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Hammi Y, Baati R, Ferjeni M, Sayari T, Naija O, Gargah T. Urodynamic assessment in the management of the child's posterior urethral valves. LA TUNISIE MEDICALE 2022; 99:985-991. [PMID: 35288900 PMCID: PMC8972179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bladder dysfunction may be associated with valves of the posterior urethra. Their evaluation by urodynamic assessment is an important parameter for the therapeutic management. The objective of our study was to study the contribution of urodynamic assessment in the management of valves of the posterior urethra of the child. METHODS Our study was descriptive, retrospective, involving 43 children with posterior urethral valves (PUV), followed at the pediatric ward at Charles Nicolle Hospital in Tunis from January 1995 to December 2015. All the children had an urodynamic assessment after valves of the posterior urethra treatment. RESULTS The mean age was 15.8 months. Preoperatively, creatinine clearance was below 60 ml / min in 32 patients (74%). The worsening of renal function was noted in 32 (74%). A significant post-voiding residue proved in 34 patients (79%). Cystometry revealed a hypo compliant bladder in 24 (56%), low bladder capacity in 42% of cases; a hypertonic detrusor in 37% of cases. Bladder sphincter dyssynergia was diagnosed in 6 patients. Like urodynamic assessment data, bladder enlargement associated with a Mitrofanoff-type shunt was indicated and performed in 3 patients (7%). CONCLUSION Through our study, the urodynamic profile made it possible to specify the type of vesico-sphincter dysfunctions persistent in patients operated for PUV, and subsequently to adapt the therapeutic conduct in these patients. Given the lack of management and the consequences on the health of the child as well as on his quality of life, reflections on the preventive and therapeutic approach after PUV treatment are necessary.
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Cornwell LB, Ingulli EG, Mason MD, Ewing E, Riddell JV. Renal Transplants Due to Congenital Anomalies of the Kidney and Urinary Tract (CAKUT) Have Better Graft Survival Than Non-CAKUT Controls: Analysis of Over 10,000 Patients. Urology 2021; 154:255-262. [PMID: 33454356 DOI: 10.1016/j.urology.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/28/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether graft survival for patients with congenital anomalies of the kidney and urinary tract (CAKUT) is impaired compared to non-CAKUT counterparts. METHODS The United States Renal Data System (USRDS) is a national data system that has collected information about end stage renal disease (ESRD) and renal transplantation since 1995. We identified 10,635 first-time renal transplant patients with ESRD attributed to a CAKUT diagnosis transplanted between 1995 and 2018, with follow-up of 7.9 ± 5.8 years. We matched 1:1 with non-CAKUT transplant recipients, using age at transplant, sex, race, year of transplant, and donor-type. We compared renal transplant death-censored graft survival between CAKUT vs non-CAKUT controls, with further stratification for age at transplant and lower urinary tract malformations (LUTM) vs upper urinary tract malformations (UUTM). RESULTS Graft survival was better in CAKUT patients with a 5-year survival of 83.3% vs 79.3% (P< .001), and CAKUT status infers a hazard ratio of 0.878 for graft failure on multivariable analysis with Cox regression. Favorability of CAKUT status persisted when stratifying for both pediatric (80.3 vs 77.6% P< .001) and adult (84.5 vs 81.4% P< .001) age groups. Looking within the CAKUT population: comparison of LUTM to UUTM yielded no difference, implying that LUTM is not a risk factor for graft failure. Examining pediatric LUTM alone, graft survival was not better than matched non-CAKUT counterparts with 5-year graft survival of 69%-75% for LUTM adolescents. CONCLUSION Renal transplant graft survival is better overall in CAKUT patients as opposed to non-CAKUT counterparts. Pediatric LUTM patients have similar graft survival to controls.
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Affiliation(s)
- Laura B Cornwell
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY; Rady Children's Hospital San Diego, San Diego, CA.
| | | | - Matthew D Mason
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY
| | - Emily Ewing
- Rady Children's Hospital San Diego, San Diego, CA
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Long-term outcome of kidney transplantation in patients with congenital anomalies of the kidney and urinary tract. Pediatr Nephrol 2019; 34:2409-2415. [PMID: 31309282 DOI: 10.1007/s00467-019-04300-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/29/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Congenital anomalies of the kidney and urinary tract (CAKUT) are a leading cause of end-stage kidney failure in the young. However, there is limited information on long-term outcomes after kidney transplantation in this group. We explored the outcomes of kidney transplant in patients with the 3 most common severe forms of CAKUT: posterior urethral valves (PUV), reflux nephropathy and renal hypoplasia/dysplasia. METHODS Data were extracted from the Australian & New Zealand Dialysis & Transplant Registry on first kidney transplants performed between 1985 and 2015 in recipients with a primary diagnosis of PUV, renal hypoplasia/dysplasia or reflux nephropathy (under the age of 30 years). Using multivariate Cox regression, we compared death-censored graft survival between the three groups. RESULTS One hundred twenty-seven patients with PUV, 245 with hypoplasia/dysplasia and 727 with reflux nephropathy were included. A 10-year graft survival in PUV, hypoplasia/dysplasia and reflux nephropathy was 70%, 76% and 70%, respectively and a 20-year graft survival was 30%, 53% and 49%. After adjusting for age at transplant, graft source and HLA matching, there was evidence for poorer graft survival in PUV (HR, 1.65; 95% CI, 1.15 to 2.38). CONCLUSIONS Graft survival of the first transplant in CAKUT is favourable at 10 years; however, recipients with PUV have increased risk of graft loss beyond a 10-year post-transplant, which may be related to bladder dysfunction.
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Does bladder augmentation negatively affect renal transplant outcome in posterior urethral valve patients? J Pediatr Urol 2014; 10:892-7. [PMID: 24569042 DOI: 10.1016/j.jpurol.2014.01.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 01/13/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Although renal transplant (RT) is a safe and effective treatment for end-stage renal disease, the outcome of RT has been mixed for posterior urethral valve (PUV) patients. In addition, some PUV patients need an augmentation cystoplasty (AC), which may negatively affect their RT outcome. The aim of this study is to compare RT outcome between PUV children with and without AC. MATERIALS AND METHODS Between 1985 and 2012 a total of 309 children received 369 RTs at our institution. Among these patients, 36 were had classified as having PUV. Of these, 12 underwent an AC before RT (AC group) and 24 did not (controls). Data, including age at transplant, allograft source, urological complications, urinary tract infection (UTI) incidence, the presence of vesicoureteral reflux (VUR), and patient and graft survival, were compared between groups. RESULTS Mean age at RT and mean follow-up were 7.6 versus 7.9 years and 8.9 versus 7.9 years in the AC group and in the control group, respectively (not significant [NS]). Allografts were from living donors in 50% of the AC group and in 41.6% of the controls (NS). The rate of UTI was 0.02 UTI/patient/year and 0.004 UTI/patient/year in the AC and control group, respectively (p = 0.001). Of the nine patients with UTI in the augmented group, five (55.5%) had VUR, while 5/8 (62.5%) patients in the control group with UTI had VUR. All patients with VUR in either group had UTIs previously. Of the five AC patients with more than three UTIs, two (40%) were non-compliant with clean intermittent catheterization (CIC), and UTI incidence was not associated with either a Mitrofanoff conduit or the urethra being used for CIC. Graft function at the end of study was 87.8 ± 40.5 ml/min/m(2) in the AC group and 88.17 ± 28.20 ml/min/m(2) in the control group (NS). The 10-year graft survival rate was 100% in AC group and 84.8% in controls. Two patients in the AC group lost their grafts (mean follow-up 13.3 ± 0.8 years) and five in the control group (mean follow-up 7.1 ± 4.7 years). CONCLUSIONS Bladder augmentation does not negatively affect renal outcome in PUV patients undergoing transplantation. However, recurrent UTIs are more frequent in transplanted PUV patients with an AC than in those without AC, and they are generally related to non-compliance with CIC or the presence of VUR but, mostly, they will not result in impaired graft function.
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Pereira PL, Urrutia MJM, Lobato R, Jaureguizar E. Renal Transplantation in Augmented Bladders. Curr Urol Rep 2014; 15:431. [DOI: 10.1007/s11934-014-0431-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lopez Pereira P, Martinez Urrutia MJ, Espinosa L, Jaureguizar E. Long-term consequences of posterior urethral valves. J Pediatr Urol 2013; 9:590-6. [PMID: 23871421 DOI: 10.1016/j.jpurol.2013.06.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 06/15/2013] [Indexed: 11/29/2022]
Abstract
Posterior urethral valves (PUV) are the most common congenital cause of bladder outlet obstruction in infancy, and it is the effect of this obstruction on the bladder and the kidneys that will decide a patient's prognosis. With the improvements in diagnosis and treatments, what was previously a poor prognosis for boys with PUV has improved, and more patients will encounter the long-term sequelae of PUV during puberty and adulthood. In these patients the long-term prognosis in terms of renal and bladder function and fertility, as well as the risk of malignancy in those whose bladders were augmented with gastrointestinal segments, is still a matter of great concern and all of these topics will be discussed in this article.
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Affiliation(s)
- Pedro Lopez Pereira
- Unit of Paediatric Urology and Nephrology, University Hospital La Paz, Madrid, Spain.
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Al-Khudairi N, Riley P, Desai DY, Reid C, Marks SD, Mamode N. Interventions for impaired bladders in paediatric renal transplant recipients with lower urinary tract dysfunction. Transpl Int 2013; 26:428-34. [PMID: 23350943 DOI: 10.1111/tri.12063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Revised: 11/18/2012] [Accepted: 12/23/2012] [Indexed: 11/30/2022]
Abstract
Dysfunctional bladders in paediatric patients were thought to be a contraindication for renal transplantation, but advances in surgical techniques have meant that surgical correction can allow safe transplantation. This study compares the outcomes of renal transplantation for different interventions, and the timing of such interventions, in relation to transplantation. We identified all paediatric renal transplant recipients with LUTD that received intervention for their impaired bladders at two hospitals between 2002 and 2010. Outcome measures included patient and graft survival, perioperative complications, UTI incidence, acute rejection episodes and serum creatinine levels. A total of 288 allografts were transplanted, 77 were in 75 children with LUTD, of which 46 received intervention. Patient survival was 100% in the intervention group and 97% in the nonintervention group (P = 0.815). Death-censored graft survival was 96% and 100% respectively (P = 0.688). In the groups receiving intervention pretransplant or post-transplant, graft survival rates were 95% and 100% respectively (P = 0.476). The follow-up serum creatinine levels were higher in the pretransplant intervention group (P < 0.001). Interventions for dysfunctional bladders can be performed safely in paediatric renal transplant recipients. The mode of intervention and timing of intervention, in relation to transplant, do not influence outcomes if guided by careful assessment and investigation.
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Mencarelli F, Marks SD. Non-viral infections in children after renal transplantation. Pediatr Nephrol 2012; 27:1465-76. [PMID: 22318475 PMCID: PMC3407356 DOI: 10.1007/s00467-011-2099-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 11/05/2011] [Accepted: 11/11/2011] [Indexed: 12/20/2022]
Abstract
Renal transplantation has long been recognised as the gold standard treatment for children with end-stage renal failure. There has been an improvement over the years in patient and renal allograft survival because of improved immunosuppression, surgical techniques and living kidney donation. Despite reduced acute allograft rejection rates, non-viral infections continue to be a serious complication for paediatric renal transplant recipients (RTR). The risk of infections in RTR is determined by the pre-transplantation immunisation status, post-transplant exposure to potential pathogens and the amount of immunosuppression. The greatest risk of life-threatening and Cytomegalovirus infections is during the first 6 months post-transplant owing to a high immunosuppressive burden. The potential sources of bacterial infections are donor derived, transplant medium fluid, peritoneal and haemodialysis catheter and transplant ureteric stent. Urinary tract infections are frequent in patients with lower urinary tract dysfunction and can result in renal allograft damage. This review outlines the incidence, timing, risk factors, prevention and treatment of non-viral infections in paediatric RTR by critically reviewing current immunosuppressive regimens, their risk-benefit ratio in order to optimise renal allograft survival with reduced rates of rejection and infectious complications.
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Affiliation(s)
- Francesca Mencarelli
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH England UK
| | - Stephen D. Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH England UK
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Ounissi M, Gargah T, Bacha M, Boubaker K, Hedri H, Abderrahim E, Derouich A, Slama R, Chebil M, Abdallah T, Kheder A. Malformative Uropathies and Kidney Transplantation. Transplant Proc 2011; 43:437-40. [DOI: 10.1016/j.transproceed.2011.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Challenges Facing Renal Transplantation in Pediatric Patients With Lower Urinary Tract Dysfunction. Transplantation 2010; 89:1299-1307. [DOI: 10.1097/tp.0b013e3181de5b8c] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Capozza N, Torino G, Collura G, Battaglia S, Guzzo I, Caione P, Strologo LD. Renal Transplantation in Patients With “Valve Bladder”: Is Bladder Augmentation Necessary? Transplant Proc 2010; 42:1069-73. [DOI: 10.1016/j.transproceed.2010.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rees L. Long-term outcome after renal transplantation in childhood. Pediatr Nephrol 2009; 24:475-84. [PMID: 17687572 PMCID: PMC2755795 DOI: 10.1007/s00467-007-0559-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 06/19/2007] [Accepted: 06/19/2007] [Indexed: 10/27/2022]
Abstract
The purpose of this article is to review: 1. Factors influencing long-term outcome data after transplantation 2. Patient survival overall, the effect of recipient age and donor type, causes of death, comparison of mortality after transplantation with that on dialysis, and effect of pre-emptive transplantation and race 3. Transplant survival overall, and the effect of recipient and donor age, donor type, pre-emptive transplantation, recurrent diseases, human leukocyte antigen (HLA) matching, immunosuppression, concordance, hypertension, bladder dynamics and type of donor nephrectomy 4. Final height and obesity 5. Psycho-social outcome.
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Affiliation(s)
- Lesley Rees
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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Otukesh H, Basiri A, Simfroosh N, Hoseini R, Fereshtehnejad SM, Chalian M. Kidney transplantation in children with posterior urethral valves. Pediatr Transplant 2008; 12:516-9. [PMID: 18266799 DOI: 10.1111/j.1399-3046.2007.00846.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There is controversy about the outcome of renal transplantation in patients with PUV. The objective of this study was to analyze the outcome of renal transplantation in children with PUV. Fifteen patients had a history of PUV as the etiology of their ESRD. Forty-five patients comprised a control group without lower urinary tract anomalies. Mean age and follow-up duration were not significantly different between the case and the control group (p = 0.1). The immunosuppressive protocol and the year of transplantation were similar in these two groups (p = 0.2, 0.4, respectively). Among patients with PUV, 37.5% had acute rejection; and 56.2% had chronic rejection. Among the controls, 22.2% had acute rejection and 28.8% had chronic rejection. None of these differences was significant. Mean survival time was seven yr in affected patients and 6.2 yr in the control group (p = 0.9). Among patients with PUV, the rate of graft survival in the first year after transplantation was 95%; and those in the third, fifth, and seventh yr, 91%, 65%, and 50%, respectively. For the controls, the graft survival was 83% at one yr; 80% at three yr; 71% at five yr; and 60% at seven yr after transplantation (p = 0.9). Conclusively, this study showed that a history of PUV had no effect on graft function. Graft survival was not different among these patients compared with patients free of these anomalies. We also showed that urological complications were few in these patients.
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Affiliation(s)
- Hasan Otukesh
- Labafi Nejad Hospital, Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Ramalingam M, Senthil K, Pai MG, Balasubramanian R, Premkumar K. Laparoscopic ureterocystoplasty before kidney transplantation. J Endourol 2008; 22:321-5. [PMID: 18211208 DOI: 10.1089/end.2007.0123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To describe the technique of total laparoscopic ureterocystoplasty. MATERIALS AND METHODS Laparoscopic ureterocystoplasty was performed to optimize the bladder function before kidney transplantation in a 23-year-old man. This patient had undergone bilateral cutaneous ureterostomy with fulguration of a posterior urethral valve at the age of 11 months. He underwent open surgical removal of multiple renal stones at age 10. He progressed to chronic renal failure at the age of 20, at which time hemodialysis was initiated. Because of grade IV vesicoureteral reflux and a poorly compliant bladder, the patient underwent laparoscopic ureterocystoplasty. RESULTS The patient's lower urinary tract symptoms improved, and a urodynamic study performed after 6 months revealed a compliant bladder. Subsequently, a right nephrectomy and a live-donor renal transplantation from his mother were performed. At 1-year follow-up, his renal parameters were within normal range, he does not have any significant residual urine or urinary symptoms. CONCLUSION Laparoscopic ureterocystoplasty is an excellent option for a poorly compliant bladder, especially when a patient has had multiple open surgeries and is awaiting renal transplantation.
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Affiliation(s)
- Manickam Ramalingam
- Department of Urology, K.G. Hospital and Post Graduate Institute, Coimbatore, India.
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Khositseth S, Askiti V, Nevins TE, Matas AJ, Ingulli EG, Najarian JS, Gillingham KJ, Chavers BM. Increased urologic complications in children after kidney transplants for obstructive and reflux uropathy. Am J Transplant 2007; 7:2152-7. [PMID: 17697261 DOI: 10.1111/j.1600-6143.2007.01912.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the cyclosporine era, reports on pediatric kidney transplant (KTx) patients with obstructive and reflux uropathy are limited by small numbers, short follow-up, and/or lack of control groups. Our single-center study evaluated long-term outcomes (patient and graft survival, urinary tract infections [UTIs], urologic complications) in a large cohort of KTx recipients (<20 years old). We matched our 117 study patients with obstructive and reflux uropathy with 117 controls whose KTx was needed for other reasons; all 234 underwent their KTx between April 25, 1984, and October 23, 2002. The mean age was 8.0 +/- 6.2 years; mean follow-up, 133 +/- 67 months. The urologic complication rate was higher in study patients (43%) than in controls (11%) (p < 0.0001), as was the UTI rate (45% vs. 2%; p < 0.0001). The metabolic acidosis and UTI rates were higher in study patients who did (vs. did not) undergo bladder augmentation (p < 0.0001). We found no significant difference between study patients and controls in patient or graft survival, acute or chronic rejection, or mean estimated glomerular filtration rates. Unique to our study is the finding of higher metabolic acidosis and UTI rates in study patients who underwent bladder augmentation.
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Affiliation(s)
- S Khositseth
- Department of Pediatrics, Thammasat University, Pathumthani, Thailand
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Canon S, Alpert S, Koff SA. Nocturnal bladder emptying for reversing urinary tract deterioration due to neurogenic bladder. Curr Urol Rep 2007; 8:60-5. [PMID: 17239318 DOI: 10.1007/s11934-007-0022-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Although daytime clean intermittent catheterization with urotropic medications is often sufficient therapy to relieve urinary retention and elevated intravesical pressures, neglecting the bladder affected by neuropathy or other significant pathologies during sleeping hours can lead to overdistension of the bladder and its deleterious consequences. The effect of this seemingly inconsequential clean intermittent catheterization interlude for some patients on an ideal daytime-only management protocol can lead to a syndrome of nighttime overdistension of the bladder, which can result in recurrent urinary tract infections, worsened incontinence, decreased bladder compliance and capacity, and progressive hydroureteronephrosis and renal insufficiency. Fortunately, nocturnal bladder emptying has emerged as a specific antidote for the syndrome of nighttime overdistension of the bladder, and because nocturnal bladder emptying can reverse or prevent bladder and upper tract deterioration, it is suggested that conventional therapies performed only during the daytime may have been inadequate for certain subgroups of patients who require a new therapeutic paradigm for their optimal management.
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Affiliation(s)
- Stephen Canon
- Section of Pediatric Urology, Children's Hospital, Room # ED314, Education Building, 700 Children's Drive, Columbus, OH 43205-2696, USA
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Abstract
INTRODUCTION AND AIM Antenatal treatment of obstructive uropathy, although widely performed, remains controversial. This study evaluated the long-term outcome of managing patients with posterior urethral valves (PUV), highlighting the effect of antenatal vesicoamniotic shunt placement for patients who underwent fetal surgery. METHODS The medical records of 58 patients with PUV were retrospectively reviewed from June 1998 to June 2004. On the basis of prenatal assessment of sonographic findings and serial urinary electrolytes and protein measurements, patients were divided into two groups: group 1 comprised patients who had antenatal vesicoamniotic shunt placement whereas group 2 comprised patients who underwent postnatal surgical correction of PUV. Their outcomes and long-term results were evaluated. RESULTS Patients were followed up from 6 months to 6(1/2) years (mean 3.9 years). Group 1 included 12 patients who had vesicoamniotic shunt placement and were confirmed postnatally to have PUV. Four patients out of 12 died (33.3%); three out of the eight living patients had perinatal complications. Of the eight living patients, three (37.5%) underwent valve ablation and five (62.5%) underwent urinary diversion (three vesicostomies and two cutaneous ureterostomies). Renal function returned to normal in only four patients (50%). Radiological abnormalities (hydronephrosis and/or reflux) resolved in three (37.5%) patients, was downgraded in one (12.5%) patient and persisted in four patients (50%). Group 2 included 46 patients who were treated postnatally. Thirty-five patients (76%) underwent primary valve ablation, while 11 (24%) underwent urinary diversion (seven vesicostomies, four cutaneous ureterostomy and one pyelostomy). Renal function returned to normal in all patients who underwent valve ablation, except in three, while renal function returned to normal in only three of 11 patients who underwent urinary diversion. Radiological hydronephrosis and/or reflux resolved in 28 patients (60.9%), was downgraded in six patients (13%) and persisted in 12 patients (26.1%). CONCLUSIONS Antenatal vesicoamniotic shunt placement makes no difference to the outcome and long-term results of patients with PUV and debate about its efficacy on renal outcome remains. Primary valve ablation is the keystone of treatment for patients with PUV that might achieve the primary goal of nephron preservation. The lowest creatinine concentration in the first year of life is the most appropriate predictor of future renal function.
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Affiliation(s)
- Mamdouh A Salam
- Pediatric Surgery Department, Ain Shams University, Cairo, Egypt.
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Neild GH, Dakmish A, Wood S, Nauth-Misir R, Woodhouse CRJ. RENAL TRANSPLANTATION IN ADULTS WITH ABNORMAL BLADDERS. Transplantation 2004; 77:1123-7. [PMID: 15087786 DOI: 10.1097/01.tp.0000116712.56265.78] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since January 1, 1985, we have performed 73 renal transplants in 66 patients with abnormal bladders who had end-stage renal failure as a consequence of urologic abnormalities (mean age 32 years). Their outcome is compared with 58 renal transplants in 54 patients (mean age 40 years) who had renal failure from primary vesicoureteric reflux or renal dysplasia and whose bladder function was considered to be normal. There is no difference in actuarial graft survival in the two groups at 10 years (abnormal 66%, normal bladders 61%), although longer follow-up is showing an advantage for normal bladders, with a kidney half-life of 29 to 33 years compared with 15 years for the abnormal bladder group. Similarly, actuarial patient survival at 10 years is 86% in both groups. Current renal function is better in the group with normal bladders. At latest follow-up, the abnormal, unaugmented bladder group (n=34) has been followed for 92 (87) months (mean [median]) and has a plasma creatinine of 178 (161) micromol/L, whereas the normal bladder group (n=33) has been followed for 104 (93) months and has a creatinine concentration of 143 (140) micromol/L. A strict policy, since 1991, of prophylactic antibiotics for the first 6 months has halved the subsequent incidence of urinary tract infection. Urinary tract infections only produced problems in patients with abnormal bladders. Renal transplantation into the abnormal lower urinary tract is successful but requires careful preoperative evaluation and posttransplant follow-up.
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Affiliation(s)
- Guy H Neild
- Institute of Urology and Nephrology, University College London, UK.
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DeFoor W, Tackett L, Minevich E, McEnery P, Kitchens D, Reeves D, Sheldon C. Successful renal transplantation in children with posterior urethral valves. J Urol 2004; 170:2402-4. [PMID: 14634437 DOI: 10.1097/01.ju.0000089773.40598.b3] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The treatment of children with posterior urethral valve (PUV) and end-stage renal disease can be challenging. Some series have had poor outcomes after renal transplantation with an increased risk of graft dysfunction and urinary tract infections. We present our experience with a pediatric population and compare it to all the other pediatric renal transplants done at our institution. MATERIALS AND METHODS We identified 10 patients with PUV who underwent a total of 13 renal transplants between 1990 and 2000. The comparison group included 120 transplants done in 95 patients during the same period. Cumulative allograft survival and function were recorded. RESULTS Overall patient survival in the PUV group was 100%. Mean age at transplant in the PUV group was 10.0 years and mean followup was 3.9 years. Six patients underwent high proximal urinary tract diversion, while the remainder had primary transurethral valve ablation. Three patients had bladder augmentation before transplantation. Cumulative allograft survival in the PUV group at 1 and 5 years was 85% and 64%, respectively. Of the 10 patients 9 currently have functioning living related donor transplants. One patient lost 3 cadaveric donor transplants to chronic rejection. No patients lost grafts due to infection or bladder dysfunction. Mean serum creatinine of the functioning grafts was 1.1 mg/dl. CONCLUSIONS Renal transplantation can be performed safely and effectively in patients with PUV, including those who have undergone previous proximal urinary tract diversion. Preoperative bladder management and continued monitoring of bladder and kidney function postoperatively are paramount in the preservation of allograft function.
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Affiliation(s)
- William DeFoor
- Division of Pediatric Urology, Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA.
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Yohannes P, Hanna M. Current trends in the management of posterior urethral valves in the pediatric population. Urology 2002; 60:947-53. [PMID: 12475647 DOI: 10.1016/s0090-4295(02)01621-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Paulos Yohannes
- Division of Urology, Department of Surgery, Creighton University, Omaha, Nebraska, USA
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Abstract
Children who develop end-stage renal disease (ESRD) as a result of obstructive uropathies require evaluation and treatment of associated bladder dysfunction to ensure a good outcome following renal transplantation. Bladder dynamics can often be optimized medically, although surgical intervention is occasionally necessary. For those patients who require bladder augmentation, the use of a dilated native ureter (ureterocystoplasty) is preferred to the more commonly used intestine or stomach (enterocystoplasty), which carry a higher risk of complications. Unfortunately, most patients do not have a suitable anatomy for ureterocystoplasty and, by necessity, intestine or stomach has to be utilized. Herein, we describe the successful application of ureterocystoplasty in the presence of ESRD and a solitary kidney prior to renal transplantation. We believe that owing to the many advantages of native urothelium, every effort should be made to use ureter and avoid the use of intestine.
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Affiliation(s)
- Eric A Kurzrock
- Department of Urology, University of California, Davis Children's Hospital, Sacramento, California 95817, USA
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Koff SA, Mutabagani KH, Jayanthi VR. The valve bladder syndrome: pathophysiology and treatment with nocturnal bladder emptying. J Urol 2002; 167:291-7. [PMID: 11743343 DOI: 10.1016/s0022-5347(05)65453-5] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE We determine the etiology and treat the specific pathophysiology of the valve bladder syndrome. MATERIALS AND METHODS Defined as persisting or progressive severe hydroureteronephrosis without residual or recurrent obstruction, the valve bladder syndrome developed in 18 boys who underwent successful ablation of the posterior urethral valve. Serial radiographic, renal function, renographic, urodynamic and perfusion studies were performed for a mean time of 11 years. RESULTS The cause of the valve bladder syndrome proved to be sustained bladder over distention due to a combination of polyuria with 24-hour urine volume greater than 2 l. in 10 boys, impaired bladder sensation in 18 and residual urine volume in 14. Treatment of over distention during the daytime alone was unsuccessful. Nocturnal bladder emptying was performed with an indwelling nighttime catheter, intermittent nocturnal catheterization and/or frequent nocturnal double voiding. Hydronephrosis markedly improved once nocturnal bladder emptying was started and was comparable to the results after urinary diversion. CONCLUSIONS The valve bladder syndrome is not due to a permanent prenatal alteration in bladder anatomy and function. Instead, it appears to result from sustained postnatal bladder over distention due to a combination of polyuria, impaired bladder sensation and residual urine volume, which represent sequelae of prenatal valve injury. These factors synergize to prevent bladder normalization after valve ablation and progressively reduce functional bladder capacity to maintain bladder over distention. Bladder decompensation, upper tract dilation, and renal injury develop and characterize the valve bladder syndrome. Because current therapy, including intermittent catheterization, leaves the bladder full throughout the night, it remains markedly over distended. Nocturnal bladder emptying is the specific antidote for this pathophysiological situation, and results in prompt and impressive improvement or elimination of hydronephrosis in these and similar groups of patients. This response to nocturnal bladder emptying suggests that the bladder is not the primary cause for the valve bladder syndrome.
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Affiliation(s)
- Stephen A Koff
- Section of Pediatric Urology, Children's Hospital, Columbus, Ohio, USA
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Woolf AS, Thiruchelvam N. Congenital obstructive uropathy: its origin and contribution to end-stage renal disease in children. ADVANCES IN RENAL REPLACEMENT THERAPY 2001; 8:157-63. [PMID: 11533916 DOI: 10.1053/jarr.2001.26348] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Most children with end-stage renal failure are born with abnormal kidneys, with fetal obstructive uropathy accounting for about half these cases. Posterior urethral valves (PUV) is overwhelmingly the most common, specific diagnosis, and is confined to boys. In general, the condition is sporadic, although familial cases have been reported, perhaps suggesting that genetic factors play a role in pathogenesis. PUV can present antenatally, detected on routine fetal ultrasonography, or postnatally, when it is associated with renal failure and bladder dysfunction. Advances in postnatal surgery and medical management have reduced the mortality in PUV, but it is uncertain whether antenatal diagnosis or treatment (eg, with vesicoamniotic shunts) improves long-term renal outcome. Other disorders associated with human fetal obstructive uropathy are urethral atresia, the prune belly syndrome, and multicystic dysplastic kidney. The nephropathy associated with fetal obstructive uropathy is renal dysplasia and comprises undifferentiated and metaplastic tissues. Several studies in animals and in humans suggest that fetal urine flow impairment causes deregulation of renal precursor cell turnover and expression of growth factor/survival and transcription factor genes. Furthermore, some of these morphologic and molecular changes can be ameliorated experimentally by fetal surgical decompression or administration of specific growth factors.
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Affiliation(s)
- A S Woolf
- Nephro-Urology Unit, Institute of Child Health, University College London, London, United Kingdom.
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Guys JM, Meyrat B, Siméoni-Alias J, Coquet M, Monfort G. [Persistent urination disorders after treatment of posterior urethral valve: incidence and semiology]. Arch Pediatr 2000; 4 Suppl 1:27s-30s. [PMID: 9181007 DOI: 10.1016/s0929-693x(97)86439-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Micturition disorders were studied retrospectively in a series of 165 children over a period of 15 years. Among patients without lesions of the upper tract at the time of diagnosis (group A, n = 131), 18 (14%) had persistent nocturnal and diurnal enuresis: one urethral stenosis and six vesicoureteric reflux required surgery; three experienced persistent pollakiuria and enuresis. Among patients with upper urinary tract damage at the time of diagnosis (group B, n = 34), seven presented with recurrent urinary tract infection, five with nocturnal and diurnal enuresis and three with urolithiasis. In the long term, only 52% of them had normal renal function and two were successfully transplanted. Micturition disorders following treatment of posterior urethral valves are frequent and usually related to the so-called valve bladder syndrome. Iatrogenic complications and mortality rate have dramatically decreased during the recent years but long-term renal function impairment remains the most critical problem.
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Affiliation(s)
- J M Guys
- Fédération de chirurgie pédiatrique, hôpital de La Timone, Marseille, France
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Abstract
Posterior urethral valves (PUV) is the most common congenital urine flow impairment in boys. Long-term prognosis involves: renal function impaired in 30 to 50% of PUV and leading to hyperdiuresis, low GFR and acidosis; bladder urodynamics impaired in 75% of PUV with abnormal urine storage, abnormal micturition and vesicoureteric reflux. Incontinence and recurrent urinary tract infections commonly reflect bladder and renal failures; abnormal bladder outlet leads to incontinence and abnormal ejaculation. The roles of antenatal treatments (vesico-amniotic shunts), neonatal treatments (resuscitation and endoscopic treatment of PUV) and long-term treatments (urinary diversions, bladder augmentation, alpha blockers, anticholinergic, dialysis and renal transplant) in the long-term outcomes of PUV are reviewed.
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Affiliation(s)
- P D Mouriquand
- Great Ormond Street Hospital for Sick Children, Institute of Child Health, University of London
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ROLE OF THE BLADDER IN DELAYED FAILURE OF KIDNEY TRANSPLANTS IN BOYS WITH POSTERIOR URETHRAL VALVES. J Urol 2000. [DOI: 10.1097/00005392-200004000-00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nicol D, Hirst G. Urological assessment and complications in renal transplantation. Transplant Rev (Orlando) 1999. [DOI: 10.1016/s0955-470x(99)80003-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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KOO HARRYP, BUNCHMAN TIMOTHYE, FLYNN JOSEPHT, PUNCH JEFFREYD, SCHWARTZ ANNEC, BLOOM DAVIDA. RENAL TRANSPLANTATION IN CHILDREN WITH SEVERE LOWER URINARY TRACT DYSFUNCTION. J Urol 1999. [DOI: 10.1016/s0022-5347(01)62119-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- HARRY P. KOO
- Departments of Surgery (Sections of Urology and Transplant Surgery) and Pediatrics (Section of Nephrology), University of Michigan, Ann Arbor, Michigan
| | - TIMOTHY E. BUNCHMAN
- Departments of Surgery (Sections of Urology and Transplant Surgery) and Pediatrics (Section of Nephrology), University of Michigan, Ann Arbor, Michigan
| | - JOSEPH T. FLYNN
- Departments of Surgery (Sections of Urology and Transplant Surgery) and Pediatrics (Section of Nephrology), University of Michigan, Ann Arbor, Michigan
| | - JEFFREY D. PUNCH
- Departments of Surgery (Sections of Urology and Transplant Surgery) and Pediatrics (Section of Nephrology), University of Michigan, Ann Arbor, Michigan
| | - ANNE C. SCHWARTZ
- Departments of Surgery (Sections of Urology and Transplant Surgery) and Pediatrics (Section of Nephrology), University of Michigan, Ann Arbor, Michigan
| | - DAVID A. BLOOM
- Departments of Surgery (Sections of Urology and Transplant Surgery) and Pediatrics (Section of Nephrology), University of Michigan, Ann Arbor, Michigan
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EDITORIAL. J Urol 1999. [DOI: 10.1097/00005392-199901000-00079] [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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Khudair WKAI, Mansi MK. Rehabilitation of long-term defunctionalized bladder for renal transplantation. Transpl Int 1998. [DOI: 10.1111/j.1432-2277.1998.tb00836.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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RENAL TRANSPLANTATION IN CHILDREN WITH POSTERIOR URETHRAL VALVES REVISITED. J Urol 1998. [DOI: 10.1097/00005392-199809020-00068] [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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Affiliation(s)
- Ricardo Gonzalez
- Department of Pediatric Urology; Children's Hospital of Michigan; Wayne State University; Detroit, Michigan
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Salomon L, Fontaine E, Gagnadoux MF, Broyer M, Beurton D. Posterior urethral valves: long-term renal function consequences after transplantation. J Urol 1997; 157:992-5. [PMID: 9072633 DOI: 10.1016/s0022-5347(01)65128-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE We assessed the long-term efficacy of renal transplantation in children with posterior urethral valves. MATERIALS AND METHODS We retrospectively compared the outcomes of renal transplantation in 66 children with posterior urethral valves and 116 with malformation uropathies (controls). RESULTS Graft survival in the posterior urethral valves and control groups was 69 and 72% at 5 years, and 54 and 50% at 10 years, respectively (not statistically significant). A statistically significant increase in serum creatinine was noted at 10 years in children with posterior urethral valves but not in controls (p < 0.05). CONCLUSIONS Renal transplantation in children with posterior urethral valves is not associated with a high rate of failure. However, long-term deterioration of graft function is likely related to lower urinary tract dysfunction.
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Affiliation(s)
- L Salomon
- Department of Urology, Ambroise Paré Hospital, University of West Paris, Boulogne, France
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Connolly JA, Miller B, Bretan PN. Renal Transplantation in Patients with Posterior Urethral Valves: Favorable Long-Term Outcome. J Urol 1995. [DOI: 10.1016/s0022-5347(01)67016-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John A. Connolly
- Department of Urology and Surgery, Renal Transplant Service, University of California School of Medicine, San Francisco, California
| | - Bulaklak Miller
- Department of Urology and Surgery, Renal Transplant Service, University of California School of Medicine, San Francisco, California
| | - Peter N. Bretan
- Department of Urology and Surgery, Renal Transplant Service, University of California School of Medicine, San Francisco, California
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