Reflux most common kidney transplant complication

San Francisco-Vesicoureteral reflux appears to be the most common complication of ureteral reimplantation at the time of kidney transplantation, as indicated by findings from St. Barnabas Healthcare System, Livingston, NJ.

St. Barnabas is the site where Matthew Whang, MD, performed more than 2,000 ureteral reimplantations at the time of kidney transplantation between 1993 and 2007.

"Reflux was the most common complication I have seen," Dr. Whang told the American College of Surgery Clinical Congress in San Francisco. "We saw it in 37 of our patients, or 1.8%. I think we have underestimated the true incidence of reflux because we do not routinely perform voiding cystograms on everyone."

Dr. Whang noted that while reflux was relatively uncommon in the St. Barnabas kidney transplant population, it occurred in 33 women and only four men. He attributed the problem to an inadequate anti-reflux tunnel, most often the result of a thinner bladder muscle in female patients. Surgical reconstruction, most often a ureteroureterostomy (UU) using the native ureter, is the most reliable treatment, he added. He performed a UU on 26 of the 37 reflux patients.

Other successful strategies include the Politano-Leadbetter technique, used in three patients who do not have a native ureter available; antibiotic suppression, used in three patients; and dextranomer/hyaluronic acid (DxHA [Deflux]) treatment, used in five patients.

DxHA alone was effective in only two of the five patients, Dr. Whang added. Two patients still required UU following DxHA and one was given antibiotic therapy following failure of DxHA.

Ureteral strictures, the second most common complication, were most often caused by distal ureteral ischemia. Balloon dilation was the most common treatment, used in 22 patients, but was not universally successful. Five patients had ureteroneocystostomy (UNC) following dilation and one patient needed a UU following dilation. Six patients were treated with UNC alone, six with UU alone, and one patient had pyeloplasty.

Urine leak was due to either distal ureteral necrosis or infarction of a segmental artery in patients who had kidneys with multiple arteries. In the case of infarction, Dr. Whang said, the only option is a partial nephrectomy to remove damaged tissue. Two patients required partial nephrectomy.

Of the other 14 patients with leaks, five were treated with UU, two with UNC, and one with pyeloplasty. Four had minor leaks that were treated successfuly with a stent and Foley catheter. One patient needed ureteropyelostomy when the stent and Foley catheter failed to close the leak and one patient required a ureteroileostomy because his bladder was deemed unsuitable.