Surgical management of vesicoureteral reflux with recurrent urinary tract infection after renal transplantation in a dog

Kyung-Mee Park Section of Veterinary Surgery, College of Veterinary Medicine, and the Stem Cell Institute-KNU, Kangwon National University, Chuncheon, Republic of Korea, 200-701.

Search for other papers by Kyung-Mee Park in
Current site
Google Scholar
PubMed
Close
 DVM, PhD
,
Hyun-Suk Nam Section of Veterinary Surgery, College of Veterinary Medicine, and the Stem Cell Institute-KNU, Kangwon National University, Chuncheon, Republic of Korea, 200-701.

Search for other papers by Hyun-Suk Nam in
Current site
Google Scholar
PubMed
Close
 DVM, PhD
,
Kamal Hany Hussein Section of Veterinary Surgery, College of Veterinary Medicine, and the Stem Cell Institute-KNU, Kangwon National University, Chuncheon, Republic of Korea, 200-701.

Search for other papers by Kamal Hany Hussein in
Current site
Google Scholar
PubMed
Close
 DVM
, and
Heung-Myong Woo Section of Veterinary Surgery, College of Veterinary Medicine, and the Stem Cell Institute-KNU, Kangwon National University, Chuncheon, Republic of Korea, 200-701.

Search for other papers by Heung-Myong Woo in
Current site
Google Scholar
PubMed
Close
 DVM, PhD

Click on author name to view affiliation information

Abstract

CASE DESCRIPTION A 3-year-old male Cocker Spaniel renal transplant recipient was readmitted 39 weeks after transplantation because of acute clinical signs of pollakiuria, intermittent vomiting, decreased appetite, lethargy, and mild fever.

CLINICAL FINDINGS Hydronephrosis and hydroureter were observed with ultrasonography and contrast cystography, and a diagnosis of vesicoureteral reflux (VUR) was made. Urinary tract infection (UTI) caused by Escherichia coli was also diagnosed on the basis of results of urine culture.

TREATMENT AND OUTCOME Despite treatment of the UTI with an appropriate antimicrobial for 6 weeks, the VUR persisted and the UTI recurred 9 weeks after cessation of antimicrobial treatment. Therefore, surgical correction by means of revision extravesicular ureteroneocytostomy was performed. Both VUR and hydronephrosis resolved after surgery. No recurrences of clinical signs of urinary tract complications were observed during the subsequent 22-month follow-up period.

CLINICAL RELEVANCE Results suggested that ureteral reimplantation with an extravesicular technique incorporating a long submucosal tunnel may be an effective treatment for VUR when medical management fails in canine renal transplant recipients with recurrent UTIs.

Abstract

CASE DESCRIPTION A 3-year-old male Cocker Spaniel renal transplant recipient was readmitted 39 weeks after transplantation because of acute clinical signs of pollakiuria, intermittent vomiting, decreased appetite, lethargy, and mild fever.

CLINICAL FINDINGS Hydronephrosis and hydroureter were observed with ultrasonography and contrast cystography, and a diagnosis of vesicoureteral reflux (VUR) was made. Urinary tract infection (UTI) caused by Escherichia coli was also diagnosed on the basis of results of urine culture.

TREATMENT AND OUTCOME Despite treatment of the UTI with an appropriate antimicrobial for 6 weeks, the VUR persisted and the UTI recurred 9 weeks after cessation of antimicrobial treatment. Therefore, surgical correction by means of revision extravesicular ureteroneocytostomy was performed. Both VUR and hydronephrosis resolved after surgery. No recurrences of clinical signs of urinary tract complications were observed during the subsequent 22-month follow-up period.

CLINICAL RELEVANCE Results suggested that ureteral reimplantation with an extravesicular technique incorporating a long submucosal tunnel may be an effective treatment for VUR when medical management fails in canine renal transplant recipients with recurrent UTIs.

A 3-year-old 7.8 kg (17.2 lb) male Cocker Spaniel was referred to the Kangwon National University Veterinary Teaching Hospital for renal transplantation because of chronic renal failure. Renal failure had been diagnosed at a local veterinary hospital 10 months prior to referral, and the dog had failed to respond to supportive care, including feeding a commercial diet.a At admission, the dog had a body condition score of 4 on a scale from 1 to 9, severe azotemia (serum creatinine concentration, 6.2 mg/dL; BUN concentration, 210 mg/dL), and oliguria. Bilateral small hyperechoic kidneys with an unclear corticomedullary junction were evident on ultrasonography. Hemodialysis was performed with a dialysis machineb and a cellulose hollow fiber hemodialyzerc at a rate of 20 mL/min for 120 minutes via the jugular vein. The owners provided a samebreed healthy donor dog from an acquaintance, and informed consent was obtained for all procedures. Preoperative examination of the donor and recipient dogs consisted of a CBC, serum biochemical analyses, urinalysis, urine culture, heartworm antigen test, indirect (noninvasive) blood pressure monitoring, transabdominal ultrasonography, and abdominal radiography (dorsoventral and ventrodorsal views). Blood typing, erythrocyte crossmatching, and complementdependent cytotoxic crossmatching were performed according to previously described renal transplantation protocols.1 Serologic testing for tick-borne diseases and leptospirosis was not performed because the donor and recipient dog were indoor dogs, were vaccinated annually including leptospirosis, and were treated monthly with a parasiticide.d,e

The recipient dog was premedicated with butorphanolf (0.4 mg/kg [0.18 mg/lb], IM) and atropine sulfateg (0.04 mg/kg [0.018 mg/lb], SC) for surgery. Anesthesia was induced with propofolh (4 mg/kg [1.8 mg/lb], IV) and maintained with isofluranei in oxygen. Ventilation was controlled with a volume-controlled ventilator. During surgery, an ECG, oxygen saturation, a capnogram, blood pressure, and body temperature were monitored. The renal artery of the donor kidney was anastomosed end-to-end with the iliac artery of the recipient, and the renal vein was anastomosed end-to-side with the iliac vein with 7–0 polypropylene.j The ureteroneocytostomy was performed by means of an extravesicular technique with a submucosal tunnel that provided an approximate 3:1 tunnel length-to-ureteral diameter ratio in accordance with a previously described technique.2 Three immunosuppressants—cyclosporinek (20 mg/kg [9.1 mg/lb], PO, q 24 h), prednisolonel (1 mg/kg [0.45 mg/lb], PO, q 24 h), and azathioprinem (5 mg/kg [2.3 mg/lb], PO, q 48 h)—were administered to prevent graft rejection according to a previously described protocol.1 Cefazolinn (22 mg/kg [10 mg/lb], IV, q 12 h) was administered for 5 days after surgery as antimicrobial prophylaxis. The recipient dog recovered well and was discharged from the hospital 1 week after surgery without any evidence of postoperative complications. After discharge, the recipient dog was evaluated once per week for the first 6 weeks and then monthly for 6 months, and the dog's condition was stable. At each examination, a physical examination, CBC, serum biochemical analyses, and urinalysis were performed and cyclosporine concentration was measured.

At 39 weeks after transplantation, the recipient dog was readmitted with acute clinical signs of pollakiuria, intermittent vomiting, decreased appetite, and lethargy. A physical examination revealed a body condition score of 4 and a mild fever (39.4°C [102.9°F]); however, a CBC and serum biochemical analyses did not reveal any abnormalities except a neutrophil count (14.3 × 103 neutrophils/μL; reference range, 4 × 103 neutrophils/μL to 15.5 × 103 neutrophils/μL) in the upper end of the reference range.

On an ultrasonographic examination, hydroureter (ureteral diameter, 4 to 6.5 mm) and hydronephrosis (transverse diameter of renal pelvis, 20 to 22 mm; ventrodorsal diameter of renal pelvis, 2 to 6 mm; width of renal pelvis, 8 mm) of the grafted kidney were observed (Figure 1). Positive contrast cystography was performed by filling the bladder with warm contrast medium,° and retrograde urine flow through the dilated ureter into the renal pelvis was observed (Figure 2). A urine sample obtained by means of cystocentesis and blood samples were submitted for bacterial culture and antimicrobial susceptibility testing. A renal transplant biopsy was not performed because of concerns of iatrogenic graft damage.

Figure 1—
Figure 1—

Ultrasonographic appearance of the abdomen in a 3-year-old 7.8-kg (17.2 lb) male Cocker Spaniel renal transplant recipient that was readmitted 39 weeks after transplantation because of acute clinical signs of pollakiuria, intermittent vomiting, decreased appetite, lethargy, and mild fever. The proximal (A; arrow) and distal (B; white arrows) sections of the ureter near the bladder (black arrow) are dilated. Mild hydronephrosis (arrow) can be seen in the pelvic region in transverse (C) and sagittal (D) views of the transplanted kidney.

Citation: Journal of the American Veterinary Medical Association 248, 3; 10.2460/javma.248.3.309

Figure 2—
Figure 2—

Ventrodorsal (A) and lateral (B) views of the abdomen of the dog in Figure 1 obtained during positive-contrast cystography. The renal pelvis (arrowhead) and ureter (black arrow) are filled with contrast medium, indicative of VUR. The urinary bladder (white arrow) can also be seen.

Citation: Journal of the American Veterinary Medical Association 248, 3; 10.2460/javma.248.3.309

An Escherichia coli strain was isolated from the urine sample, but results of aerobic and anaerobic bacterial culture of blood samples were negative. The UTI was treated with cephradinep (25 mg/kg [11.4 mg/lb], q 12 h, PO) for 6 weeks on the basis of results of antimicrobial susceptibility testing. The UTI responded to antimicrobial treatment. No leukocytes or bacteria were detected in the urine, and the clinical signs resolved; however, VUR and pyeloureteral dilatation persisted during the antimicrobial treatment period. The E coli–induced UTI recurred 9 weeks after cessation of cephradrine treatment.

Ureteral reimplantation was performed to treat the VUR and limit additional renal damage (Figure 3). Prior to revision surgery, cefazolin was administered (22 mg/kg, IV, q 12 h) for a week to treat the UTI and alleviate the clinical signs. The dog was anesthetized with the previously described protocol. For ureteral reimplantation, the distal portion of the grafted ureter adjacent to the bladder was ligated with 3–0 silk and transected. An incision that was 5 times the ureteral diameter was created in the bladder seromuscular layer, and a small caudal mucosal incision was made. The spatulated ureteral mucosa was sutured to the bladder mucosa by means of an end-to-side anastomosis with 7–0 polypropylene in a simple continuous pattern. The ureteral tunnel was created by suturing the bladder seromuscular layer with simple interrupted 4–0 polypropylene sutures. The length of the tunnel was approximately 5 times the inner diameter of the ureteral orifice, as recommended for human patients.3,4 Recovery from anesthesia was uncomplicated. For analgesia, butorphanol (0.2 mg/kg [0.09 mg/lb], IM, q 6 h) and tramadolq (1 mg/kg, IV, q 6 h) were given for 3 days after the surgery. Cephradine (25 mg/kg, PO, q 12 h) was administered for 6 weeks on the basis of results of antimicrobial susceptibility testing of the E coli strain recovered at the time the recurrent UTI was diagnosed. A physical examination, ultrasonography, CBC, serum biochemical analyses, and urinalysis were performed weekly for the first 2 months after surgery, then monthly for the subsequent 4 months, and then every 3 to 4 months.

Figure 3—
Figure 3—

Intraoperative photographs obtained during ureteral reimplantation in the dog in Figure 1. The grafted kidney (black arrow) in the iliac fossa and bladder (white arrow) are shown (A). The implanted ureter (white arrow) was tied with 2–0 silk and dissected from the bladder (B and C). The spatulated ureteral mucosa (white arrow) was anastomosed with the bladder mucosa (black arrow) with simple continuous sutures (D and E). A seromucosal tunnel approximately 5 times the diameter of the ureteral orifice was made by suturing the bladder seromuscular layer in a simple interrupted pattern (F).

Citation: Journal of the American Veterinary Medical Association 248, 3; 10.2460/javma.248.3.309

The hydronephrosis and hydroureter resolved within a week after ureteral reimplantation (Figure 4), and contrast medium did not reflux into the renal pelvis or ureter. The dog had no further episodes of UTI after cessation of antimicrobial treatment, and renal function was maintained during the subsequent 22 months of follow-up.

Figure 4—
Figure 4—

Transverse (A) and sagittal (B) ultrasonographic and ventrodorsal (C) and lateral (D) positive-contrast cystographic views of the dog in Figure 1 obtained following ureteral reimplantation. Notice on the ultrasonographic images that the hydronephrosis has resolved and on the cystographic images that VUR is no longer present.

Citation: Journal of the American Veterinary Medical Association 248, 3; 10.2460/javma.248.3.309

Discussion

Renal transplantation is one of the most difficult clinical challenges in veterinary patients and has high mortality and morbidity rates associated with various postsurgical complications in dogs.5,6 Median survival time of clinical renal transplant cases has been reported to be as low as 24 days (range, 0.5 to 4,014 days), with a 100-day survival probability rate of 36%.5 However, other studies8–10 of renal transplantation in dogs found longer survival times of 7 months to > 5 years, likely because dogs used in those studies were healthy and histocompatibilitymatched donors and recipients were used in some studies. Because of aggressive rejection episodes, dogs show poorer outcomes after renal transplantation, compared with feline and human patients.5 To overcome severe immune rejection, intensive immunosuppression is needed but unfortunately causes diverse complications. Thromboembolism is one of the leading causes of death in recipient dogs, and other complications such as secondary infection, intestinal intussusception, lymphoma, and gingival overgrowth have been reported in previous studies.1,5,11,12

A number of urinary complications after renal transplantation and their successful management have been reported in human patients13–15; however, insufficiency of these data has made it difficult to apply the information to clinical canine renal transplant patients. Vesicoureteral reflux frequently occurs after renal transplantation in humans, and the incidence may be as high as 86%16,17; however, recurrent UTI with VUR is rare (0% to 2%) in human patients.13 The incidence of VUR following renal transplantation in dogs has not been reported. The mean time reported for a diagnosis of VUR after renal transplantation in humans is 9 months (range, 2 to 23 months).18 In the dog of the present report, signs of VUR were evident 39 weeks after surgery.

Management of VUR is critical in renal transplant recipients because this complication can induce chronic recurrent UTIs, pyelonephritis, graft damage, and even renal failure.19,20 However, an effective management protocol for VUR after renal transplantation has not been described in dogs. In the present report, we described surgical correction of VUR by means of ureteral reimplantation in a canine renal transplant recipient with recurrent UTIs.

Vesicoureteral reflux is highly associated with UTI in children,21–23 and management of VUR is recommended to decrease the risk of UTI and renal damage.24 The severity of VUR can be classified according criteria developed for the International Reflux Study in Children25 as follows: grade I, results in urine reflux into the ureter only; grade II, results in urine reflux into the ureter and the renal pelvis without dilation; grade III, results in urine reflux into the ureter and the renal pelvis, causing mild to moderate dilation of the ureter and renal pelvis; grade IV, results in moderate hydronephrosis; and grade V, results in severe hydronephrosis and tortuosity of the ureter. According to this grading system, the dog described in the present report had grade III VUR. In human patients, a conservative nonoperative approach with prophylactic antimicrobial administration to prevent UTI and renal scarring is the initial approach for grades I to III VUR because mild-to-moderate VUR has been found to have a high rate of spontaneous resolution in pediatric patients.26 In patients with grade III to IV VUR, medical management is appropriate, with surgical intervention indicated for patients with recurrent UTIs. In patients with grade V VUR, surgical repair may be required because of the low incidence of spontaneous resolution.

Recently, an endoscopic approach with a dextranomer-hyaluronic acid polymer has been successfully used for treatment of mild-to-moderate VUR in human patients.26,27 However, an open surgical approach is performed for patients in whom an endoscopic technique has failed or when this is not available.26 In the present report, we chose an open surgical approach because medical treatment had failed and because the successful use of an endoscopic revision technique has not been established in canine patients.

A recent study13 found that approximately 3.6% of human renal transplant recipients with VUR and recurrent UTIs underwent open surgical correction despite the use of prophylactic antimicrobial administration. The extravesicular technique is the most commonly used surgical method for ureteral reimplantation.13 Submucosal tunnel length at the time of transplantation is an important consideration for implantation. Previous reports4,24,26,28–31 recommend a longer submucosal tunnel (a 5:1 ratio between submucosal length and ureteral diameter) with the use of a Lich-Gregoir technique to prevent reflux in patients with VUR. As the bladder fills with urine, the bladder wall and intramural portion of the ureter stretch, functioning as a flap-valve mechanism. Results of an experimental study28 in dogs suggest that this process prevents retrograde reflux of urine from the bladder to the kidney. In the present case, we created a seromuscular tunnel approximately 5 times the diameter of the ureteral orifice during the corrective surgery. A submucosal tunnel length 3 times the ureteral orifice diameter has been reported to be effective in dogs2; however, the optimal seromuscular tunnel length for either a normal or dilated ureter has not been well established to date in canine patients and requires further study.

The recommended radiographic evaluation of VUR in human patients includes voiding cystoureterography, ultrasonography, and, in some cases, nuclear renal scintigraphy. Voiding cystoureterography provides anatomic detail and allows accurate grading of VUR.32 Ultrasonography may be used to screen for renal and bladder abnormalities. Nuclear renal scintigraphy has many advantages because of its high sensitivity and relatively lower radiation exposure. In human patients, it is a voided study and no external pressure is applied, whereas in veterinary patients, the bladder is filled with contrast medium and external pressure is applied to obtain a cystourethrogram. A good voiding urethral view is recommended in human patients because it has been reported33 that approximately 20% of reflux may be missed if voiding has not occurred. Comparative data for voiding versus nonvoiding techniques have not been reported, and future studies should compare the clinical accuracy in veterinary patients.

Diverse factors have been reported to increase the risk of UTIs in human patients, including female gender, intermittent or continuous bladder catheterization, lower urinary tract abnormalities, and VUR.34 The most frequent causes of UTIs in human renal transplant recipients are E coli, Klebsiella spp, Pseudomonas spp, Morganella spp, Enterococcus spp, Enterobacter spp, Corynebacterium spp, Candida spp, and BK virus.6 In dogs, the most common bacteria are E coli, Klebsiella spp, Staphylococcus spp, Enterococcus spp, Proteus spp, and Pseudomonas spp.35

We did not identify the primary cause of the VUR with recurrent UTIs in the patient of this report. However, we speculate that malfunction of the submucosal tunnel as an antireflux valve due to impairment of the bladder mucosa by infection may have induced VUR. Recurrent UTIs with VUR can occur in immunosuppressed human patients,18,36 and UTI has been reported as a complication in cyclosporine-treated dogs.37,38 Our patient was administered cyclosporine for the first 6 months to maintain blood trough concentrations of 400 to 800 ng/mL, and then the cyclosporine dosage was gradually reduced. At the time of VUR occurrence, the dog had a blood cyclosporine trough concentration of approximately 250 ng/mL, and we do not know why the UTI occurred after reduction of the cyclosporine dosage rather than during the highdosage cyclosporine period. Vesicoureteral reflux can also be a primary cause of UTI in human renal transplant recipients,13 but we did not determine which complication came first in our case.

Inappropriate ureteroneocytostomy technique can induce VUR.39 The extravesicular technique with a submucosal tunnel is one of the recommended protocols that is associated with fewer urinary complications for both human and canine renal recipients.2,40 In our hospital, we also use this technique for canine kidney transplantation and no other cases of VUR with UTIs have occurred.

The combination of VUR and a UTI can result in deterioration of kidney function by causing permanent renal scarring.41 However, our patient did not develop other urinary complications such as urinary leakage, ureteral stricture, or calculi formation, which are common in human renal recipients,20 or any signs of renal failure after surgery. We speculate that the dog did not develop kidney damage as a result of VUR and a UTI because the condition was in its initial phase and antimicrobial treatment prevented severe kidney damage. However, a conflicting report42 stated that VUR does not have detrimental effects on grafted kidney function. Thus, the relationship among VUR, UTI, and grafted kidney function should be further studied in canine patients.

In this report, we describe a dog with VUR and recurrent UTI after renal transplantation. Regular recheck examinations with repeated ultrasonography and urinalysis were important to detect postsurgical complications. Although recommendations cannot be made on the basis of a single case, we suggest that clinicians performing renal transplantation in dogs might consider creating a sufficiently long tunnel during transplantation to avoid VUR.

Acknowledgments

Supported by 2014 research grant from Kangwon National University (C1010831-01-01), the Korea Research Foundation grant funded by the Korean government (KRF-2010-0025387), and a grant (Project Code No. Z-1541745-2013-14-01, Z-1541745-2013-14-02) from Animal and Plant Quarantine Agency, Ministry of Agriculture, Food and Rural Affairs (MAFRA), Republic of Korea in 2013.

The authors declare that there were no conflicts of interest.

ABBREVIATIONS

UTI

Urinary tract infection

VUR

Vesicoureteral reflux

Footnotes

a.

Veterinary Diet Renal Support Dry Dog Food, Royal Canin, Aimargues, France.

b.

NBM-1000, MERA Pharmaceuticals Inc, Tokyo, Japan.

c.

MCA 0.1L, MERA Pharmaceuticals Inc, Tokyo, Japan.

d.

Revolution, Pfizer Inc, New York, NY.

e.

Advocate, Bayer Corp, Leverkusen, Germany.

f.

Butophan, Myungmoon Pharmaceutical Co, Seoul, South Korea.

g.

Atropine, Daehan New Pharmaceutical Co Ltd, Seoul, South Korea.

h.

Provive, Myungmoon Pharmaceutical Co Ltd, Seoul, South Korea.

i.

Forane, Choongwae Corp, Seoul, South Korea.

j.

Prolene, Ethicon Inc, San Angelo, Tex.

k.

Implanta, Hanmi Pharmaceutical Co Ltd, Seoul, South Korea.

l.

Solondo, Yuhan Medica Corp, Ochang, South Korea.

m.

Immuthera, Celltrion Inc, Incheon, South Korea.

n.

Cefazolin, Chong Kun Dang Pharmaceutical Corp, Seoul, South Korea.

o.

Omnipaque, Armersham Health Co, Cork, Ireland.

p.

Cephradine, Myungmoon Pharmaceutical Co, Seoul, South Korea.

q.

Tramadol, Huons Co Ltd, Seongnam, South Korea.

References

  • 1. Nam HS, McAnulty JF, Kwak HH, et al. Gingival overgrowth in dogs associated with clinically relevant cyclosporine blood levels: observations in a canine renal transplantation model. Vet Surg 2008; 37: 247253.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2. Aronson LR, Phillips H. Renal transplant. In: Tobias KM, Johnston SA, eds. Veterinary surgery: small animal. Philadelphia: WB Saunders Co, 2012;20272028

    • Search Google Scholar
    • Export Citation
  • 3. Altobelli E, Bove AM, Sergi F, et al. Severe hydronephrosis and dysuria-hematuria syndrome after 20 years of bladder exstrophy correction:a case report. Case Rep Urol 2012; 2012;324510.

    • Search Google Scholar
    • Export Citation
  • 4. Arlen AM, Caldamone AA, Kirsh AJ. Complication of antireflux surgery. In: Godbole PP, Koyle MA, Wilcox DT, eds. Pediatric urology: surgical complications and management. New York: John Wiley & Sons Inc, 2015;93:

    • Search Google Scholar
    • Export Citation
  • 5. Hopper K, Mehl ML, Kass PH, et al. Outcome after renal transplantation in 26 dogs. Vet Surg 2012; 41: 316327.

  • 6. Castañeda DA, León K, Martín R, et al. Urinary tract infection and kidney transplantation: a review of diagnosis, causes, and current clinical approach. Transplant Proc 2013; 45: 15901592.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7. Kyles AE, Gregory CR, Griffey SM, et al. Immunosuppression with a combination of the leflunomide analog, FK778, and microemulsified cyclosporine for renal transplantation in mongrel dogs. Transplantation 2003; 75: 11281133.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8. Kuhr CS, Allen MD, Junghanss C, et al. Tolerance to vascularized kidney grafts in canine mixed hematopoietic chimeras. Transplantation 2002; 73: 14871492.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9. Kuhr CS, Yunusov M, Sale G, et al. Long-term tolerance to kidney allografts in a preclinical canine model. Transplantation 2007; 84: 545547.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10. Niemeyer GP, Welch JA, Tillson M, et al. Renal allograft tolerance in DLA-identical and haploidentical dogs after nonmyeloablative conditioning and transient immunosuppression with cyclosporine and mycophenolate mofetil. Transplant Proc 2005; 37: 45794586.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11. Mathews KA, Holmberg D, Miller C. Kidney transplantation in dogs with naturally occurring end-stage renal disease. J Am Anim Hosp Assoc 2000; 36: 294301.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12. Park KM, Nam HS, Woo HM. Successful management of multidrug-resistant Pseudomonas aeruginosa pneumonia after kidney transplantation in a dog. J Vet Med Sci 2013; 75: 15291533.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13. Dinckan A, Aliosmanoglu I, Kocak H, et al. Surgical correction of vesico-ureteric reflux for recurrent febrile urinary tract infections after kidney transplantation. BJU Int 2013; 112: E366E371.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14. Vasdev N, Coulthard MG, Lambert H, et al. The modified Barry technique to prevent vesicoureteric reflux in paediatric renal transplant recipients: initial recipient outcomes. J Pediatr Urol 2012; 8: 97102.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15. Bouzouita A, Dugardin F, Safsaf A, et al. A novel surgical technique for management of vesicoureteral reflux following kidney transplantation: prospective study of 12 cases. Transplant Proc 2010; 42: 43264328.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16. Nie ZL, Li QS, Jin FS, et al. Urological complications in 1223 kidney transplants. Zhonghua Yi Xue Za Zhi 2009; 89: 12691271.

  • 17. Mastrosimone S, Pignata G, Maresca MC, et al. Clinical significance of vesicoureteral reflux after kidney transplantation. Clin Nephrol 1993; 40: 3845.

    • Search Google Scholar
    • Export Citation
  • 18. Abbott KC, Swanson SJ, Richter ER, et al. Late urinary tract infection after renal transplantation in the United States. Am J Kidney Dis 2004; 44: 353362.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19. Ranchin B, Chapuis F, Dawhara M, et al. Vesicoureteral reflux after kidney transplantation in children. Nephrol Dial Transplant 2000; 15: 18521858.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20. Veale JL, Yew J, Gjertson DW, et al. Long-term comparative outcomes between 2 common ureteroneocystostomy techniques for renal transplantation. J Urol 2007; 177: 632636.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21. Cleper R, Krause I, Eisenstein B, et al. Prevalence of vesicoureteral reflux in neonatal urinary tract infection. Clin Pediatr (Phila) 2004; 43: 619625.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22. Swerkersson S, Jodal U, Åhrén C, et al. Urinary tract infection in infants: the significance of low bacterial count [published online ahead of print]. Pediatric Nephrol 2016; 31: 245.

    • Search Google Scholar
    • Export Citation
  • 23. Larcombe J. Urinary tract infection in children: recurrent infections. BMJ Clin Evid 2015; 2015: 0306.

  • 24. Moradi M, Diamond D. Summary of recent AUA guidelines for the management of vesicoureteral reflux in children. Afr J Urol 2013; 19: 155159.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25. Lebowitz RL, Olbing H, Parkkulainen KV, et al. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol 1985; 15: 105109.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26. Greenbaum LA, Mesrobian HO. Vesicoureteral reflux. Pediatr Clin North Am 2006; 53: 413427.

  • 27. Capozza N, Caione P. Vesicoureteral reflux: surgical and endoscopic treatment. Pediatr Nephrol 2007; 22: 12611265.

  • 28. Shokeir AA, el-Hammady S. A novel technique of ureteroneocystostomy (extravesical seromuscular tunnel): an experimental study in dogs. II. Optimization of surgical technique. Urology 1996; 48: 917922.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29. Gregoir W, Van Regemorter G. Le reflux vesico-ureteral congenital. Urol Int 1964; 18: 122136.

  • 30. Secin FP, Rovegno AR, Marrugat RE, et al. Comparing Taguchi and Lich-Gregoir ureterovesical reimplantation techniques for kidney transplants. J Urol 2002; 168: 926930.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31. Lich R, Howerton L, Davis L. Recurrent urosepsis in children. J Urol 1961; 86: 554558.

  • 32. Rothwell DL, Constable AR, Albrecht M. Radionuclide cystography in the investigation of vesicoureteric reflux in children. Lancet 1977; 1: 10721075.

    • Search Google Scholar
    • Export Citation
  • 33. Fernbach SK, Feinstein KA, Schmidt MB. Pediatric voiding cystourethrography: a pictorial guide 1. Radiographics 2000; 20: 155168.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34. Esezobor CI, Nourse P, Gajjar P. Urinary tract infection following kidney transplantation: frequency, risk factors and graft function. Pediatr Nephrol 2012; 27: 651657.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35. Thompson MF, Litster AL, Platell JL, et al. Canine bacterial urinary tract infections: new developments in old pathogens. Vet J 2011; 190: 2227.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36. Prát V, Horcicková M, Matousovic K, et al. Urinary tract infection in renal transplant patients. Infection 1985; 13: 207210.

  • 37. Radowicz SN, Power HT. Long-term use of cyclosporine in the treatment of canine atopic dermatitis. Vet Dermatol 2005; 16: 8186.

  • 38. Peterson AL, Torres SM, Rendahl A, et al. Frequency of urinary tract infection in dogs with inflammatory skin disorders treated with ciclosporin alone or in combination with glucocorticoid therapy: a retrospective study. Vet Dermatol 2012; 23: 201243.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39. Jung GO, Chun JM, Park JB, et al. Clinical significance of posttransplantation vesicoureteral reflux during short-term period after kidney transplantation. Transplant Proc 2008; 40: 23392341.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 40. Slagt IK, Dor FJ, Tran TC, et al. A randomized controlled trial comparing intravesical to extravesical ureteroneocystostomy in living donor kidney transplantation recipients. Kidney Int 2014; 85: 471477.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 41. Roupakias S, Sinopidis X, Karatza A, et al. Predictive risk factors in childhood urinary tract infection, vesicoureteral reflux, and renal scarring management. Clin Pediatr (Phila) 2014; 53: 11191133.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42. Lee S, Moon HH, Kim TS, et al. Presence of vesicoureteral reflux in the graft kidney does not adversely affect long-term graft outcome in kidney transplant recipients. Transplant Proc 2013; 45: 29842987.

    • Crossref
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 258 0 0
Full Text Views 912 813 372
PDF Downloads 222 114 11
Advertisement