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Kidney transplantation in children with urinary diversion or bladder augmentation
D A Hatch1, M A Koyle, L S Baskin
1Department of Urology, Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
Insights
Kidney transplantation in children with bladder augmentation or urinary diversion is appropriate when the native bladder is unsuitable. Patients face increased infection risk, but graft survival remains comparable to historical controls.
Area of Science:
- Pediatric Nephrology
- Urology
- Transplantation Surgery
Background:
- Urinary tract anomalies often render the native bladder unsuitable for urine drainage in pediatric kidney transplant candidates.
- Bladder augmentation or urinary diversion is frequently necessary for successful kidney transplantation in children.
Purpose of the Study:
- To evaluate the outcomes and complications of kidney transplantation in children requiring bladder augmentation or urinary diversion.
- To assess the long-term graft survival in this patient population.
Main Methods:
- A multi-institutional review of 31 kidney transplants performed over 28 years in children (1.7-18 years old).
- Patients received transplants with either augmented bladders (ileum, ureter, sigmoid, stomach) or incontinent urinary conduits (ileum, colon).
- Etiologies of end-stage renal disease included renal dysplasia, posterior urethral valves, obstructive uropathy, and neurogenic bladder.
Main Results:
- Surgical complications were infrequent. Medical complications included urinary tract infections (21 cases) and metabolic acidosis (5 cases).
- Graft survival rates were 90% at 1 year, 78% at 5 years, and 60% at 10 years.
- No significant correlation was found between the type of urinary drainage and symptomatic urinary tract infections or acidosis, though acidosis was more common with augmented bladders.
Conclusions:
- Kidney transplantation into an augmented bladder or urinary conduit is a viable strategy for children with unsuitable native bladders.
- While patients are at higher risk for urinary tract infections, graft survival is not compromised compared to historical data.
- This approach supports successful kidney replacement therapy in complex pediatric cases.
Purpose:
Urinary tract anomalies or dysfunction leaves the bladder unsuitable for urine drainage in a significant proportion of children presenting for kidney transplantation. We reviewed a multi-institutional experience to determine the ramifications of kidney transplantation in children with bladder augmentation or urinary diversion.
Materials And Methods:
During a 28-year period 18 boys and 12 girls 1.7 to 18 years old (mean age 12.1) received 31 kidney transplants. Cause of end stage renal disease was renal dysplasia in 8 cases, posterior urethral valves in 5, obstructive uropathy in 5, neurogenic bladder/chronic pyelonephritis in 4, spina bifida/chronic pyelonephritis in 3, prune belly syndrome in 3 and reflux in 2.
Results:
Of the patients 17 had augmented bladder (ileum 9, ureter 5, sigmoid 2 and stomach 1), 12 had incontinent urinary conduits (8 ileum, 6 colon) and 1 had a continent urinary reservoir. Surgical complications included 1 case each of stomal stenosis, stomal prolapse, renal artery stenosis, urine leak, enterovesical fistula and wound dehiscence. Medical complications included urinary tract infection in 21 cases and metabolic acidosis in 5. A bladder stone developed in 1 patient. There was no correlation between the incidence of symptomatic urinary tract infections and type of urinary drainage. Acidosis was more common in patients with augmented bladder (4 of 17 versus 1 of 14) but there was no correlation between the bowel segment used and the occurrence of acidosis. Graft survival was 90% at 1 year, 78% at 5 years and 60% at 10 years. Etiology of graft loss included chronic rejection in 6 cases, noncompliance in 4 and acute rejection in 1. There were no deaths.
Conclusions:
Drainage of transplanted kidneys into an augmented bladder or urinary conduit is an appropriate management strategy when the native bladder is unsuitable or absent. Patients with kidney transplants drained into augmented bladder or urinary conduit are at increased risk for urine infection. Graft survival is not adversely affected compared to historical controls when a kidney transplant is drained into a urinary conduit or augmented bladder.
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