Diagnostic and therapeutic management of vesico‐ureteral reflux in pediatric kidney transplantation—Results of an online survey on behalf of the European Society for Paediatric Nephrology

Abstract

Background: Vesico-ureteral reflux (VUR) is considered to be a risk factor for recurrent febrile urinary tract infections and impaired renal transplant survival. Methods: An online survey supported by the European Society for PaediatricNephrology was designed to evaluate current management strategies of VUR in native and transplanted kidneys of recipients aged <18 years.Results: Seventy-three pediatric transplant centers from 32 countries contributed to the survey. All centers performed urological evaluation prior to pediatric kidney transplantation (KTx) with subsequent interdisciplinary discussion. Screening for VUR in native kidneys (30% in all, 70% in selected patients) led to surgical intervention in 78% (11% in all, 89% in selected patients) with a decided preference of endoscopic intervention over ureterocystoneostomy. Following KTx, continuous antibiotic prophylaxis was applied in 65% of the patients and screening for allograft VUR performed in 93% of selected patients. The main management strategies of symptomatic allograft VUR were continuous antibiotic prophylaxis (83%) and surgical treatment (74%) (endoscopic intervention 55%, redo ureterocystoneostomy 26%).Conclusions: This survey demonstrates the high variability in the management of VUR in pediatric KTx recipients, points to knowledge gaps, and might serve as a starting point for improving the care for patients with VUR in native and transplanted kidneys.

Current management of symptomatic vesicoureteral reflux in pediatric kidney transplantation—A European survey among surgical transplant professionals

“…This finding is in contrast to our previous survey of pediatric nephrologists who first considered continuous antibiotic prophylaxis despite the unlikely spontaneous resolution 8 . In addition, among the pediatric nephrologists surveyed previously, endoscopic allograft VUR correction was preferred over other surgical techniques 11 . Compared to the correction of native kidney VUR, surgical treatment of allograft VUR is more challenging due to ureteral scarring and the atypical orifice of the graft ureter, which should inevitably result in a more stringent surgical indication 41 .…”

“…Considering the specific pediatric anatomy and the high proportion of patients with urinary tract anomalies, especially bladder anomalies, an increased multidisciplinary collaboration involving trained pediatric surgeons/urologists needs to be discussed to benefit from the presumed higher expertise in this field. 3,9,11,31 As expected, almost all transplant centers place a stent in the transplant ureter, preferably a double-J-stent, to prevent major urological complications, especially urinary drainage impairment. 32,33 The ureteral stent is usually removed within 4 weeks after KTx, a practice supported by data indicating that the benefits of a longer duration (>3 weeks) of indwelling ureteral stents are outweighed by harms, especially increased risk of UTI.…”

“…Screening for native kidney VUR has become a routine part of the pre‐transplant urologic evaluation, particularly in patients with febrile UTI, bladder pathology, and ureteral and/or pelvicalyceal dilatation 1–3,11 . When symptomatic native kidney VUR is detected, more than two‐thirds of the participating centers aim to correct VUR in either all or selected patients, primarily prior to KTx.…”

“…12,13 These contacts were solicited from pediatric nephrologists who had participated in a previous survey on VUR management in pediatric KTx recipients and supplemented by using Eurotransplant database searches. 11 The invitation to participate in the survey included study information and a personal link to the survey website (SurveyMonkey Inc., www. surve ymonk ey.…”

“…8 In addition, among the pediatric nephrologists surveyed previously, endoscopic allograft VUR correction was preferred over other surgical techniques. 11 Compared to the correction 41 Of note, although endoscopic treatment has been shown to be effective in some studies, the success rates remain higher with open surgical redo ureteral anastomosis techniques. 8,[41][42][43][44][45][46] In failed endoscopic treatment of VUR, most centers tend to redo UCN, considering that the latter is less successful after previous endoscopic injection.…”