Urine Reservoir: Evaluation and Transplant Strategies

Abstract

Children with end-stage renal disease (ESRD) are a unique group of patients because of the high incidence of underlying congenital anomalies of the kidney and the urinary tract (CAKUT) seen in about 15–25 % of the cases (Churchill, J Urol 140, 1129–1133, 1988; Zaragoza, J Urol 150, 1463–1466, 1993; Koo, J Urol 161, 240–245, 1999). Congenital urinary tract abnormalities may lead to severe bladder dysfunction. A noncompliant bladder that stores urine in low volumes and under high pressure, often referred to as “valve bladder,” may lead to deterioration of the upper urinary tracts resulting in chronic kidney disease. Children with poorly compliant bladders may fail conservative treatment with initiation of anticholinergic therapy and clean intermittent catheterizations (CIC) and become candidates for reconstructive bladder surgery. The success of kidney transplantation in children with abnormal bladders and end-stage renal disease (ESRD) was controversial. Augmentation cystoplasty with or without a continent catheterizable channel is often done to ensure development of a low-pressure and compliant reservoir. An abnormal native bladder that contributed to renal insufficiency may jeopardize subsequent kidney transplantation resulting in allograft loss. Opponents of kidney transplantation draining into reconstructed bladders often cite increased risk of urinary tract infections (UTIs) in immunocompromised recipients leading to an enhanced immunological response and accelerating graft loss. Some authors have advocated taking down augmented bladders prior to kidney transplantation for the fear of septic complications, graft loss, or even death (Alfrey, Pediatr Nephrol 11, 672–675, 1997). Conversely, other reports have documented that kidney transplantation can be safely drained into reconstructed bladders with comparable graft survival to allografts draining into normal bladders (Nguyen, J Urol 144, 1349–1351, 1990; Sheldon, J Urol 152, 972–975, 1994; Rischmann, Transplant Proc 27, 2427–2429, 1995; Fontaine, J Urol 159, 2110–2113, 1998; Koo, J Urol 161, 240–245, 1999; Hatch, J Urol 165, 2265–2268, 2001; Nahas, Urology 60, 770–774, 2002; Power, J Urol 167, 477–479, 2002; Rigamonti, Transplantation 80, 1435–1440, 2005; Aki, Transplant Proc 47, 1114–1116, 2014). Unfortunately, few controlled studies are available to permit meaningful comparison of outcomes between kidney transplantation in native versus reconstructed bladders.