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ORIGINAL ARTICLE
Year : 2018  |  Volume : 12  |  Issue : 2  |  Page : 136-142

Kidney transplant in patients with abnormal bladder: Experience of tertiary care center in developing country-Is the outcome same?


Department of Urology and Renal Transplant, Max Super Speciality Hospital, Saket, New Delhi, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Dr. Anant Kumar
Department of Urology and Renal Transplant, Robotics and Uro-Oncology, Max Super Speciality Hospital, 2, Press Enclave Road, Saket, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_64_17

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  Abstract 


Background: Fifteen percent of adults and 20%–30% of pediatric patients develop renal failure, results from structural urological abnormalities. Successful renal transplantation depends partly on a bladder which has adequate capacity, good compliance, and efficient voluntary emptying. Urinary bladder rehabilitation with augmentation or diversion is necessary before transplant in these patients to achieve good graft outcome. We, hereby report our last 10 years' experience of such patients undergoing kidney transplant in abnormal bladder. Materials and Methods: A total of 14 patients underwent renal transplantation in rehabilitated bladder from 2006 to 2016. Demographic details, prereconstruction bladder and urodynamic findings, and type of pretransplant reconstruction were recorded. Posttransplant creatinine levels, graft survival at 7 days, 3 months, 1 year, and 3 years were recorded. Results: Mean (± standard deviation) serum creatinine posttransplant at 7 days, 3 months, 1 year, and 3 years was 0.9 (±0.20), 1.58 (±0.65), 1.92 (±1.02), and 2.47 (1.17) mg/dl, respectively. Four patients developed rejection within 6 months of transplant. Kidney biopsy was suggestive of acute cellular rejection in all cases, which was treated successfully. At three years follow-up, four patients who had rejection-have rising creatinine levels and diminishing renal functions. No patient needed dialysis support till last follow-up. All these four patients had rejection, urinary tract infection (UTI) episodes and pyelonephritis in the past. Conclusion: Native bladder is the best reservoir for urinary storage and drainage. The main cause of graft dysfunction in rehabilitated bladder is UTI as a result of poor hygiene, contamination during clean intermittent self-catheterization (CISC) and noncompliance for CISC leading to high residual urine. Controlling frequent attacks of UTI posttransplant is essential, otherwise long-term graft survival and function will deteriorate faster and might trigger rejection.

Keywords: Abnormal bladder, kidney transplant, urinary tract infection


How to cite this article:
Desai P, Yadav R, Chaturvedi S, Maheshwari R, Gulia A, Kumar A. Kidney transplant in patients with abnormal bladder: Experience of tertiary care center in developing country-Is the outcome same?. Indian J Transplant 2018;12:136-42

How to cite this URL:
Desai P, Yadav R, Chaturvedi S, Maheshwari R, Gulia A, Kumar A. Kidney transplant in patients with abnormal bladder: Experience of tertiary care center in developing country-Is the outcome same?. Indian J Transplant [serial online] 2018 [cited 2021 Apr 11];12:136-42. Available from: https://www.ijtonline.in/text.asp?2018/12/2/136/235598




  Introduction Top


Fifteen percent of adults and 20%–30% of pediatric patients who develop renal failure results from lower urinary tract dysfunction caused by structural urological abnormalities.[1]

Successful renal transplantation depends partly on a bladder which has adequate capacity, good compliance, and efficient voluntary emptying. Urinary bladder augmentation or diversion or rehabilitation is necessary before transplant in abnormal bladder patients to achieve good graft outcome.

Reconstruction of the urinary tract may be performed months or years before or after renal transplant depending on practices of a transplant center. Kelly reported first successful kidney transplant in rehabilitated bladder, 12 years after initiation of transplant programme.[2]

Safety of kidney transplantation in patient with reconstructed urinary tract is debatable, though, as per available literature, long-term graft and patient survival seems to be similar to the results of kidney transplantation for patient with native functioning bladder.[3],[4],[5],[6],[7]

We report our experience of such patients undergoing kidney transplant in abnormal bladder from 2006 to 2016 in a developing country.


  Materials and Methods Top


This is an observational retrospective study of cases. Between 2006 and 2016, 14 patients underwent renal transplantation in reconstructed or rehabilitated urinary bladder. Demographic details (age, sex, etiology, causes of renal failure, and duration of dialysis) were noted. Prereconstruction bladder findings, type of pretransplant reconstruction or rehabilitation of urinary bladder, and pretransplant urodynamic findings were recorded.

All donors were live related and ABO compatible. Donor kidney glomerular filtration rate (GFR), HLA match percentage, pretransplant induction, and posttransplant immunosuppression were noted.

Posttransplant creatinine levels, graft survival at 7 days, 3 months, 1 and 3 years, and complications (urinary tract infection [UTI], lymphocele, urinary leak, stricture, reflux, etc.) were recorded. Most patients had follow-up of more than 3 years which was noted. Graft survival was defined by a functioning kidney without the need for dialysis or graft removal during follow up.

All renal transplantations were done by experienced transplant surgeons. The allograft was implanted into iliac fossa in extraperitoneal space on the right side or left side. In cases of Mitrofanoff's or urostoma on the right side, kidney was transplanted on the left side.

Renal vein was anastomosed end-to-side with external or common iliac vein. Renal artery was anastomosed to internal iliac artery (end-to-end) or external or common iliac artery (end-to-side) or inferior epigastric artery (end-to-end) in case of multiple donor arteries. Ureter was implanted using extravesical modified Lich-Gregoir antirefluxing technique after putting Double J (DJ) stent, in the bladder or augmented segment or in the ileal conduit.

Warm and cold ischemia time, number of donor kidney arteries and their anastomosis in recipient were noted. Per-urethral catheter was kept for 5 to 7 days and DJ stent was removed between 2 and 3 weeks in all patients.

Ethical clearance was not required as these are standard procedures, in accordance with the principles of Helsinki declaration. Outcomes and complications were analyzed following descriptive statistics.


  Results Top


Fourteen patients were transplanted with rehabilitated or reconstructed bladder from 2006 to 2016. The mean (±standard deviation [SD]) age (22.5 ± 9.70 years), gender ratio (m:f = 12:2) and other demographic details of patients at time of transplant are shown in [Table 1].
Table 1: Demographic details at the time of renal transplant

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One patient which is not included in the study had small capacity bladder following genitourinary tuberculosis. The patient underwent ileocystoplasty in 2013 at our Centre. Postaugmentation, patient developed bladder perforation and rectovesical abscess leading to sepsis and death before transplantation. This could have happened while the patient was trying to self-catheterize to wash the bladder.

All included patients underwent bladder reconstruction before renal transplantation. Some patients had badder reconstruction only few months or weeks before kidney transplant. Duration of reconstruction/rehabilitation of bladder before transplant ranges from 3 weeks to 104 Months. Prereconstruction bladder characteristics, pretransplant bladder management, urodynamic findings before transplant, individual time between reconstruction/rehabilitation, and transplant are shown in [Table 2].
Table 2: Pretransplant bladder characteristics

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All donors were live related and ABO compatible. Mean (±SD) donor kidney GFR was 47.9 (±5.58) ml/min as shown in [Table 3]. Median HLA match percentage was 50% [Table 3]. Pretransplant induction is either Basiliximab or Rabbit Antithymocyte globulin or none [Table 3]. Mean (±SD) warm and cold ischemia time was 5.3 (±1.1) and 28.7 (±8.8) mins, respectively. Donor artery was single except in two patients. Donor artery anastomosis was either to internal/external/common iliac and inferior epigastric artery in case of multiple arteries as shown in [Table 3]. Posttransplant immunosuppression is shown in [Table 3].
Table 3: Donor kidney characteristics, human leukocyte antigen match percentages, intraoperative and posttransplant immunosuppression details

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Figure 1: Micturating cystourethrogram showing neurogenic bladder with small capacity with bilateral vesicoureteral reflux

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Figure 2: Postoperative picture after gastrocystoplasty with mitrofanoff using appendix

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Figure 3: Intraoperative picture of ureterocystoplasty (a) bladder, (b and c) right and left ureter, respectively

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Figure 4: (a) Transplant in ileal conduit. (b) End colostomy postabdominoperineal resection

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Complications are shown in [Table 4]. All patients had episodes of asymptomatic bacteriuria. Eight patients developed UTI with urinary symptoms and six patients developed acute pyelonephritis during follow-up. Superficial Surgical site infection occurred in two patients, managed by daily dressing followed by secondary suturing. Two patients developed opportunistic infection (cytomegalovirus), which was managed conservatively. No patient developed lymphocele/urinary leak or stricture. Antibiotic usage posttransplant ranges from 6 to 8 months in all cases. All patients were prescribed co-trimoxazole for pneumocystis carinii and usually given for 6 months. Almost all patients received multiple urinary antibiotics (doxycycline/cephalexin/cefuroxime/nitrofurantoin/quinolones/) on many occasions.
Table 4: Posttransplant complications in 14 patients

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Outcome result is shown in [Table 5]. Mean (±SD) serum creatinine posttransplant at 7 days, 3 months, 1 year and 3 years is 0.9 (±0.20), 1.58 (±0.65), 1.92 (±1.02), and 2.47 (1.17) mg/dl, respectively. Four patients developed rejection within 6 months of transplant. Kidney biopsy was suggestive of acute cellular rejection in all cases, which was treated successfully. At three years follow-up, all these four patients have rising creatinine levels and diminishing renal functions, but no patient needed dialysis support till last follow-up. All these four patients had rejection, UTI episodes, and pyelonephritis in the past. Graft survival was 100% at 3 years' follow-up though mean (±SD) serum creatinine is 2.47 (±1.17) mg/dl. Eight patient had follow-up of more than three years with different time interval of follow-ups and mean (±SD) serum creatinine in these patients is 2.75 (±1.29) mg/dl at last follow-up as shown in [Table 5].
Table 5: Posttransplant outcome results

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None of these patients were followed with urodynamic study.


  Discussion Top


Key factors in success of renal transplant in patients with abnormal bladder are renal allograft preservation, maintenance of continence, and prevention of UTI s. The incidence of UTI in renal transplant recipients with normal bladder ranges from 6% to 86%.[8] UTI can worsen graft survival in such patients. The incidence of UTI increases more in patient who underwent renal allografting with reconstructed or rehabilitated bladder thereby affecting graft survival. In our series of 14 patients, almost all had asymptomatic bacteriuria on various occasions. Many patients had more than three episodes of UTI during follow-up. Asymptomatic UTI in patient with renal allografting can be the consequence of immunosuppression. Acute pyelonephritis perse is a strong risk factor for deterioration of graft function in short and long term.[9] In our study, six patient developed acute pyelonephritis leading to graft function deterioration and rise in serum creatinine. All patients with UTI were started on broad-spectrum antibiotics with coverage of common uropathogens such as  Escherichia More Details coli, Klebsiella pneumonia, Enterococcus, Proteus mirabilis, and Pseudomonas aeruginosa. Urine culture was sent at the same time, and antibiotics were changed later on, if required depending on antibiotic susceptibility test of urine culture isolate. All pyelonephritic episodes were hospitalized and catheterized. They received intravenous antibiotics as per urine culture sensitivity report. They all had imaging to see development of any complications.

It is extremely important to find any predisposing factor for UTI in renal transplant recipient with reconstructed bladder to prevent further frequent attacks of urinary infections. Those patients with frequent attacks of UTI and on clean intermittent self-catheterization, we switch to sterile intermittent self-catheterization using new or sterilized catheters every time. These patients are repeatedly trained and biofeed for the technique of intermittent self-catheterization and maintaining a good hygiene. Those who were self-voiding, uroflowmetry, and postvoid residual urine (PVRU) were often checked to ensure adequate emptying. These patients were encouraged to have frequent voiding (every 2–3 hourly) and all of these patients were given alpha blockers and anticholinergics as well.

About 42.8% of our patients had pyelonephritis compared to 18.7% in patients with normal native bladder in other series,[9] thus potentiating the fact that severity of UTI also increases with reconstructed or rehabilitated bladder patients undergoing renal transplantation. None of our patients with urinary infection had any predisposing factor for UTI except high PVRU in some patients who were on clean intermittent self-catheterization (CISC), which was managed conservatively. All patients who had pyelonephritis had developed rising serum creatinine and graft dysfunction at one and three-year follow-up.

Possible reasons for increased incidence of UTI in rehabilitated bladder patients, in developing country, could be poor hygienic conditions, less optimal clean environment, and contamination during CISC. Other potential reason could be decreased bacteriostatic acidity of urine with intestinal segments, leading to persistence of bacteria in augmented bladders causing frequent UTI.[6]

Timing of reconstruction of bladder relative to renal transplant is controversial.

Since immunosuppression might affect healing of reservoir, so some groups advocate reconstruction/rehabilitation of bladder before transplant.[10] Reimplantation of graft ureter in a nonreconstructed bladder can jeopardize graft which can eventually lead to graft failure and this can also be prevented by rehabilitating the bladder before transplant.[11],[12],[13]

Reconstruction of bladder along with transplant is not usually practiced because of complexity of both the procedures, higher incidence of infective complications and impaired wound healing in the presence of higher level of immunosuppression in the beginning.[14]

Some transplant surgeons advocate that the reconstruction of the bladder should be done after transplant when renal function is stable and immunosuppression regimen has been reduced.[10],[15] This also avoids the risk of dry cystoplasty, i.e., recurrent pyocystitis needing lavage due to persistent mucus production.[16],[17] Risk of damage to the vascular pedicle of cystoplasty can also be avoided if reconstruction is done after transplant.[16]

Formally randomizing patients to bladder reconstruction prior, at the time or after transplant has never been done in the literature so far.[18] Most of the studies do not accurately specify the interval between reconstruction of bladder and transplantation.[18] In all our patients, who underwent reconstruction of the bladder, done before transplant.

Four patients out of fourteen developed acute cellular rejection on follow up and treated successfully with anti rejection therapy. These patients had rising creatinine and deteriorating graft function. One additional cause of graft dysfunction could be pyelonephritis in such patient of graft dysfunction with rejection. Cairns et al. proposed that UTI might initiate or trigger rejection, thereby emphasizing the role of timely detection and adequate treatment of UTI.[19] At 3 years' follow-up, almost all patients who does not have severe graft dysfunction, serum creatinine ranges between 1.4 and 2.1mg/dl. No patient developed graft loss i.e., requiring dialysis or graft nephrectomy till last follow-up. On reviewing literature, graft survival in our study was not different from patients with transplant in native normal bladder.[7],[20],[21] When comparing graft dysfunction with other studies in literature in such subsets of patients, our results are inferior as many patients have graft dysfunction which will finally lead to graft loss in near future.[20],[21]

Few limitations of our study are inclusion of small number of patients, retrospective descriptive study, and relatively short follow-up. The reason for small number of patients in our study could be because of small number of reconstructed bladder patients reaching to the stage of renal transplantation after extensive preoperative preparation. Although prospective studies usually have fewer potential sources of bias and confounding than retrospective studies, it is difficult to conduct such prospective studies in such small subset of patients needing transplantation. All the previous studies examining long-term graft function, graft survival, and complications in patient with reconstructed bladder, and renal transplant are mostly from either developed countries or western world, where the level of home and workplace hygiene is better than developing countries. To the best of our knowledge, this is the largest case series from a developing country comparing results in patient with reconstructed or rehabilitated bladder after renal transplant.


  Conclusion Top


Native bladder is the best reservoir for urinary storage and drainage. Renal transplantation in such patients achieves best long-term results. In western literature, though the incidence of complication like UTI is higher for transplant in rehabilitated bladder, but long-term graft function and graft survival is comparable to the patients with native normal bladder. Our results, in such patients, are poor regarding graft dysfunction which will lead to graft loss in near future. The causes of graft dysfunction are poor hygiene, nonstringent or infrequent CISC leading to high PVRU and contamination during CISC which eventually leads to higher incidence of UTI and pyelonephritis. Controlling frequent attacks of UTI posttransplant is essential, otherwise long-term graft survival and function will deteriorate faster and might trigger rejection which will further affect the graft.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Crowe A, Cairns HS, Wood S, Rudge CJ, Woodhouse CR, Neild GH, et al. Renal transplantation following renal failure due to urological disorders. Nephrol Dial Transplant 1998;13:2065-9.  Back to cited text no. 1
    
2.
Kelly WD, Merkel FK, Markland C. Ileal urinary diversion in conjunction with renal homotransplantation. Lancet 1966;1:222-6.  Back to cited text no. 2
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3.
Hatch DA, Belitsky P, Barry JM, Novick AC, Taylor RJ, Jordan ML, et al. Fate of renal allografts transplanted in patients with urinary diversion. Transplantation 1993;56:838-42.  Back to cited text no. 3
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Hatch DA, Koyle MA, Baskin LS, Zaontz MR, Burns MW, Tarry WF, et al. Kidney transplantation in children with urinary diversion or bladder augmentation. J Urol 2001;165:2265-8.  Back to cited text no. 4
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Blanco M, Medina J, Pamplona M, Miranda N, Gonzalez E, Aguirre JF, et al. Outcome of renal transplantation in adult patients with augmented bladders. Transplant Proc 2009;41:2382-4.  Back to cited text no. 5
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Coosemans W, Baert L, Kuypers D, Maes B, Messiaen T, Vanrenterghem Y, et al. Renal transplantation onto abnormal urinary tract: Ileal conduit urinary diversion. Transplant Proc 2001;33:2493-4.  Back to cited text no. 6
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Surange RS, Johnson RW, Tavakoli A, Parrott NR, Riad HN, Campbell BA, et al. Kidney transplantation into an ileal conduit: A single center experience of 59 cases. J Urol 2003;170:1727-30.  Back to cited text no. 7
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8.
Säemann M, Hörl WH. Urinary tract infection in renal transplant recipients. Eur J Clin Invest 2008;38 Suppl 2:58-65.  Back to cited text no. 8
    
9.
Pellé G, Vimont S, Levy PP, Hertig A, Ouali N, Chassin C, et al. Acute pyelonephritis represents a risk factor impairing long-term kidney graft function. Am J Transplant 2007;7:899-907.  Back to cited text no. 9
    
10.
Zaragoza MR, Ritchey ML, Bloom DA, McGuire EJ. Enterocystoplasty in renal transplantation candidates: Urodynamic evaluation and outcome. J Urol 1993;150:1463-6.  Back to cited text no. 10
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11.
Taghizadeh AK, Desai D, Ledermann SE, Shroff R, Marks SD, Koffman G, et al. Renal transplantation or bladder augmentation first? A comparison of complications and outcomes in children. BJU Int 2007;100:1365-70.  Back to cited text no. 11
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González R. Renal transplantation into abnormal bladders. J Urol 1997;158:895-6.  Back to cited text no. 12
    
13.
Martín MG, Castro SN, Castelo LA, Abal VC, Rodríguez JS, Novo JD, et al. Enterocystoplasty and renal transplantation. J Urol 2001;165:393-6.  Back to cited text no. 13
    
14.
Malone MJ, Khauli RB, Lowell J. Use of small and large bowel in renal transplantation. Urol Clin North Am 1997;24:837-43.  Back to cited text no. 14
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Najarian JS, Matas AJ. The present and future of kidney transplantation. Transplant Proc 1991;23:2075-82.  Back to cited text no. 15
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McInerney PD, Picramenos D, Koffman CG, Mundy AR. Is cystoplasty a safe alternative to urinary diversion in patients requiring renal transplantation? Eur Urol 1995;27:117-20.  Back to cited text no. 16
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Nguyen DH, Reinberg Y, Gonzalez R, Fryd D, Najarian JS. Outcome of renal transplantation after urinary diversion and enterocystoplasty: A retrospective, controlled study. J Urol 1990;144:1349-51.  Back to cited text no. 17
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Rudge CJ. Transplantation and the abnormal bladder. In: Morris PJ, editor. Kidney Transplantation. 5th ed. Philadelphia: WB Saunders; 2001. p. 173-83.  Back to cited text no. 18
    
19.
Cairns HS, Leaker B, Woodhouse CR, Rudge CJ, Neild GH. Renal transplantation into abnormal lower urinary tract. Lancet 1991;338:1376-9.  Back to cited text no. 19
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Slagt IK, Ijzermans JN, Alamyar M, Verhagen PC, Weimar W, Roodnat JI, et al. Long-term outcome of kidney transplantation in patients with a urinary conduit: A case-control study. Int Urol Nephrol 2013;45:405-11.  Back to cited text no. 20
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Sager C, Burek C, Durán V, Corbetta JP, Weller S, Paz E, et al. Outcome of renal transplant in patients with abnormal urinary tract. Pediatr Surg Int 2011;27:423-30.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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