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Evaluation of Lower Urinary Tract Function in Renal Transplant Recipients by Urodynamic Study
Evaluation of Lower Urinary Tract Function in Renal Transplant Recipients by Urodynamic Study H. Asakura, K. Nakamura, M. Tachibana, S. Baba, and M. Murai
R
ENAL transplantation is now a common treatment for end-stage renal failure. The indications for renal transplantation should be broadened for the patient with end-stage renal failure. On the other hand, a renal transplant candidate has a defunctionalized bladder and it can return to the normal situation after renal transplantation. However, some recipients have problems of the lower urinary tract and additional treatment such as clean intermittent self-catheterization may be required. Assessing the lower urinary tract is important in postoperative follow-up. Therefore the aim of this study is to evaluate lower urinary tract function in renal transplant patients by urodynamic study. PATIENTS AND METHOD Thirteen patients (5 males, 8 females) were examined. Twelve patients received allografts from living donors, and only one patient received a cadaver kidney in United States (Table 1). The median age was 32 (range 14 to 55). They were free of episodes of neurogenic bladder and had sterile urine. The median of the period of hemodialysis prior to renal transplantation was 12 months (range 3–28). All patients had functioning allografts 5 to 108 months after transplantation, with creatinine levels of 1.0 to 3.3 mg/dL. The median post-void residual was 15 mL. Causes of end-stage renal disease were chronic glomerulonephritis, Goodpasture syndrome, and acute renal failure that developed into the
irreversible renal failure. As a reference group, five hemodialysis patients were chosen to evaluate their lower urinary tract function (Table 2). All hemodialysis patients were females. The median of age in these hemodialysis patients was 39 years old (range 28 to 55). Causes of renal failure were chronic glomerulonephritis and graft loss of primary transplantation. The period of hemodialysis ranged from 2 to 272 months. Procedures related to evaluation of bladder function included uroflowmetry, cystometry, resting urethral pressure profile, and pressure flow study. The patient with urinary tract infection was excluded in this study. Uroflowmetry was performed in renal transplant and hemodialysis patients. In hemodialysis patients, prior to uroflowmetry, cystometry was performed, then uroflowmetry was performed after the removal of the catheter. Cystometry was performed in the supine position and the filling rate of saline was 50 mL/min. The vesical pressure was monitored and the abdominal pressure was estimated from rectal pressure measurement. In resting urethral pressure profile, an 8 Fr of four side-hole catheter was placed into the bladder. Rate of catheter withdrawal was 10 mm/min. In pressure-flow study, the detrusor pressure was monitored with a 5 Fr catheter transurethrally inserted.
From the Department of Urology, Keio University School of Medicine, Tokyo, Japan. Address reprint requests to Dr H. Asakura, Keio University School of Medicine, Dept of Urology, Tokyo, Japan.
Table 1. Transplant Patient Profiles Patient No
1 2 3 4 5 6 7 8 9 10 11 12 13 Median (Range)
Sex/Age at Tx
Cause of ESRD
Period of HD (m)
Postop Followup (M)
Current Cr (mg/dL)
F/32 F/38 F/34 F/25 F/38 F/29 F/14 F/26 M/23 M/37 M/26 M/55 M/41 32 (14 –55)
CG CG (IgA) CG Goodpasture CG CG (Nephrotic syndrome) AR CG CG CG (IgA) CG (IgA) CG CG
14 6 10 17 28 12 3 10 12 12 6 24 6 12 (3–28)
36 72 8 48 60 108 48 5 14 18 60 84 76 48 (5–108)
3.0 3.2 1.0 1.9 3.3 1.1 1.5 1.5 1.0 1.2 1.6 1.1 2.2 1.5 (1.0 –3.3)
Abbreviations: AR, acute renal failure; CG, chronic glomerulonephritis; Cr, creatinine; ESRD, end-stage renal disease; Tx, transplantation.
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 30, 119–121 (1998)
0041-1345/98/$19.00 PII S0041-1345(97)01206-2 119
120
ASAKURA, NAKAMURA, TACHIBANA ET AL Table 2. Hemodialysis (Control) Patient Profiles
Patient No
Age/Sex
Cause of ESRD
Age at HD Induction
1 51/F Drug induced 2 39/F FGS 3 28/F CG 4 35/F Graft loss (CG) 5 44/F Graft loss (CG) Median 39 (28 –51) 35 (Range)
Period of HD (mo)
28 39 26 35 44 (26 – 44)
272 4 31 2 3 4 (2–272)
Abbreviations: CG, chronic glomerulonephritis; ESRD, end-stage renal disease; FGS, focal glomerulosclerosis HD, hemodialysis.
RESULTS (TABLE 3) Cystometry
The cystometric evaluation of renal transplantation patients was normal; on the other hand, the vesical capacity was small in the hemodialysis patients. One of the hemodialysis patients had markedly decreased capacity. This female patient has taken hemodialysis for greater than 20 years. Any uninhibited contraction was not observed in transplant and hemodialysis patients. Uroflowmetry
The results of all patients (female transplant, male transplant, and female hemodialysis patients) were normal except for one male transplant patient who had benign prostatic hyperplasia. Resting Urethral Pressure Profile
The results of resting urethral pressure profile of male and female transplant and female hemodialysis patients were normal. Pressure Flow Study
In this study, pressure flow study was performed in transplant patients only (5 females and 5 males). The results
were evaluated by the diagram of the International Continence Society. The results of pressure flow study were as follows: non-obstructive (3 patients); equivocal (2 patients) in females; equivocal (4 patients); obstructed (1 patient) in males. This obstructed pattern was shown in a 55-year-old man with benign prostatic hyperplasia. This results do not show any particular characteristics of transplant patients. DISCUSSION
There are ample experimental and clinical data showing that if the bladder does not receive a significant urine input for a prolonged period it suffers a reduction in capacity and develops hypertonicity. Tanagho1 reported that defunctionalization of a normal bladder does not limit its ability to recover, which was further proved in subsequent studies. Serrano2 reported that a progressive increase in bladder capacity was noted in all patients (median, 300 cc) within the first 3 months after transplantation, and all voided with a median peak flow rate of 18 mL/sec and disappearance of uninhibited bladder contractions. Chronic inflammation or previous surgery may cause extreme fibrosis leading to impaired bladder recovery. The vesical muscle layer probably undergoes histologic changes that further reduce its compliance.3 Kashi et al.4 reported that their study appeared to identify a subgroup of patients with a bladder capacity of less than 100 mL, which, in association with a history of urinary tract infection, had the poorest long-term renal allograft survival and function. Therefore the history of urinary tract infection is a risk factor to impair the recovery of bladder. Our observation, in line with these reports, are as follows. Longer hemodialysis and disuse of the bladder result in the defunctionalized and reduced capacity bladder. Urodynamic study demonstrated the obstructed pattern in one older patient, and this patient requires additional treatment. These findings suggested that adequate urine output can improve the voiding function. Generally, the period of
Table 3. Results of Urodynamic Studies FDV (mL)
Cystometry Transplant HD
Uroflowmetry Transplant male Transplant female HD female
Resting UPP Transplant male Transplant female HD female
MDV (mL)
Compliance (mL/cm H2O)
458 (327– 610) 302 (82– 466)
16.9 (6.3– 42.2) 15.0 (1.9 –36.8)
MFR (mL/sec)
AFR (mL/s)
Residual Urine (mL)
13.0 (9.1–21.4) 19.0 (9.7–33.1) 13.8 (11.9 –33.1)
6.75 (3.7–11.6) 11.1 (5.8 –16.5) 9.4 (7.54 –17.0)
93 (0 –150) 0 (0 –22) 0 (0 – 49)
MCUP(cmH2O)
FL(mm)
199 (88 –289) 89 (45–199)
96 (60 –128) 77 (70 –121) 70 (40 –130)
48 (46 –58) 35 (31– 48) 37 (29 –39)
Abbreviations: AFR, average flow rate; FDV, first desire to void; FL, functional length; MP, maximum urethral closure pressure; MDV, maximum desire to void; MFR, maximum flow rate.
URINARY TRACT FUNCTION IN RENAL TX
hemodialysis is not a risk factor for recovery of bladder function. It is possible that the high intravesical pressure may be transmitted to the ureter and renal pelvis, with subsequent impaired renal function and reduced graft survival. Therefore, urodynamic study is necessary and important, especially in older renal transplant patients.
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REFERENCES 1. Tanagho E: J Urol 111:102, 1974 2. Serrano DP, Flechner SR, Modlin CS, et al: J Urol 156:885, 1996 3. Schmaelzle JF, Cass AS, Hinman F: J Urol 101:700, 1969 4. Kashi SB, Wynne KS, Sadek SA, et al: Transplantation 57:1455, 1994
R
ENAL transplantation is now a common treatment for end-stage renal failure. The indications for renal transplantation should be broadened for the patient with end-stage renal failure. On the other hand, a renal transplant candidate has a defunctionalized bladder and it can return to the normal situation after renal transplantation. However, some recipients have problems of the lower urinary tract and additional treatment such as clean intermittent self-catheterization may be required. Assessing the lower urinary tract is important in postoperative follow-up. Therefore the aim of this study is to evaluate lower urinary tract function in renal transplant patients by urodynamic study. PATIENTS AND METHOD Thirteen patients (5 males, 8 females) were examined. Twelve patients received allografts from living donors, and only one patient received a cadaver kidney in United States (Table 1). The median age was 32 (range 14 to 55). They were free of episodes of neurogenic bladder and had sterile urine. The median of the period of hemodialysis prior to renal transplantation was 12 months (range 3–28). All patients had functioning allografts 5 to 108 months after transplantation, with creatinine levels of 1.0 to 3.3 mg/dL. The median post-void residual was 15 mL. Causes of end-stage renal disease were chronic glomerulonephritis, Goodpasture syndrome, and acute renal failure that developed into the
irreversible renal failure. As a reference group, five hemodialysis patients were chosen to evaluate their lower urinary tract function (Table 2). All hemodialysis patients were females. The median of age in these hemodialysis patients was 39 years old (range 28 to 55). Causes of renal failure were chronic glomerulonephritis and graft loss of primary transplantation. The period of hemodialysis ranged from 2 to 272 months. Procedures related to evaluation of bladder function included uroflowmetry, cystometry, resting urethral pressure profile, and pressure flow study. The patient with urinary tract infection was excluded in this study. Uroflowmetry was performed in renal transplant and hemodialysis patients. In hemodialysis patients, prior to uroflowmetry, cystometry was performed, then uroflowmetry was performed after the removal of the catheter. Cystometry was performed in the supine position and the filling rate of saline was 50 mL/min. The vesical pressure was monitored and the abdominal pressure was estimated from rectal pressure measurement. In resting urethral pressure profile, an 8 Fr of four side-hole catheter was placed into the bladder. Rate of catheter withdrawal was 10 mm/min. In pressure-flow study, the detrusor pressure was monitored with a 5 Fr catheter transurethrally inserted.
From the Department of Urology, Keio University School of Medicine, Tokyo, Japan. Address reprint requests to Dr H. Asakura, Keio University School of Medicine, Dept of Urology, Tokyo, Japan.
Table 1. Transplant Patient Profiles Patient No
1 2 3 4 5 6 7 8 9 10 11 12 13 Median (Range)
Sex/Age at Tx
Cause of ESRD
Period of HD (m)
Postop Followup (M)
Current Cr (mg/dL)
F/32 F/38 F/34 F/25 F/38 F/29 F/14 F/26 M/23 M/37 M/26 M/55 M/41 32 (14 –55)
CG CG (IgA) CG Goodpasture CG CG (Nephrotic syndrome) AR CG CG CG (IgA) CG (IgA) CG CG
14 6 10 17 28 12 3 10 12 12 6 24 6 12 (3–28)
36 72 8 48 60 108 48 5 14 18 60 84 76 48 (5–108)
3.0 3.2 1.0 1.9 3.3 1.1 1.5 1.5 1.0 1.2 1.6 1.1 2.2 1.5 (1.0 –3.3)
Abbreviations: AR, acute renal failure; CG, chronic glomerulonephritis; Cr, creatinine; ESRD, end-stage renal disease; Tx, transplantation.
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 30, 119–121 (1998)
0041-1345/98/$19.00 PII S0041-1345(97)01206-2 119
120
ASAKURA, NAKAMURA, TACHIBANA ET AL Table 2. Hemodialysis (Control) Patient Profiles
Patient No
Age/Sex
Cause of ESRD
Age at HD Induction
1 51/F Drug induced 2 39/F FGS 3 28/F CG 4 35/F Graft loss (CG) 5 44/F Graft loss (CG) Median 39 (28 –51) 35 (Range)
Period of HD (mo)
28 39 26 35 44 (26 – 44)
272 4 31 2 3 4 (2–272)
Abbreviations: CG, chronic glomerulonephritis; ESRD, end-stage renal disease; FGS, focal glomerulosclerosis HD, hemodialysis.
RESULTS (TABLE 3) Cystometry
The cystometric evaluation of renal transplantation patients was normal; on the other hand, the vesical capacity was small in the hemodialysis patients. One of the hemodialysis patients had markedly decreased capacity. This female patient has taken hemodialysis for greater than 20 years. Any uninhibited contraction was not observed in transplant and hemodialysis patients. Uroflowmetry
The results of all patients (female transplant, male transplant, and female hemodialysis patients) were normal except for one male transplant patient who had benign prostatic hyperplasia. Resting Urethral Pressure Profile
The results of resting urethral pressure profile of male and female transplant and female hemodialysis patients were normal. Pressure Flow Study
In this study, pressure flow study was performed in transplant patients only (5 females and 5 males). The results
were evaluated by the diagram of the International Continence Society. The results of pressure flow study were as follows: non-obstructive (3 patients); equivocal (2 patients) in females; equivocal (4 patients); obstructed (1 patient) in males. This obstructed pattern was shown in a 55-year-old man with benign prostatic hyperplasia. This results do not show any particular characteristics of transplant patients. DISCUSSION
There are ample experimental and clinical data showing that if the bladder does not receive a significant urine input for a prolonged period it suffers a reduction in capacity and develops hypertonicity. Tanagho1 reported that defunctionalization of a normal bladder does not limit its ability to recover, which was further proved in subsequent studies. Serrano2 reported that a progressive increase in bladder capacity was noted in all patients (median, 300 cc) within the first 3 months after transplantation, and all voided with a median peak flow rate of 18 mL/sec and disappearance of uninhibited bladder contractions. Chronic inflammation or previous surgery may cause extreme fibrosis leading to impaired bladder recovery. The vesical muscle layer probably undergoes histologic changes that further reduce its compliance.3 Kashi et al.4 reported that their study appeared to identify a subgroup of patients with a bladder capacity of less than 100 mL, which, in association with a history of urinary tract infection, had the poorest long-term renal allograft survival and function. Therefore the history of urinary tract infection is a risk factor to impair the recovery of bladder. Our observation, in line with these reports, are as follows. Longer hemodialysis and disuse of the bladder result in the defunctionalized and reduced capacity bladder. Urodynamic study demonstrated the obstructed pattern in one older patient, and this patient requires additional treatment. These findings suggested that adequate urine output can improve the voiding function. Generally, the period of
Table 3. Results of Urodynamic Studies FDV (mL)
Cystometry Transplant HD
Uroflowmetry Transplant male Transplant female HD female
Resting UPP Transplant male Transplant female HD female
MDV (mL)
Compliance (mL/cm H2O)
458 (327– 610) 302 (82– 466)
16.9 (6.3– 42.2) 15.0 (1.9 –36.8)
MFR (mL/sec)
AFR (mL/s)
Residual Urine (mL)
13.0 (9.1–21.4) 19.0 (9.7–33.1) 13.8 (11.9 –33.1)
6.75 (3.7–11.6) 11.1 (5.8 –16.5) 9.4 (7.54 –17.0)
93 (0 –150) 0 (0 –22) 0 (0 – 49)
MCUP(cmH2O)
FL(mm)
199 (88 –289) 89 (45–199)
96 (60 –128) 77 (70 –121) 70 (40 –130)
48 (46 –58) 35 (31– 48) 37 (29 –39)
Abbreviations: AFR, average flow rate; FDV, first desire to void; FL, functional length; MP, maximum urethral closure pressure; MDV, maximum desire to void; MFR, maximum flow rate.
URINARY TRACT FUNCTION IN RENAL TX
hemodialysis is not a risk factor for recovery of bladder function. It is possible that the high intravesical pressure may be transmitted to the ureter and renal pelvis, with subsequent impaired renal function and reduced graft survival. Therefore, urodynamic study is necessary and important, especially in older renal transplant patients.
121
REFERENCES 1. Tanagho E: J Urol 111:102, 1974 2. Serrano DP, Flechner SR, Modlin CS, et al: J Urol 156:885, 1996 3. Schmaelzle JF, Cass AS, Hinman F: J Urol 101:700, 1969 4. Kashi SB, Wynne KS, Sadek SA, et al: Transplantation 57:1455, 1994