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J Urol. 2018 Mar;199(3):824-830. doi: 10.1016/j.juro.2017.10.024. Epub 2017 Oct 20.

Impact of Adjuvant Urinary Diversion versus Valve Ablation Alone on Progression from Chronic to End Stage Renal Disease in Posterior Urethral Valves: A Single Institution 15-Year Time-to-Event Analysis.

Author information

1
Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
2
Division of Nephrology, The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
3
Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Urology, American University of Beirut-Medical Center, Beirut, Lebanon.
4
Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada. Electronic address: darius.bagli@sickkids.ca.

Abstract

PURPOSE:

Long-term progression to end stage renal disease of valve ablation alone vs ablation followed by additional urinary diversion were compared among children with stage 3 chronic kidney disease due to posterior urethral valves.

MATERIALS AND METHODS:

We performed a retrospective study of children with posterior urethral valves and stage 3 chronic kidney disease treated at a single institution between 1986 and 2011. The 3 treatment groups were classified as group 1-valve ablation alone, group 2-ablation plus subsequent vesicostomy and group 3-ablation followed by ureterostomies and/or pyelostomies. Baseline demographic characteristics were analyzed. Statistical analyses compared the incidence of time to end stage renal disease among the intervention groups using the Fisher-Freeman-Halton exact test and Kaplan-Meier analysis with the log rank test. Cox regression was used to determine predictors of end stage renal disease progression.

RESULTS:

A total of 40 eligible patients were included in the study (group 1-14 patients, group 2-13 patients, group 3-13 patients). Baseline characteristics and post-intervention estimated glomerular filtration rate revealed no significant between-group differences. A statistically significant difference in progression to end stage renal disease was noted within 1 year after diagnosis of stage 3 chronic kidney disease among the treatment groups (log rank test p=0.02). However, cumulative end stage renal disease incidence at 15-year followup showed no statistical difference (log rank test p=0.628). Cox regression analysis determined that bilateral renal dysplasia (HR 2.76, 95% CI 1.21-6.30) and estimated glomerular filtration rate 60 ml/minute/1.73 m2 or greater after intervention (HR 0.23, 95% CI 0.09-0.61) were predictive of the likelihood of progression to end stage renal disease.

CONCLUSIONS:

Urinary diversion following valve ablation in children with stage 3 chronic kidney disease associated with posterior urethral valves may temporarily delay progression to end stage renal disease. However, no long-term benefit was noted from diversion in the ultimate incidence of end stage renal disease, suggesting that these interventions should be seen as a temporizing measure. Bilateral renal dysplasia and post-intervention estimated glomerular filtration rate are independent variables predicting overall chronic kidney disease progression.

KEYWORDS:

chronic; cystostomy; kidney failure; renal insufficiency; urinary diversion

Comment in

PMID:
29061539
DOI:
10.1016/j.juro.2017.10.024
[Indexed for MEDLINE]

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