Authors
Year
No. pt.
Mean age (yrs)
Surgical reconstruction (no. pt.)
Median follow-up
Results
Conclusion
Broniszczak et al. [60]
2010
33
11.8
IC, BA, CR
32 months
Patient survival 100 %, graft survival 97 %. UTIs most common complication
Excellent medium-term results with renal transplantation in children with lower urinary tract dysfunction and end-stage renal failure
Djakovic et al. [61]
2009
12
9.5
IC, BA, CR
5.4 years
Patient survival 100 %, graft survival 75 % (no graft loss due to LUTD)
Reconstruction of the lower urinary tract prior to renal transplantation is a safe management strategy
Nahas et al. [28]
2008
211
13
BA, CR
75 months
Compared children with ESRD due to nonurological cause, ESRD due to urological cause but with an adequate bladder, and ESRD due to urological cause requiring preoperative surgical intervention. Similar patient survival, graft survival, and surgical complication rate across all groups
With individualized management, children with severely compromised LUT function may undergo renal transplantation
Taghizadeh et al. [62]
2007
16
7.5
BA (16)
58.4 months
Patient survival 100 %, graft survival 94, 89, and 67 % at 1, 5, 10 years
Bladder reconstruction can be safely performed prior to transplantation
Mendizabal et al. [63]
2005
15
13
BA, IC
7 years
Patient survival 100, 92, 92 % and graft survival 77, 62, and 30 % at 1, 5, and 10 years with no significant difference between LUTD and non-LUTD group
Children with severe LUT dysfunction can achieve similar results to the general population following renal transplantation
Rigamonti et al. [64]
2005
24
14
BA, IC
67.2 months
Graft survival 96, 82, and 66 % at 1, 5, and 10 years (no significant difference compared to a non-LUTD group)
Drainage of the renal allograft into an augmented bladder or urinary diversion is an appropriate management strategy in the absence of a suitable native bladder
Ali-El-Dein et al. [65]
2004
15
13.5
BA, CR
4.5 years
Patient survival 93, 85, and 85 % and graft survival 93, 86, and 34 % at 1, 5, and 10 years, no significant difference compared to non-LUTD group
Renal transplantation is feasible and provides good outcomes for children with an abnormal LUT
Nahas et al. [34]
2004
8
18
BA
50 months
Patient survival 100 %, graft survival 100 %, UTIs most common complication
Ureterocystoplasty is a safe alternative to enterocystoplasty that provides similar benefits to the use of bowel for bladder augmentation without adding further complications or risks
Neild et al. [27]
2004
66
32
IC, BA, CR
92 months
Patient survival 86 % and graft survival 66 % at 10 years, no significant difference compared to non-LUTD group
Successful renal transplantation into the abnormal LUT is possible but requires thorough preoperative evaluation and post-transplant follow-up
Luke et al. [40]
2003
20
9.3
BA, IC
62 months
Patient survival 100 %, graft survival 83 % at 5 years with no significant difference compared to a non-LUTD group
Pediatric renal transplantation into a dysfunctional LUT yields similar outcomes to transplantation into the normal LUT
Defoor et al. [66]
2003
20
4.5
BA, CR
7.3 years
Patient survival 95 %, graft survival 82 %
Severe LUT dysfunction can be effectively managed with continent urinary reconstruction in children with ESRD
Hatch et al. [31]
2001
30
12.1
IC, BA, CR
59 months
Patient survival 100 %, graft survival 90, 78, and 60 % at 1, 5, and 10 years
Drainage of transplanted kidneys into an augmented bladder or urinary conduit is acceptable in the absence of a suitable bladder
Conclusion
LUT dysfunction is attributed to a range of etiologies and may lead to devastating effects on the upper urinary tract resulting in the need for renal transplantation. Patients with concomitant ESRD and LUTD pose unique management challenges to the provider team and optimal management strategies remain controversial. In general, there is consensus that establishing a high-capacity, compliant urinary reservoir with effective drainage prior to transplantation is desirable to avoid the potential risks of UTI, surgical complications, allograft dysfunction, and graft loss. Preoperative assessment including cystogram and UDS is essential to the successful guidance of treatment strategies. Restoration of bladder function is initially approached using conservative measures such as medication, CIC, and bladder cycling. When hostile bladder conditions despite medical management, a wide range of surgical interventions are available to address both urinary storage and emptying. Small case series in both the young adult and pediatric populations in recent years have shown promising results for the patient with LUTD undergoing renal transplantation. However, indications regarding the most appropriate surgical intervention and the timing of these interventions remain unclear, and future studies are needed with a focus on the potential risks and benefits of each approach.
Summary
Uncorrected LUT problems at the time of renal transplantation expose the patient to significant risks of morbidity including higher rates of UTI, surgical complications, allograft dysfunction, and graft loss.
Complications may be avoided by appropriate preoperative assessment of bladder characteristics, initiation of appropriate medical therapy and CIC, and determination of the need for surgical management with either bladder reconstruction or urinary diversion.
Surgical intervention for LUT dysfunction in the ESRD patient undergoing renal transplantation is considered when the patient has failed pharmacological therapy, adequate drainage, and bladder cycling. Bladder augmentation offers transplant recipients increased storage capacity at safe pressures and, when combined with CIC, provides most patients with satisfactory urinary continence. Ideally, bladder reconstruction should be performed prior to renal transplantation.
After transplantation, it is crucial to carefully monitor bladder function. Posttransplantation bladder dysfunction may manifest as graft dysfunction that is associated with infection, incontinence, bladder hypertonicity, or hydronephrosis and, if untreated, may predispose to allograft loss.
With appropriate preoperative evaluation and management of LUT dysfunction and close postoperative monitoring, the long-term outcomes of patients with ESRD and LUT dysfunction undergoing renal transplantation are comparable to those of the general ESRD population.
References
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Kelly WD, Merkel FK, Markland C. Ileal urinary diversion in conjunction with renal homotransplantation. Lancet. 1966;1(7431):222–6.CrossRefPubMed
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