Long-Term Renal Transplant Outcome in Patients With Posterior Urethral Valves. Prognostic Factors Related to Bladder Dysfunction Management

Abstract

Introduction: To obtain a successful renal transplant (RT) outcome in patients with posterior urethral valves (PUV), it is necessary to accomplish an adequate bladder dysfunction treatment. Our aim was to determine prognostic factors related to bladder dysfunction management in long-term RT outcome in patients with PUV.Methods: A retrospective review of patients with PUV who received a first RT after 1985 in our institution with at least 5 years of follow-up was performed. Variables analyzed included prenatal diagnosis, age of diagnosis, initial presentation and management, bladder dysfunction treatment, other surgical treatments, pre-transplant dialysis, age of transplantation, type of donor, immunosuppression regimen, vascular and urological complications, rejections episodes, and graft survival.Results: Fifty-one patients were included in the analysis. Prenatal diagnosis was done in 37.3%. Median age of diagnosis was 0.30 (0–88) months. Initial presentation was vesicoureteral reflux (VUR) in 78% and obstructive ureterohydronefrosis in 35.3%. Initial management was valve ablation (29.4%), pyelo-ureterostomy (64.7%), and vesicostomy (5.9%). In 33.3%, a type of bladder dysfunction treatment was performed: 21.6% bladder augmentation (BA), 15.7% Mitrofanoff procedure, 17.6% anticholinergic drugs, and 27.5% clean intermittent catheterization (CIC). Pre-transplant dialysis was received by 66.7%. Transplantation was performed at 6.28 ± 5.12 years, 62.7% were cadaveric and 37.3% living-donor grafts. Acute rejection episodes were found in 23.6%. Urological complications included recurrent urinary tract infections (UTIs) (31.4%); native kidneys VUR (31.4%); graft VUR (45.1%); and ureteral obstruction (2%). Vascular complications occurred in 3.9%. Mean graft survival was 11.1 ± 6.9 years. Analyzing the prognostic factor that influenced graft survival, patients with had CIC or a Mitrofanoff procedure had a significant better long-term graft survival after 10 years of follow-up (p < 0.05), despite of the existence of more recurrent UTIs in them. A better graft survival was also found in living-donor transplants (p < 0.05). No significant differences were observed in long-term graft survival regarding native kidneys or graft VUR, BA, immunosuppression regimen, or post-transplant UTIs.Conclusion: Optimal bladder dysfunction treatment, including CIC with or without a Mitrofanoff procedure, might result in better long-term graft survival in patients with PUV. These procedures were not related to a worse RT outcome in spite of being associated with more frequent UTIs.

Ureterocystoplasty in Boys with Valve Bladder Syndrome—Is This Method Still up to Date?

“…Most of their patients (10/12) were augmented with a ureter. Amesty et al recently conducted a review to determine prognostic factors related to managing bladder dysfunction in boys with PUV and a renal transplant but did not find any clear indication regarding the time of bladder augmentation in relation to the time of transplantation [ 19 ]. These findings are consistent with our results.…”

Development and validation of a novel fetal vesico‐amniotic shunt, the vortex shunt

“…Neonates with LUTO have been shown to have significant bladder dysfunction (sometimes referred to as "valve bladder"), which is manifested by decreased bladder capacity and compliance with increased instability, and optimal bladder dysfunction management in neonates and children may even improve renal transplant outcomes in LUTO cases. 44,45 Tanaka et al demonstrated that a low pressurelimited valve system (15-54 mm Hg) can preserve fetal lamb bladder volume with reduction of both interstitial fibrosis and bladder muscle hypertrophy. 46 Our hope is that incorporating a one-way valve will allow bladder cycling and preservation of function.…”

Chronic Kidney Disease in Boys with Posterior Urethral Valves–Pathogenesis, Prognosis and Management

“…Rigid management of bladder dysfunction should also be performed in PUV patients with renal transplantation. Two recent studies showed that patients with Mitrofanoff procedures or clean intermittent catheterizations had significantly better graft survival rates, which was also comparable to graft survival rates for other indications [ 64 , 65 ]. Unsurprisingly, the sonomorphologic hallmarks of hypodysplastic kidneys such as hyperechogenicity, low kidney volume and pathologic corticomedullary differentiation also are prognostic factors for the progression towards ESKD [ 47 ].…”

“…In a French multicenter study, Marchal et al found that even though enterocystoplasties and continent urinary diversions exposed grafts to more frequent acute graft pyelonephritis, patient and graft survival rates in lower urinary tract malformations at 10 years were similar to the survival rates of other kidney transplantations on native bladders [ 65 ]. Amesty et al recently showed that optimal bladder control using either clean intermittent catheterization or Mitrofanoff procedures resulted in more urinary tract infections, but prolonged graft survival [ 64 ]. It should therefore be mandatory to screen for and treat bladder dysfunction before renal transplantation, in order to prolong graft survival and ensure the optimal use of scarce transplant organs.…”