Transplantation in Children with End Stage Renal Disease of Urologic Origin

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Abstract
Urologic disease is an important cause of end stage renal failure in children. Experience with more than 700 renal transplants includes 30 children with renal failure of urologic origin who have received 34 renal homografts. The nature and natural history of the primary disease corrective operations before transplantation, transplantation technique, complications and over-all success rate of these cases are reviewed. Vesicoureteral reflux and posterior urethral valves were the most common causes of end stage renal disease. The average time between diagnosis of a urologic problem and transplantation was 8.1 yr. The incidence of renal dysplasia was high. It appears that many patients had limited potential for long-term urologic rehabilitation when they were evaluated initially. A wide variety of genitourinary tract operative procedures were done on 28 patients before transplantation (average 3.3 operations/patient). Cutaneous ureterostomy was the most frequent procedure, often following unsuccessful urologic reconstruction. Ten patients had uncorrectable lower urinary tracts and required construction of intestinal conduits. Bilateral nephrectomy, correction of lower urinary tract abnormalities or construction of an intestinal conduit, if necessary, should be performed before renal transplantation. Transplantation techniques were highly variable. In 16 instances, the graft was placed in the iliac fossa. Eighteen grafts were placed intra-abdominally because of small patient stature or to facilitate use of intestinal conduits. Intra-abdominal graft placement or use of intestinal conduits did not adversely affect allograft success. Complications were frequent and occurred after 30 allografts (88%). Surgical complications occurred after 10 allografts. Most surgical complications were urologic. Infectious complications followed 27 allografts, with urinary tract infection as the most frequent complication. Additional surgical procedures were done at the time of 8 transplants and the incidence of complications was especially high in this group. Of the 34 renal transplants, 20 (59%) were successful, comparing favorably with the success rate in pediatric and adult transplantation. Apparently, renal transplantation is the treatment of choice for children with end stage renal disease of urologic origin.