Renal transplant outcome in children with an augmented bladder

Safety of augmentation cystoplasty in patients with bladder abnormalities undergoing renal transplantation: a systematic review

BACKGROUND Augmentation cystoplasty (AC) has been recently proposed to improve a bladder condition before or after a renal transplantation for an optimal allograft function. Until now, AC in adults with end-stage renal disease (ESRD) is uncommon and rarely practiced. This study aimed to investigate the safety of AC in patients with bladder abnormalities who required renal transplantation. METHODS Studies of patients with ESRD and abnormal bladder who underwent AC were searched in ProQuest, PubMed, EBSCO, and Cochrane Library online databases. Only studies published in English from January 1985 to May 2020 were included. The keywords used were renal transplantation, bladder dysfunction, cystoplasty, and their synonyms. Data were extracted by two independent authors who selected, screened, and assessed the articles’ eligibility and quality. The outcomes were graft survival rate and complications of AC. RESULTS A total of 19 articles were included. AC improved an intravesical pressure, a bladder capacity, and a compliance in patients with ESRD and bladder abnormalities, allowing patients to undergo the renal transplantation. Even though AC in patients with renal transplantation resulted in a significantly higher urinary tract infection rate than patients who underwent renal transplantation only, performing AC after renal transplantation was considered safe. CONCLUSIONS AC was considered safe for patients with bladder abnormalities who underwent renal transplantation.

Long-term outcome of transplant ureterostomy in children: A National Review

BACKGROUND

CAKUT are the most common cause of end-stage renal failure in children (Pediatr Nephrol. 24, 2009, 1719). Many children with CAKUT have poor urinary drainage which can compromise post-transplant outcome. Identifying safe ways to manage anatomical abnormalities and provide effective urinary drainage is key to transplant success. Much debate exists regarding optimum urinary diversion techniques. The definitive formation of a continent urinary diversion is always preferable but may not always be possible. We explore the role of ureterostomy formation at transplantation in a complex pediatric group.

METHODS

We report six pediatric patients who had ureterostomy formation at the time of transplantation at the National Paediatric Transplant Centre in Dublin, Ireland. We compared renal function and burden of urinary tract infection to a group with alternative urinary diversion procedures and a group with normal bladders over a 5-year period.

RESULTS

There was no demonstrable difference in estimated glomerular filtration rate between the groups at 5-year follow-up. The overall burden of UTI was low and similar in frequency between the three groups.

CONCLUSIONS

Ureterostomy formation is a safe and effective option for temporary urinary diversion in children with complex abdominal anatomy facilitating transplantation; it is, however, important to consider the implications and risk of ureterostomy for definitive surgery after transplantation.

Renal transplantation in patients with an augmentation cystoplasty

Background

The effects of renal transplantation in patients with augmentation cystoplasty are still controversial. We retrospectively analyzed nine patients who underwent renal transplantation after augmentation cystoplasty.

Methods

A total of nine patients who underwent augmentation cystoplasty prior to renal transplantation between January 1990 and May 2020 were reviewed. Basic information on augmentation cystoplasty, transplant procedures, and long-term outcomes of renal transplantation were analyzed.

Results

The bowel segments utilized for augmentation cystoplasty were the stomach in two patients (one patient needed revision using the ileum), the ileum in four patients, the ileocolic pouch in one patient, the sigmoid in one patient, and the ureter in one patient. All the cystoplasties were performed prior to renal transplantation. The mean follow-up period after transplantation was 161 months (range, 2–341 months). Two patients had an episode of acute rejection each; however, their graft functions were well-maintained. Five patients had recurrent urinary tract infections, and three of these patients progressed to allograft failure. One patient died from bladder cancer with a functioning graft. Five of nine patients showed well-maintained graft function.

Conclusions

Renal transplantation after bladder augmentation surgery is a major operation requiring a high level of surgical skill. Based on our long-term experiences, we recommend diligent postoperative monitoring for urinary tract infections, optimal catheter use, and use of appropriate antibiotic prophylaxis to avoid severe complications.

5-Year Long-Term Outcome of Live-Donor Renal Transplant Recipients With Enterocystoplasty and Ureterocystoplasty: An Age- and Sex-Matched Pair Analysis

OBJECTIVE

To assess surgical complications, febrile UTI, graft function and 5-year graft survival after renal transplantation (RT) in patients with augmentation cytsoplasty (AC) and to compare them to RT patients with normal lower urinary tract.

MATERIALS AND METHODS

A case-control study of 34 RT patients with AC including 23 patients with enterocystoplasty (EC) and 11 patients with ureterocystoplasty (UC) was performed. The primary outcome was to determine the difference between both groups regarding postoperative surgical complications and febrile UTI episodes. Graft function was compared at 1, 3, and 5 years and 5-year graft survival was determined. The secondary outcome was to compare them to an age- and gender-matched control group (122 patients) with normal lower urinary tract.

RESULTS

There was no significant difference regarding surgical complications or rates of hospital readmission between AC groups. Seventeen (73.9%) and 5 (45.5%) patients developed 33 and 14 episodes of febrile UTI in EC and UC groups, respectively (P= .5). Control group had shown lower incidence surgical complications (P = .001) and febrile UTIs (P = .02) compared to AC groups. At 3 and 5 years, UC had higher median eGFR than EC (P = .08, 0.008, respectively). The 5-year graft survival was 32 (94.1%) with no statistically significant difference between EC (95.7%) and UC (90.9%) (P = .5) or between AC and control (85.2%, P = .3).

CONCLUSION

Although RT after AC was associated with higher surgical complications and UTI episodes, they had comparable 5-year graft survival to their control. When indicated, UC should be the preferred choice of AC whenever possible.

Urologic issues in pediatric transplant recipients

The limited supply of kidneys for pediatric transplantation leads to a large number of children in waiting transplant list. These patients have to be properly evaluated and prepared before organ transplantation to increase its success. The aim of this review is focus on urologic issues of pediatric kidney transplants such as preoperative evaluation and urinary tract abnormalities correction, surgical technique, and postoperative complications. All children that are candidates for kidney transplantation should be submitted to abdominal ultrasound. If bladder dysfunction is suspected, a more detailed evaluation is mandatory, including a voiding cystourethrography and urodynamic study. Patients with a poor bladder capacity and compliance will require bladder augmentation. Whenever possible the native ureter is recommended for that. Regarding kidney transplantation, recipient surgery can be safely performed through an extraperitoneal access, even in children weighting less than 10 kilograms. It allows adequate access to iliac vessels, aorta and vena cava. Graft survival continued to improve over the past decade and it is around 80% in 5 years. Postoperative complications such as urinary fistula may occur in less than 5% of cases, while vascular complications are reported in 1% to 2% of cases.

Anuria since birth: does it impact outcome of kidney transplant in infants?

Kidney transplantation (txp) in infants has recently made much progress but provides a unique challenge in infants anuric since birth. Little data exists on outcome of renal txp recipients with anuria since birth. Retrospective chart review was done for outcome of 27 children with wt ≤15 kg and they were divided into two groups: Group A (N=21) with urine output and Group B (N=6) anuric since birth had their urological complications and long-term outcome compared. Median age at the time of txp 18 vs 23 months, mean wt 10.8 vs 11.8 kg, and mean ht 77 cm in both, mean follow-up post-txp: 9.4 vs 5.6 years, and neurological problems were noted in 48% and 33% in Group A and Group B. There was no graft thrombosis or post-transplant lymphoproliferative disease and only two rejections. Anuric Group B were older, had more post-txp urological surgeries (66% vs 19%) and UTIs (66% vs 38%) compared to Group A. The overall graft survival at 1, 5, and 10 years was 96%, 86%, and 70%; patient survival at 1, 5, and 10 years was 96%, 85%, and 85%. Long-term graft outcomes in small children, anuric prior to txp, were excellent despite higher rates for UTIs and urological complications.

Preoperative Risk Factors Predicting Complication Rates of Augmentation Cystoplasty Using the Modified Clavien Classification System in Pediatric Population

OBJECTIVE

To evaluate preoperative predictive factors for postoperative complications of augmentation cystoplasty in children by using the modified Clavien classification system (MCCS).

PATIENTS AND METHODS

A retrospective review of medical records between 1994 and 2014 identified 117 children (64 males and 53 females) who underwent augmentation cystoplasty. Complications were evaluated according to the MCCS. Univariate and multivariate analyses were used to determine predictive factors affecting complication rates.

RESULTS

The mean (SD) age was 9.3 (1.9) years and the mean (SD) hospitalization time was 9.7 (3.6) days. Patients with an adverse or unexpected event within 30 days of surgery were identified. Complications occurred in 29 (24.7%) children; 13 (11.1%) were MCCS grade I, 8 (5.1%) were grade II, 5 (4.2%) were grade III, and 3 (2.5%) were grade IV. Antireflux surgery, outlet resistance increasing procedures, Society of Fetal Urology (SFU) grades 3-4 hydronephrosis, posterior urethral valves, scoliosis, and serum creatinine greater than 1.0 mg/dL were statistically significant predictors of complications on univariate analysis. In the multivariate analysis, SFU grades 3-4 hydronephrosis, bladder neck reconstruction, and serum creatinine greater than 1.0 mg/dL were statistically significant independent predictors of complications.

CONCLUSION

Augmentation cystoplasty remains a valid method of treating severe bladder dysfunction in children. SFU grades 3-4 hydronephrosis, outlet resistance increasing procedures, and serum creatinine greater than 1.0 mg/dL were the main predictive factors for postoperative complications. Use of a standardized complication grading system, such as the MCCS, should be encouraged to allow the valid comparison of complication rates between series.

Renal transplantation in infants

Renal transplantation (RTx) has become an accepted mode of therapy in infants with severe renal failure. The major indications are structural abnormalities of the urinary tract, congenital nephrotic syndrome, polycystic diseases, and neonatal kidney injury. Assessment of these infants needs expertise and time as well as active treatment before RTx to ensure optimal growth and development, and to avoid complications that could lead to permanent neurological defects. RTx can be performed already in infants weighing around 5 kg, but most operations occur in infants with a weight of 10 kg or more. Perioperative management focuses on adequate perfusion of the allograft and avoidance of thrombotic and other surgical complications. Important long-term issues include rejections, infections, graft function, growth, bone health, metabolic problems, neurocognitive development, adherence to medication, pubertal maturation, and quality of life. The overall outcome of infant RTx has dramatically improved, with long-term patient and graft survivals of over 90 and 80 %, respectively.

Kidney transplant in pediatric patients with severe bladder pathology

The aim of the current study was to compare results in pediatric renal transplantation of patients with and without SBP. Between 2001 and 2013, a total of 168 kidney transplants were performed at our center. A retrospective analysis was performed and recipients were divided into two groups: NB and SBP. Incidence of surgical complications after procedure, and graft and patient survival were evaluated. A total of 155 recipients (92%) with complete data were analyzed, and 13 recipients that had had previous bladder surgeries were excluded (11 with VUR surgery and two with previous kidney transplants), of the 155 recipients: 123 (79%) patients had NB, and 32 (21%) patients had SBP, with a median follow-up of 60 (1-137) and 52 (1-144) months, respectively. Among post-transplant complications, UTI (68.8% vs. 23%, p < 0.0001) and symptomatic VUR to the graft (40.6% vs. 7.3%, p < 0.0001) were significantly higher in the SBP group. There was no significant difference in overall graft and patient survival between groups. Renal transplantation is safe in pediatric recipients with SBP; however, urologic complications such as UTI and VUR were significantly higher in this group. Graft and patient survival was similar in SBP and NB groups.