Impact of Adjuvant Urinary Diversion versus Valve Ablation Alone on Progression from Chronic to End Stage Renal Disease in Posterior Urethral Valves: A Single Institution 15-Year Time-to-Event Analysis

• Published in: The Journal of urology Vol. 199; no. 3; pp. 824 - 830
• Main Authors: Chua, Michael E., Ming, Jessica M., Carter, Simon, El Hout, Yaser, Koyle, Martin A., Noone, Damien, Farhat, Walid A., Lorenzo, Armando J., Bägli, Darius J.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-03-2018
• Subjects: chronic; cystostomy; kidney failure; renal insufficiency; urinary diversion; eGFR; ESRD; PUV; VUR; renal insufficiency; kidney failure; cystostomy; CKD 3; chronic; CKD; urinary diversion
• ISSN: 0022-5347; 1527-3792
• DOI: 10.1016/j.juro.2017.10.024

Long-term progression to end stage renal disease of valve ablation alone vs ablation followed by additional urinary diversion were compared among children with stage 3 chronic kidney disease due to posterior urethral valves.
We performed a retrospective study of children with posterior urethral valves and stage 3 chronic kidney disease treated at a single institution between 1986 and 2011. The 3 treatment groups were classified as group 1—valve ablation alone, group 2—ablation plus subsequent vesicostomy and group 3—ablation followed by ureterostomies and/or pyelostomies. Baseline demographic characteristics were analyzed. Statistical analyses compared the incidence of time to end stage renal disease among the intervention groups using the Fisher-Freeman-Halton exact test and Kaplan-Meier analysis with the log rank test. Cox regression was used to determine predictors of end stage renal disease progression.
A total of 40 eligible patients were included in the study (group 1—14 patients, group 2—13 patients, group 3—13 patients). Baseline characteristics and post-intervention estimated glomerular filtration rate revealed no significant between-group differences. A statistically significant difference in progression to end stage renal disease was noted within 1 year after diagnosis of stage 3 chronic kidney disease among the treatment groups (log rank test p=0.02). However, cumulative end stage renal disease incidence at 15-year followup showed no statistical difference (log rank test p=0.628). Cox regression analysis determined that bilateral renal dysplasia (HR 2.76, 95% CI 1.21–6.30) and estimated glomerular filtration rate 60 ml/minute/1.73 m2 or greater after intervention (HR 0.23, 95% CI 0.09–0.61) were predictive of the likelihood of progression to end stage renal disease.
Urinary diversion following valve ablation in children with stage 3 chronic kidney disease associated with posterior urethral valves may temporarily delay progression to end stage renal disease. However, no long-term benefit was noted from diversion in the ultimate incidence of end stage renal disease, suggesting that these interventions should be seen as a temporizing measure. Bilateral renal dysplasia and post-intervention estimated glomerular filtration rate are independent variables predicting overall chronic kidney disease progression.