Early Transplantation Into A Vesicostomy: A Safe Approach To Managing Anephric Patients With Severe Obstructive Lesions Identified Antenatally
Aravind Viswanathan, MD, Thomas G. Leffler, MPH, Neil J. Paloian, MD, Patrick H. McKenna, MD.
University of Wisconsin-Madison, Madison, WI, USA.
BACKGROUND: Historically, pediatric renal transplants were not performed into diverted urinary systems. These children instead underwent undiversion surgeries prior to transplant due to concerns of increased risks for infection and decreased graft survival; this approach is changing because transplantation is occurring at a much younger age making diversion plus transplant difficult. Furthermore, advances in antenatal management of severe renal failure such as amnio-infusion for oligohydramnios is resulting in a higher survival rate of anephric patients.
METHODS: Three cases of children who underwent simultaneous renal transplantation into vesicostomies after extensive bladder evaluation in our clinical practice are presented.
RESULTS: Patient A is a 30-month-old male with history of renal failure at birth secondary to severe obstructive uropathy from posterior urethral valves who had several amnio-infusions antenatally, both to assess fetal anatomy and to facilitate shunt placement. Patient was delivered preterm at 35 weeks gestation with severe pulmonary hypoplasia. He was peritoneal dialysis dependent until he underwent a simultaneous living donor renal transplantation onto a diverted vesicostomy at 20 months of age. Post-operatively, patient had persistent grade 3 hydronephrosis, for which he initially underwent revision of vescicostomy 2 months after the transplant, and balloon dilation of his uretero-vesical junction anastomosis 3 months after the transplant. Patient also had an episode of Haemophilus parainfluenzae UTI at 1 month after transplant that resolved with an appropriate antibiotic course. Patient is no longer dialysis dependent; his creatinine levels have been normal on several follow-up visits. He still has persistent grade 2 hydronephrosis.
Patient B is a 32-month-old male with a history of renal failure (without need for dialysis) secondary to Eagle-Barrett syndrome who underwent a simultaneous living donor renal transplantation onto a diverted vesicostomy at 24 months of age. His post-operative course has been relatively unremarkable - creatinine levels have been normal and no reports of UTI, transplant rejection, or a need for revision of the vesicostomy.
Patient C is a 27-month-old male with history of renal failure at birth secondary to posterior urethral valves with persistent chronic kidney disease, despite having undergone bilateral end cutaneous ureterostomy for upper tract diversion at 6 days of age. The patient eventually underwent excision of end cutaneous ureterostomies and simultaneous living donor renal transplantation onto a diverted vesicostomy at 26 months of age. His post-operative course has been unremarkable - normal creatinine levels, no UTIs, transplant rejection, or need for further surgical revisions.
CONCLUSIONS: An increasing number of patients are born anephric, or with severe obstructive lesions and oligohydramnios, and have survived. They have normal development and good outcomes. Recent advances in antenatal management such as amnio-infusion for oligohydramnios have made significant impacts in pulmonary and renal management and have increased the survival rate of this patient population over recent years. There is a need for a paradigm shift in regards to antenatal and postnatal management of these children, many of whom previously would not have survived. We report here three recent cases of early pediatric renal failure, one with severe pulmonary hypoplasia that highlight these reformed approaches.
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