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Campbell P, Ingulli E, Christman M, Marietti S. Revision ureteroneocystostomy in pediatric renal transplant patients for symptomatic vesicoureteral reflux and its effect on recurrent hospitalizations. J Pediatr Urol 2022; 18:675.e1-675.e7. [PMID: 36167649 DOI: 10.1016/j.jpurol.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/08/2022] [Accepted: 09/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nearly 13,000 pediatric renal transplantations have been performed since 1987 with improving overall mortality and morbidity; however, graft infection remains a significant post-transplant concern. Recurrent urinary tract infections in pediatric patients with vesicoureteral reflux into their renal transplant can result in graft dysfunction, increased hospital cost, and impaired social and cognitive development due to time spent hospitalized. OBJECTIVE To evaluate the effect of revision ureteroneocystostomy on pediatric renal transplant patients with symptomatic vesicoureteral reflux in reducing hospitalizations and recurrent urinary tract infections. METHODS We retrospectively reviewed pediatric patients from 2002 through 2021 who underwent renal transplantation and required revision ureteroneocystostomy due to symptomatic vesicoureteral reflux. We analyzed the differences in days hospitalized, days hospitalized due to urinary tract infection, and treated urinary tract infections prior to and after revision ureteroneocystostomy. RESULTS Ten patients requiring revision ureteroneocystostomy secondary to symptomatic vesicoureteral reflux were identified. There was no difference in the observation time between transplant to revision, and revision to last follow up (2.3 years (IQR 1.3-6.5) vs 1.7 years (IQR 1-6.7), p = 0.4446). Overall, there was a significant decrease in the total number of hospitalization days (21.5 days (IQR 3-43) vs 5.5 days (IQR 0-9), p = 0.006), total number of hospitalization days related to urinary tract infection (14.5 days (IQR 3-28) vs 0 days (IQR 0-3), p = 0.008) and treated urinary tract infections (3.5 (IQR 3-6) vs 1 (IQR 0-2), p = 0.019) following revision ureteroneocystostomy. The rate of hospitalization days for urinary tract infection was also significantly decreased following revision ureteroneocystostomy (7.15 per/year (IQR 0.4-11.75) vs 0 per/year (IQR 0-0.8), p = 0.008). DISCUSSION Symptomatic vesicoureteral reflux in pediatric transplant patients is difficult to manage and some patients will ultimately require surgery. There have been previous studies on the success of revision ureteroneocystostomy in treating reflux but no data on the reduction in hospitalizations associated with recurrent infections following the procedure. Limitations of this study are the small cohort size, retrospective nature, multi-surgeon study, and inherent selection bias due to evaluation of only surgical patients. CONCLUSION Revision ureteroneocystostomy can limit the negative consequences of recurrent graft infections with reduction in hospitalization days and improved hospitalization rates due to urinary tract infections. The reduction in hospitalizations can greatly improve the cost of care along with quality of life for transplant patients and should be strongly considered in children with symptomatic vesicoureteral reflux who have failed conservative therapy.
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Affiliation(s)
- Paul Campbell
- Department of Urology, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA, 92134, USA.
| | - Elizabeth Ingulli
- University California San Diego, Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, USA.
| | - Matthew Christman
- Department of Urology, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA, 92134, USA.
| | - Sarah Marietti
- University California San Diego, Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, USA.
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Acharya R, Aly R, Upadhyay K. Renal Transplant Hydroureteronephrosis as a Manifestation of Rejection: An Under-Recognized Entity? Case Rep Nephrol Dial 2021; 11:87-94. [PMID: 33829046 PMCID: PMC7991281 DOI: 10.1159/000514199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/03/2021] [Indexed: 11/19/2022] Open
Abstract
Hydroureteronephrosis (HUN) of the renal transplant (RT) can be obstructive or non-obstructive, refluxing or non-refluxing, and can cause allograft dysfunction. HUN of the RT as a manifestation of rejection is uncommon and has not been described in children. We describe two pediatric RT recipients who presented with late-onset HUN, 5 and 10 years after transplantation. Both had new-onset HUN which occurred at the time of rejection; HUN resolved in both patients after treatment of rejection. Renal function stabilized in both patients without the need for stent or nephrostomy tube placement. There was no obstruction or vesicoureteral reflux (VUR). Edema of the uroepithelial cells leading to transient obstruction causing HUN is a most likely explanation. We conclude that treatment of rejection in patients without obstruction or VUR may lead to resolution of HUN without the need for urological interventions.
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Affiliation(s)
- Ratna Acharya
- Division of General Pediatrics, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Rasha Aly
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Kiran Upadhyay
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
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Vesicoureteral Reflux: Special Considerations and Specific Populations. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00608-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wu HY, Concepcion W, Grimm PC. When does vesicoureteral reflux in pediatric kidney transplant patients need treatment? Pediatr Transplant 2018; 22:e13299. [PMID: 30324753 DOI: 10.1111/petr.13299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 08/09/2018] [Accepted: 09/07/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE The treatment of VUR in children with UTI has changed significantly, due to studies showing that antibiotic prophylaxis does not decrease renal scarring. As children with kidney transplants are at higher risk for UTI, we investigated if select patients with renal transplant VUR could be managed without surgery. MATERIALS AND METHODS A total of 18 patients with VUR into their renal grafts were identified, and 319 patients underwent transplantation from 2006 to 2016. The cause for the detection of the VUR, treatment, and graft function was reviewed. RESULTS Six boys and 12 girls were identified, 13 of whom had grade 3 or 4 VUR into the renal graft. Nine patients presented with hydronephrosis or abnormal renal biopsy: eight were successfully managed with antibiotic prophylaxis and bladder training, one developed UTI and underwent Dx/HA subureteric injection. Nine patients presented with recurrent febrile UTI, only one was successfully managed without surgery. Only 2 of 9 (22%) patients who underwent Dx/HA injection had resolution of their reflux. Of the remaining seven, five required open ureteral reimplantation (two for obstruction), one lost the graft due to rejection, and one had significant hydronephrosis. eGFR was similar between the hydronephrosis, UTI, and abnormal renal biopsy groups at all times. CONCLUSION Patients with transplant VUR and recurrent febrile UTI are more likely to require surgical therapy, but the complication and failure rate for Dx/HA injection is significant. Patients with transplant VUR without febrile UTI can be successfully managed with bladder training and temporary antibiotic prophylaxis.
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Affiliation(s)
- Hsi-Yang Wu
- Division of Pediatric Urology, Lucile Packard Children's Hospital, Stanford, California
| | - Waldo Concepcion
- Division of Kidney Transplantation, Lucile Packard Children's Hospital, Stanford, California
| | - Paul C Grimm
- Division of Kidney Transplantation, Lucile Packard Children's Hospital, Stanford, California
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Wang MK, Chuang KW, Li Y, Gaither T, Brakeman P, Gonzalez L, Brennan J, Baskin LS. Renal function outcomes in pediatric patients with symptomatic reflux into the transplanted kidney treated with redo ureteroneocystostomy. J Pediatr Urol 2018; 14:275.e1-275.e5. [PMID: 29605164 DOI: 10.1016/j.jpurol.2018.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 01/03/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Asymptomatic post-renal transplant reflux is common but only 5-10% patients are diagnosed with vesico-ureteral reflux in the setting of post-transplant febrile urinary tract infections, requiring redo ureteroneocystostomy (redo-UNC). Here we report the renal function outcomes of 37 such patients, stratified by lower urinary tract (LUT) status. OBJECTIVE We hypothesized that those with pre-transplant LUT dysfunction would have lower glomerular filtration rate (GFR) on follow-up. STUDY DESIGN Using procedure codes, 37 patients who underwent renal transplant followed by redo-UNC for transplant reflux at our institution between 1991 and 2014 were identified. Patient characteristics and GFR levels from four different time points were recorded. Comparisons were made between those with and without LUT dysfunction, using Fisher's exact, Wilcoxon rank sum, or signed-rank tests. Generalized estimating equations were constructed to account for the clustered nature of GFR within each LUT group and to assess their change over time. RESULTS Twelve patients (32%) had pre-transplant LUT dysfunction. The proportion of males in this group was significantly higher (75% vs. 32%, p = 0.032), and there was no statistical difference towards presenting earlier with post-transplant reflux (1.4 vs. 2.3 years, p = 0.087). After an average of 4.9 years, the median GFRs were similar between the two groups (53 mg/dL vs. 58 mg/dL, p = 0.936). There was no significant difference in GFR at this last follow-up time point in patients with and without LUT dysfunction. DISCUSSION Vesicoureteral reflux in the setting of renal transplantation is common and doesn't often require repair. In our series, we found that those with LUT dysfunction did not present statistically sooner with symptomatic transplant reflux. Longer-term follow-up did show a decline in GFR but did not reveal a difference in GFR in patients' with and without LUT dysfunction. CONCLUSIONS Pediatric post-transplant GFR after open redo ureteral reimplant decreases over time in similar fashion in patients with symptomatic reflux regardless of whether they have LUT dysfunction or normal anatomy. Vigilance should apply to the recognition, treatment, and follow-up of all symptomatic transplant reflux regardless of LUT status.
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Affiliation(s)
- Mary K Wang
- Department of Urology, University of California, San Francisco, CA, USA.
| | - Kai-Wen Chuang
- Department of Urology, University of California, San Francisco, CA, USA
| | - Yi Li
- Department of Urology, University of California, San Francisco, CA, USA
| | - Thomas Gaither
- Department of Urology, University of California, San Francisco, CA, USA
| | - Paul Brakeman
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Lynette Gonzalez
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Jessica Brennan
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Laurence S Baskin
- Department of Urology, University of California, San Francisco, CA, USA
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Van Arendonk KJ, Goldstein SD, Salazar JH, Kumar K, Lau HT, Colombani PM. A nipple-valve technique for ureteroneocystostomy in pediatric kidney transplantation. Pediatr Transplant 2015; 19:42-7. [PMID: 25400105 DOI: 10.1111/petr.12393] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2014] [Indexed: 11/29/2022]
Abstract
The ureteroneocystostomy in kidney transplantation can be performed with a variety of techniques. Over a 20-yr period, we utilized a technique of nipple-valve ureteroneocystostomy for the pediatric kidney transplants performed at our institution. The distal ureter is everted upon itself and anchored in place with four interrupted sutures to create a nipple valve, which is then inserted into the bladder and sewn mucosa-to-mucosa with the same sutures. The muscularis layer is closed around the ureter without tunneling and without routine ureteral stenting. After 109 transplants, patient survival was 97.2, 97.2, and 86.9% at one, five, and 10 yr, respectively. Graft survival was 91.7, 71.7, and 53.9% at one, five, and 10 yr, respectively. The most common cause of graft loss was acute or chronic rejection, seen in 75% of those experiencing graft loss. Two patients (1.8%) developed pyelonephritis in the transplanted kidney. Nipple-valve ureteroneocystostomy in pediatric kidney transplantation is a safe and simple method for performing the ureterovesical anastomosis with a low rate of pyelonephritis after transplantation.
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Affiliation(s)
- Kyle J Van Arendonk
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Zhang L, Liu C, Li F, Li X, Sun C, Sun H. Diagnosis of 65 cases of ampullary renal pelvis after postnatal follow-up of 1,167 newborn infants with prenatally suspected hydronephrosis. Exp Ther Med 2014; 9:151-153. [PMID: 25452792 PMCID: PMC4247286 DOI: 10.3892/etm.2014.2076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 10/10/2014] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to assess the morbidity of ampullary renal pelvis (ARP) and document its natural history in post-natal life. A total of 1,167 newborn infants with prenatally suspected hydronephrosis were retrospectively analyzed. Of these, 65 patients were diagnosed with ARP by computed tomography urography (CTU) and/or magnetic resonance urography (MRU). All cases were followed up with ultrasonogrophy at 1, 3, 6 and 12 months after birth, and one case was followed up for 5 years. Changes in the separation of the renal pelvis collection system were recorded. Children with ARP accounted for 5.57% of the total cases (65/1,167) followed-up. No lack of connection between the renal calyces and the renal pelvis was detected. The long-term follow-up revealed that the separation of the renal pelvis collection system did not tend to increase over time. In addition to imaging examinations, long-term follow-up observation is recommended for the accurate diagnosis of pediatric ARP, particularly for differentiation from hydronephrosis.
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Affiliation(s)
- Lei Zhang
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Chao Liu
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Fujiang Li
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xiang Li
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Chao Sun
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Hao Sun
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
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Abstract
Kidney transplantation can be associated with various complications that vary from vascular complications to urologic disorders to immunologic adverse effects. In evaluating the recipient with graft dysfunction, clinicians can choose among several imaging modalities, including ultrasonography, nuclear medicine studies, computed tomography, and magnetic resonance imaging. This review discusses the evaluation of the kidney transplant recipient using these imaging procedures, emphasizing the clinical diagnostic utility and role of each modality. A kidney biopsy is often required as a gold standard for diagnostic purposes. However, because of the inherent risks of a kidney biopsy, noninvasive imaging in diagnosing causes of graft dysfunction is a highly desired tool used and needed by the transplant community. Because the diagnostic accuracy varies depending on the time course and nature of the transplant-related complication, this review also addresses the advantages and limitations of each modality. The recent advances in kidney transplant imaging techniques and their clinical implications are also discussed.
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Affiliation(s)
- Asif Sharfuddin
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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