*Purpose: Congenital anomalies of the kidney and urinary tract (CAKUT) are a leading cause of pediatric end-stage renal disease (ESRD). Prior studies have shown an association between UTI and impaired graft function for those with kidney transplants. We hypothesized that having ESRD resulting from CAKUT is associated with post kidney transplant febrile UTI (pT-fUTI) and graft rejection.

*Methods: Patients less than 21 years of age who underwent renal transplant between 1/2014 and 10/2018 at a single high-volume tertiary pediatric transplant center were identified. Patients without at least one year of follow up after transplant were excluded. Data regarding ESRD etiology, post-transplant UTI, eGFR, and graft rejection were abstracted from the electronic health record. Patients with medical renal disease were compared to those with a CAKUT condition. Primary outcomes were pT-fUTI, eGFR at 12 months (Bedside-Schwartz equation), and biopsy-diagnosed graft rejection. Data were analyzed using Fisher’s exact test for nominal data, and t-test for continuous data.

*Results: Ninety-seven patients met inclusion criteria. Mean age at transplant was 15.5 years (Range: 1 -20). The majority of patients were male (51.5%) and 36.1% had CAKUT diagnoses. CAKUT patients had a greater rate of pT-fUTI (32.4% vs 11.7%, p=0.027). There was no difference in graft rejection rates (31.4% vs 16.1%, p=0.12) or 12-month post-transplant eGFR between the two groups. On subgroup analysis, patients with pT-fUTI had a greater rate of graft rejection (50% vs 15.8%, p=0.004), specifically cellular mediated rejection (p: 0.032), but not de-novo donor specific antibody (DSA) formation (p>0.05).

*Conclusions: In this study, we found that children with ESRD due to CAKUT conditions had a higher risk of pT-fUTI, and that pT-fUTI was associated with an increased risk of cellular-mediated rejection, but not de-novo DSA formation or anti-body mediated rejection. While our study did not show a direct association between CAKUT conditions and graft rejection, these findings suggest that heightened scrutiny and management of UTI risk in these patients may ultimately improve graft survival from an immunologic perspective.

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