, Simon J. Renal transplantation in children with severe bladder dysfunction. J Urol 2005;173:226e9. [11] Nahas WC, Antonopoulos IM, Piovesan AC, Pereira LM, Kanashiro H, David-Neto E, et al. Comparison of transplantation outcomes in children with and without bladder dysfunction. A customized approach equals the difference. J Urol 2008;179:712e6. [12] Esezobor CI, Nourse P, Gajjar P. Urinary tract infection following kidney transplantation: frequency, risk factors and graft function. Pediatr Nephrol 2012;27:651e7. [13] Silva A, Rodig N, Passerotti CP, Recabal P, Borer JG, Retik AB, et al. Risk factors for urinary tract infection after renal transplantation and its impact on graft function in children and young adults. J Urol 2010;184:1462e8.