الفهرس 
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Abstract
The aim of the study
This study aims at evaluation the effect of VUR on renal graft survival in pediatric patients who suffer from End stage renal disease (ESRD). Also it evaluates the renal graft function in terms of serum creatinine level and glomerular filtration rate measurement.
Patients and methods
Our study was done in children’s hospital, Cairo University on a group of 145 pediatric recipients who had renal graft during the period between April 2009 till March 2020 and who met the inclusion criteria and classified into 2 main groups according to the VCUG result, group (A) included 66 pediatric patients who had renal graft VUR and group (B) included 79 patients who had not refluxing renal graft. The 2 main groups were further subdivided into 4 subgroups according to lower urinary tract condition (LUT) condition either defunctionalized or normal LUT function as following: group (A1) which included 32 pediatric recipients and presented those who had renal graft VUR with normal LUT condition post transplantation, group (A2) which included 34 pediatric recipients and presented those who had renal graft VUR with abnormal LUT condition post transplantation, group (B1) which included 58 pediatric recipients and presented those who hadn’t renal graft VUR with normal LUT condition post transplantation ,and lastly group (B2) which included 21 pediatric recipients and presented those who hadn’t renal graft VUR with abnormal LUT condition post transplantation. Urodynamic assessment UDS was done in106 patients in all total sample [65 patients in group (A), and 41 patients in group (B) to know the state of the bladder either normal or defunctionalized.
All pediatric patients received live donor transplantation by almost uniform surgical team. Pediatric recipients were evaluated for development of surgical complication, infection, acute rejection episodes and if there was early graft loss. Also we did long term evaluation for the graft function evaluation, VUR diagnosis, and if there was graft related complication (hypertension, biopsy proven chronic rejection and if there was vascular complication in the form of renal artery stenosis
Study results
The bladder was evaluated before transplantation by using voiding cystourethrography (VCUG) and 64 cases with reflux nephropathy (RN) with different grades as a cause of ESRD were diagnosed and pre transplant native nephrectomy was done in 50 patients of all patients who had reflux nephropathy and nephrectomy was done in the previous cases due to reflux associated renal hypertension or repeated UTIs.
The right kidney was used for donation in 51 cases [23 cases in group (A), and 28 cases in group (B)], while the left kidney was used in 94 cases [43 cases in group (A) and 51 cases in group (B)].
In our series, we had 11 cases that had pre-emptive renal graft [4 patients in group (A), and 7 patients in group (B)].
Regarding to donor’s demographics, there was no significant difference between both main groups regarding donor’s age, sex, and donated side.
No significant difference between both main groups regarding recipients demographics except recipient’s weight and age at time of transplantation and at time of follow up at outpatient clinic.
The median (range) 5 years creatinine level was1mg/dl ranging from 0.6 to3 mg/dl in group A, while was1mg/dl ranging from 0.6 to 3.5 in group B with insignificant difference between both main groups.
The median last serum creatinine was 1.2mg/dl ranging from0.4 to5.5 mg/dl and1.2 mg/dl ranging from 0.6 to 5 mg/dl in group A and B, respectively with no significant difference. The mean GFR was measured using Schwartz formula based on last serum creatinine was 80.1± 29.2 ml/min, and 86.5±30.7 ml/min, respectively with no significant difference.
We diagnosed 66 cases with graft VUR of total 145 cases [Asymptomatic VUR in 30/66 cases and symptomatic VUR in 36/66 cases.
We treated graft VUR (n=66) as following: Suppressive antibiotics in 30 cases, , anticholinergics + CIC +suppressive antibiotics in 12 cases , anticholinergics + suppressive antibiotics in 10 cases , CIC+ suppressive antibiotics in 10 cases , endoscopic Dextranomer/Hyalouronic acid injection in 2 cases and lastly augmentation ileocystoplasty in 2 cases.
Urinary tract infections occurred with no significant difference between group A and group B (40 patients in group A versus 49 patients in group B), but the frequency of UTIs was more in the refluxing graft group than the non refluxing group. After graft VUR treatment, the frequency of urinary tract infections decreased when compared to urinary tract infections before management.
There wasn’t significant difference between refluxing and non refluxing main groups regarding 5 years and 10 years graft survival rate were (100% versus 98.5%), and (76.2% versus 84.7%) ,respectively with insignificant p value.
Nine patients of all total sample returned into dialysis (3 patients in group A, and 6 patients in group B). Graft nephrectomy due to graft non function was done in 3 cases (1 case in group A and 2 patients in group B).
Conclusions
A- Post transplantation VUR didn’t affect graft function negatively in most cases unlike primary native VUR and could be managed conservatively.
B- Asymptomatic renal graft VUR needs just follow up only.
C- Endoscopic correction of renal graft VUR did not yield successful outcome in recipients treated with DX/HA injection with reflux recurrence even in low grade reflux.
D- No significant difference between refluxing and non refluxing renal graft in terms of long term graft survival and outcome.
E- No significant difference between refluxing and non refluxing renal graft in terms of UTIs occurrence but the frequency of UTIs episodes is more in refluxing grafts.
F- No significant difference in renal graft GFR between normal lower urinary tract group (LUT) and abnormal lower urinary tract (LUT).
Recommendations
A-We don’t recommend doing VCUG post Tx as a routine protocol to diagnose graft VUR , as it is asymptomatic in most cases and we recommend doing it only if indicated like in patients with recurrent UTIs as the possibility of having reflux in these scenarios is high.
B- Video urodynamic study is an ideal standard to diagnose graft VUR to determine at which volume and pressure the reflux had been occurred, and the presence of associated bladder pathology like bladder diverticula so it will help in diagnosis and decision making regarding reflux treatment.
C- Endoscopic injection for graft VUR has bad results and shouldn’t be used as a definitive management.
D-No treatment is needed for asymptomatic renal graft VUR and it needs just follow up.
E- Conservative management for symptomatic refluxing grafts either in the form of suppressive antibiotics alone or anticholinergics plus suppressive antibiotics or anticholinergics plus suppressive antibiotics plus CIC is considered the ideal approach for refluxing grafts management.