Challenges Facing Renal Transplantation in Pediatric Patients With Lower Urinary Tract Dysfunction

Abstract

In pediatric patients with end-stage renal disease, renal transplantation is the established therapy of choice. The commonest cause is a congenital abnormality of the kidneys and urinary tract, often associated with lower urinary tract dysfunction (LUTD). Historically, such patients were denied transplantation, but it is now widely accepted that transplant outcomes comparable with the non-LUTD population are achievable. Nonetheless, the optimal management of pediatric end-stage renal disease patients with LUTD is unclear, with no guidelines to distinguish between the need for conservative management or surgical reconstruction of the lower urinary tract. Furthermore, the most appropriate surgical procedure and optimal timing of surgical intervention is far from clear. In this review, we outline common conditions that produce LUTD in children; discuss difficulties encountered in assessing the need for surgical treatment; provide an overview of the surgical procedures available; and consider the evidence for and against surgical intervention before, during, and after renal transplantation.

Outcomes of living donor renal transplantation in children with lower urinary tract dysfunction: a comparative retrospective study

“…Historically, there have been concerns over the suitability of RTx for patients with ESRD resulting from LUTD because of the expected higher risks of UTI and other urological [2,3]. Although some authors confirmed that outcomes for RTx in children with LUTD were similar to those in children with normal lower urinary tracts [9][10][11][12][13][14], LUTD may have a significant impact on graft survival if not managed appropriately [4,15]. Low intravesical pressure with adequate bladder capacity and compliance, together with efficient drainage, should be achieved for a successful transplantation [11,12,[16][17][18].…”

“…Similarly to reports by many other authors, we prefer reconstructive surgeries before RTx to avoid the possible adverse effects of immunosuppression, such as delayed wound healing and severe infection, in addition to the prevention of any harmful effect of LUTD on the graft [16,19]. It may not always be necessary to intervene in patients with borderline bladder compliance, however, as a small non-compliant bladder may improve after transplantation in some cases after restoration of urinary flow, sparing the patients a reconstructive surgery [10,21,22]. This requires close follow-up after transplantation to continuously assess the bladder and decide early on augmentation if needed.…”

Kidney Transplantation in Children

“…33,34 Some pediatric kidney-transplant recipients require specialized ureteral reimplantation, bladder augmentation, or urinary diversion procedures. 35 …”

Pediatric Kidney Transplant in Uropaties

“…In general terms, the actuarial global functional survival rate after the first year postoperatively was higher than 93%, and at year 5 it was between 75% and 85% ( Other authors have shown that patients with dysfunction in the urinary tract that required reconstructions had an increased risk of complications and loss of the graft (Mochon et al, 1992;Salomón et al, 1997). Such discrepancies can be explained because of the heterogeneity of the series published, the wide scope of the disease, the severity of the lower urinary tract and its different treatments (Riley et al, 2010) …”

“…Nevertheless, there exists considerable controversy around the best approach to handle these types of patients, since there are no guidelines designed with defined reconstructive surgical criteria, optimal surgical procedures or recommendations as to when the best time to perform such interventions (Riley et al,2010).…”