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NDT Advance Access originally published online on September 8, 2006
Nephrology Dialysis Transplantation 2006 21(11):3269-3274; doi:10.1093/ndt/gfl464
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© The Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

High prevalence of febrile urinary tract infections after paediatric renal transplantation

Ulrike John1, Anne Schulze Everding2, Eberhard Kuwertz-Bröking2, Monika Bulla2, Dirk E. Müller-Wiefel3, Joachim Misselwitz1 and Markus J. Kemper3

1Pediatric Nephrology, Friedrich Schiller University Children's Hospital, Kochstraße 2, D-07740 Jena, 2Pediatric Nephrology, University Children's Hospital, Albert-Schweitzer-Straße 22, D-48149 Münster and 3Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany

Correspondence and offprint requests to: Ulrike John, MD, Department of Pediatric Nephrology, University Children's Hospital, Kochstraße 2, D-07740 Jena, Germany. Email: ulrike.john{at}med.uni-jena.de



   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 References
 
Background. Adult data suggest that urinary tract infections occur frequently after renal transplantation (RTx) and contribute to mortality and graft loss; data in children are limited. Therefore, we evaluated prevalence, short and long-term morbidity and confounding factors of febrile UTI (fUTI) after paediatric RTx.

Methods. In a retrospective cross-sectional study of three centres, we analysed data on 110 children followed for 4.9 ± 3.4 years after successful transplantation.

Results. 40/110 (36%) patients had at least one fUTI at a median time of 0.98 years (range 0.02–8.96) after RTx; 11 patients (28%) had recurrent fUTI. Serum creatinine (SCr) rose significantly from 1.15 ± 1.13 to 1.83 ± 1.69 mg/dl, (P < 0.001) during the fUTI, declining to baseline values after treatment. At the last followed-up calculated mean, GFR was comparable between fUTI and non-fUTI groups (75 ± 26 vs 71 ± 22 ml/min/1.73 m2). During fUTI mean, C-reactive protein (CRP) increased to 123 ± 75 mg/l. Febrile UTI were significantly more frequent in girls compared to boys (22/44 vs 18/66, P < 0.05) but occurred significantly earlier in boys than in girls [median 0.63 (range 0.02–4.15) vs 1.07 (0.04–8.96) years after RTx; P < 0.02]. Also, patients with urinary tract malformations (UTMs) and neurogenic bladder as underlying diagnosis and those with urological surgery prior to transplantation had an increased risk for fUTI.

Conclusion. fUTI is a frequent complication with significant short-term morbidity especially in girls and children with UTMs, neurogenic bladder and those with urological surgery. Long-term follow-up and prospective studies confirming specific risk factors, preventive measures and impact on graft survival are necessary.

Keywords: congenital urinary tract malformation; paediatric renal transplantation; risk factor; urinary tract infection



   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 References
 
Renal transplantation (RTx) is the preferred treatment modality for children with end-stage renal disease [1]. Nowadays, patient survival is approaching 100%, and also graft survival has improved significantly in recent years, mainly due to improved immunosuppressive strategies [2,3]. Nevertheless, chronic allograft nephropathy remains an unsolved challenge, and specific immunological and non-immunological risk factors, such as hypertension and urinary tract infections seem to play a role [4].

Prior to RTx, febrile urinary tract infections play a crucial role in the progression of chronic kidney disease associated with urogenital abnormalities, which are often associated with an abnormal bladder function. However, also after RTx, fUTI leads to parenchymal infection of the kidney graft, affecting long-term graft survival by scarring and interstitial injury, as suggested by clinical data and DMSA studies in RTx [5,6]. Although recent studies indicate that in urinary tract infections adults may negatively influence long-term graft function and even survival, precise data for the paediatric population are scarce [7–9].

Therefore, the aim of our study was a retrospective evaluation of the prevalence, epidemiology and clinical features of UTI in children after RTx, followed in three paediatric renal transplant centres. We hypothesized that specific risk factors, especially demographic features (e.g. age, sex), underlying diagnoses (such as UTM) and surgery before transplantation would increase the risk of fUTI after transplantation.



   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 References
 
A retrospective chart analysis was performed, and the episodes of fUTIs were recorded for all patients currently followed at the three paediatric renal transplant centres; the multicentre approach was used to increase the number of patients, allowing for more robust statistical evaluation and reduction of local bias.

A total of 110 children and adolescents (66 males, 44 females) were included, four of which had received two renal allografts. One hundred and four grafts were of cadaveric origin and six from living related donors. Median age at transplantation was 10.9 (range 2.1–20.0) years and median follow-up was 4.2 (range 0.5–14.4) years.

Primary renal disease/cause of end-stage renal disease
Of the 110 patients, the primary renal diseases were glomerular disorders (acquired and genetic) in 28 patients (26%), UTM in 19 (18%), renal dysplasia in 17 (15%), nephronophthisis in 15 (14%), haemolytic uraemic syndrome in 6 (5%) and autosomal recessive polycystic kidney disease (ARPKD) in 6 (5%) patients respectively. Neurogenic bladder was present in 5 patients (5%) and metabolic disorders (cystinosis and primary hyperoxaluria) were present in 8 patients (7%). Six patients (5%) had other diagnoses (Table 1).


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  		Table 1. fUTI: association to underlying diseases, surgery prior to RTx and gender

 
Twenty-five (23%) patients had urological operations before transplantation. Table 1 summarizes the details of patients with fUTI including underlying diagnosis, surgical procedure and gender.

fUTI was defined by fever >38.5°C, leucocyturia and a positive urine culture. Urine samples were mainly obtained by bladder catheterization or suprapubic aspiration in two centres, while collection of clean catch midstream urine was standard in one centre. Samples were processed according to clinical routine and standard microbiological procedures. Serum creatinine (SCr) was determined by a modified Jaffe reaction. SCr was recorded prior to fUTI (e.g. last out-patient value), during fUTI (maximum value within 5 days) and after fUTI (next out-patient visit). GFR was calculated according to the Schwartz formula [8]. The maximum serum C-reactive protein (CRP) value as determined by nephelometry within 3 days after documentation of fUTI was recorded. All patients were hospitalized. Thirty-five patients received intravenous antibiotics: monotherapy was given to 22 patients (cefotaxim n = 16, ceftazidim n = 3, ciprofloxacin n = 2, ampicillin clavulanic acid n = 1). Thirteen patients received a combination of cephalosporine with ampicillin, gentamycin or piperacillin, respectively. Five children were treated with oral cefixime.

Immunosuppression consisted of triple therapy in 86 patients: corticosteroids, ciclosporin A and mycophenolate mofetil were used in 73; corticosteroids, ciclosporin A and azathioprine were used in 7 patients; and corticosteroids, tacrolimus and mycophenolate were used in 6 patients. Steroid free immunosuppression consisting of ciclosporin A and mycophenolate mofetil was used in 20 patients, and 4 patients had other regimens.

The data were analysed using the statistical software SPSS version 13.0 (SPSS, Chicago Ill USA). Chi-square test or Fisher exact tests were used as appropriate. For parametric data, the Mann–Whitney U-test and the log-rank test were used as appropriate. A P-value <0.05 was considered to be statistically significant. The study was approved by the local ethical committees.



   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 References
 
Prevalence
fUTI was diagnosed in 40 out of 110 patients (36%) during the observation period. They occurred at median of 0.98 (0.02–8.96) years after RTx. Chronological age of patients at the time of RTx was similar in the fUTI and non-fUTI groups (9.4 ± 4.6 vs 10.7 ± 4.6 years, P = NS). Eleven out of 40 patients with fUTI showed recurrences (one recurrence: n = 7; two recurrences: n = 3; three or more recurrences: n = 1).

Epidemiology
The most frequently isolated causative microorganisms in the urine culture were Escherichia coli (n = 21; 37%) followed by Enterococcus (n = 9; 15%) and Pseudomonas aeroginosa (n = 7; 13%) (Figure 1).


Figure 1
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  		Fig. 1. Relative frequency of bacteria isolated in urinary culture.

 
Clinical features
Short and long-term morbidity
During fUTI SCr increased significantly from 1.15 ± 1.13 to 1.83 ± 1.69 mg/dl (P < 0.001), returning to baseline afterwards (Figure 2). After a mean 4.7 ± 3.3 and 4.9 ± 3.2 years, follow-up mean calculated GFR of patients with and without fUTI, however, was comparable at 75 ± 26 vs 71 ± 22 ml/min/1.73 m2 body surface area (BSA), respectively (P = NS).


Figure 2
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  		Fig. 2. Renal function during fUTI: Changes in SCr from baseline to time of fUTI and at the next out-patient visit in 40 patients.

 
During fUTI serum CRP levels increased to a mean of 123 (±75) mg/l (normal <5).

Risk factors
UTI was significantly more frequent in girls than in boys (22/44 vs 18/66, P < 0.01) (Table 1). In girls, these occurred considerably later [median 1.07 (range 0.04–8.96) years] than in boys [median 0.63 (range 0.02–4.15) years], respectively (P < 0.05) (Figure 3).


Figure 3
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  		Fig. 3. fUTI in boys occurs significantly earlier than in girls.

 
The risk of fUTI was also much higher in patients with congenital UTM (9/19) and those with neurogenic bladder (4/5) compared to other diagnoses (27/86 patients) (P < 0.001), respectively. Finally, patients with urinary tract surgery prior to RTx were more likely to have fUTI (13/40) than those without (P < 0.05). Baseline immunosuppression did not have an impact on the prevalence of fUTI.

Vesico ureteral reflux (VUR)
After RTx, a VCUG was performed in 20 patients, revealing a VUR in 16 patients. Indication for voiding cystourethrography VCUG was fUTI in 15 patients, demonstrating VUR in 12. In the remainder (n = 5), VCUG was performed because of suspected ureteric occlusion (n = 1) and a decline of renal function with dysfunctional voiding without fUTI (n = 4). Four of these 5 patients had VUR without a history of fUTI.

Antibiotic chemoprophylaxis before and after fUTI
Fourteen out of 40 patients (35%) developed the first fUTI despite antibiotic prophylaxis with trimethoprim (n = 8) or nitrofurantoin (n = 6). After the first fUTI antibiotic prophylaxis was initiated (or continued) in 33 out of 40 patients (83%); trimethoprim was used in 19 patients and nitrofurantoin was used in 14 patients. Despite this, 11 patients (28%) had recurrences of fUTI.



   Discussion
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 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
References
 
Our study demonstrates a high prevalence of fUTI in children after RTx, which is not limited to the immediate post-transplant period but could also occur later, especially in girls. During fUTI, renal dysfunction and inflammatory response is significant. Girls, patients with congenital UTM and neurogenic bladder as well as those with pre-transplant urological surgery have an increased risk for fUTI, which may contribute to long-term morbidity in children after RTx.

The incidence and morbidity of pyelonephritis after transplantation in adults and children is not well-documented, often due to methodological problems. In paediatric studies, the prevalence ranged from 15 to 33% [7,9–11]. Some studies demonstrated an even higher prevalence of up to 61%, however, entry criteria were less strict such as inclusion of patients with asymptomatic bacteriuria [12]. Our data are in contrast to studies demonstrating an early occurrence of fUTI [13], possibly because a multicentre approach with inclusion of all currently treated patients was sought. Although E. coli remained the most frequently isolated microorganism like in other studies [14,15], it was isolated less frequently than in the general paediatric population, where it is found in up to 80% of the UTIs [16]. This may be due to the underlying immunosuppression and colonization, although specific factors could not be elaborated in our study.

One important result is the severe but reversible deterioration of renal function during fUTI, confirming other studies [9,11]. Together with the significant inflammatory parenchymal response, this underlines the potential risk of tissue damage in the transplanted kidney in long-term follow-up. In the current study, a reduction of calculated GFR after fUTI could not be documented, however, this parameter may not be sensitive enough to document early changes. With graft half-lives now approaching 15 years and more, an effect of fUTI on reduction of GFR may take much longer. That this occurs, is suggested by paediatric [17,18] and adult data [5,6,19]. In this respect, especially the retrospective cohort study of Abbott et al. [20] in nearly 29 000 adult renal transplant patients of the United States Renal Data System (USRDS) database is of interest, because late UTI were independently associated with the risk of subsequent graft loss and even death [20]. It is noted that increases of SCr can even be caused by asymptomatic UTI [15]. Therefore, other more-sensitive methods of determining kidney graft dysfunction and damage should be employed and studied such as specific urinary markers or DMSA-scintigraphy.

We are able to delineate several risk factors for fUTI. The increased rate of UTI in adult females has been reported to be twice as high in male renal transplant recipients [14,20], and we can confirm this finding for children. Anatomical reasons (e.g. shortness of urethra) may be relevant in children and adults. Female adolescents with sexual activities have an increased risk for UTI. In our study, however, only 11 out of 22 girls were in the sexually active range, but activity was denied by all but one patient. Our data, however, clearly indicate, that UTMs are not likely to be the most important causative factor in females, since most patients had other underlying diagnoses. Due to the variety of confounding factors in females, recommendations to reduce the incidence of fUTI in girls, therefore, have to focus on several issues. Regular bladder emptying and specific hygienic measures should be addressed, and sexually active patients should be counselled specifically. Antibiotic prophylaxis might be necessary for longer periods in girls. Lastly, immunological predisposing factors may be present in females as indicated by a recent study from Sadeghi et al. [21] who demonstrated gender-related urinary cytokine patterns. Anti-inflammatory soluble interleukin-1 receptor antagonist (sIL-1RA) was significantly higher in females than in males and was more pronounced in bacteriuric than in non-bacteriuric patients. Also, the inflammatory cytokine response was different between males and females.

Second, the underlying diagnosis had an impact in our cohort. UTMs and neurogenic bladder were present in 33% of all patients with fUTI, and predominated by male gender. About 15–25% of the children with end-stage renal failure have associated structural urological disorders (including posterior urethral valves, prune belly syndrome, myelodysplasia or urogenital sinus abnormalities) that may lead to lower urinary tract dysfunction [17,22]. This abnormal bladder anatomy and function leads to a higher incidence of UTI with associated morbidity and poorer graft function [19]. Renal biopsies in patients with deteriorating function have demonstrated multifocal areas of scarring with extensive tubular atrophy and interstitial fibrosis but little evidence of chronic cellular or vascular rejection. 99Tc-DMSA scanning with tomography has shown multiple scars in patients with abnormal lower urinary tract and deteriorating renal function, consistent with a ‘reflux nephropathy’ process rather than chronic rejection. Further, the presence of scars was associated with either raised intravesical pressures or recurrent UTIs [5]. The influence of bladder dysfunction with dysfunctional voiding on the risk of fUTI has been described and this problem seems to be more prevalent in girls. Luke et al. [18] demonstrated comparable patient and graft survival between groups with and without abnormal lower urinary tract. However, patients with dysfunctional voiding experienced more urological complications including UTI. Also, we were not able to document specific urodynamic risk factors, mainly due to methodological problems (e.g. impossibility to retrospectively assess bladder dysfunction). The individual patient should be counselled accordingly and regular non-invasive monitoring (standardized diary, uroflowmetry) should be included in the prospective studies.

The limitations of our retrospective study are acknowledged and, therefore, some questions and concerns cannot be answered. The diagnostic strategy following fUTI was not standardized and as a consequence, voiding cystography and functional bladder studies were not routinely performed after transplantation. For instance, we cannot definitively comment on the impact of VUR, although this is interesting in two respects. VUR in the native kidneys (e.g. due to obstructive uropathy or neuropathic bladder) may be a risk factor for fUTI, which led to the recommendation of native nephrectomy of kidneys with VUR [23]. Second, VUR into the transplanted kidney in a previously normal urinary tract may develop secondary to transplant surgery. The exact pathogenic role of VUR for fUTI is still under debate, however, Dunn et al. [7] found an increased incidence of pyelonephritis in paediatric renal transplant patients who had VUR. A recent study by Ranchin et al. [10] demonstrated that VUR was present in 58% of the children after transplantation. This condition was associated with episodes of acute pyelonephritis, only after excluding episodes related to catheterization. VUR was not associated with graft dysfunction and mean GFR did not decrease during a 5-year follow-up in the subgroup of 7 patients with pyelonephritis independent of VUR. In contrast to this, a study in 103 patients by Vianello et al. [24] could not demonstrate an impact of transplant VUR on hypertension, graft dysfunction or urinary tract infection, although the prevalence was 86%. Also, the study by Fontana et al. [25] could not document an increased risk of UTI or long-term sequela of reflux. Whether strict antirefluxive surgery can reduce the risk of fUTI after RTx without increasing the risk of obstruction has not been studied so far.

The present study did not prospectively address the use of prophylactic antibiotics after RTx. We would suggest, however, that prophylactic antibiotics may be useful in the view of the high prevalence of UTI. In fact, most transplant centres prescribe prophylactic antibiotics for the first 3–6 months post transplantation or longer in refluxive patients [19,25], although not all studies confirmed a beneficial effect and even demonstrated a high bacterial resistance rate [15]. This is underlined by the fact that 35% of our patients developed a first fUTI despite chemoprophylaxis, and 28% of the patients developed recurrences on prophylaxis indicating that several pathomechanisms must be present. If prophylactic antibiotics are used, it seems that they should be administered for prolonged periods, as fUTI may occur late, especially in girls.

In conclusion, children after RTx are at high risk for febrile urinary tract infections. Although patients with UTM, neurogenic bladder and those with urological surgery prior to transplantation are at increased risk, the high prevalence in girls and in non-anatomical underlying disorders indicate that further risk factors are present. The severe renal dysfunction during fUTI and inflammatory response indicates that fUTI has to be regarded as a serious complication following transplantation, endangering long-term graft survival. It is also associated with high costs for the health care systems because hospitalization is often inevitable.

Taken together, there is a need for prospective studies in order to evaluate precise mechanisms and develop preventive measures for this important complication. Data on risk factors (demographical, anatomical, immunosuppression, use of antibiotic prophylaxis, voiding dysfunction, etc.) should be collected prospectively and parameter of organ damage should be assessed by sensitive methodolgy such as DMSA scans. Specific strategies to prevent fUTI after RTx are urgently needed.

Conflict of interest statement. None declared.



   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

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Received for publication: 18. 4.06
Accepted in revised form: 7. 7.06


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