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Kidney Transplants and Neuropathic Bladder: Latest news from the last 20 years
Abigail R. Jones, MBChB MRCS, Alun R. Williams, FRCS.
Nottingham Children's Hospital, Nottingham, United Kingdom.

Background
Management of the neuropathic bladder is evolving. Despite undoubtedly improved surveillance programmes for these patients, a proportion will go on to develop chronic kidney disease, and some will progress to require renal replacement. There is evidence to suggest that fewer patients progress to established renal disease (ERD) in contemporary series. We know from numerous case series that transplantation into the abnormal lower urinary tract can be safe. With the hypothesis that contemporary management of the neuropathic bladder preserves renal function, we sought to establish the ages of patient cohorts progressing to ERD over the past twenty years, and examine retransplant rate as a surrogate of graft failure.
Methods
We queried the UK transplant registry (NHS Blood and Transplant (NHSBT), formerly UK Transplant) from 1993 to 2013. We retrieved the cohorts of kidney only transplant recipients registered under the diagnostic category 'neuropathic'. Data was analysed by year, and grouped into five periods of four years. We analysed age at first transplant and re transplant rate. Statistical tests were performed using ‘Graphpad InStat’ software.
Results
Of 33117 kidney only transplants during the study period, 236 (0.7%) were for neuropathic bladder. Of these, 35 were in children. The mean age at first transplant in the neuropathic bladder group increased over the twenty year period from 31.7 to 40.3 years of age (p=0.0112, CI 2.003-15.197 ANOVA).
The retransplant rate was 22.4% for the neuropathic group versus 14.2% for the rest of the transplant recipient population during the study period. There was no significant difference in the proportion of neuropaths who required regraft over time (10/58 in 1993-1997 and 14/55 in 2009-2013, p=0.3592, CI 0.6581-4.082, Fisher’s exact test), however there was improvement in regraft rate for all other conditions (p=0.0251, CI 0.8269-0.9866, Chi squared test).
Conclusions
Clearly, the increase in age to first transplant is multifactorial, however, we believe that this data is further evidence for the benefit of surveillance and aggressive bladder management in the neuropathic group. In the non-neuropathic group, graft survival is better, in parallel with other registries' data. This is also multifactorial, but improved transplant management, including immunosuppressive evolution and improved management of cardiovascular risk factors are important factors. Both these have clear ramifications for healthcare economic planning.
Although age to first transplant is increasing, the regraft rate in neuropaths remains grossly unchanged. We present the first registry level evidence of this in a contemporary series. It raises a number of important issues for pre-transplant assessment and ongoing evaluation of the lower urinary tract in the transplant recipient.
We accept the limitations of registry data, in particular heterogeneity within individual groups, and the insensitivity of the data for considering time spent on dialysis, but this data lays the foundations for more detailed population-based study.


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