0041-1337/03/7611-1578/0 TRANSPLANTATION Vol. 76, 1578–1582, No. 11, December 15, 2003 Copyright © 2003 by Lippincott Williams & Wilkins, Inc. Printed in U.S.A. LONG-TERM RESULTS OF PEDIATRIC RENAL TRANSPLANTATION INTO A DYSFUNCTIONAL LOWER URINARY TRACT PATRICK P. W. LUKE, 1,2,3,5 DANIEL B. HERZ, 1 MARK F. BELLINGER, 1 PRADIP CHAKRABARTI, 2 CARLOS A. VIVAS, 1 VELMA P. SCANTLEBURY, 2 THOMAS R. HAKALA, 1 ANTHONY M. JEVNIKAR, 4 ASHOK JAIN, 2 RON SHAPIRO, 2 AND MARK L. JORDAN 1 Background. The authors reviewed their long-term experience with pediatric renal transplantation into a dysfunctional lower urinary tract to evaluate the re- sults of contemporary lower urinary tract evaluation and management on graft survival and function. Methods. Between 1990 and 1996, 21 renal transplants were performed in 20 children with dysfunctional lower urinary tracts and 61 transplants were performed in 61 patients with normal lower urinary tracts. The mini- mum follow-up was 36 months (mean, 62.019.6 months). The cause of lower urinary tract dysfunction included posterior urethral valves (n13), prune belly syndrome (n4), meningomyelocele (n2), and urogenital sinus ab- normality (n1). Urodynamics were performed on all children with dysfunctional lower urinary tracts. Using these perioperative assessments, lower tract manage- ment strategies were devised, including timed voiding alone (n6), clean intermittent catheterization (n8), bladder augmentation (n4), and supravesical urinary diversion (n2). Results. Overall 5-year actuarial patient and graft survival rates were 100% versus 95% (Pnot signifi- cant [NS]) and 83% versus 69% in the dysfunctional and normal urinary tract groups (PNS), respectively. Mean serum creatinine levels in dysfunctional and normal urinary tract patients with functioning grafts at 3 years were 1.30.5 and 1.30.7 mg/dL, respectively (PNS). However, 35% of patients with a dysfunctional lower urinary tract experienced urologic complications. Conclusions. Pediatric renal transplantation into a dysfunctional lower urinary tract yields outcomes comparable to transplantation into the normal lower urinary tract. Because of the high urologic complica- tion rates, careful surveillance of lower urinary tract function by urodynamic evaluation is essential to op- timize these outcomes. Renal transplantation in pediatric patients is highly suc- cessful (1). However, transplantation into the dysfunctional lower urinary tract (DLUT) has been associated with rela- tively high complication rates (2, 3) and inferior graft sur- vival according to historic case series (4–6). With the evolu- tion of lower urinary tract evaluation (7, 8) and management using anticholinergic medications, clean intermittent cathe- terization (CIC) (9 –11), and bladder augmentation proce- dures (12, 13) in the past 20 years, improvements in renal function and lower urinary tract preservation have been ac- complished in the majority of pediatric patients with congen- ital lower urinary tract anomalies. Contemporary studies have indicated that renal transplan- tation outcomes in adult patients with DLUT are comparable to those observed in patients with normal lower urinary tracts (NLUT) (14 –16). However, there are limited data re- garding the results of transplantation in the pediatric popu- lation (17). A distinction between pediatric and adult pa- tients needs to be emphasized, because adherence to strict timed voiding schedules and CIC regimens is far more chal- lenging in the pediatric and adolescent population, placing these patients at greater risk for upper tract deterioration. We hypothesize that with rigorous lower tract follow-up and compliance with contemporary techniques in the manage- ment of lower tract dysfunction, pediatric renal transplant patients can maintain excellent long-term graft survival and function in accordance with the excellent results seen in the adult population. In this report, we compared the long-term outcomes of pediatric renal transplantation in children with DLUT with outcomes in children with NLUT during the 1990s at the University of Pittsburgh Medical Center. PATIENTS AND METHODS Patient Demographics Between 1990 and 1996, 21 renal allografts were transplanted into 20 patients with DLUT (18 male patients and 2 female patients). Over the same period of time, 61 renal allografts were transplanted into 61 patients with NLUT (26 male patients and 25 female pa- tients). Patients were followed for a minimum of 36 months (mean, 62.019.6 months; range, 36 –98 months) from the time of trans- plantation. Patient demographics are shown in Table 1. Patients were comparable in all demographic categories except for the cold ischemia time, which was higher in the DLUT group than in the NLUT group (P=0.008). DLUT Patients The cause of lower urinary tract dysfunction included 13 patients with posterior urethral valves (PUV), four with prune belly syn- drome (PBS), two with meningomyelocele, and one with urethral atresia-imperforate anus syndrome. Preoperatively, patients with lower urinary tract dysfunction were evaluated using voiding cys- 1 Department of Urology, University of Pittsburgh Medical Cen- ter, Childrens Hospital of Pittsburgh, Pittsburgh, PA. 2 Thomas E. Starzl Transplantation Institute, University of Pitts- burgh Medical Center, Childrens Hospital of Pittsburgh, Pittsburgh, PA. 3 Division of Urology, London Health Sciences Centre, London, Ontario, Canada. 4 Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada. 5 Address correspondence to: Patrick P. W. Luke, M.D., F.R.C.S., Division of Urology, 339 Windermere Road, London, Ontario N6A 5A5, Canada. E-mail: patrick.luke@lhsc.on.ca. Received 14 April 2003. Revision requested 15 May 2003. Accepted 27 June 2003. 1578 DOI: 10.1097/01.TP.0000090866.00241.0C