PDF(Pubmed)
Abstract：
BACKGROUND: Major urological complications (MUCs) after kidney transplantation contribute to patient morbidity and compromise graft function. The majority arise from vesicoureteric anastomosis and present early after transplantation. Ureteric stents have been successfully used to treat such complications. A number of centres have adopted a policy of universal prophylactic stenting at the time of graft implantation to reduce the incidence of urine leaks and ureteric stenosis. Stents are associated with specific complications, and some centres advocate a policy of only stenting selected anastomoses. This is an update of our review, first published in 2005 and last updated in 2013.
OBJECTIVE: To examine the benefits and harms of routine ureteric stenting to prevent MUCs in kidney transplant recipients.
METHODS: We contacted the Information Specialist and searched the Cochrane Kidney and Transplant\'s Specialised Register (up to 19 June 2024) using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.
METHODS: Our meta-analysis included all randomised controlled trials (RCTs) and quasi-RCTs designed to examine the impact of using stents for kidney transplant recipients. We aimed to include studies regardless of the type of graft, the technique of ureteric implantation, or the patient group.
METHODS: Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
RESULTS: Twelve studies (1960 patients) were identified. One study was deemed to be at low risk of bias across all domains. The remaining 11 studies were of low or medium quality, with a high or unclear risk of bias in at least one domain. Universal prophylactic ureteric stenting versus control probably reduces major urological complications (11 studies: 1834 participants: RR 0.30, 95% CI 0.16 to 0.55; P < 0.0001; I2 = 16%; moderate certainty evidence; number needed to treat (17)); this benefit was confirmed in the only study deemed to be at low risk of bias across all domains. This benefit was also seen for the individual components of urine leak and ureteric obstruction. Universal prophylactic ureteric stent insertion reduces the risk of MUC in the subgroup of studies with short duration (≤ 14 days) of stenting (2 studies, 480 participants: RR 0.39, 95% CI CI 0.21 to 0.72; P = 0.003; I2 = 0%) and where stenting was continued for > 14 days (8 studies, 124 participants: RR 0.22, 95% CI 0.08 to 0.61; P = 0.004; I2 = 29%). It is uncertain whether stenting has an impact on the development of urinary tract infection (UTI) (10 studies, 1726 participants: RR 1.32, 95% CI 0.97 to 1.80; P = 0.07; I² = 60%; very low certainty evidence due to risk of bias, heterogeneity and imprecision). Subgroup analysis showed that the risk of UTI did not increase if short-duration stenting was used (9 days) and that there was no impact on UTI risk when the prophylactic antibiotic regime co-trimoxazole 480 mg/day was used. Stents appear generally well tolerated, although studies using longer stents (≥ 20 cm) for longer periods (> 6 weeks) had more problems with encrustation and migration. There was no evidence that the presence of a stent resulted in recurrent or severe haematuria (8 studies, 1546 participants: RR 1.09, 95% CI 0.59 to 2.00; P = 0.79; I2 = 33%). The impact of stents on graft and patient survival and other stent-related complications remains unclear as these outcomes were either poorly reported or not reported at all.
CONCLUSIONS: Routine prophylactic stenting probably reduces the incidence of MUCs, even when the duration of stenting is short (≤ 14 days). Further high-quality studies are required to assess optimal stent duration. Studies comparing selective stenting and universal prophylactic stenting, whilst difficult to design and analyse, would address the unresolved quality of life and economic issues.
OBJECTIVE: To examine the benefits and harms of routine ureteric stenting to prevent MUCs in kidney transplant recipients.
METHODS: We contacted the Information Specialist and searched the Cochrane Kidney and Transplant\'s Specialised Register (up to 19 June 2024) using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.
METHODS: Our meta-analysis included all randomised controlled trials (RCTs) and quasi-RCTs designed to examine the impact of using stents for kidney transplant recipients. We aimed to include studies regardless of the type of graft, the technique of ureteric implantation, or the patient group.
METHODS: Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
RESULTS: Twelve studies (1960 patients) were identified. One study was deemed to be at low risk of bias across all domains. The remaining 11 studies were of low or medium quality, with a high or unclear risk of bias in at least one domain. Universal prophylactic ureteric stenting versus control probably reduces major urological complications (11 studies: 1834 participants: RR 0.30, 95% CI 0.16 to 0.55; P < 0.0001; I2 = 16%; moderate certainty evidence; number needed to treat (17)); this benefit was confirmed in the only study deemed to be at low risk of bias across all domains. This benefit was also seen for the individual components of urine leak and ureteric obstruction. Universal prophylactic ureteric stent insertion reduces the risk of MUC in the subgroup of studies with short duration (≤ 14 days) of stenting (2 studies, 480 participants: RR 0.39, 95% CI CI 0.21 to 0.72; P = 0.003; I2 = 0%) and where stenting was continued for > 14 days (8 studies, 124 participants: RR 0.22, 95% CI 0.08 to 0.61; P = 0.004; I2 = 29%). It is uncertain whether stenting has an impact on the development of urinary tract infection (UTI) (10 studies, 1726 participants: RR 1.32, 95% CI 0.97 to 1.80; P = 0.07; I² = 60%; very low certainty evidence due to risk of bias, heterogeneity and imprecision). Subgroup analysis showed that the risk of UTI did not increase if short-duration stenting was used (9 days) and that there was no impact on UTI risk when the prophylactic antibiotic regime co-trimoxazole 480 mg/day was used. Stents appear generally well tolerated, although studies using longer stents (≥ 20 cm) for longer periods (> 6 weeks) had more problems with encrustation and migration. There was no evidence that the presence of a stent resulted in recurrent or severe haematuria (8 studies, 1546 participants: RR 1.09, 95% CI 0.59 to 2.00; P = 0.79; I2 = 33%). The impact of stents on graft and patient survival and other stent-related complications remains unclear as these outcomes were either poorly reported or not reported at all.
CONCLUSIONS: Routine prophylactic stenting probably reduces the incidence of MUCs, even when the duration of stenting is short (≤ 14 days). Further high-quality studies are required to assess optimal stent duration. Studies comparing selective stenting and universal prophylactic stenting, whilst difficult to design and analyse, would address the unresolved quality of life and economic issues.
摘要：
背景：肾移植后的主要泌尿系统并发症（MUCs）会导致患者发病并损害移植物功能。大多数起源于膀胱输尿管吻合术，并在移植后早期出现。输尿管支架已成功用于治疗此类并发症。许多中心在移植物植入时采取了普遍预防性支架置入的政策，以减少尿漏和输尿管狭窄的发生率。支架与特定的并发症有关，一些中心提倡仅对选定的吻合进行支架的政策。这是我们评论的更新，首次出版于2005年，最后更新于2013年。
目的：研究常规输尿管支架置入术预防肾移植受者MUC的益处和危害。
方法：我们联系了信息专家，并使用与本评论相关的搜索词搜索了Cochrane肾脏和移植专业注册（截至2024年6月19日）。登记册中的研究是通过对CENTRAL的搜索确定的，MEDLINE,和EMBASE,会议记录,国际临床试验注册平台(ICTRP)搜索门户，和ClinicalTrials.gov.
方法：我们的荟萃分析包括所有随机对照试验（RCT）和准RCT，旨在检查使用支架对肾移植受者的影响。我们的目标是纳入研究，无论移植类型如何，输尿管植入技术，或患者组。
方法：使用随机效应模型获得效果的摘要估计，结果表示为风险比(RR)及其95%置信区间(CI).对证据的信心是使用建议分级评估来评估的，开发和评估(等级)方法。
结果：确定了12项研究（1960例患者）。一项研究被认为在所有领域都存在低偏倚风险。其余11项研究质量较低或中等，在至少一个领域有较高或不清楚的偏倚风险。与对照相比，通用预防性输尿管支架置入术可能会减少主要泌尿系统并发症（11项研究：1834名参与者：RR0.30，95％CI0.16至0.55；P<0.0001；I2=16％；中度确定性证据；需要治疗的数量（17））；在唯一一项被认为在所有领域均具有低偏倚风险的研究中证实了这一益处。对于尿液渗漏和输尿管阻塞的各个成分也可以看到这种益处。在支架置入时间短（≤14天）的研究亚组中，通用预防性输尿管支架置入可降低MUC的风险（2项研究，480名参与者：RR0.39，95%CICI0.21至0.72；P=0.003；I2=0%），支架置入持续>14天（8项研究，124名参与者：RR0.22，95%CI0.08至0.61；P=0.004；I2=29%）。尚不确定支架置入是否会对尿路感染（UTI）的发展产生影响（10项研究，1726名参与者：RR1.32，95％CI0.97至1.80；P=0.07；I²=60％；由于偏见风险，确定性证据非常低，异质性和不精确性)。亚组分析显示，如果使用短期支架（9天），UTI的风险不会增加，并且当使用预防性抗生素方案复方新诺明480mg/天时，对UTI风险没有影响。支架通常表现出良好的耐受性，尽管使用更长的支架(≥20cm)进行更长时间(>6周)的研究有更多的结壳和迁移问题。没有证据表明支架的存在导致复发性或严重血尿（8项研究，1546名参与者：RR1.09，95%CI0.59至2.00；P=0.79；I2=33%）。支架对移植物和患者存活和其他支架相关并发症的影响仍不清楚，因为这些结果要么报道不充分，要么根本没有报道。
结论：常规预防性支架可能会降低MUC的发生率，即使支架置入的持续时间很短（≤14天）。需要进一步的高质量研究来评估最佳支架持续时间。比较选择性支架置入术和通用预防性支架置入术的研究，虽然很难设计和分析，将解决尚未解决的生活质量和经济问题。
目的：研究常规输尿管支架置入术预防肾移植受者MUC的益处和危害。
方法：我们联系了信息专家，并使用与本评论相关的搜索词搜索了Cochrane肾脏和移植专业注册（截至2024年6月19日）。登记册中的研究是通过对CENTRAL的搜索确定的，MEDLINE,和EMBASE,会议记录,国际临床试验注册平台(ICTRP)搜索门户，和ClinicalTrials.gov.
方法：我们的荟萃分析包括所有随机对照试验（RCT）和准RCT，旨在检查使用支架对肾移植受者的影响。我们的目标是纳入研究，无论移植类型如何，输尿管植入技术，或患者组。
方法：使用随机效应模型获得效果的摘要估计，结果表示为风险比(RR)及其95%置信区间(CI).对证据的信心是使用建议分级评估来评估的，开发和评估(等级)方法。
结果：确定了12项研究（1960例患者）。一项研究被认为在所有领域都存在低偏倚风险。其余11项研究质量较低或中等，在至少一个领域有较高或不清楚的偏倚风险。与对照相比，通用预防性输尿管支架置入术可能会减少主要泌尿系统并发症（11项研究：1834名参与者：RR0.30，95％CI0.16至0.55；P<0.0001；I2=16％；中度确定性证据；需要治疗的数量（17））；在唯一一项被认为在所有领域均具有低偏倚风险的研究中证实了这一益处。对于尿液渗漏和输尿管阻塞的各个成分也可以看到这种益处。在支架置入时间短（≤14天）的研究亚组中，通用预防性输尿管支架置入可降低MUC的风险（2项研究，480名参与者：RR0.39，95%CICI0.21至0.72；P=0.003；I2=0%），支架置入持续>14天（8项研究，124名参与者：RR0.22，95%CI0.08至0.61；P=0.004；I2=29%）。尚不确定支架置入是否会对尿路感染（UTI）的发展产生影响（10项研究，1726名参与者：RR1.32，95％CI0.97至1.80；P=0.07；I²=60％；由于偏见风险，确定性证据非常低，异质性和不精确性)。亚组分析显示，如果使用短期支架（9天），UTI的风险不会增加，并且当使用预防性抗生素方案复方新诺明480mg/天时，对UTI风险没有影响。支架通常表现出良好的耐受性，尽管使用更长的支架(≥20cm)进行更长时间(>6周)的研究有更多的结壳和迁移问题。没有证据表明支架的存在导致复发性或严重血尿（8项研究，1546名参与者：RR1.09，95%CI0.59至2.00；P=0.79；I2=33%）。支架对移植物和患者存活和其他支架相关并发症的影响仍不清楚，因为这些结果要么报道不充分，要么根本没有报道。
结论：常规预防性支架可能会降低MUC的发生率，即使支架置入的持续时间很短（≤14天）。需要进一步的高质量研究来评估最佳支架持续时间。比较选择性支架置入术和通用预防性支架置入术的研究，虽然很难设计和分析，将解决尚未解决的生活质量和经济问题。
