Allograft Vesicoureteral Reflux after Kidney Transplantation.

Carmelo Puliatti,Mariano Ferraresso,Evaldo Favi,Marta Perego,Sonia Guzzo,Samuele Iesari,Carlo Maria Alfieri,Alessandra Brescacin,Ruggero Darisi

doi:10.3390/medicina58010081

Abstract

Allograft vesicoureteral reflux (VUR) is a leading urological complication of kidney transplantation. Despite the relatively high incidence, there is a lack of consensus regarding VUR risk factors, impact on renal function, and management. Dialysis vintage and atrophic bladder have been recognized as the most relevant recipient-related determinants of post-transplant VUR, whilst possible relationships with sex, age, and ureteral implantation technique remain debated. Clinical manifestations vary from an asymptomatic condition to persistent or recurrent urinary tract infections (UTIs). Voiding cystourethrography is widely accepted as the gold standard diagnostic modality, and the reflux is generally graded following the International Reflux Study Committee Scale. Long-term transplant outcomes of recipients with asymptomatic grade I-III VUR are yet to be clarified. On the contrary, available data suggest that symptomatic grade IV-V VUR may lead to progressive allograft dysfunction and premature transplant loss. Therapeutic options include watchful waiting, prolonged antibiotic suppression, sub-mucosal endoscopic injection of dextranomer/hyaluronic acid copolymer at the site of the ureteral anastomosis, and surgery. Indication for specific treatments depends on recipient’s characteristics (age, frailty, compliance with antibiotics), renal function (serum creatinine concentration < 2.5 vs. ≥ 2.5 mg/dL), severity of UTIs, and VUR grading (grade I-III vs. IV-V). Current evidence supporting surgical referral over more conservative strategies is weak. Therefore, a tailored approach should be preferred. Properly designed studies, with adequate sample size and follow-up, are warranted to clarify those unresolved issues.

Highlights

Clinical features range from an asymptomatic condition to end-stage renal disease (ESRD) and appear as directly related to the severity of the reflux and the occurrence of urinary tract infections (UTIs) [5,6,7]
The clinical management of vesicoureteral reflux (VUR) occurring in a kidney allograft depends on the grade of the reflux and, most importantly, on the severity and frequency of UTIs
Atrophic bladder is the most relevant predisposing factor, and it is predominantly related to pre-existing urological disorders or dialysis vintage

Summary

Introduction

Vesicoureteral reflux (VUR) represents one of the most frequently observed urological complications of kidney transplantation (KT) [1,2,3]. It is defined as an abnormal flow of urine backward from the bladder to the ureter or, in extreme cases, up to the renal pelvis. The technique adopted for ureteral implantation and bladder function, at the time of transplant, certainly are key factors in the development of post-operative VUR. The transplant community has yet to reach an agreement on optimal pre-emptive strategy, clinical relevance, management, and impact on long-term allograft function and survival [8]

Literature Research

Management of Post-Transplant VUR

Impact of Post-Transplant VUR on Allograft Function and Survival

Participants

Conclusions