Renal transplantation in patients with ileal conduits

Patients with renal failure and lower urinary tract abnormalities of persistent incontinence, neurogenic bladder or previous cystectomy require urinary conduit construction prior to renal transplantation. These patients were traditionally considered poor risks for transplantation. From Nov. 1, 1967 to Dec. 31, 1988, 947 patients underwent 1185 renal transplants at our institution. Since 1972, 15 patients or 1.6% (mean age 26.3 ± 14.3 yr, range 8-51) underwent renal transplantation into an ileal conduit. A total of 19 transplants were performed, (12 cadaveric [CRT], 7 living-related donor [LRT]). One patient died postoperatively with overwhelming bacterial sepsis and a non-functioning graft (ATN), 3 grafts were lost in 2 patients in the peri-operative period from rejection, 3 patients with functioning grafts died at 8, 9 and 10 yr post-transplant of causes unrelated to the transplant and 5 kidneys were lost in 3 patients from chronic rejection 3 months to 8 yr post-transplant. Seven patients are currently alive with functioning grafts with follow-up from 1 to 15 yr. Sixteen urologic complications occurred in 10 recipients, including ureteral stenosis (5), calculi (3), recurrent urosepsis (2), parastomal hernia (1), metabolic acidosis (2) and ileal conduit stenosis (3). The incidence of ureteral stenosis (33%) is higher than that seen in non-transplant recipients undergoing ureteroileal anastomosis (5-22%) and may be due to ischemia and rejection. Calculi, urosepsis, and metabolic acidosis are related to changes in length or peristalsis of the conduit with stasis leading to increased Cl-HCO₃ exchange and infection. Despite the high rate of urologic complications, satisfactory 5-yr patient (86%) and graft survival (100% LRD, 42% CRT) were achieved. No patients or grafts were lost as a result of these complications. Recipients who present with renal dysfunction require complete evaluation of their urinary tract, including cultures, loopography and looposcopy, to differentiate rejection from surgically correctable urologic abnormalities.