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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2015  |  Volume : 26  |  Issue : 3  |  Page : 443-446
Frequency of occurrence of urinary tract infection in double j stented versus non-stented renal transplant recipients


Department of Urology and Kidney Transplant, Pakistan Kidney Institute, Shifa International Hospital, Islamabad, Pakistan

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Date of Web Publication20-May-2015
 

   Abstract 

Prophylactic ureteric stenting in renal transplant recipients prevents major surgical complications such as ureteric leak and obstruction on the one hand while, on the other hand, it is associated with complications like urinary tract infections (UTI), hematuria, stent migration, stent encrustation and forgotten stents. UTI is documented to be most common complication associated with double J (DJ) stent. In this retrospective observational study involving 157 patients, we compared the frequency of occurrence of UTI in DJ-stented versus non-stented renal transplant recipients. The study patients had undergone renal transplantation, with or without DJ-stenting, between January 2007 and June 2012. The mean age of the study subjects was 34.01 ± 14.63 years. The patients were followed-up for one year post-transplantation with regular evaluation, including detailed assessment, complete blood picture, renal function tests, routine urine examination and cultures. Data were collected through chart and electronic record review. Of a total of 157 patients, 61 (38.85%) developed UTI, including 30 of 74 stented patients (40.54%) and 31 of 83 non-stented renal transplant recipients (37.34%). Relative risk was calculated to be 1.08. The mean serum creatinine at the end of one year was 1.47 mg/dL in DJ-stented patients and 1.36 mg/dL in nonstented patients. Our study suggests that there is no significant difference in the frequency of UTI between DJ-stented and non-stented renal transplant recipients.

How to cite this article:
Shohab D, Khawaja A, Atif E, Jamil I, Ali I, Akhter S. Frequency of occurrence of urinary tract infection in double j stented versus non-stented renal transplant recipients. Saudi J Kidney Dis Transpl 2015;26:443-6

How to cite this URL:
Shohab D, Khawaja A, Atif E, Jamil I, Ali I, Akhter S. Frequency of occurrence of urinary tract infection in double j stented versus non-stented renal transplant recipients. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Jun 16];26:443-6. Available from: https://www.sjkdt.org/text.asp?2015/26/3/443/157298

   Introduction Top


Renal transplantation has become a much wider accepted treatment option for patients with end-stage renal disease in the last three decades in many parts of the world. [1] Urologic complications such as urine leak and ureteric obstruction can be a cause of significant morbidity after renal transplantation. [2] The risk of these complications is estimated to be 0-30%. [3] Prophylactic ureteric stenting has been in widespread use in order to reduce these complications. [2] Srivastava et al reported a 7.7% complication rate with non-stented and 2% with stented ureteral anastomosis. [4] However, prophylactic ureteric stenting is associated with complications like increase in the incidence and severity of urinary tract infections (UTIs), hematuria, stent migration, stent encrustation and forgotten stents. [2] This has made regular prophylactic ureteric stenting in renal transplant surgery a controversial issue. [5] Some centers have adopted a policy of universal prophylactic stenting, [6] while others advocate a policy of stenting only selected patients. [3],[4],[5] In our center, we follow a policy of selective double J (DJ)-stenting in renal transplant recipients.

Stent-related UTI is the most frequent related complication following renal transplantation. We conducted the current study to compare the frequency of occurrence of UTI in stented versus non-stented renal transplant recipients.


   Patients and Methods Top


This retrospective observational study was conducted from January 2007 to June 2012. Data were collected through chart and electronic record reviews. A total of 157 patients (n = 157) were included, with a mean age of 34.01 ± 14.63 years. Patients who had suffered graft loss not secondary to UTI, had expired or had developed acute rejection requiring pulse therapy or anti-thymocyte globulin (ATG) were not included in the study. All patients received the same immunosuppressant regime with mycophenolate mofetil/cylosporin and steroids. Steroids were tapered to a dose of 5 mg daily over a period of six months. Induction with ATG was used only in patients with poor antigen match, pediatric patients and in patients receiving second transplants. All patients were given prophylactic co-trimoxazole (80 mg trimethoprim/400 mg sulphamethoxazole) once daily for pneumocystis pneumonia, nystatin 500,000 units once daily for fungal prophylaxis and acyclovir 400 mg thrice daily for six months. However, no specific drug was given for prophylaxis against UTI. Patients were divided into two groups (stented and nonstented). There were 74 patients in the stented group and 83 patients in the non-stented group [Table 1]. The DJ stent was normally removed on the 7th-10th post-operative day by flexible cystoscopy. A policy of selective DJ stenting was adopted and the DJ stent was used only in cases of difficult ureteric re-implantation, delayed renal function and/or compromised vascularity.
Table 1: Patient characteristics in our study group.

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As per our institutional protocol, renal transplant recipients, after being discharged from the hospital, are followed-up in the transplant clinic on alternate days in the first month, bi-weekly in the second month, weekly in the third month and then monthly for one year. On each visit, the following tests are performed: Complete blood picture, renal function tests and urine routine examination. Any patient with irritative lower urinary tract symptoms (burning, dysuria, urgency, increased frequency and nocturia), raised total leukocyte count, rising trend in serum creatinine and >5 white blood cells/highpower field and bacteriuria on routine urine examination was subjected to urine culture. A patient with positive urine culture any time during one year of follow-up was labeled to have UTI. Data regarding patient's follow-up with details of regular clinic check up, urine routine examinations and cultures were collected on specified forms up to a period of one year.

Data were analyzed using SPSS v16.0. P-value was calculated using the chi square test. P-value less than 0.05 was considered significant.


   Results Top


In this study, UTI was reported in 38.85% (61/157) of the patients, including 30 of 74 DJ-stented patients (40.5%) and 31 of 83 nonstented renal transplant patients (37.34%). The mean serum creatinine at the end of one year was 1.47 mg/dL in the DJ-stented patients and 1.36 mg/dL in the non-stented patients [Table 2]. E. coli was the most frequent causative organism, followed by Klebsiella and Enterococcus. Six patients developed Candida infection [Table 3].
Table 2: Frequency of occurrence of urinary tract infection and mean serum creatinine levels in the stented and non-stented groups.

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Table 3: Frequency of various organisms causing urinary tract infection in the study patients.

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   Discussion Top


Prophylactic ureteric stenting in renal transplant recipients remains a matter of controversy. [5] On the one hand, ureteric stent prevents major surgical complications like ureteric leak and obstruction while on the other hand, it itself is associated with complications like UTI, hematuria, stent migration, stent encrustation and forgotten stents. [2],[7]

UTI is the most common stent-related complication in renal transplant recipients, [8] and its incidence has been found to be higher not only in the immediate post-operative period but also after removal of the stents. [4],[9],[10] In a case series of stented renal transplant patients, of 12 patients who developed urological complications, seven had UTI. [11]

However, there are wide variations in the frequency of UTI in stented versus non-stented renal transplant subjects. Ranganathan et al found a significantly higher incidence of UTI in stented versus non-stented subjects (71% vs 39%; P = 0.02). [10] Yasser Ossman et al also reported that 36% of stented renal transplant patients had UTI compared with 18% in the non-stented group. However, in a retrospective, comparative, single-center study involving 310 renal transplant patients, Mathe et al found similar rates of UTI in stented (43.3%) versus non-stented patients (40.1%). [12] Derouich et al reported a frequency of occurrence of postoperative UTI of 47.2% in stented versus 48.7% in non-stented renal transplant recipients. [13] In our study, we found that there was no significant difference in the frequency of UTI in stented and non-stented renal transplant recipients (40.29% vs 37.34%), with a relative risk (RR) of 1.08 and P-value of 0.628.

Early removal of the DJ stent may have some role in the prevention of stent-related complications. [14] Tavakoli et al advocated removal of the DJ stent within 28 days and reported a significantly high rate of UTI after 30 days of stent insertion in renal transplant recipients. [15]

In our study, there was no significant difference in graft function in the two groups after one year of follow-up (serum creatinine; 1.47 mg/dL versus 1.36 mg/dL in stented versus non-stented groups, respectively). This finding is similar to most of the published literature. [16] Slightly elevated creatinine in the stented group is probably a reflection of our policy of selective DJ stenting, where we stent cases having delayed graft function, poor ureteric blood supply or difficult anastomosis. Also, E. coli was the most common organism causing UTI in both stented and non-stented groups. Both groups had an equal frequency of fungal infections; however, Pseudomonas and Acetinobacter were only found in the stented group.

As far as our results are concerned, placing a stent in renal transplant recipients does not result in a statistically significant risk for the deve-lopment of UTI.

Conflict of Interest: None declared.

 
   References Top

1.
Ashraf HS, Khan MU, Hussain I, Hyder I. Urological complications in ureteric stenting live related renal transplantation. J Coll Physicians Surg Pak 2011;21:34-6.  Back to cited text no. 1
    
2.
Indu KN, Lakshminarayana G, Anil M, et al. Is early removal of prophylactic ureteric stents beneficial in live donor renal transplantation? Indian J Nephrol 2012;22:275-9.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Dols LF, Terkivatan T, Kok NF, et al. Use of stenting in living donor kidney transplantation: Does it reduce vesicoureteral complications? Transplant Proc 2011;43:1623-6.   Back to cited text no. 3
    
4.
Srivastava A, Chudhary H, Sehgal A, Dubey D, Kapoor R, Kumar A. Ureteric complication in live related donor renal transplant: impact on graft and patient survival. Indian J Urol 2004;20:11-4.  Back to cited text no. 4
  Medknow Journal  
5.
Mangus RS, Haag BW. Stented versus nonstented extravesical ureteroneocystostomy in renal transplantation: A meta analysis. Am J Transplant 2004;4:1889-96.  Back to cited text no. 5
    
6.
Georgiev P, Böni C, Dahm F, et al. Routine stenting reduces urologic complications as compared with stenting "on demand" in adult kidney transplantation. Urology 2007;70:893-7.  Back to cited text no. 6
    
7.
de Souza RM, Olsburgh J. Urinary tract infection in the renal transplant patient. Nat Clin Pract Nephrol 2008;4:252-64.  Back to cited text no. 7
    
8.
Mongha R, Kumar A. Transplant ureter should be stented routinely. Indian J Urol 2010;26:450-3.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
Rajaian S, Kumar S. There is no need to stent the ureterovesic anastomosis in live renal transplants. Indian J Urol 2010;26:454-6.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Ranganathan M, Akbar M, Ilham MA, Chavez R, Kumar N, Asderakis A. Infective complications associated with ureteral stents in renal transplant recipients. Transplant Proc 2009;41:162-4.  Back to cited text no. 10
    
11.
Ashraf HS, Khan MU, Hussain I, Hyder I. Urological complications in ureteric stenting live related renal transplantation. J Coll Physicians Surg Pak 2011;21:34-6.  Back to cited text no. 11
    
12.
Mathe Z, Treckmann JW, Heuer M, et al. Stented ureterovesical anastomosis in renal transplantation: Does it influence the rate of urinary tract infections? Eur J Med Res 2010;15:297-302.  Back to cited text no. 12
    
13.
Derouich A, Hajri M, Pacha K, Ben Hassine L, Chebil M, Ayed M. Impact of the use of double J stents in renal transplantation on incidence of urologic complications and urinary infection. Prog Urol 2002;12:1209-12.  Back to cited text no. 13
    
14.
Sansalone CV, Maione G, Aseni P, et al. Advantages of short-time ureteric stenting for prevention of urological complications in kidney transplantation: An 18-year experience. Transplant Proc 2005;37:2511-5.  Back to cited text no. 14
    
15.
Tavakoli A, Surange RS, Pearson RC, Parrott NR, Augustine T, Riad HN. Impact of stents on urological complications and health care expenditure in renal transplant recipients: Results of a prospective, randomized clinical trial. J Urol 2007;177: 2260-4.  Back to cited text no. 15
    
16.
Osman Y, Ali-El-Dein B, Shokeir AA, Kamal M, El-Din AB. Routine insertion of ureteral stent in live-donor renal transplantation: Is it worthwhile? Urology 2005;65:867-71.  Back to cited text no. 16
    

Top
Correspondence Address:
Dr. Durre Shohab
Department of Urology and Kidney Transplant, Pakistan Kidney Institute, Shifa International Hospital, Islamabad
Pakistan
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DOI: 10.4103/1319-2442.157298

PMID: 26022012

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    Abstract
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