When does vesicoureteral reflux in pediatric kidney transplant patients need treatment?

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.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

“…In addition to results in "uncomplicated" VUR, numerous studies have provided evidence that endoscopic injection is also effective in specific patient populations that may be deemed more difficult to treat (historically not considered for endoscopic therapy). These include high-grade VUR, duplicated systems, adult women and kidney transplant patients (85,86,(89)(90)(91)(92)(93)(94)(95)(96)(97)(98)(99)(100)(101)(102)(103)(104). Resolution rates may be reduced in these groups of patients: for example, Läckgren et al reported a positive response rate of 63% in patients with duplicated ureters, compared with 68% in the broader population of VUR patients (104,105).…”

Urologic Considerations in Pediatric Chronic Kidney Disease

“…While endoscopic subureteric injections of dextranomer/hyaluronic acid may be considered, success rates in correcting post-Tx VUR have been low, and their use has been associated with many complications. 71,73 POSTTRANSPLANT OUTCOMES When comparing outcomes in children with and without urologic causes of ESRD, most studies have shown comparable graft or patient survival in children with CA-KUT, 74 in spite of higher risk of post-Tx UTIs, even in the presence of severe bladder dysfunction. 75,76 Therefore, for pediatric patients with advanced CKD and ESRD due to CAKUT, Tx is the goal for renal replacement therapy because of the better long-term survival, growth and development, and quality of life after Tx than remaining on maintenance dialysis.…”

Renal Transplant Hydroureteronephrosis as a Manifestation of Rejection: An Under-Recognized Entity?

“…Hydroureteronephrosis (HUN) of renal transplant (RT) can occur secondary to ureteral obstruction or vesicoureteral reflux (VUR) [1,2]. However, secondary megaureter of various etiologies, neurogenic bladder, loss of ureteral tonicity following denervation, and polyuric states can also present with non-obstructive non-refluxing transplant HUN [3].…”