Introduction: The incidence of acute renal allograft rejection has declined with advances in immunosuppression, making the evaluation of other risk factors for graft failure vital. Ureteral complications (UC) are associated with increased patient and graft morbidity. We sought to investigate the incidence of UC to assess the impact on post-transplant outcomes.

Methods: Retrospectively reviewed 49 pediatric patients who underwent 57 renal transplants at a single institution from 2004-2014. 90% had a Lich-Gregoire ureterocystostomy and 61% underwent ureteral stenting. We evaluated the incidence of UC, defined as vesicoureteral reflux (VUR), stricture, or obstruction, and compared the post-transplant outcomes of patients with UC to those without known UC. Fisher's exact and Mann-Whitney U tests were performed.

Results: A post-transplant urodynamic study or VCUG detected VUR in 22 of 25 screened patients. VUR in the remaining 24 recipients is unknown. Overall, 29 UC were encountered in 24 patients, with 5 cases of stricture and 2 of obstruction. There was no difference between groups in deceased versus living donor (p=0.91), warm ischemia time (p=0.51) or ureteral stenting (p=0.21). Children with UC were more likely to be male (p=0.02), require a nephrostomy tube (p=0.05), develop UTIs (p<0.0001), and be hospitalized (p=0.0002). 95% of UC patients had creatinine values elevated from nadir (increase range 0.3-1.9 mg/dL) and median creatinine clearance decrease was 20.34 mL/min (IQR 10.76-41). 7 children underwent 10 operations to treat UC.

Conclusions: Although only 25 children had urologic studies post-transplant, almost 1/2 of our renal transplant recipients had UC. These complications carried significant morbidity, including marked rises in creatinine, 58% developing UTIs, and 29% requiring surgery. Moreover, 88% of studies showed pathology, indicating the importance of post-transplant urologic evaluation.

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