RESUMO
BACKGROUND: Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM: To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD: Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS: Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS: Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.
Assuntos
Bexiga Urinaria Neurogênica , Bexiga Urinária Hiperativa , Refluxo Vesicoureteral , Criança , Pré-Escolar , Humanos , Lactente , Estudos Retrospectivos , Bexiga Urinária , Bexiga Urinaria Neurogênica/terapiaRESUMO
Kidney transplantation (KT) is the best treatment for children in end-stage renal disease. KT has less mortality than dialysis and provides a better quality of life. Thus, the inclusion criteria have been progressively broadened. Histocompatibility and the source of donation are the most relevant factors that influence graft survival. Graft and patient survival have improved dramatically in recent decades, coming close to the results of KT in adults. Some of the specific factors that differentiate it from the adult are: donor-recipient size mismatch,the impact on growth and therapeutic non-compliance. Overall graft survival at 5-years is 90% for living donor KT and 70% for cadaveric donor KT.The most frequent cause of graft loss is chronic rejection.Mortality in the first post-transplant years is less than 6.5%. Infections and cardiovascular complications are the main causes of transplant-related death.Despite the good results, it is imperative to continue investigating how to achieve immunological tolerance. In order to improve the long-term results of the kidney graftis necessary to reduce immunosuppressive treatment and its side effects, such as chronic rejection.
El Trasplante Renal (TR) es el tratamiento de elección para los niños que se encuentran en insuficiencia renal terminal. Los criterios de inclusión se han ido ampliando de manera progresiva al conocerse que su mortalidad es menor que la que ocurre en diálisis y proporciona una mejor calidad de vida. La histocompatibilidad y la fuente de donación son, de entre los numerosos factores que influyen en la supervivencia del injerto, los de mayor relevancia. La supervivencia del injerto y la del paciente han mejorado de forma espectacular en las últimas décadas, aproximándose a los resultados del TR en el adulto. La diferencia de tamaño entre donante y receptor, la afectación del crecimiento y la falta de cumplimiento terapéutico, son algunos de los factores específicos que lo diferencian del adulto.La supervivencia global del injerto a los 5 años es del 90% para el TR de donante vivo y del 70% para el TRde donante cadáver.La causa más frecuente de pérdida del injerto es el rechazo crónico. La mortalidad en los primeros años post-trasplante es inferior al 6,5%. La infección y las complicaciones cardiovasculares son las causas principales de muerte relacionada con el trasplante.Sin embargo, a pesar de estos buenos resultados, es preciso continuar investigando en cómo alcanzar la tolerancia inmunológica, que permita reducir el tratamiento inmunosupresor y sus efectos colaterales, entre los que se encuentra el rechazo crónico; y así poder mejorar los resultados a largo plazo del injerto renal.
Assuntos
Falência Renal Crônica , Transplante de Rim , Cadáver , Criança , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Falência Renal Crônica/cirurgia , Doadores Vivos , Qualidade de Vida , Doadores de TecidosRESUMO
BACKGROUND: Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM: To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD: Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS: Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS: Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.
RESUMO
Objetivo: En los casos de vejigas neurogénicas de alto riesgo (VNAR) se plantea la vesicostomía como una alternativa válida. El objetivo de este estudio es analizar los resultados de este procedimiento desde la creación del policlínico de mielomeningocele (MMC) en nuestro hospital. Métodos: Revisión retrospectiva de fichas clínicas e imágenes radiológicas de todos los pacientes con MMC controlados en nuestra unidad entre los años 1992-2005.Resultados: En un período de 13 años hubo 195 pacientes con MMC. De ellos 120 fueron catalogados como VNAR 69 niñas y 51 niños, sólo 20 requirieron vesicostomía. Todas fueron realizadas antes de los 4 años. Sólo 11 pacientes se han desderivado en una edad promedio de 5 años 8 meses. Cuatro pacientes están en lista de espera, 2 se cambiaron de hospital y 3 se perdieron de controles. El período de seguimiento promedio fue de 4 años. Hubo sólo 2 ostomías que se estenosaron; 1 requirió revisión quirúrgica. No hubo prolapso de las vesicostomías en esta serie. En todos los pacientes se logró estabilizar las infecciones y disminuir la hidronefrosis. No hubo pérdida de función renal en ninguno. Todos los pacientes desderivados a la fecha han requerido una ampliación vesical. Conclusiones: Podemos concluir que la vesicostomía es una buena medida que preserva la función renal, controla las infecciones urinarias a repetición y hace más fácil el manejo para los padres. Su cierre es relativamente fácil y de preferencia debe realizarse antes de la etapa escolar. Generalmente debe asociarse alguna cirugía de agrandamiento vesical.
Objective: Neurogenic bladder is a condition of difficult management. In those cases of high-risk neurogenic bladder (HRNB), vesicostomy have been rise as an alternative. The aim of this study is to evaluate the results of this practice since 1992, when the myelomeningocele (MMC) clinic was created. Methods: A retrospective case note review was carried out on all patients with diagnosis of MMC who assist our clinic between 1992-2005.Results: There were 195 patients with MMC in the 13 years period; 120 were HRNB (69 girls and 59 boys) and only 20 underwent vesicostomy. All of them were done before 4 years old. 11 were closed at a mean age of 5.8 years. Four are still in the waiting list, 2/20 moved to another hospital and 3/20had been lost from follow-up. After a mean follow-up of 4 years, there were 2 stenosis; one required surgical review. There was no prolapse in this series. All children were infection free and presented a decreased of the hydronephrosis measures. There was no lost of kidney function. The 11/11 patients who had the stoma closed required a bladder augmentation. Conclusions: Vesicostomy is a good alternative to preserve kidney function, manage urine infection and make parent supervision easier. Its closing is relatively simple and we recommend to perform it before school age. All the cases in this series required a concomitant bladder augmentation.
