1110-5712 Vol. 19, No. 2, 2013 Egyptian Journal of Urology 63-68 63 RENAL TRANSPLANT INTO ABNORMAL LOWER URINARY TRACT: PATIENT AND GRAFT SURVIVAL Mohamed H Zahran and Bedeir Ali-El-Dein Urology and Nephrology Center, Mansoura University, Mansoura, Egypt. INTRODUCTION Renal transplantation is the optimal treatment for patient with end stage renal disease (ESRD). Congenital and acquired disorders of the lower urinary tract (LUT) are major causes of developing ESRD. About 15- 25% of children with ESRD have abnormal lower urinary tract function. Renal transplantation in this group of patients is a unique challenge, as they are at higher risk of urinary tract infection, sepsis, surgical complications, allograft dysfunction and graft loss. 1 One decade after the first successful renal transplantation, this procedure was offered for a patient without functioning bladder. 2 Advances in surgical technique, technical expertise, immunotherapeutic agents, reconstructive surgeries and understanding the cause and treatment of bladder dysfunction allowed many children with ESRD to live normal after transplantation. There is still a controversy whether to normalize the LUT before, with or after transplantation. Prevalence of LUT dysfunction among dialysis patients: Many patients with ESRD have suffered undiagnosed LUT dysfunction in the past. The incidence of LUT dysfunction among patients with ESRD is similar worldwide. Koo et al stated that the incidence of LUT dysfunction among children with ESRD is 15-25%. 1 Hatch et al reported that 6 % of American populations who are under dialysis have LUT dysfunction. 3 In Europe, 7.6% of dialyzed adult and 25% of dialyzed children have abnormal LUT function. The incidence of LUT dysfunction among patients awaiting for transplant is 30 %. 4 In a recent study from Asia, Chen et al stated that two third of patients with ESRD have abnormal finding in urodynamic studies. 5 Causes of LUT dysfunction in transplant patients: Many causes have been reported to cause LUT dysfunction in patients awaiting for renal transplantation. 6 These causes include congenital diseases as neuropathic bladder (spina bifida, meningeomyelocele), posterior urethral valve (PUV), duplicate bladder, bladder extrophy, urogenital sinus anomalies, prune-belly syndrome, vesicoureteral reflux (VUR) and acquired diseases such as neuropathic bladder due to spinal cord injury, contracted bladder, bladder malignancies. In such condition, the bladder need to be modified to be safe for subsequent transplantation or the graft needed to be transplanted into a suitable form of urinary diversion. Otherwise, the graft function will be lost as the cause of native kidney damaged is still present. Preoperative evaluation of patients with abnormal LUT: Patient with abnormal LUT that ended in ESRD should be fully evaluated before renal transplantation. The aim is to determine whether the native bladder is efficient for transplantation or it needs modification to render it suitable for transplantation. It should include detailed history to assess the initial pathology, duration of renal impairment, lower urinary tract symptoms, the total daily urine output and previous surgical procedure that was done for management of the lower urinary tract disorders. All tests should be done before transplantation to avoid unnecessary complications. 4 Voiding cystourethrography (VCUG) and panendoscopy are mandatory in this group of patients to assess the nature of the lower urinary tract disorders and the bladder capacity. VCUG can diagnose presence of VUR, PUV, stricture urethra, presence of high post voiding residual urine and assess the bladder capacity, which affect the decision of transplantation on the native bladder. The detection rate of abnormality is higher in patients with lower urinary tract symptoms, complex urological history and a defunctionalized bladder. 7 Singer et al, recommended selective use of VCUG in patients with history of urinary tract infection, hydronephrosis or voiding dysfunction. 8 Presence of low bladder capacity does not preclude transplantation into this native bladder. 9 Patients with prolonged renal impairment resulting in oliguria or anuria, have bladder with small capacity and thickened wall (defunctionalized bladder). There is no standard definition of defunctionalized bladder. MacGregor et al, noted that the bladder capacity of patients with good graft function increased gradually after transplantation and