Kidney transplantation in children with urinary diversion or bladder augmentation

Purpose: Urinary tract anomalies or dysfunction leaves the bladder unsuitab le for urine drainage in a significant proportion of children presenting fo r kidney transplantation. We reviewed a multi-institutional experience to d etermine the ramifications of kidney transplantation in children with bladd er 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 s tage renal disease was renal dysplasia in 8 cases, posterior urethral valve s in 5, obstructive uropathy in 5, neurogenic bladder/chronic pyelonephriti s 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, sigmo id 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, urin e leak, enterovesical fistula and wound dehiscence. Medical complications i ncluded 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 drain age. Acidosis was more common in patients with augmented bladder (4 of 17 v ersus 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 rejectio n in 6 cases, noncompliance in 4 and acute rejection in 1. There were no de aths. Conclusions: Drainage of transplanted kidneys into an augmented bladder or urinary conduit is an appropriate management strategy when the native bladd er is unsuitable or absent. Patients with kidney transplants drained into a ugmented bladder or urinary conduit are at increased risk for urine infecti on. Graft survival is not adversely affected compared to historical control s when a kidney transplant is drained into a urinary conduit or augmented b ladder.