1. A 47-year-old male is keen to donate a kidney to his brother, 111 mismatch, no DSA and FCXM is negative. Excellent kidney function. He gave a past history of passing a small stone 10 years ago, never recurred. CT KUB is normal.
- How do you manage this case?
Thank you, All
What is the incidence of the stone coming back?
Dear Professor,
There is no concrete quantification of data regarding stone recurrence.
Basing on the available data, these conclusions can be drawn:
Reference:
Dear Dr Vali,
I note 4 observations based on published literature that your typed. But I can not find any mention of what you will choose to do or recommend this patient.
Ajay
Dear Sir,
I posted my answer as a separate post. This was the answer for Prof Ahmed Halawa’s supplementary question.
Dear Dr Vali,
I had noted your other reply. Your answer to the supplementary question is excellent.
Ajay
Thank you, are you sure?
50% RECURRENCE IS HIGH regarding the index case. This means we shout not accept him as a kidney donor.
This stone is usually a tiny stone (<5mm).
A patient with a history of renal stone has the following recurrence rate :
REFERANCES
1. Hiatt RA, Ettinger B, Caan B, et al. Randomized controlled trial of a low animal protein, high fiber diet in the prevention of recurrent calcium oxalate kidney stones. Am J Epidemiol 1996; 144:25.
2. Kocvara R, Plasgura P, Petrík A, et al. A prospective study of nonmedical prophylaxis after a first kidney stone. BJU Int 1999; 84:393.
3. Borghi L, Schianchi T, Meschi T, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med 2002; 346:77.
4. Uribarri J, Oh MS, Carroll HJ. The first kidney stone. Ann Intern Med 1989; 111:1006.
5. Ferraro PM, Curhan GC, D’Addessi A, Gambaro G. Risk of recurrence of idiopathic calcium kidney stones: analysis of data from the literature. J Nephrol 2017; 30:227.
Thank you, are you sure?
50% RECURRENCE IS HIGH. This means we shout not accept him as a kidney donor.
This stone is usually a tiny stone (<5mm).
Stone disease is a chronic disease. It’s a disease that can come back. It doesn’t go away If a patient has an initial kidney stone attack, they may actually have another stone forming, depending on the type of stone and the conditions of the patient, they may have recurrence of stone disease within a couple of years. Sometimes the stone-free period lasts longer
On average, around 30- 50% of patients may have recurrence or another stone attack within 3 to 5 years. There are actually reports dating back more than 30-40 years suggesting that the recurrence of stone disease is 100%
Stephen Y. Nakada, MD. Managing stone recurrence: What practitioners should know
Thank you, what about the index case?
Dear our prof.Halawa
-Clinical trials best inform stone prevention efforts, but strict criteria for identifying kidney stone recurrence are often not used.
-The use of various combinations of symptomatic and radiographic recurrence as a composite endpoint helps increase the event rate in clinical trials.
Key Points
Conclusion
Asymptomatic stone formers may lack the co-morbidities found in symptomatic stone formers and that different mechanisms may be involved in asymptomatic versus symptomatic stone formation.
Reference
1- BTS/RA Living Donor Kidney Transplantation Guidelines 2018 140
2- Ferraro PM, Curhan GC, D’Addessi A, Gambaro G. Risk of recurrence of idiopathic calcium kidney stones: analysis of data from the literature. J Nephrol. 2017;30(2):227–33.
3-Bozzini G, Verze P, Arcaniolo D, Dal Piaz O, Buffi NM, Guazzoni G, et al. A prospective randomized comparison among SWL, PCNL and RIRS for lower calyceal stones less than 2 cm: a multicenter experience : A better understanding on the treatment options for lower pole stones. World J Urol. 2017;35(12):1967–75.
Recurrence of stones is more in younger donors those below 35 years .
Handbook kidney transplantation 6th edition
The main factors that determine the RATE,TIME INTERVAL for reccurrence ,% of reccurrence would be determined by:
metabolic profile.
stone panel.
anatomy of the urinary tract .
Thanks you very much prof,Dawlat
Patients with small asymptomatic stones (4 mm) in the general population have a high incidence of future stone events, 23% at 2.6 years follow up.
Renal donors with small asymptomatic stones (2-3mm) seem to have a low incidence of stone events, 0-2% at 2 years follow up.
In a database study by Thomas et al 2000 kidney donors in Ontario were compared to 20,000 healthy non-donors linked from health care databases. Donors were not reported to have more surgical interventions for kidney stones nor did they have more hospital encounters for kidney stones. At 8 years follow up over 99% of donors had no need for stone interventions, comparable to the general healthy population with 2 kidneys.
Ref:
1- Tatapudi VS, Goldfarb DS. Differences in national and international guidelines regarding use of kidney stone formers as living kidney donors. Curr Opin Nephrol Hypertens. 2019 Mar;28(2):140-147. doi: 10.1097/MNH.0000000000000480. PMID: 30531468; PMCID: PMC6425959.
2- D. Serur, M.Charlton. ATS. Donors with Stones. Microsoft Word – Chapter 6 Donors with stones.doc (myast.org)
3- Thomas SM, Lam NN, Welk BK, et al. Risk of kidney stones with surgical intervention in living kidney donors. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. Nov 2013;13(11):2935-2944.
Thank you, Fakhriya
This is an interesting article addressing those
donors who had a kidney stone requiring either intervention or admission.
Can find out the incidence of recurrence of a kidney stone which was small and passed 10 years ago?
As per Thomas SM et cohort analysis, most donors (99.3%) did not experience a kidney stone intervention or hospital encounter over a median follow-up of 8.8 years (maximum follow-up of 19.7 years). Of the 2019 donors and 20 190 nondonors, there was no difference in the rate of kidney stones with surgical intervention in donors compared to non-donors (8.3 vs. 9.7 events/10 000 person-years). Similarly, there was no difference in the rate of hospital encounters for kidney stones (12.1 vs. 16.1 events/10 000 person-years).
There was also no evidence that donation increased the risk of either kidney stone event when examined in subgroups defined by age, sex or index date (length of follow-up).
so I guess the recurrence for this patient is very low.
The lifetime risk of recurrent kidney stones is an important consideration in evaluating the suitability for kidney donation.
There are few data on the lifetime risk specific to the kidney donor population. However, data relating to the risk of further stone episodes are available for people who present with a symptomatic kidney stone (overall 50% chance of developing a further stone within five years), and a risk prediction tool exists.
Risk prediction tools do not yet exist for asymptomatic stone formers, but ≥1 stone at presentation confers an increased risk of metabolic risk factors and future stone episodes.
Thank you, are you sure?
50% RECURRENCE IS HIGH. This means we shout not accept him as a kidney donor.
This stone is usually a tiny stone (<5mm).
thank you
the recurrence rate above is for symptomatic stones, this potential donor has small asymptomatic stone
Thank you Prof. Halawa,
The patient passed a stone long time ago(10 years ago, no data wither symptomatic or not, it was small also.
the prevalence of kidney stones in general population is 5%. with history of small asymptomatic stones increased to 13%.
In patients whom had asymptomatic kidney stone or >/= 1 cm – there is 50% incidence to recur.
Thank you, are you sure?
50% RECURRENCE IS HIGH. This means we shout not accept him as a kidney donor.
This stone is usually a tiny stone (<5mm)
Thank you Prof. Ahmad. in this particular patient the recurrence is not 50 % after 10 years without any attack of another kidney stone so it is in our case 5-10% mostly.
Sir,
There is varied incidence of recurrent stone formers
Strohmaier WL. Course of calcium stone disease without treatment. What can we expect? Eur Urol. 2000 Mar;37(3):339-44.
Ferraro, Pietro Manuel; Curhan, Gary C.; D’Addessi, Alessandro; Gambaro, Giovanni (2017). Risk of recurrence of idiopathic calcium kidney stones: analysis of data from the literature. Journal of Nephrology, 30(2), 227–233
Regarding this case:
He is 47 year old, with only one history of small stone.
He can be accepted as donor as
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Thank you, what about if all investigations came back normal?
There are few data . However, data relating to the risk of further stone episodes are available for people who present with a asymptomatic kidney stone. Overall 50 % chance of developing a further stne within 5 years.
Thank you, what about the recurrence rate in the index case?
Varied recurrence rates of renal stone have been reported from study to study .
Rule et al observed that KSD recurrence rates at 2, 5, 10, and 15 years were 11%, 20%, 31%, and 39%, respectively .
Vaughan et al looked at a random sample of incident symptomatic kidney stone formers consisting of 3,364 patients, and found that the stone recurrence rates per 100 person-years were 3.4 after the first episode, 7.1 after the second episode, 12.1 after the third episode, and 17.6 after the fourth or higher episode .
Reference ;
1-Rule AD, Lieske JC, Li X, Melton LJ 3rd, Krambeck AE, Bergstralh EJ. The ROKS nomogram for predicting a second symptomatic stone episode. J Am Soc Nephrol. 2014;25(12):2878–2886. doi: 10.1681/ASN.2013091011.
2- Vaughan LE, Enders FT, Lieske JC, Pais VM, Rivera ME, Mehta RA, Vrtiska TJ. et al. Predictors of symptomatic kidney stone recurrence after the first and subsequent episodes. Mayo Clin Proc. 2019;94(2):202–210
Thank you, what about the recurrence rate in the index case?
Are you sure Ben?
You give a recurrence rate of 30% in this donor. Please review the answer and get back to us.
Results for ROKS – Recurrence Of Kidney Stone (2014) by QxMD
Risk of a Second Symptomatic Kidney Stone Event at 2-Years: 6.3 %
Risk of a Second Symptomatic Kidney Stone Event at 5-Years: 12.7 %
Risk of a Second Symptomatic Kidney Stone Event at 10-Years: 21.2 %
In comparison, the risk in the average first time symptomatic stone former is 11% at 2-years, 20% at 5-years, and 31% at 10-years.
Answers calculated to formulate result:
1. First Symptomatic Stone? — Yes
2. Age? — 47 Years
3. Gender? — Male
4. Race? — Caucasian
5. Family History of Kidney Stones? — No
6. Gross Hematuria? — No
7. Brushite, struvite, or uric acid composition? — No
8. Imaging Performed? — Yes
9. Symptomatic Ureterovesical Junction Stone? — No
10. Symptomatic Renal Pelvic or Lower Pole Stone? — No
11. Concurrent Asymptomatic Stone? — No
12. Prior Incidental (Asymptomatic) Stone? — No
13. Prior Suspected Kidney Stone Event (No Stone Seen)? — No
October 3, 2022 at 22:12
Calculated at: https://qxmd.com/calculator_3/roks-recurrence-of-kidney-stone-2014
Get Calculate by QxMD for iOS, Android and web at http://qx.md/calculate
Thankyou Ben from calculating form ,it excludes Uris acid, struvite, brushite ??
so we are dealing with a calcium oxalate?
how does calculation not include a stone panel study?
Prospective studies have shown the median recurrence rate of kidney stones is 15 per 100 person-years, However, the risk of recurrence after a single stone is difficult to predict in an individual.
Characteristics associated with a higher lifetime risk of stone recurrence include :
• Younger age (<40 years)
• A family history of kidney stones
• Frequent, recurrent kidney stones
Characteristics associated with a lower lifetime risk of stone
recurrence include:
• Older age (≥40 years)
• No prior symptoms of kidney stones
• A kidney stone that is less than 15 mm, solitary and
unilateral.
Thank you
Patients who have passed one kidney stone, the lifetime recurrence rate is 60%–80%.
Ref:
Morton AR, Iliescu EA, Wilson JW. Nephrology: 1. Investigation and treatment of recurrent kidney stones. CMAJ. 2002 Jan 22;166(2):213-8. PMID: 11829004; PMCID: PMC99277.
Thank you, All
What is the incidence of the stone coming back in the index case?
It is anound 30-50% of patients and way has attack of recurrence or attack from 3-5 years
As this patient has only one previous episode of nephrinohisis , small sized and had no symptomatic recurrence for 10 years . The risk of recurrence would be 2-25%
Ref
Mostafa M. Ebraheema,d, Alsayed S. Abdelazizb,d, Ayman M. Ghoneemc,d,
Esam A. Elnady.Recurrence of nephrolithiasis: incidence and risk factors in
Egyptian patients
Al-Azhar Assiut Medical Journal 2020,
18:176–182
0-2% at 2 years follow up
D. Serur, MD. Donors with Stones. Living Donor Community of Practice of AST.
I think the risk of having recurrent renal stone is really futile in this patient , as he passed only once before 10 years with negative past history of renal stone disease and negative CT scanning .I am suspecting all tests that we requested to evaluate the underlying etiology and possible risk factors will turn unremarkable as he passed only one stone in his life, which is consistent with absence of significant underlying pathological factors..
In our case, the risk of recurrence after a single stone is difficult to predict.(small stone, no family history, clear CT KUB).
Overall ,o risk of further stone episodes are available for people who present with a symptomatic kidney stone (overall 50% chance of developing a further stone within 5 years) (1).
References:
Rule AD, Lieske JC, Li X, et al. The ROKS nomogram for predicting a second symptomatic stone episode. J Am Soc Nephrol 2014; 25: 2878-86.
Dear Dr Ahmed,
The recurrence rate of renal stones is variable in different literature, reflecting the diverse nature of the problem (There are different types of renal stones with various metabolic, dietary and drug-induced precipitating factors). Therefore, the accurate estimation of the risk of stone recurrence will depend on a detailed history and the results of the metabolic screen (1).
I believe that a history of a single small stone ten years back that did not recure and the current normal CT scan with excellent kidney function in this case scenario makes the possibility of recurrence highly unlikely, and I will proceed with kidney transplantation from this donor (after reviewing his metabolic screen). Nevertheless, I will strongly recommend that the patient maintain a healthy lifestyle with plenty of fruits and vegetable intake, adequate water intake (more than 2.5 litres/day), decrease salt and animal protein intake, and annual U/S KUB screening for early detection and intervention in case of any stone recurrence (2).
References:
1) Ferraro PM, Curhan GC, D’Addessi A, et al.
Risk of recurrence of idiopathic calcium kidney stones: analysis of data from the literature. J Nephrol. 2017;30(2):227.
2) Steddon S, Ashman N, Chesser A, et al. Oxford Handbook of Nephrology and Hypertension. Second edition, Oxford University Press, ISBN 978–0–19–965161–0, 2014.
Results for ROKS – Recurrence Of Kidney Stone (2014) by QxMD
Risk of a Second Symptomatic Kidney Stone Event at 2-Years: 6.3 %
Risk of a Second Symptomatic Kidney Stone Event at 5-Years: 12.7 %
Risk of a Second Symptomatic Kidney Stone Event at 10-Years: 21.2 %
In comparison, the risk in the average first time symptomatic stone former is 11% at 2-years, 20% at 5-years, and 31% at 10-years.
Answers calculated to formulate result:
1. First Symptomatic Stone? — Yes
2. Age? — 47 Years
3. Gender? — Male
4. Race? — Caucasian
5. Family History of Kidney Stones? — No
6. Gross Hematuria? — No
7. Brushite, struvite, or uric acid composition? — No
8. Imaging Performed? — Yes
9. Symptomatic Ureterovesical Junction Stone? — No
10. Symptomatic Renal Pelvic or Lower Pole Stone? — No
11. Concurrent Asymptomatic Stone? — No
12. Prior Incidental (Asymptomatic) Stone? — No
13. Prior Suspected Kidney Stone Event (No Stone Seen)? — No
October 3, 2022 at 22:12
Calculated at: https://qxmd.com/calculator_3/roks-recurrence-of-kidney-stone-2014
Get Calculate by QxMD for iOS, Android and web at http://qx.md/calculate
Reported recurrence rate of kidney stone disease is 6.1 – 66 % in the general population with more than 30% recurrence rate in the kidney transplant recipient population in the first 10 years.
References :
Prevalence of symptomatic renal stone in UK ~3-5%, & asymptomatic renal stone in a potential donors ~5%. The chance of stone recurrence reach 50% within 5 years.
This donor needs the following measures before accept him as a donor:
Kasiske et al suggest to accept donors with renal stone if:
So this potential donor can accepted if he hasn’t non correctable metabolic abnormality, & he should be counseled about the risk of stone recurrence in single kidney, in addition to life long encouraging of increase fluid intake(>2.5L) with regular follow-up bi-annually or annually by renal US.
References:
References :
If there is no underlying metabolic disorder the chance of recurrence at this age is very low
Donors with small stones (2–3mm) have an incidence of stone-related events of 0–2%
at 2 years follow up .lower incidence compared to general population.
Prospective studies have shown the median recurrence rate of kidney stones is 15 per 100 person-years, However, the risk of recurrence after a single stone is difficult to predict in an individual.
Characteristics associated with a higher lifetime risk of stone recurrence include :
• Younger age (<40 years)
• A family history of kidney stones
• Frequent, recurrent kidney stones
Characteristics associated with a lower lifetime risk of stone
recurrence include:
• Older age (≥40 years)
• No prior symptoms of kidney stones
• A kidney stone that is less than 15 mm, solitary and
unilateral.
The risk of recurrence in this index case is low. this because for 10years it did not recur.
The recurrence of kidney stones has not been studied like other known or common pathologies but it is estimated that 13 percent of men and 7 percent of female develop kidney stones in their life time. Following the first kidney stone, there is a possibility of recurrence rate of 35 to 50 percent.
References:
Evidence based practice centre systematic review protocol, Recurrent nephrolithiasis in adults: a comparative effectiveness review of preventive medical strategies.
The incidence of recurrence between 30-50% within 3 to 5 years
The pooling data suggested that the patients with family history of nephrolithiasis, personal history of nephrolithiasis, suspected nephrolithiasis episode a prior to first confirmed stone episode, any concurrent asymptomatic (nonobstructing) stone, pelvic or lower pole nephrolithiasis, or uric acid stone would have a higher risk for recurrence of KSD .
Additionally, patients with ureterovesical junction stone might have a lower risk in KSD recurrence. Meanwhile, any gross hematuria with first symptomatic stone, calcium oxalate monohydrate stone, calcium phosphate stone, diameter of largest nephrolithiasis, multiple stones, bilateral nephrolithiasis or ureteral stone might not be the risk factors for recurrence of KSD.
Reference:
Risk factors for kidney stone disease recurrence: a comprehensive meta-analysis
In the donor or in the recipient?
The incidence of stone coming back in the recipient is negligible and in the donor it should be minimal.
The incidence of recurring kidney stone is 23% in the next 3 years of follow up
so we need to do full panel metabolic screen to the donor urine to calcium,urate,oxalate and citrate before accepting him as kidney donor
sir as per the available literature the risk of recurrence of nephrolithiasis is 10-30% at 3 years and 50% at 10 years….AS the donor has already passed 10years we can accept the donation
we need some information about previous stone (symptomatic , type) and about the patient ( family history of stone, obesity, metabolic disease, urological problem). As long as no recurrence for the last 10 years, mostly he has very low risk to form stone again
Lifetime prevalence is estimated at 13 percent for men and 7 percent for women.1,2 Following an initial stone event, the spontaneous 5-year recurrence rate is 35 to 50 percent.
The risk of recurrence of stone is about 50% within 5 years but in symptomatic patients. If patient has asymptomatic stone detected only by imaging studies (ultrasonography or CT scan) recurrence rate is lower. As in this case nowadays with the use of CT scan small stone less than 4 cm, frequently are detected. For these stones, risk predication tools do not yet exit.
there is no solid data but generally seems to be small risk of recurrence
in one study- At 8 years follow up over 99% of donors had no need for stone interventions, comparable to the general healthy population with 2 kidneys.
other study – Renal donors with small asymptomatic stones (2-3mm) seem to have a low incidence of stone events , 0-2% at 2 years follow up.
Such patient was not accepted as a donor due to the possibility of association between kidney stones and CKD in some studies which resulted in wide variability among US transplant centers regarding the acceptance of kidney donors with stones.(1)
When surveyed,
· 23% of US transplant centers indicated they exclude donors with any kidney stones.
· 19% would accept those with a history of stones as long as none is present at the time of donation.
· 53% would accept donor candidates with a history of kidney stones provided none is currently present and metabolic studies are normal.
The 10-year recurrence rate of kidney stones varies greatly, but it is generally around 30% for all patients. (2).
I will evaluate him with non contrast CT KUB in addition to biochemical testing for stones including uric acid , calcium , oxalate and phosphate , PTH . if all normal he can proceed for donation
(1) Mandelbrot DA, Pavlakis M, Danovitch GM, et al. The medical eval[1]uation of living kidney donors: a survey of US transplant centers. Am J Transplant. 2007;7(10):2333-2343.
(2) Rule AD, Lieske JC, Li X, Melton LJ 3rd, Krambeck AE, Bergstralh EJ. The ROKS nomogram for predicting a second symptomatic stone episode. J Am Soc Nephrol. 2014;25(12):2878-2886.
BTS Guidelines:
– In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
– Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2).
This donor should be assessed for the risk of recurrence through
full history including family history of stones as well as full examination and investigations including metabolic profile and previous stone analysis if available
recurrence of kidney stones occur in patients with Yong age at presentation of 1st stone , family history os stones , recurrent stone passer
Yet regarding Tx , we shall proceed for Tx after excluding the risk of recurrence of renal stones in the donor
Patient has history of spontaneous small stone passage
Stone disease inactive for 10 years
No kidney stones on current CT KUB
He requires a metabolic evaluation to rule out (1):
UTI should also be ruled out.
If above evaluation are normal, considering no DSA and FCXM negative, i will accept him as donor(1)
Reference:
Kidney stone is not uncommon in potential living donors. As kidney stones are very common in general, also improved imaging techniques enable the detection of small, asymptomatic kidney stones.
The major concern for living donor is recurrent stone post-nephrectomy causing obstruction of the remaining kidney.
Age of the donor at onset and time since the symptomatic episode. Younger age at the onset of renal stone carry a risk of recurrence due to the expected long lifespan.
Donors with stone attacks more than 10 years are at a decreased risk for recurrence.
Metabolic workup including s. ca+ and bicarbonate to rule out metabolic acidosis, 24 hrs urine collection (better on two occasions) should be performed to assess Ca+, oxalate, uric acid, and citrate excretion.
Exclude donors with recurrent stones and those with metabolic abnormalities.
Most transplant programs (53%) accept donors with H/O kidney stones if the metabolic workup is normal. After good counselling of the donor and recipient.
reference
PRIMER ON KIDNEY DISEASE
seventh edition
A kidney donor is a healthy person with a low risk of developing ESRD after donation. Potential donors with a history of stones are exposed to the extra risk of developing kidney disease that’s why only patients with unilateral solitary small-size stones with no underlying anatomical or metabolic abnormalities can be accepted as potential donors.
This case is 47years old male with a history of stone 10 years ago and CT showed no recurrence. His metabolic profile showed be evaluated including 24h urine collection and analysis of urinary calcium, citrate, uric acid, cysteine, and oxalate. Serum calcium, uric acid, and PTH are also needed. If his metabolic profile appears to be normal so he has a low risk of recurrence and he can be accepted as a potential donor after proper counseling
Acceptance of donation with a history of stones is still controversial but there is almost agreement between international guidelines regarding the acceptance of donors with a history of single small-size unilateral stone with no underlying anatomical or metabolic profile abnormalities.
Donor candidates and donors with current or prior kidney stones should have an evidence-based evaluation of nephrolithiasis.
detailed medical and dietary history, serum chemistries and urinalysis .
Serum intact parathyroid hormone (PTH) concentration should be obtained as part of the screening evaluation if primary hyperparathyroidism is suspected.
Metabolic testing should of one or two 24-hour urine collections obtained on a random diet and analyzed at minimum for total volume, pH, calcium, oxalate, uric acid, citrate, sodium, potassium and creatinine.
Characteristics associated with a higher lifetime risk of stone recurrence include:
• Younger age (<40 years)
• A family history of kidney stones
• Frequent, recurrent kidney stones
Characteristics associated with a lower lifetime risk of stone recurrence include:
• Older age (≥40 years)
• No prior symptoms of kidney stones
• A kidney stone that is less than 15 mm, solitary and unilateral
This candidate is 49 years, excellent immunological match and kidney function with only one small stone history if no metabolic abnormality he is of lower risk of recurrence and can proceed to donation.
This donor should be asked about detailed history of prior kidney stones, and related medical records should be reviewed.
this donor should be assessed by imaging to assess the anatomy (eg, computed tomography angiogram) and the presence of kidney stones. This donor should be assessed for an underlying cause. Donor acceptance will depend on an assessment of stone recurrence risk and knowledge of the possible consequences of kidney stones after donation. Donor candidates with prior kidney stones should be kept guideline based recommondation to prevention of recurrent stones.
1. This donor should undergo screening evaluation consisting of a
a. detailed medical and dietary history,
b. serum chemistries and
c. urinalysis
2. Serum ( iPTH) concentration if primary hyperparathyroidism is suspected.
3. a stone analysis if available should be performed at least once.
4. Clinicians should obtain or review available imaging studies to quantify stone burden.
5. Additional metabolic testing should be performed in high-risk or interested first-time stone formers and recurrent stone formers.
6. Metabolic testing should consist of one or two 24-hour urine collections obtained on a random diet and analyzed at minimum for total volume, pH, calcium, oxalate, uric acid, citrate, sodium, potassium and creatinine.
According to BRITISH TRANSPLANT SOCIETY patient with history of a renal stone should be managed as such
1- In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging , may still be considered as potential kidney donors.
2- Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease.
3- In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation .
Reffrences
1- Andrews PA, Burnapp L. British Transplantation Society / Renal Association UK Guidelines for Living Donor Kidney Transplantation 2018: Summary of Updated Guidance. Transplantation. 2018 Jul;102(7):e307.
2- KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation 2017; 101(Suppl 8S):S1–S109.
▪︎Donors with nephrolithiasis (with either a history of symptomatic stones or those who are incidentally found to have kidney stones during evaluation for living kidney donation) serve as exemplars of complex living donors.
▪︎Traditionally, nephrolithiasis was considered a relative contraindication to kidney donation, both because of a risk of recurrent stones in donors and adverse stone-related outcomes in recipients[1].
▪︎ The workup plan for kidney donation in this scenario of a 47-year-old male who is keen to donate a kidney to his brother, 111 mismatch, no DSA and FCXM is negative. With an excellent kidney function and a past history of passing a small stone 10 years ago, never recurred. CT KUB is normal.
Some studies suggested that a stone former could be allowed to donate if he or she has passed only one stone, has stone disease that has been inactive for greater than 10 years, and no kidney stones were present on current radiographic studies.
▪︎The work up for donation will include:
– screening for metabolic abnormalities (using a 24-hour urine sample to assess urinary volume, calcium, citrate, uric acid, and oxalate excretion) to ensure that there are no risk factors for active stone disease.
– Donor candidates with detectable metabolic abnormalities should “probably be excluded from donation”[2].
– Screening for:
-hypercalciuria, hyper- uricemia, or metabolic acidosis.
– scystinuria or hyperoxaluria.
– Urinary tract infection.
– X ray and CT scan
– Screening for systemic disorders that are associated with stone formation such as primary or enteric hyperoxaluria, distal renal tubular acidosis, and sarcoidosis.
According to KDIGO guidelines:
– Donor candidates should be asked about prior kidney stones, and related medical records should be reviewed if available.
– The imaging performed to assess anatomy before donor nephrectomy (e.g. computed tomography angiogram) should be reviewed for the presence of kidney stones.
– Donor candidates with prior or current kidney stones should be assessed for an underlying cause.
– The acceptance of a donor candidate with prior or current kidney stones should be based on an assessment of stone recurrence risk and knowledge of the possible consequences of kidney stones after donation.
– Donor candidates and donors with current or prior kidney stones should follow general population, evidence-based guidelines for the prevention of recurrent stones [3].
_______________________
References:
1. Strang AM, et al., Living renal donor allograft lithiasis: a review of stone related morbidity in donors and recipients. J Urol, 2008. 179(3): p. 832–6. [PubMed].
2. Kasiske BL, et al., The evaluation of living renal transplant donors: clinical practice guidelines. Ad Hoc Clinical Practice Guidelines Subcommittee of the Patient Care and Education Committee of the American Society of Transplant Physicians. J Am Soc Nephrol, 1996. 7(11): p. 2288–313. [PubMed]
3. Lentine KL, et al., KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation, 2017. 101(8S Suppl 1): p. S1–s109. [PubMed]
In this case, he needs a complete assessment for nephrolithiasis. Biochemical assessment includes 24-hours urine for calcium, oxalate, creatinine and citrate in an acidic collection and uric acid another plain urine collection. Assessment of early morning urine for PH and sodium nitroprusside test to evaluate presence of cystine in urine are helpful, too. If a significant metabolic abnormality was determined, he is contraindicated for donation.
Otherwise after proper imaging studies (Ultrasonography or CT scan) to rule out presence of stone or anatomical abnormality he could donate a stone-free kidney. After donation he should be advised about high fluid intake and regular follow-up imaging and re-evaluation for metabolic risks.
Any taken medication to reduce stone formation should be continued.
Assessment of potential kidney donor with history of passing renal stone should start with the following:
1- History: passing renal stones, was it first time or recurrent? Complications or interventions related to the previous stone (s). Family history of renal stones, gout, metabolic or GIT disorders or ESRD.
2- Cause of ESRD in his brother.
3- Laboratory investigations: serum calcium, urate, urinary electrolytes, oxalate, urate, citrate and urine PH.
4- Radiological investigations: CTA for renal vasculature can be used to detect any renal stones. CT-KUB or MRI can be used to detect renal stones. DMSA scan is helpful to detect renal scarring and split renal function.
in the current scenario, a potential donor with history of passing small renal stone, 10 years ago with normal kidney functions without any metabolic abnormality in the stone work up can still be considered for donation after proper counselling for donor and recipient.
Asymptomatic stone formers are less likely to have recurrent stone formation.
Patients who present with a symptomatic renal stone carry a 50% risk of recurrence within 5 years. However, for asymptomatic stone formers, there is no risk prediction tool. On ther hand, those with asymptomatic more than one stone are at higher risk of future stone attacks.
The risks for transplant recipients to develop a small stone from the donor kidney are low.
Reference:
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
The potential donor has previous history of single small stone, metabolic screen should be done and if negative he can be considered for donation.
He should be counselled about the need for long term follow up after donation.
He will be advised to increase fluid intake for life.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018.
This case mandates good history taking ;regarding the donor’s diet , history of medications ,over the counter supplements ,history of recurrent UTI , total fluid intake , the previous stone analysis if available would be beneficial , the history of original renal disease of the candidate recipient if related to stone formation ,family history of stones if present ,the prophylactic measure he is adopting like high fluid intake .
According to the KDIGO and the British Transplantation Society guidelines , donors with single small sized stones less than 5 mm stone with no evidence of obstruction can donate provided that the metabolic work up and the urinary tract anatomy is intact .
So , full metabolic workup is recommended including 24 urinary Calcium ,phosphorous , serum uric acid, citrate level ,cysteine level , vitamin d level ,serum PTH level .Further urological investigations may be required according to the urology team advice .
Full explanation of the risk of recurrence which may occur post donation in this borderline candidate donor (more than 40 t0 50 % after 10 years), also the frequent close follow up post donation is mandatory in such cases, on annual basis with follow up renal functions, imaging if needed, metabolic work up, high fluid intake and cessation of smoking is also advised, after all these data being clarified the donor should be counselled for the approval of donation.
According literation there is 50 % recurrent rate with in 5 year and up to 70% after 10 years. but no consensus of stone size.
1) Elicit history of recurrent UTI. Do send urine for screening culture. If no evidence of infection allow to proceed for kidney donation.
British Transplant Society 2018
1) potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors provided metabolic abnormality has been rule out.
2)Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. Cystine stones is associated with cystinuria and people with these stones should not donate a kidney. Infection urolithiasis not advisable to donate kidney as it is commonly associate with anatomical abnormality.
3) In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation if vascular anatomy and split kidney function permit.
Several questions must be answered before widely accepted and generalizable criteria for selection of donor with nephrolithiasis can be developed:
Furthermore, ethical questions abound, since donors may sometimes wish to proceed with surgery despite a disproportionate risk to their health[12]. In such a scenario, preserving the autonomy of donors while also upholding the principles of beneficence to the recipient and non-maleficence to the donor is a difficult balance to strike[12]. These uncertainties have led to evolving professional society guidelines and significant variations in practices pertaining to selection of living kidney donors with nephrolithiasis across transplant centers in the United States[13, 20, 22, 24].
22. Lentine KL, et al., KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation, 2017. 101(8S Suppl 1): p. S1–s109. [PMC free article] [PubMed] [Google Scholar]
24. Ennis J, et al., Trends in kidney donation among kidney stone formers: a survey of US transplant centers. Am J Nephrol, 2009. 30(1): p. 12–8. [PubMed] [Google Scholar]
20. Kasiske BL, et al., The evaluation of living renal transplant donors: clinical practice guidelines. Ad Hoc Clinical Practice Guidelines Subcommittee of the Patient Care and Education Committee of the American Society of Transplant Physicians. J Am Soc Nephrol, 1996. 7(11): p. 2288–313. [PubMed] [Google Scholar]
13. Delmonico F, A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines. Transplantation, 2005. 79(6 Suppl): p. S53–66. [PubMed] [Google Scholar]
In this scenario the donor have agood match ,no DSA, no past medical history to prevent donation apart from passing small stone 10 years ago .
His current imaging is free
▪︎Befor accepting him as a donor we need to know:
-Full metabolic work up .
-family history of renal stones
-cause of of renal failure in the his brother (the recipient).
Concern of recurrence in single kidney will always be there
Most of Guidelines didn’t prevent donation with past history of kidney stones.
Asymptomatic potential donors with a history of a single stone as well as those with a single radiographically discovered stone (<1.5 cm or that is potentially removable) were considered suitable if they met the following requirements:
*KDIGO permits potential donors with asymptomatic kidney stones that are incidentally detected on imaging, as well as donor candidates with prior or current kidney stones, to donate.
With recommendations;
The AST Live Donor COP recommendations suggested that kidney donors with small asymptomatic stones (2–3mm) have an incidence of stone-related events of 0–2% at 2 years follow up, a low incidence compared to 23% at 2.6 years of follow-up among patients with small (4 mm) asymptomatic stones in the general population.
The AST live donor COP statement infers that this low frequency recurrence is perhaps due to the donors being healthier overall than the general population.
They recommend allowing kidney donors with small incidental renal stones to donate if they are left with the stone-free kidney and the metabolic stone work-up is negative.
No guidance regarding the number of stones or role of ex-vivo ureteroscopy to remove stones before transplantation is provided.
The AST Live Donor COP recommends that potential donors with symptomatic stone disease be considered if they have a distant history of having passed a single stone, currently have no detectable stones on imaging and have negative metabolic testing.
They suggest using the recurrence of kidney stones (ROKS) online calculator to help guide decision making.
the AST COP recommendations do not define how long a potential kidney donor with a history of symptomatic stones must be symptom-free before donation.
British Transplantation Society (BTS)The 2018 BTS Guidelines suggest that potential donors with a limited history of previous kidney stones, or small stone(s) on imaging may be allowed to donate provided there have no significant metabolic abnormalities.
they recommend consultation with a specialist in kidney stone disease if metabolic abnormalities are diagnosed.
In appropriate donors with unilateral kidney stone(s) the BTS recommends transplantation of the stone-bearing kidney in order to leave the donor with the stone-free kidney unless vascular anatomy and split renal function assessment preclude this.
The BTS stresses the importance of post-donation follow up and counseling of the donor and recipient regarding the risks and consequences of stone-related morbidity.
AS WE KNOW THE INCIDANCE OF RENAL STONE IS ABOUT 3-5 % WORLD WIDE AND THE USE OF CT FOR EVALUATIONS OF KIDNEY DONOR INCREASE THE INCIDANCE OF INCIDANTALLY FINDING OF SMALL STONES
THIS PATIENT WITH HISTORY OF PREVIOUS STONE SHOULD UNDERGO full metabolic and imaging screen
If metabolic screen is negative we can proceed with donation and if positive donation is contraindication
In potential donors who have a history of previous stones but no metabolic
abnormality, proceeding with donation should be considered providing the number,
size and frequency of previous stones has been low.
and finally full counselling of the donor and recipient is mandatory
after donation
thanks
-This will require two separate urine collections as calcium, oxalate and citrate
analyses require an acidified collection, whereas electrolytes, urate and pH are
measured in a plain urine collection
· If donation proceeds, it is preferable to remove the kidney containing the
suspected calculus
The given scenario talk about a potential donor for his brother with a haplomatch and a negative cross match.. The donor has normal renal function…The donor has history of passing renal stone which were small 10 years ago and had no history of recurrence…His current CT KUB is normal….
Do we accept the case as a donor?
The Organ procurement and Transplant Network recommend monitoring or evaluating donors with history of renal stones prior to transplant…The 2018 BTS guidelines also suggest metabolic workup before accepting a stone forming donor for organ donation
Once a renal stone is formed, there is a lifetime recurrence of >50% of stone formation…There are no validated tools available to estimate the risk of stone recurrence after an episode of nephrolithiasis….So we rely on the clinical methods for the same…
In general stone <5mm, they pass by themselves and have no problems of urological intervention…The risk of stone recurrence is more in younger males, obesity and 1 episode of bilateral stones. If the stone are more than 5 mm and they have more than >1 episode of nephrolithiasis, it is recommended to do a full metabolic workup for renal stones…In this patient the size of the stone was small and it got excreted by itself with no recurrence…..In view of organ donation and given the high percentage of recurrence of renal stones, I will do as per the guidelines of BTS 2018 a full metabolic panel namely urine routine for pH, urine culture, calcium, phosphorus, uric acid, spot urinary creatinine and urinary calcium, urinary uric acid and spot urine citrate. I would also do a PTH level and 25 (oh) Vit D levels.. I will also look at the blood pH to detect any distal RTA if the donor has…
If the metabolic workup is negative, I will accept this donor as there is no recurrence in 10 years and current CT KUB is normal …
I would also like to know the basic disease of the recipient and see if any history of renal stone is there in the recipient – to rule of primary oxalosis in which case different line of treatment has to be planned
how do you manage this case?
regarding history of passing stone is first to investigate this patient if he has metabolic disorder or any family history of passing stone
the incidence of recurrence is
10 to 30% at 3 years
35-40 at 5 years
50% at 10 year.
if this patient found that he is symptomatic stone former or asymptotic avoid donation
still emphasize full assessment start from urine ,CT kub without contrast and metabolic screening .
A retrospective study reviewed medical records and identified 146 cases of stone recurrence in a total of 3,985 patients from January 2012 to January 2016. Reported that:
1) Sixty-four out of 146 patients with stone recurrence were overweight or obese.
2) Of all 146 patients with stone recurrence, (86 had hyperlipidemia, 77 had hyperuricemia and 64 had hyperglycemia; 3) Seventy-nine patients with recurrence had stones of calcium oxalate.
Recurrence rates at 2, 5, 10, and 15 years were 11%, 20%, 31%, and 39%, respectively
Management:
Accurate workup and assessment starting with BMI, fasting lipid profile, fasting glucose level, and uric acid.
REF:
1. Zeng J, Wang S, Zhong L, Huang Z, Zeng Y, Zheng D, Zou W, Lai H. A retrospective study of kidney stone recurrence in adults. Journal of clinical medicine research. 2019 Mar;11(3):208.
Recurrence of confirmed symptomatic kidney stone episodes resulting in clinical care among first-time symptomatic stone formers were 11%, 20%, 31%, and 39% at 2, 5, 10, and 15 years, respectively.
Donor : 47 years old , 111 mismatch , no DSA , FCXM negative
Excellent kidney function
past history of passing a small stone 10 years ago , never recurred , CT KUB is normal
he can donate his kidney safely.if there is no significant metabolic abnormality.
Evaluation of history of stones :
first using of CT to evaluate potential kidney donor to detect a symptomatic kidney stone and in this donor it is free .
in absence of a significant metabolic abnormality, potential donor with a limited history of previous kidney may still be considered a potential donor with appropriate long term donor follow up.
Yes, I will accept this donor, with past medical history of small stone 10 years ago, never recurred and normal CT KUB, also he considered acceptable donor from immunological point of view.
*According to recommendations of BTS/RA Living Donor Kidney Transplantation Guidelines 2018:
*In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to
appropriate long-term donor follow up. (C2)
*To evaluate the Potential Donors:
# Imaging
* CT for renal vascular imaging increased the detection rate of asymptomatic kidney stones.
*Where CT is not used routinely for vascular imaging and a stone is suspected from USS or MRI,
* a non-contrast CT KUB is advisable to determine the number, size and location of suspected stones.
* A DMSA scan is useful if renal scarring is suspected and will give an estimate of split renal function.
# Biochemical Assessment
A full metabolic and imaging screen should be carried out before donation on potential donors with a history of stone disease or radiological evidence of a current stone.
*24-hour urine collections for calcium, oxalate,citrate and urate, and early morning pH assessment. This will require two separate urine collections as calcium, oxalate and citrate analyses require an acidified collection, whereas electrolytes, urate and pH are measured in a plain urine collection. Urine creatinine should be measured on each collection as an internal
marker of completeness and the 24 hour urine volume should be noted.
A pH measurement on an early morning urine sample is useful, together with a qualitative cystine screen for cystinuria, followed, if positive, by a 24-hour collection for cystine concentration.
*Serum calcium and urate should be measured.
*A metabolic screen (urine and plasma biochemistry) may also be indicated in potential donors with a significant family history of stone disease or with
significant risk factors for the development of stones e.g. inflammatory bowel
disease.
*In patients with previous calculus disease, where a stone has been retrieved,
biochemical stone analysis is also of value.
# The American Society of Transplantation Communities of Practice are specialty-area focused groups within AST. The current AST Live Donor COP recommendations: They cite data that suggest that kidney donors with small asymptomatic stones (2–3mm) have an incidence of stone-related events of 0–2% at 2 years follow up, a low incidence compared to 23% at 2.6 years of follow-up among patients with small (4 mm) asymptomatic stones in the general population.
# The AST live donor COP statement infers that this low frequency recurrence is perhaps due to the donors being healthier overall than the general population.
They recommend allowing kidney donors with small incidental renal stones to donate if they are left with the stone-free kidney and the metabolic stone work-up is negative.
#Kasiske et al suggested that a stone former could be allowed to donate if he or she has passed only one stone, has stone disease that has been inactive for greater than 10 years, and no kidney stones were present on current radiographic studies. They recommended that such individuals should be screened for metabolic abnormalities (using a 24-hour urine sample to assess urinary volume, calcium, citrate, uric acid, and oxalate excretion).
* BTS/RA Living Donor Kidney Transplantation Guidelines 2018:
* Differences in national and international guidelines regarding use of kidney stone formers as living kidney donors
Tatapudi, Vasishta S. Goldfarb, David S.
Author Information Current Opinion in Nephrology and Hypertension: March 2019 – Volume 28 – Issue 2 – p 140-147
recurrence of kidney stone is high specially 5 to 10 years , generally we need to know the type of the stone to avoid further stone formation but it is not contraindications for donation specially if it is not with genetic background
Presentation of kidney stones varies between people some of them are symptomatic and other could be silent.
The risk of recurrence seems to be around 10-30% at three to five years among those with the most common form of stone viz calcium oxalate
Since the patient has a small and asymptomatic stone and has not recurred within 10 years, the proportion of recurrence later will be very low
So I will accept this donor with strict follow up after donation to early detection recurrence of stones and to Take all possible precautions to prevent the recurrence of stones from high intake of water and diet rich in citrate, magnesium and potassium and poor in oxalate and sodium and avoid high-protein diets
If the metabolic stone workup is normal, we can proceed ahead with the transplant. the donor should be counselled regarding importance of a thorough check up in the follow up for stones. I would use induction and triple drug maintenance.
First we started with history taking about
If it was the first time of having stone hx
symptoms and complications associated with the previous stone
Way of treatment
Family hx about ESRD and it cause ,also about stones formations
history of gout, ileostomy, diarrhoea or with the metabolic syndrome
Investigations
A full metabolic and imaging screen should be carried out before donation on potential donors with a history of stone disease or radiological evidence of a current stone.
This screen should include
>>> This will require two separate urine collections as calcium, oxalate and citrate analyses require an acidified collection, whereas electrolytes, urate and pH are measured in a plain urine collection.
Imaging
The use of CT for renal vascular imaging has increased the detection rate of asymptomatic kidney stones. Where CT is not used routinely for vascular imaging and a stone is suspected from USS or MRI, a non-contrast CT KUB is advisable to determine the number, size and location of suspected stones.
If a probable stone is identified on imaging, a urological and radiological review should be undertaken. The number, size, position and density of the potential stones should be considered; as should the presence of any underlying structural renal abnormality.
A CT IVU may be useful in these circumstances.
A DMSA scan is useful if renal scarring is suspected and will give an estimate of split renal function.
>>> In the absence of a significant metabolic abnormality e.g. (hypercalciuria, hyperoxaluria, or hypocitraturia), potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors.
Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up.
The lifetime risk of recurrent kidney stones is an important consideration in evaluating the suitability for kidney donation. There are few data on the lifetime risk specific to the kidney donor population.
However, data relating to risk of further stone episodes are available for people who present with a symptomatic kidney stone (overall 50% chance of developing a further stone within 5 years) and a risk prediction tool exists .
Risk prediction tools do not yet exist for asymptomatic stone formers, but ≥1 stone at presentation confers an increased risk of metabolic risk factors and future stone episodes
asymptomatic stone formers were not characterised by older age, male gender, hypertension, obesity, metabolic syndrome, abnormal kidney function, hyperuricaemia, hypercalcaemia or hypophosphataemia.
One conclusion is that asymptomatic stone formers may lack the co-morbidities found in symptomatic stone formers and that different mechanisms may be involved in asymptomatic versus symptomatic stone formation.
>>>> It is likely that the risks of recurrent stone formation are low in asymptomatic potential kidney donors
>>>> transplant recipients, the long-term risks associated with a small stone transferred from the donor kidney appear low.
After discussion the case with urologist and MDT I will accept such potential donor with good follow up and encouraging him to have daily water intake of around 2.5 litres of urine, low sodium diet.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Potential kidney donor with hx of passing small stone 10 ys back, never recurred with normal CT KUB at time being , I will proceed as following :
1- Detailed Hx & physical examination
2- Serum calcium, uric acid, PTH, vit D
3- Urine analysis for PH, 24 hrs collection of calcium, cystine, urate, oxalate & citrate.
>>>if negative metabolic work up ( with hx of spontaneous passing small stone , no recurrence & normal CT KUB ) , I will accept him as a donor after counselling & instruction for good hydration & regular follow up after donation .
The concern of this potential donor is his past history of passing stone. According to BTS guidelines 2018, in the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up.
This potential donor needs a thorough workup to rule out metabolic abnormality that may predispose to stone recurrence:
a) To search in the history for relevant systemic diseases that may predispose to stone formation(e.g.; Crohn’s disease, hypercalcemic disorder, obesity and insulin resistance(uric acid stones)).
b) Blood tests for U & E, calcium, phosphate, uric acid and PTH is needed if serum calcium is high.
c) Urine for specific gravity.
d) 24hr urine analysis for excretion of calcium, citrate and urate.
e) Early morning urine pH.
f) Urine for qualitative cystine to screen for cystinuria, followed, if positive, by a 24-hour collection for cystine concentration. Cystinuria is a contraindication to donation.
g) Urine for creatinine as an internal marker of completeness.
h) Urine for M,C&S to rule out concomitant infection.
i) Stone analysis if possible.
If a significant and uncorrectable metabolic abnormality is identified then kidney donation is contra-indicated.
Considering kidney stone, donation may be considered in the followings:
a) Potential donors with minor or correctable metabolic abnormalities e.g: isolated hypocitraturia, isolated hypercalciuria, isolated hyperuricosuria, particularly if the history of calculus disease is very limited.
b) Donation may be considered where factors that have previously put the patient at risk of stone formation e.g. diet or medication, have been successfully modified, urine pH has been corrected to normal and 24 hr urine levels have demonstrated to a return to the normal range.
c) Single kidney stone < 15mm, may be suitable for donation if the donor is not at high risk for recurrence and the stone is potentially removable during the transplantation1.
Donation is contraindicated in the followings:
a) A history of a previous infection-related stone (struvite).
b) Cystine renal stone is generally considered a contraindication to donation.
c) Bilateral kidney stones.
d) Large stone(> 1.5 cm).
To proceed with donation we would require
CT KUB
Metabolic screen to rule out any cause for stone formation
If this is normal we can proceed after detail discussion with donor that there is still chance of recurrence.The overall recurrence rate of stones depends on factors such as previous stone history and type of treatment.
Dietary advice aims to reduce the majority of lithogenic risk factors, reducing the supersaturation of urine, mainly for calcium oxalate, calcium phosphate, and uric acid. For this purpose, current guidelines recommend increasing fluid intake, maintaining a balanced calcium intake, reducing dietary intake of sodium and animal proteins, and increasing intake of fruits and fibers.
Previously, donors with asymptomatic stones found incidentally on CT were not considered ideal donor candidates because of the presumed risk of morbidity to both the donor and recipient. Increasingly, studies show that these risks are low.
Kidney stones are found incidentally in 4-9% of potential renal donors , and there is concern that they may become symptomatic and cause damage in the remaining kidney.
While studies of patients with small asymptomatic stones (4 mm) in the general population have a high incidence of future stone events, 23% at 2.6 years follow up ,renal donors with small asymptomatic stones (2-3mm) seem to have a low incidence of stone events , 0-2% at 2 years follow up .This is perhaps due to the donors being healthier overall. In a study of 1957 kidney donors, 9.7 % had asymptomatic stones. These donors were not characterized by the typical risk factors for symptomatic stone formation such as older age, male gender, hypertension, obesity, metabolic syndrome, decreased GFR, hyperuricemia, hypercalcemia or hypophosphatemia .The authors suggest that perhaps they have a different pathophysiology than other stone formers, which leads to a lower rate of stone events.
In a database study by Thomas et al , 2000 kidney donors in Ontario were compared to 20,000 healthy non-donors linked from health care databases. Donors were not reported to have more surgical interventions for kidney stones nor did they have more hospital encounters for kidney stones. At 8 years follow up over 99% of donors had no need for stone interventions, comparable to the general healthy population with 2 kidneys.
So as per AST recommendation:
1. Kidney donors with small incidental renal stones have a low rate of stone events, 0-2% at two- year follow-up. While longer follow-up is needed to obtain stronger data, we recommend allowing such donors to donate as long as they are left with the stone-free kidney and the metabolic stone work-up is negative.
2. While it is generally agreed that potential donors with symptomatic stone disease should be denied (8), one may consider accepting donors with a distant history of a single passed stone, as long as there are no stones on current imaging and the metabolic testing is negative.
While per BTS recommendation:
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up.
Contraindication for donation:
1- recurrent stone
2-Nephrocalcinosis
3- associated metabolic abonormality
4- presence of risk factors for stone formation
5- positive family history of stone formation.
So for the index case , we will accept donation after proper metabolic screening and counseling the donor and recipient about the small risk of recurrence and about changing lifestyle after donation by increasing water intake and low salt and protein consumption with reducing body weight and continue follow up for recurrence of stones after donation.
Reference:
AST recommendation
BTS guidelines 2018
In absence of metabolic abnormalities, This donor can donate safely because low risk of recurrence.
Pt need radiological evaluation by ultrasound and Low contrast CT abdomen to role out presence of small renal stone in urinary tract. 24 hr urinary excretion of calcium oxalate and urate, magnesium, cystine.
Laboratory studies for uric acid and calcium
urine routine for Ph urine/ arterial blood gas to role out acidosis in cases of renal tubular acidosis
urinary calciuric excretion
I will proceed with kidney transplantation :
Good positive data :
Related
111 mismatch
No DSA
Negative flow cytometry crossmatch
Good anatomy showed on CTUT with no recurrence of stones
40 years old male donor
However Negative Data :
That the donor had passed a stone but fortunately there is no stones passing or forming in the past 10 years
So according to The Amsterdam Forum
Asymptomatic potential donors with a history of a single stone as well as those with a single radiographically discovered stone (<1.5 cm or that is potentially removable) were considered suitable if there were no metabolic abnormalities
And according to :
Kasiske et al suggested that a stone former could be allowed to donate if he or she has passed only one stone, has a stone disease that has been inactive for greater than 10 years, and no kidney stones were present in current radiographic studies like this donor.
This index donor has normal renal functions, negative cross match and no DSA. However, he has had a history of non-recurrent small stone since 10 years with normal imaging currently.
The raised question whether he will be allowed to donate his kidney and the consequences of this donation?
· Urolithiasis in context of transplant is a quite rare event found in 4-9% of potential kidney donors especially with the use of CT that helped in identifying small renal stones
· The main impediments to acceptance of donors with nephrolithiasis are stone. recurrence in a single kidney causing obstruction and acute renal failure in donors, and to a lesser extent, recipients of living donor kidneys due to passage of stones left in situ (donor-gifted lithiasis.
· When reviewing literature, there was a lack of evidence-based, widely accepted guidelines to evaluate outcomes in donors with nephrolithiasis and their recipients(attached table for different guidelines). Accordingly, each transplant center has its own rules about who can donate.
· generally accepted rules for contraindications of kidney donation with stone disease:
– Significant and uncorrectable metabolic abnormality
– History of recurrent or bilateral or currently symptomatic kidney stones
– Nephrocalcinosis.
– History of a previous infection-related (struvite) or cystine renal stones
· From the AST data, donors with small incidental renal stones have a low rate of stone events( 0-2% at two[1]year follow-up) but longer follow-up is still required. Moreover, useful online calculator to predict stone recurrence are helpful to aid in the decision of donation
· How to proceed in this case:
– Detailed medical and family history ,dietary habits, prior stones history.
– Metabolic Stone screening: 24 hour Urine collection for calcium, oxalate, citrate and urate. Serum Corrected Calcium and Uric acid levels. Early morning Urine PH measurement. Qualitative urine screen for Cysteine.
– Renal imaging US or non-contrast CT KUB to determine the number, size and location of suspected stones. If stone is identified urological advice is taken to rule our structural abnormalities.
– DMSA scan is useful if renal scarring is suspected and will give an estimate of split renal function
– Stone analysis can help with clinical decision-making for the treatment of existing stones and prevention of new stone formation.
Conclusion:
Back to our case who had a single passed stone with no stones on current imaging and the assessed metabolic testing is negative. he can proceed for donation after proper counseling as long as he is left with the stone-free kidney .Additionally, he should receive proper counseling about the general measures to prevent stone recurrence with regular follow-up imaging.
References:
VS Tatapudiand DS Goldfarb. Differences in American and International Guidelines Regarding Use of Kidney Stone Formers as Living Kidney Donors. Curr Opin Nephrol Hypertens. 2019 March ; 28(2): 140–147
The index prospective donor has excellent renal function with 111 mismatch, no DSA and a negative GCXM. There is history of passing a small stone 10 years ago and a normal imaging at present.
A study showed that 3% of prospective renal donors had a prior history of symptomatic renal stone (1).
In such a scenario, predicting the risk of stone recurrence is difficult, with studies showing recurrence rates of 15 (range of 0-100) per 100 person-years having higher rates in those with 2 or more stone episodes (2). Risk prediction tools are available for symptomatic stone formers, but not for asymptomatic stone formers (3).
The risk factors for higher stone recurrence include: age <40 years, frequent, recurrent stones, and a positive family history. Those with age >40 years, without prior renal stone symptoms, and a solitary and unilateral renal stone less than 15 mm size have lower risk of stone recurrence (4). A prior history of renal stone has not been found to be associated with increased risk of ESKD (5,6).
The evaluation of such prospective donors include:
a) Detailed history: Family history, history of passing stone in past and dietary history should be ascertained.
b) Investigations: Metabolic workup including a routine urinalysis, serum PTH (if primary hyperparathyroidism is suspected), serum calcium and uric acid, one or two 24-hour urine collections for pH, volume, calcium, oxalate, uric acid, sodium, potassium, creatinine and citrate.
c) Stone analysis: if available
d) Renal imaging: USG/ CT KUB
Different international guidelines exist with respect to kidney donation in a prospective donor with renal stones with no uniformity. The consensus in these guidelines regarding asymptomatic subjects with history of single stone episode is that they can be taken up as donor, provided the metabolic work-up is negative (4,7,8).
In our transplant unit:
a) A prospective donor with a prior history of renal stone, but no stone on imaging is taken up for donation, if otherwise fit to donate.
b) A prospective donor with multiple stones (>2) unilaterally or bilateral stones is excluded.
c) For a prospective donor with 1-2 stones, detailed history is obtained and metabolic evaluation is done. Urology consultation is taken. If no metabolic abnormalities, the kidney with stone is taken up after counselling the donor and recipient and a long-term follow-up with emphasis on dietary changes and high liquid intake in the donor is recommended.
The index subject is more than 40 year of age, has normal CT KUB (that means no current renal stone) and prior history of passing small stone 10 years ago with no recurrence (hence low risk of recurrence). If the metabolic workup is normal, I will accept this donor with emphasis on high liquid intake life-long with close follow-up post-donation.
References:
1) Lorenz EC, Lieske JC, Vrtiska TJ, Krambeck AE, Li X, Bergstralh EJ, Melton LJ 3rd, Rule AD. Clinical characteristics of potential kidney donors with asymptomatic kidney stones. Nephrol Dial Transplant. 2011 Aug;26(8):2695-700. doi: 10.1093/ndt/gfq769. Epub 2011 Feb 1. PMID: 21285126; PMCID: PMC3145914.
2) Ferraro PM, Curhan GC, D’Addessi A, Gambaro G. Risk of recurrence of idiopathic calcium kidney stones: analysis of data from the literature. J Nephrol. 2017 Apr;30(2):227-233. doi: 10.1007/s40620-016-0283-8. Epub 2016 Mar 11. PMID: 26969574.
3) Rule AD, Lieske JC, Li X, Melton LJ 3rd, Krambeck AE, Bergstralh EJ. The ROKS nomogram for predicting a second symptomatic stone episode. J Am Soc Nephrol. 2014 Dec;25(12):2878-86. doi: 10.1681/ASN.2013091011. Epub 2014 Aug 7. PMID: 25104803; PMCID: PMC4243346.
4) Lentine KL, Kasiske BL, Levey AS, Adams PL, Alberú J, Bakr MA, Gallon L, Garvey CA, Guleria S, Li PK, Segev DL, Taler SJ, Tanabe K, Wright L, Zeier MG, Cheung M, Garg AX. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017 Aug;101(8S Suppl 1):S1-S109. doi: 10.1097/TP.0000000000001769. PMID: 28742762; PMCID: PMC5540357.
5) Murad DN, Nguyen H, Hebert SA, Nguyen DT, Graviss EA, Adrogue HE, Ibrahim HN. Outcomes of kidney donors with pre- and post-donation kidney stones. Clin Transplant. 2021 Feb;35(2):e14189. doi: 10.1111/ctr.14189. Epub 2020 Dec 25. PMID: 33320374.
6) Grams ME, Sang Y, Levey AS, Matsushita K, Ballew S, Chang AR, Chow EK, Kasiske BL, Kovesdy CP, Nadkarni GN, Shalev V, Segev DL, Coresh J, Lentine KL, Garg AX; Chronic Kidney Disease Prognosis Consortium. Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. N Engl J Med. 2016 Feb 4;374(5):411-21. doi: 10.1056/NEJMoa1510491. Epub 2015 Nov 6. PMID: 26544982; PMCID: PMC4758367.
7) Tatapudi VS, Goldfarb DS. Differences in national and international guidelines regarding use of kidney stone formers as living kidney donors. Curr Opin Nephrol Hypertens. 2019 Mar;28(2):140-147. doi: 10.1097/MNH.0000000000000480. PMID: 30531468; PMCID: PMC6425959.
8) British Transplantation Society. Renal Association Guidelines for Living Donor Kidney Transplantation, 4th ed.; British Transplantation Society: Macclesfield, UK, 2018; Available online: https//bts.org.uk/wp-content/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf (accessed on 3 October 2022).
In this donor, I do not expect a recurrent metabolic cause. so we can accept him as a donor. CT is sensitive in evaluating millimetric stones, so according to this, we can accept the donor with excellent kidney function.
In case series of 18 patients (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125573/) one case had recurrent sone (in the recipient). This was related to the history of a newly passed stone attributed to hyperoxaluria.
Potential donors with stone need to be assessed for underlying cause and recurrence risk. .Lower risk is expected index case considering age of more than 40,absence of symptoms, ,smaller stone of less than 15 mm unilateral and solitary .According to AST guidelines ,potential candidates can be accepted with incidental st one less than 2-3 mm ,with negative metabolic assessment. Lower rate of stone recurrence compared with general population is attributed to better metabolic profile and lifestyle .Stone free kidney is the one left for the donor.
References :
Live donor toolkit, provided by American Society of transplantation,2015
This potential donor looks straight forward except for the history of passing small stone 10 years before.
We need to confirm the history this stone, how big?
Having stone more than 10years, means that the risk of recurrence is very low. Doing metabolic screen to see if there is any abnormal urine chemistry that increases risk of recurrence.
Guidelines such BTS stated that:
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2).
Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) to leave the donor with a stone-free kidney after donation. (C2).
So, this potential donor with remote history of small stone, and current CT KUB did not show any stone. So this donor can proceed for donation after doing metabolic screening for renal stone. If normal, then consenting the donor for the risk of recurrence which is low and importance of future follow up.
Reference:
BTS 2018
In the first instance we should know if there is any family history of metabolic disease and any disease the patient may have associated with increased incidence of renal stones (e.g. crohn’s disease, gout , hyperparathyroidism). We need to know what type of stone it was 10 years previously (if this was recorded). However, from the history it seem that the stone was small (therefore less than 5 mm) with normal CT KUB.
I would request a 24 hours urine collection for urine analysis (calcium, Urate, phosphate, Oxalate, citrate, cysteine, magnesium, tubular screen and urine PH etc ) for both donor and recipient.
I would request a DMSA to assess the split function offering the kidney with reduced function.
If there is a metabolic disorder on urine analysis patient should receive a diet program to prevent future stones formation.
Both donor and recipient must be informed about the percentage of renal stones recurrence [(the incidence of stone events in case of small asymptomatic stones (between 2 and 3 mm) is between 0 and 2% at 2 years; while asymptomatic patients with a kidney stones of 4 mm have an incidence of future stones of 23 % at 2.6 years)] and the risk of acute renal dysfunction for larger kidney stones not freely passing through the excretory system.
In this case I would discuss with donor and recipient the probability of future stones and the risk of acute renal impairment (in case of obstruction of the excretory system) and considering the normal kidney function, the normal CT KUB and the fact that the renal stone 10 years before was a small stone (less than 5 mm) I would proceed with kidney transplantation.
Reference
Donors with Stones Author: D. Serur, MD, Editor: M.Charlton, RN
Joint Working Party of the British Transplantation Society and the Renal Association. United Kingdom Guidelines for Living Donor Kidney Transplantation, 3rd Ed. 2011:1.
A history of urinary tract stones is a relative contraindication for donation due to it’s tendency to recur and can lead to obstruction of a solitary kidney.
Meanwhile according to BTS 2018 guidelines if there is no significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s)on imaging, can be considered for donation after full
Counselling.
According to Amsterdam forum an asymptomatic potential donor with a history of a single stone may be suitable for kidney donation if he did not have hypercalciuria, hyperuricemia, or metabolic acidosis and if cystinuria or hyperoxaluria and UTI were excluded in addition to absence of multiple stones or nephrocalcinosis on (CT) scan.
In fact donation is contraindicated in candidates with urinary stones if nephrocalcinosis on X-ray or bilateral stone disease were detected ; and if the stone types have high recurrence risk as Cystine stones ,Struvite stones or infection stones that are difficult to eradicate, stones with inherited or other systemic disorders, such as primary or enteric hyperoxaluria, distal RTA, stones associated with inflammatory bowel disease or recuurence after being on suitable treatment.
So in this current potential donor in the case can be considered since he has a history of stone 10 year ago that did not recur and his CT KUB is normal also older donors are less likely to have recuurence of stone risk in comparison to younger candidates .
Also thorough evaluation will be needed before enrolling him including detailed personal history, dietary history and family history and metabolic assessment to exclude metabolic abnormalities , evaluate recurrence risk and follow measures to avoid it’s recurrence.
Reference
-Caliskan Y and Yildiz A., Evaluation of the Medically Complex Living Kidney Donor. Journal of Transplantation
Volume 2012, Article ID 450471, 6 pages
-BTS 2018 guidelines
This 47 year old potential donor with low immunological risk has history spontaneous passage of small kidney stone 10 years back. Currently he is stone free as CT KUB is negative.
Potentially he can be accepted for kidney donation, however there are some important aspects which need to addressed.
It is very important to take detailed medical and surgical history including history of previous stone surgeries, fluid habits, metabolic disorders, family history of stones and use of medication leading to stone formation like captopril , ciprofloxacin, antacids or sulpha drugs etc.
I will perform metablic evaluation and will check renal functions, serum calcium and uric acid. I will perform 24 hour urine studies to check level of Citrate, Oxalate, Calcium, Urate, Magnesium and Cystine . I will see 24 hour urine volume.
Two Collections needed:
Acid: Calcium, Oxalate and Citrate.
Plain: PH, Electrolytes, Urate.
I will check Urine PH and Urine spot test for Cystine.
If there no metabolic abnormality then he can donate. Otherwise in case of metabolic abnormality, this need to be treated before donation.
Post donation he has to keep very good hydration and careful follow up will be needed. Follow up should include Renal imaging and watch for any metablic abnormality.
BTS Living Donors Kidney Transplantation Guidelines 2018.
Stone disease is a chronic disease. so the chance of the recurnce based on what iread about 50%
*There are different types of renal stones with variable metabolic, dietary and drug-induced precipitating factors.
*Factors which determine rate and interval of stone recurrence determined by: metabolic profile , stone panel , urinary tract anatomy .
*kidney donors with small asymptomatic stones (2-3mm) have a low incidence of stone events about 0-2% at 2 years follow up.
*Donors with small incidental stone can donate with informed consent and counseling.
*Investigations to be done first: metabolic stone work up : serum calcium ,uric acid phosphorus, Mg , 24hrs urine analysis for calcium ,uric acid ,citrate, oxalate and creatinine .
*American society of transplantation recommended conditions to be approved as kidney donors; 1. History of passing only one stone in the past ,no recurrence diseases for 10years.
2.Normal metabolic evaluation and radiological evidence of recent stones.
*The risk in first time symptomatic stone former about 10% at 2-years, 20% at 5-years.
*The 2018 BTS Guidelines for Living Donor KTX informed that ; potential
donors with a limited history of previous kidney stones, or small stone(s) on imaging can
donate on condition that there is normal metabolic work-up.
References :
1- Tatapudi VS, Goldfarb DS.; Differences in national and international guidelines regarding use of kidney stone formers as living kidney donors. Curr Opin Nephrol Hypertension.2019 Mar;28(2):140-147.
This is a case of potential kidney donation with low immunological risk, having no DSA, negative FCXM crossmatch, living donation and HLA mismatch 111.
Patient has history of one episode of kidney stone 10 years ago, with no clinical recurrence in the last 10 years and no evidence of current kidney stone as by CT pyelogram.
So He can be accepted as donor as
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
This patient is 47 years old, history of stone 10 years ago, which is small stone and never recurred.
Excellent kidney function ,no DSA and FXCM made him immunologically compatible
History of small stone 10 years ago made him least likely to have recurrence of stone later. Risk prediction tools showed ≥1 stone at presentation confers an increased risk of metabolic risk factors and future stone episodes.
I would do a full metabolic screening for the patient.
(Two separate urine collections as calcium, oxalate and citrate analyses require an acidified collection whereas electrolytes, urate and pH are measured in a plain urine collection)
If metabolic screening is negative , no stone recurrence more than 1 , the patient has very low risk of future stone episodes.
Small <5 mm stones usually pass spontaneously but can occasionally cause ureteric obstruction leading to acute renal failure in patients with a single kidney. Small kidney stones can be treated using less invasive treatment modalities e.g. flexible ureterorenoscopy.
In general population, the evidence that treating small asymptomatic stones is superior to simply observing them is mixed , with about 25% becoming symptomatic in 5 years and 3% developing painless silent obstruction
After donation, the patient will be advised to advised to maintain a high fluid intake
for life (at least 2.5 litres of fluid per day) and also to continue any medication prescribed to reduce the risk of future stone formation. Regular follow-up imaging e.g. annual or biennial renal ultrasound may be advisable, and regular re-assessment of the metabolic profile should be considered
References
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Donors with small incidental stone can donate with informed consent and counseling.
Regarding risk of donation and recurrence of stone.
Non stone kidney is used
metabolic stone work up .
Includes serum calcium ,uric acid phosphorus, Magnesium.
24hr urine analysis for calcium ,uric acid ,citrate .
the American society of transplant physician recommended candidates to be allowed.
To donates if they had passed no more than one stone in the past ,had inactive diseases
for 10years.had normal metabolic evaluation and were found to have no stones on
radiographic studies.(1)
References :
1- VS atapudi and DS Goldfarb Differences in American and International Guidelines
Regarding Use of Kidney Stone Formers as Living Kidney Donors.
Curr Opin Nephrol Hypertension. 2019 Mar;28(2):140-147.
The 2018 BTS Guidelines for Living Donor Kidney Transplantation suggest that potential
donors with a limited history of previous kidney stones, or small stone(s) on imaging may
be allowed to donate provided there have no significant metabolic abnormalities.
Apart from routine assessment process of donation, we need to consider the following
History
+ past history and the event of passing that stone and if it passed spontaneously or with medications/intervention
+ was it discovered incidentally or he had symptoms of pain, hematuria, ….
+ any investigations were done to the passed stone (examination of the stone)
+ any systemic symptoms such as joint pain.
+ any positive family history
+ any predisposing medications such as diuretics
+ any diet modification was advised
Assessment work up for donation
+ parathyroid hormone level and bone profile
+ if hyperparathyroidism, we need to do parathyroid gland ultrasound
+ if hypercalcemia, investigate more
+ treat if any treatable predisposing factors
+ counsel him about the risk of recurrence; Following an initial stone event, the spontaneous 5-year recurrence rate is 35 to 50 percent. Medical conditions that increase the risk of nephrolithiasis include primary hyperparathyroidism, obesity, diabetes, and gout.
+ reassure him that, Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
Post donation follow up
+ counsel him about the possible features of kidney stone including features of UTI
+ counsel him about the precautions to avoid recurrence (especially if the cause of previous stone was diagnosed) as diet advice, salt restriction, inform if any new medications
+ in follow up visits, check bone profile, uric acid
+ KUB US yearly or if any indications and KUB CT may be needed for confirmation
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018, In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full
counselling of donor and recipient is required along with access to appropriate long-term donor follow up.
So, this donor can be accepted with metabolic screening and counseling.
How do you manage this case?
-Detailed medical and dietary history.
– CT KUB which was normal in this donor.
– Biochemical Assessment :
●24-hour urine collections for calcium, oxalate, sodium, potassium, citrate, and urate.
●Urine creatinine and 24 hour urine volume .
●Urine pH measurement and cystine screen for cystinuria.
●Serum calcium and urate .
●Serum intact parathyroid hormone (PTH) concentration should be obtained as part of the screening evaluation if primary hyperparathyroidism is suspected.
●Biochemical stone analysis :if the stone available.
Characteristics associated with a higher lifetime risk of stone recurrence include:
• Younger age (<40 years)
• A family history of kidney stones
• Frequent, recurrent kidney stones
Characteristics associated with a lower lifetime risk of stone recurrence include:
• Older age (≥40 years)
• No prior symptoms of kidney stones
• A kidney stone that is less than 15 mm, solitary and unilateral
-If a significant and uncorrectable metabolic abnormality is
identified then kidney donation is contra-indicated.
-If no metabolic abnormality, proceeding with a donation should be considered after full counseling of the donor and recipient. Both need to be aware of the limited data regarding long-term outcomes in these circumstances.
-Donors should be counseled about symptoms of renal/ureteric colic and
anuria and information should be provided regarding the availability of local
urological expertise. Donors should also be advised to maintain a high fluid intake
for life (at least 2.5 liters of fluid per day) and also (where appropriate) to continue any medication prescribed to reduce the risk of future stone formation. Regular follow-up imaging e.g. annual or biennial renal ultrasound may be advisable, and regular re-assessment of the metabolic profile should be considered.
Referrence :
-KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors August 2017. Volume 101. Number 8S-1.
– BTS/RA Living Donor Kidney Transplantation Guidelines 2018.