Introduction: In some pediatric kidney transplant recipients (PKTx), native nephrectomy before, after, or at the time of transplant has been implemented to address underlying issues caused by the native kidneys. These scenarios include polyuria, heavy proteinuria and nephrotic syndrome, resistant hypertension, vesicoureteral reflux, and polycystic kidney disease. In the adult population, native nephrectomy has been safely replaced with ureteral ligation to eliminate proteinuria from the native kidneys, allowing accurate monitoring of FSGS recurrence and treatment of native nephrotic syndrome (1). Based on success in the adult population, we began implementing ureteral ligation in lieu of native nephrectomy to treat select cases of polyuria and proteinuria in our PKTx. We present the outcomes in this cohort of patients to demonstrate the feasibility and safety of ureteral ligation as an alternative to native nephrectomy.
Methods: We performed a retrospective review of all PKTx in our center to identify all cases of unilateral or bilateral ureteral ligation at the time of kidney transplant. Chart review was performed on cases to determine the reason for ureteral ligation, postoperative outcomes, and the length of follow up. Outcomes of interest were pyelonephritis of native kidneys, flank pain, hypertension at four months postoperatively, and return to the operating room because of a complication of ureteral ligation. Because postoperative hypertension is frequently observed before and after pediatric transplant, we compared the rate of hypertension at four months in the cases to a group of 31 controls that included PKTx performed by the same surgeon during the same time frame who received the same immunosuppression protocol. Rate of postoperative hypertension between the two groups was compared using the chi-square test
Results: Fifteen patients underwent native ureteral ligation at the time of transplant between 12/2008 and 4/2022. Ten patients (67%) had bilateral ligation and five (33%) had unilateral ligation. Clinical indications for ligation included polyuria (12/15) and proteinuria due to nephrotic syndrome (3/15). Mean (SD) follow up was 4.6 (3.1) years. There were no instances of pyelonephritis in the native kidneys or return to the operating room for complications related to ureteral ligation. One patient reported flank pain on the side of unilateral ureteral ligation on postoperative day 6 but this was transient, and no further workup or intervention was required. The rate of postoperative hypertension was 26.7% in cases and 32.3% in controls (p = 0.70)
Conclusion: This study demonstrates that native ureteral ligation is a safe alternative to native nephrectomy at the time of kidney transplant in select cases of kidney failure among pediatric patients. These findings support more widespread implementation of ureteral ligation where feasible to avoid the more invasive alternative of native nephrectomy.