Pathology of the lower urinary tract in patients with chronic kidney disease and evaluation for kidney transplant

Abstract

Normal function of the lower urinary tract (UT) conditions the collection and low pressure storage of urine in the urinary bladder (UB) and its complete excretion through the process of micturition. When the neurovegetative nervous system is damaged, a frequent occurrence in patients with chronic kidney disease (CKD), especially those with concomitant diabetes, the above described mechanisms are disturbed, thus predisposing such patients for vesicoureteral reflux, urinary tract infections (UTIs) and CKD progression. When evaluating UT neurogenic dysfunction, ultrasound with the assessment of kidneys, bladder and urine retention following micturition is especially effective. The examination of choice is urodynamic testing that serves to assess the function of the UB and urethra. It is particularly important to evaluate urologic diseases in the population of CKD patients prior to kidney transplant (KT). Long term hemodialysis (HD) treatment is accompanied with oligo/anuria that is associated with the atrophy of the UB smooth muscle coat. No unanimous views exist as to how to deal with such cases. Some authors believe that the UB becomes extended after KT because of the following diuresis and do not recommend any preparatory procedures, whereas others favour “the extension” of the UB or recommend its surgical enlargement. Kidney recipients who had undergone cystectomy may be qualified for an ileal conduit urinary diversion (Bricker conduit) simultaneously with KT. During the urological evaluation of a potential kidney transplant recipient, indications for recipient nephrectomy should always be assessed. Anatomic and functional anomalies of the urinary tract seem not to affect prognosis of patients after KT despite a higher risk of recurrent UTIs. Consequently, thorough diagnostics, correct diagnosis and skillful correction of urological dysfunctions during the evaluation work up of a potential kidney recipient prevents the development of complications following KT and improves graft survival.