2. Would you accept kidney donation from 49-year-old male who has a 1.7 cm stone in the lower calyx of the right kidney. No history of passing stone or UTI. Excellent kidney function with no other significant medical history.
- Substantiate your answer
Dear All
It was a simple question, but I got a difficult solution from you. This donor has an abnormal kidney with a large stone; the other kidney is normal. I will accept this donor, but I will accept the normal kidney ONLY for transplantation.
I will not accept this potential donor he had higher risk for kidney disease due to his large stone which is source of Pylonephritis and it is placed in the lower caylex , also the incidence of recurring will be higher .
In the term of deceased donor I will took the other normal kidney
Dear All
Most of us agreed not to consider this
living donor. What about if he was a deceased donor?
Will you accept a kidney with a 1.7 cm stone in the lower calyx?
Please justify your answer.
We can accept from deceased donor if it is immunologically matched and recipient on waiting list for long time.
Management of nephrolithiasis can be performed prior to transplantation by means ex-vivo pyelolithotomy or ex-vivo ureteroscopy(1).
In the post-transplantation , renal transplanted stones can be managed with observation, shock wave lithotripsy, endoscopic, and percutaneous or open surgical approaches(2).
All of these choices have pros and cons and also limitations so the type of the management must be determined on a case-by-case basis.
References:
1-Ganpule A, Vyas JB, Sheladia C, Mishra S, Ganpule SA, Sabnis RB, Desai M. Management of urolithiasis in live-related kidney donors. J Endourol. 2013;27:245–250.
2-Oliveira M, Branco F, Martins L, Lima E. Percutaneous nephrolithotomy in renal transplants: a safe approach with a high stone-free rate. Int Urol Nephrol. 2011;43:329–335.
Hi Dr Saad,
The removal of stone in such a kidney must be done prior to transplantation by means ex-vivo pyelolithotomy or ex-vivo ureteroscopy.
I would not leave it to be removed in post-transplant period.
In case of potential deceased donor ,ex-vivo peylolithotomy or ex-vivo ureteroscopy before transplantation ;or even dual transplantation could be needed.
Tonyali and Aydin,2017:Evaluation of deceased kidney donors for renal stone diseases: Is computed tomography needed?
Why dual transplantation, Dr Omran?
If there was no enough functioning kidney due to anatomic disorder… A rare scenario
In this aspect, I may consider using the kidney from the donor. A special procedure can be done to remove the kidney stone like the Ex vivo ureteroscopy and as such the kidney stone can be removed before transplantation.
In stead of ‘can’, I would use ‘should’.
Also I will not accept this deseaced donor because the problem of donating a kidney with large stone > 15 mm is not a problem to the donor only (higher rate of recurrence in the remaining kidney) but carry the following risks to the recipient :
1- High risk of faliure of removal of the stone and complications (ureteric or renal injury) after preparation of the recipient
2- Lefting a nidus which will lead to higher risk of recurrence of the stone and infection in the recipients
3- Even if the stone was successfully removed the graft functioon may be impaired due to stone related fibrosis
If there is no alternative and there is urgent situation such as running out of access i may recommend treatment by in-vivo (not ex-vivo) staged (in 2 separate occasions) uretroscopy before transplantation that is to avoid unnessery preparation of the recipient and to asses the function of the kidney after removal of the stone using split kidney function
I will accept deceased donor with large kidney stone by dealing with the stone intraoperatively during transplantation with special removal procedure.
Ex-vivo ureteroscopy of deceased donor kidneysGraham L. Machen, MD, Preston A. Milburn, MD, Patrick S. Lowry, MD, Jacqueline A. Lappin, MD, Debra K. Doherty, MD, and Marawan M. El Tayeb, MD
Dear All
It was a simple question, but I got a difficult solution from you. This donor has an abnormal kidney with a large stone; the other kidney is normal. I will accept this donor, but I will accept the normal kidney ONLY for transplantation.
I will aceept the donor but I will take the other (stone free) kidney for transplantation!
Thank you, prof, then for a disease donor i will accept the kidney while planning to remove the stone before the surgery takes place
no, as it’s still the site in the lower calyx and the size of this stone will be not easy to be removed by the urologist and might be a nidus for another stone in the future for the recipient so it better to go the easiest way will take the other normal kidney from this DD.
If the stone was less than 15 mm, ex-vivo ureteroscopy prior to cadaveric renal transplant can be done
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542832/#:~:text=Ex%2Dvivo%20ureteroscopy,Tayeb%2C%20MD
There is a case report of a modified ex vivopyelolithotomy and ureteroscopy on the bench for cadaveric kidney with multiple stones
A case of kidney transplantation using donation after circulatory death with renal calculi Baoshan Gao1*, Kun Zhang1*, Chunjie Guo2 , Weigang Wang1 , Gang Wang1 , Yuantao Wang1 , Liyu Yao1 , Yaowen Fu1 , Honglan Zhou1
In the case of large stone in a deceased donor, the other normal kidney will be accepted.
Thank you, for replying.
I’m not impressed by the indirect answer of some of you for what I thought was a straightforward answer. Can you make a decision based on the imaging reported in the scenario?
Can this donor donate or not based on this scenario and why?
In view of large size of kidney stone of >1.5cm, I shall not accept for kidney donation,
Ref:
Agree
large stone > 1.5cm in lower calyx is consider risk for recurrence of symptomatic stone and infection , this patient should be referred to the urologist for further management i will declined his for donation
Agree
This is a large stone at the lower calyx of the right kidney, which might obstruct the urinary tract and lead to chronic renal damage and is usually associated with infection or a significant metabolic abnormality and people with these stones should not be considered donors.
BTS guidelines
Agree
In the current scenario with a stone of 1.7 cm, he will not be accepted as a donor. A stone of more than 1 cm at presentation confers an increased risk of metabolic risk factors and future stone episodes.
Agree
Agree
Even in the absence of metabolic abnormalities, I would not accept the donor.
Thanks prof
The short answer is yes,he can donate, as he is featuring a unilateral stone, with negative potential risk of recurrent stone formation.Similarly, rolling out underlying structural abnormality is supportive of proceeding to kidney donation. A stone size of 1.5 is the cut off for accepting kidney donation in most guidelines, however,larger stones are acceptable and the guideline is less stringent in this regard .
Reference:
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.
Thank you for your reply
I disagree with you. A large stone in the lower calyx carries a higher risk. It would be difficult to retrieve or to pass spontaneously due to its size and position. Unlikley the stone workup will come back normal given the size of the stone, even if it was normal. I would decline the donor. If retrieval of the stone failed, transplanting a kidney with a stone is associated with a high risk of infection
Thank you for your answer,
If we can retrieve the stone , can we still accept his donation.?
Yes donor can be donate after intensive investigations and precise management
After excluding cystinuria , primary hyperoxaluria and urinary tract abnormalities
We ‘d rather postpone donation to remove stone and reevaluate split kidney function
On the other hand, 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) in order to leave the donor with a stone-free kidney after donation, therefore recipient condition is very important for this decision too
Ex-vivo Removal of Kidney Stones
There are reports of nephrolithiasis-related adverse events for recipients of an allograft with a stone left in situ.There are also reports on the safety and success of ex vivo ureteroscopy to remove stones from explanted donor kidneys before transplantation.
Thank you for your reply
I disagree with you. A large stone in the lower calyx carries a higher risk. It would be difficult to retrieve or to pass spontaneously due to its size and position. Unlikley the stone workup will come back normal given the size of the stone, even if it was normal. I would decline the donor. If retrieval of the stone failed, transplanting a kidney with a stone is associated with a high risk of infection
With the available data, I would not proceed with the transplant.
Revisiting history and broad investigation can individualize donation in specific circumstances.
no , the patient is not a candidate for donation
Lower pole stones (LPS) are defined as stones located in the inferior pole calyx of the kidney and are the most common renal stones. These stones usually require some kind of active treatment as these are less likely to pass spontaneously
The optimal treatment of LPS with a size of 1–2 cm represents a point of debate among the endourologists. A variety of factors, such as the anatomy of the pelvicalyceal system, patient body habitus, and patient preference may influence the selection of the treatment method.
Agree
Thank you for the feedback, Dr Abdullah, since you are a urologist.
I would like to evaluate following points in this patient
BTS and KDIGO guidelines state that single unilateral stone upto 15mm can be accepted if there is no metabolic abnormality
So, I would accept this donor only if metabolic evaluation and HU rules out infective or cystine stone.
I would remove the stone intact ex-vivo on bench as preoperative fURS would leave some fragments in lower calyx which are difficult to pass and are nidus for further stone formation.
I would also inform donor to be under strict followup.
After exclusion of all metabolic causes .
We are left with anatomical factors such as a scar which will be detected by DMSA.
question is will this stone recur in this kidney after transplantation.
What are the causes of recurring stones in a transplanted kidney.?
Apart from an obvious anatomical reason for a stone formed , is there a chance of recurrence in the transplanted kidney?
If a nidus is left and remember the position of the kidney is not the perfect anatomical one after transplantation.
All these are possibilities but the attraction of getting a kidney after securing the safety of the donor is considerable.
Dear Professor,
Studies reported that there is increased risk of kidney stones in kidney transplanted individuals with :
References :
Thank you for your reply
I disagree with you. A large stone in the lower calyx carries a higher risk. It would be difficult to retrieve or to pass spontaneously due to its size and position. Unlikley the stone workup will come back normal given the size of the stone, even if it was normal. I would decline the donor. If retrieval of the stone failed, transplanting a kidney with a stone is associated with a high risk of infection
I recommend againest donation as it is a large stone > 15 mm and even with ex- vivo uretroscopy it will be challenging and may be associated with complications such as ureteric or renal injury although there is a case report on performing ex- vivo uretroscopy in a staghorn stone in the renal pelvis 27×18 mm
Agree
=Our potential donor with renal stone (1.7 cm) is not suitable for donation.
=To conclude:
Small stone only with normal metabolic work up can be accepted for donation after discussing with the donors.
But large stone or small one with metabolic abnormalities should be excluded from donation.
I will list the guidelines recommendation for Potential donors with asymptomatic stones seen on imaging.
1-American Society of Transplant Physicians (ASTP)1996.
Not considered candidates for donation.
2- Amsterdam Forum, 2005
Asymptomatic potential donors with single current stone that is <1.5 cm or potentially removable. may donate if:
• No hypercalcuria, hyperuricemia, or metabolic acidosis.
• No cystinuria or hyperoxaluria.
• No urinary tract infection.
• Multiple stones or nephrocalcinosis are not evident on CT scan.
3-OPTN/UNOS, 2018 .
If kidney stone >3 mm detected on radiographic imaging must have a 24-hour urine stone panel measuring calcium, oxalate, uric acid, citric acid, creatinine and sodium, but no clear evidence about larger size.
4-KDIGO Guidelines, 2017.
Does not consider stones incidentally detected on imaging a contraindication for donation.
CT scans may detect small calcifications including Randall’s plaques which are 1 to 2 mm calcifications of uncertain prognostic significance.(but not large stone).
5-BTS, 2018.
In the absence of a significant metabolic abnormality, potential donors with small renal stone(s) on imaging, may still be considered as potential kidney donors.
Agree, thank you
Generally as per guidelines, donors with stones can be accepted in donation if:
Stone size less than 1.5 cm
Asymptomatic
Not associated with complications as obestruction, infection, loss of focal cortex
After full negative metabolic screen.
So this patient has stone size more than 1.5
Need further assessment with CT and measuring Hounsfield units- HU, full metabolic screen
Contra-indications for renal stone former donation include:
These causes tend to be due to significant & non correctable metabolic abnormality, so the risk of stone recurrence is high.
This donor should be declined from donation due to large size stone.
References:
Agree, thank you
Dear prof. .
Thank you, Mohamed. Please read the guidelines and give us a clear answer.
+ I will accept him as a donor if:
1) no metabolic problem predisposes to stone formation
2) he will keep the kidney free of stone
3) ex-vivo removal of the stone is possible
+ counsel him about the risk of recurrence as per the ROKS tool
The risk of a Second Symptomatic Kidney Stone Event at 2-Years is 15 %
the Risk of a Second Symptomatic Kidney Stone Event at 5-Years is 28.7 %
The Risk of a Second Symptomatic Kidney Stone Event at 10-Years is 44.8 %
In light of the fact that the stone is 1.7 centimetres in diameter and is located in the lower calyx of the right kidney, it is quite probable that this stone will not pass on its own.
I will not accept this donor since doing so would put him at an increased risk of developing progressive renal disease if he were to continue to have a large stone that was causing symptoms.
I will not accept this donor.
prospective donor where history of distant stone exceed 1.5 cm especially not associated with metabolic abnormalities carry low recurrence risk and can be accepted for donation.
* on the other side ; current single stone with size less than 1.5 cm can be accepted for donation after been evaluated metabolically and by imaging to exclude anatomical abnormalities or nephrocalcinosis.
References:
Gabriel M. Danovitch 6th edition .
Thank you for your reply
I disagree with you. A large stone in the lower calyx carries a higher risk. It would be difficult to retrieve or to pass spontaneously due to its size and position. Unlikley the stone workup will come back normal given the size of the stone, even if it was normal. I would decline the donor. If retrieval of the stone failed, transplanting a kidney with a stone is associated with a high risk of infection
As the renal stone size is >1.5 cm, the index subject should not be taken up as donor. Instead, he should be evaluated by a urologist for his renal stone, including a metabolic work-up.
Reference:
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.
Being a lower pole large stone , carry high risk of recurrence rate ,so I will not accept this donor
Large kidney stone ,not center for kidney donation
As recommended by BTS he should have a full metabolic screening for renal stone , if all negative he can be accepted as a kidney donor.
However counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
The stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone free kidney after donation.(C2)
Substantiate your answer
As per guidelines, a donor with an asymptomatic stone more than 1.5 cm in size should be discarded as a potential donor. Even with no history of UTI or history of obstructive uropathy .
The index prospective donor is a candidate who is detected to have an asymptomatic renal stone on evaluation.
If asymptomatic stone less than 1.5 cm with normal metabolic and anatomical profile it could be acceptable.
this donor has a large stone size of 1.7 cm so, he is not accepted as a donor. small stone less than 1.5 mm can be accepted if there is no risk of recurrence.
reference
comprehensive text book
The cadaveric program in northern India is underdeveloped, and the chance of finding a cadaveric donor is slim.
If no other donor is available in the family and after ruling out metabolic abnormalities, I will accept this donor.
Prior to donation, the stone will be removed using flexible ureterorenoscopy and laser lithotripsy.
Will accept stone-bearing kidney after confirming complete stone clearance, if vascular anatomy and split kidney function allow it.
A kidney donor is a healthy person with a low risk of developing ESRD. Acceptance of potential donors with a history of stones is still controversial between the international guidelines but there is a universal agreement regarding solitary small size of less than 10mm unilateral stone with no anatomical or underlying metabolic profile abnormalities can be accepted. as a potential donor.
regarding this potential donor he has already a large stone of 1.7cm which will be associated with a high risk of recurrence, infection, and most probably underlying metabolic profile abnormalities that’s why I gonna reject this patient from donation and I will refer him to urology for better evaluation.
I won’t accept him for kidney donation.
According to BTS Large stones can commonly lead to chronic renal damage and are
usually associated with infection or a significant metabolic abnormality and people
with these stones should not be considered as donors.
The Amsterdam Forum put forth recommendations regarding the evaluation of potential kidney donors with nephrolithiasis:
Asymptomatic potential donors with a single radiographically discovered stone (<1.5 cm or that is potentially removable) were considered suitable if they met the following requirements:
1) No hypercalciuria , hyperuricemia , or metabolic acidosis.
2) No cystinuria or hyperoxaluria.
3) No urinary tract infection.
4) Multiple stones or nephrocalcinosis are not evident on CT scan.
Presence of Nephrocalcinosis on X-ray or bilateral stone disease, and stone types that have high recurrence rates and are difficult to prevent, were listed as contraindications for kidney donation.
Because of high the risk of recurrence the following condtions considered prohibitive for:
1. Cystine stones.
2. Struvite stones.
3. Stones in the setting of inflammatory bowel disease.
4. Recurrent stones while on appropriate treatment.
5. Stones associated with inherited or systemic disorders such as primary or enteric hyperoxaluria.
6. Distal renal tubular acidosis.
7. Sarcoidosis.
In the patient of question , this patient has large stone therefore I did not accept this donor
REFRENCES:
1- VS Tatapudi and DS Goldfarb, Differences in American and International Guidelines Regarding Use of Kidney Stone Formers as Living Kidney Donors, Curr Opin Nephrol Hypertens. 2019 Mar; 28(2): 140–147.
This case has a large stone (more than 1.5 cm) in the lower calyx which shows an important underlying metabolic abnormality (such as cystinuria) or infectious stones. These conditions are contraindication for donation.
I would not accept this donor.
Donors with renal stones are considered as relative contra-indication for living kidney donation because of risk of recurrence, high incidence of obstructive uropathy, and urinary tract infection.
A donor with a renal stone above 1.5 cm in the lower calyx is considered a contra-indication because of difficult removal and higher stone-related complications.
This donor should not be considered for donation as he has a large stone in the lower calyx, it can lead to chronic renal damage and carries a higher risk for infection and may be associated metabolic abnormality
BTS/RA Living Donor Kidney Transplantation Guidelines 2018.
According to BTS, this living donor with a large kidney stone > 1.5 cm in the lower calyx is declined from donation.
This stone is anatomically difficult to retrieve, can result in urinary obstruction. It is associated with recurrent infections and metabolic abnormalities(metabolic work-up is still required). Even if it is removed, there is an incidence of recurrence as a small nidus may be left at the time of retrieval , additionally, surgical removal and may be associated with scarring that is detected by DMSA.
In deceased donation we use the normal kidney, not the one with the stone disease.
In such case scenario, the presence of a large stone (exceeding 1.5 mm) in this site lower calyceal stone ,is not favorable for donation by any means;as it is likely to predict an abnormal metabolic work up ,it is also not likely to resolve spontaneously with the further need of endoscopy or ESWL procedures according to the urology team decision , also the presence of such stone carries the risk of the donor’s recurrent UTI with subsequent fibrosis and inflammation ,implies more risk for further development of renal impairment and thus we cannot by any means put this candidate donor in the future for risk of development of renal impairment .
Also these donors are at risk for recurrence of renal stones formation at any time.
According to the British Transplantation Society and KDIGO guidelines, this donor can’t be accepted.
In the other scenario ,inquired by Prof Ahmed Halawa ,the other stone free can be accepted for deceased donation .
I will not accept this donor there is high probability of progression of CKD, and recurrence.
Yes. However need to further assess the possible etiology of renal calculi and exclude infection from urine culture.
LIVING KIDNEY DONOR. KDIGO 2017.
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.
49-year-old male who has a 1.7 cm stone in the lower calyx of the right kidney.ill not accept as living donation
but if a case of deseased donor so the normal kidney will be accepted
I won’t accept this donor as this is a larg stone in the lower pole of kidney ,renal calculi were shown to be significantly associated with persistent urinary tract infection, obstruction, and affection of kidney function may occur ,
It is acceptable as per guidelines to donate with a small stone less than 4 mm after negative metabolic testing.
Ahmed A. Shokeir, et al .Urolithiasis in renal transplant donors and recipients: An update.International Journal of Surgery.2016, Pages 693-697
In case of living donation , I will not accept kidney with stone more than 15 mm as its risk for infection and obstruction , and on the same time I will not take the normal kidney and left a kidney with large stone in the donor ,, so in case of living donation I will not accept this donor
and surly the donor needs full metabolic and imaging work up
in case of diseased donation I will took the other normal kidney
thanks
Large or staghorn stones can commonly lead to chronic renal damage and are usually associated with infection or a significant metabolic abnormality and people with these stones should not be considered as donors
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
This donor has 1.7cm stone in the lower calyx of the right kidney…There is no history of stone or UTI…But this donor CANNOT be accepted as the size of the stone is large as risk of infection is more after transplant…The stone is also not in an anatomical position to remove it before transplantation and the size is against the donation…In general microliths <5mm are acceptable…Metabolic workup of the patient will reveal hyperoxaluria or any other cause as the size is significant and there is no role for kidney donation even after correction of the metabolic problem if any also…
AS per the BTS guidelines the anatomical normal kidney with near equal GFR has to be accepted for kidney donation, if we take the normal kidney for transplant, the donor will have a higher chance of recurrence of stone disease and progression of CKD to ESRD. It also not recommended to take the stone free kidney for transplant when the donor has a large 1.7cm stone
In a deceased donor the scenario becomes different, there is definite need for transplant at the earliest as the patient is waiting on dialysis for a long time. Of course the risk of infection and graft pyelonephritis is high post transplant in this patient if this was a deceased donor…I would recommend a calculated decision risk approach after discussion with the family and will recommend surgical removal of the stone at the time of transplantation by ex vivo ureteroscopy
Lack of evidence of base ground transplant for criteria to accept donor with stone
first of all need to assess the rt kidney if there is previous scaring of previous recurrent UTI and its split function if choose will take this kidney if the recipient has to weight risk versus advantage but if has other donor option better to avoid
reference
https://pubmed.ncbi.nlm.nih.gov/30531468
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: …
Common sense I should transplant a healthy kidney from a healthy donor, as I’m not sure if I treat the stone it may recur or not because I don’t know its composition
For living donors, a solitary stone larger than 10 mm in size is a relative contraindication.
In our case we should not accept him with 1.7 cm stone in the lower calyx of the right kidney.
REF:
1. Tonyali S, Aydin AM. Evaluation of Deceased Kidney Donors for Renal Stone Disease: Is Computed Tomography Needed?. Current Urology. 2017;11(3):113-6.
*According to BTS/RA Living Donor Kidney Transplantation Guidelines (2018) recommendations, potential livening related donors with large or staghorn stones can commonly lead to chronic renal damage (2) and are usually associated with infection or a significant metabolic abnormality and people with these stones should not be considered as donors.
So, I will not accept this donor.
*In potential deceased donor, I will accept this donor, with large1.7 cm stone in the lower calyx of the right kidney; however, I will take the left normal kidney for transplantation.
BTS/RA Living Donor Kidney Transplantation Guidelines (2018).
This potential kidney donor has one stone of 17mm in the lower calyx. This is a single stone but big size more than 15mm. so he is not good candidate to donate as per 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 for donation.
Also European urology guidelines exclude donors with stones more than 10mm,
If a deceased donor, I will accept him and I will take the left kidney as it is the normal one
I can not accept this donor as it has big stone in lower calyx of right kidney about 1.7 cm
as there is increased risk of presence of metabolic abnormality and increased risk of recurrence.
with such parameter with large kidney and big stone stuck in the left lower part of the ureter I will not accept this as donor ,as the recurrence rate is high adding to that his left kidney is already affected buy the obstruction
I will not accept this donor with large stone
BTS guidelines recommend that patients with large stones should not donate as they always have metabolic abnormalities and renal damage.
_The current potential donor has large stone 1.7 cm and its site in lower calyx, so it can not pass spontaneously and in addition it’s removal is technically difficult.
_ transplanting a kidney with large stone will lead to higher risk of pyelonephritis after starting immunosupressive therapy post Transplantation (so worse graft outcome).
_ in addition for the sake of the donor recurrent stone in single kidney will be problematic and risk for CKD.
_ so the current donor must be declined.
yes I would do a PCNL/RIRS in the donor and then proceed ahead with donation asap.
NO, active renal stone disease is a contraindication to kidney donation. I could not find any evidence to support this donation
A 49 year male with 1.7 cm kidney stone in the lower calyx of right kidney should not donate and referred to urologist for metabolic screening including 24 hrs urinary oxalate ,calcium, oxalate ,magnesium, and uric acid with serum calcium ,phosphorus, i.PTH and stone retrieval if possible though in the lower calyx its difficult.
Amsterdam Forum, 2005 recommendation is that single stone that is <1.5 cm or potentially removable with no metabolic abnormality can donate and BTS didn’t specify the size –just mentioned small stone with no metabolic abnormality detected can donate .
REFERENCES:
Delmonico F. A report of the Amsterdam Forum on the care of the live kidney donor: data and medical guidelines: Council of the Transplantation Society. Transplantation 2005; 79 (S6): S53-66
I would not consider him as a living kidney donor, as he has a current stone in the right kidney with a big size 1.7 cm in the lower clayex , although he hasn’t a hisotroy of passing stone, UTI or medical abnormalities. He has an excellent function status, this might cause recurrent UTI in the transplanted kidney if failed to retrieve.& carry a risk of renal failure if not treated.
if the donor is a cadaveric one, I will say yes, after counseling the recipient about the risk of infection post-transplant, & try to remove the stone pre-transplant on the backtable by endoscopy.I think this will increase the donor pool & balance the pros & cons.
I would not accept this potential donor with large kidney stone(> 15 mm). No mention for the allowable stone-size in most of guidelines apart from Amsterdam Forum1.
The Amsterdam Forum held in April 2004 brought together kidney transplant physicians and surgeons to develop an international standard of care position statement of The Transplantation Society (TTS) regarding the care of live kidney donors. The Forum put forth recommendations that have since become well known and widely cited, regarding the evaluation of potential kidney donors with nephrolithiasis.
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:
a) No hypercalciuria, hyperuricemia, or metabolic acidosis.
b) No cystinuria or hyperoxaluria.
c) No urinary tract infection.
d) Multiple stones or nephrocalcinosis are not evident on CT scan.
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. KDIGO makes no suggestions regarding the allowable number, laterality, or size of stones.
OPTN: The current OPTN policy for medical evaluation of living kidney donors states that potential donors with a history of kidney stones or a kidney stone >3 mm detected on radiographic imaging must have a 24-hour urine stone panel. OPTN does not provide guidance regarding number or laterality of incidentally detected stones and makes no recommendations about nephrolithiasis symptom-free wait time or management of metabolic abnormalities diagnosed by analysis of 24-hour urine collection.
AST: 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.
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.
The BTS 2018: In appropriate donors with unilateral kidney stone(s) the BTS recommends transplantation of the stone-bearing kidney unless vascular anatomy and split renal function assessment preclude this. No mention for the stone size2.
Reference
1. Differences in American and International Guidelines Regarding Use of Kidney Stone Formers as Living Kidney Donors. VS Tatapudi and DS Goldfarb
2. BTS/RA Living Donor Kidney Transplantation Guidelines 2018.
Large or staghorn stones can commonly lead to chronic renal damage and are usually associated with infection or a significant metabolic abnormality and people with these stones should not be considered as donors.
having unilateral asymptomatic large kidney stone (>1.5 cm), being in the lower calyx which is difficult to treat, and to pass spontaneously Preclude donation even if the metabolic workup is normal.
Risk of recurrence stone include:
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 .
Reference:
BTS guidelines
Accepting a kidney donor with 1.7 cm stone is a tough call. Ideally we should not accept him with this big stone unless he is treated for it and we have no other donor available.For living donors, a solitary stone larger than 10 mm in size is a relative contraindication
it is generally agreed that potential donors with symptomatic stone disease should be denied Ref
The Amsterdam Forum
I will not accept this donation because it’s large and carry risk of infection and obstruction.
One Small renal stone with normal metabolic work up can safely donate
I will not accept this donor :
According to the American Society of Transplant Physicians (ASTP) :
Nephrolithiasis was deemed to be at least a relative contraindication to living kidney donation given a future risk of kidney injury due to recurrent stone-related obstruction and infections with Ad Hoc Clinical Practice Subcommittee implied through these guidelines that stones discovered incidentally during donor evaluation are a contraindication to kidney donation irrespective of size or number.
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 was no metabolic abnormalities
As the stone size is more than 1.5 cm so to considered contraindicated
OPTN/UNOS,2018 :
Potential donors with kidney stones>3 mm detected on radiographic imaging must have a 24-hour urine stone panel measuring calcium, oxalate, uric acid, citric acid, creatinine, and sodium.
American Society of Transplantation (AST) Live Donor Community of Practice :
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
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.
British Transplantation Society (BTS)
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 but in our case the stone is not small.
KDIGO permits potential donors with asymptomatic kidney stones that are incidentally detected on imaging however KDIGO makes no suggestions regarding the allowable number, laterality, or size of stones. KDIGO does not comment on the time that has to elapse after an episode of symptomatic stones following which a potential donor can undergo donor nephrectomy.
Ref :
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.
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.
American Society of Transplantation (AST) Live Donor Toolkit. https://www.myast.org/patient-information/live-donor-toolkit. Accessed on September 20th, 2018
Substantiate your answer
In this case the donor is 49 year old and otherwise healthy with no significant medical history but asymptomatic stone lower pole of kidney -1.7 cm.
As per guidelines only stones which are less than 1.5 cm and are asymptomatic with no associated complications like infections and obstruction with loss of focal cortex can be accepted. This will also be subject to favourable anatomy and negative metabolic screen.
Contraindications to donation in case of stones include, Size more than 1.5 cm, Stones associated with complications like infection, obstruction , loss of cortex, and stones secondary to metabolic abnormality.
If metabolic abnormality is not correctable then donation should be declined.
In the index case , size of stone is 1.7 cm , so I will not accept him for donation. He will need urological assessment including urine culture , full metabolic profile and review of CT KUB to assess stone hardness as Hounsfield units- HU and infundibulopelvic- IPA angle to plan treatment. If stone is less than 1000 HU and IPA is favourable the he will need ESWL. Otherwise he will Flexible Ureterorenoscopy and laser stone fragmentation.
I will not consider EX Vivo clearance as stone size is large and a failure can lead to significant morbidity.
References
1-BTS Guidelines 2018
2- Olsburgh J, Thomas K, Wong K, et al. Incidental renal stones in potential live kidney donors: prevalence, assessment and donation, including role of ex vivo ureteroscopy. BJU Int. 2013 May;111(5):784-92.
Based on the guidelines from the Amsterdam held around 2004 allow donors who are asymptomatic with a history of a single stone or discovered via radiography less than 1.5 cm or can be removed can donate with the following criteria:
1) there must not be hypercalciuria, hyperuricemia, or metabolic acidosis.
2) there must not have any cystinuria or hyperoxaluria.
3) absolutely no urinary tract infection.
4) there must not have multiple stones or nephrocalcinosis that are not evident on the CT scan.
Based on these criteria, I believe the gentleman cannot donate a kidney. Also, there are special procedures that can be done to remove the stone like the Ex Vivo ureteroscopy (ExURS) but if the stone is larger than 1.5 cm and there may be added complications to the procedure and as such cause trauma and infections.
References:
Olsburgh, J., et al. NIH. Incidence renal stones in potential live kidney donors: prevalence, assessment, and donation, including the role of ex vivo ureteroscopy. doi: 10.1111/j.1464-410X.2012.11572.x. Epub 2012 Oct 30
The index prospective donor is a candidate who is detected to have an asymptomatic renal stone on evaluation.
Majority of the guidelines regarding asymptomatic prospective donor with single renal stone <1.5 cm size suggest that such a person can be taken up for donation after a negative metabolic and anatomical evaluation (1). A notable exception is KDIGO guidelines, which has not graded its recommendations and stipulate assessment of stone recurrence risk and possible consequences of kidney stones post-donation before accepting the donor with prior or current renal stone (2).
Considering these guidelines, as the renal stone size if 1.7 cm, although there is no history of UTI or of passing any stone, I will not be accepting this donor.
The index person needs to be evaluated and managed by a urologist with respect to the renal stone.
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 Hypertens. 2019 Mar;28(2):140-147. doi: 10.1097/MNH.0000000000000480. PMID: 30531468; PMCID: PMC6425959.
2) 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.
According to BTS large stones commonly lead to renal damage, infection and associated with considerable metabolic disorder, donation is precluded.
Asymptomatic small unilateral stones may be evaluated, but stones which are not occasional, but rather recurring, especially if bilateral, are unsuitable because of the risk of CKD. Renal parenchymal should be well evaluated. According to BTS guidelines in such a situation, the evaluation of stones and metabolic state is essential.
In our scenario, the donor is considered young with a tone more than 0.5 that will not pass and, if left, can have complications of AKI, pyelonephritis etc.
If it was a deceased donor, I would accept with the simultaneous excision of the stone. Here giving the kidney to a dialysis patient (In Turkey, deceased patients are allocated to patients already on dialysis), but if the renal parenchyma is not less than 10 mm
I would not proceed with transplantation, as the stone is greater than 1.5 cm which is considered a cut off risk for symptomatic stone relapse and associated risks of recurrent urinary infections. Secondarily this large stones will not be eliminated spontaneously and even surgically can be difficult to remove it, due to the size and the position.
This patient will need a urology referral and screen for metabolic disease (considering the size of the stone an underlying metabolic disease is very likely)
Reference:
Tatapudi VS, Goldfarb DS. : Differences in national and international guidelines regarding use of kidney stone formers as living kidney donors. Current Opinion Nephrol Hypertension, 2019 Mar;28(2):140-147.
BTS 2018 guidelines stated that in the absence of a significant metabolic abnormality, potential donors with small renal stone(s) on imaging, may still be considered as potential kidney donors.
But in the current scenario the donor’s kidney lower calyx carries a stone>1.7 cm
and the risk prediction tools are not there for asymptomatic stone formers, but ≥1 stone at presentation indicates an increased risk of metabolic abnormality and high tendency of future stone formation and hazardous long term outcomes
Therefore it is better to decline this donor .
Reference BTS 2018
large stone > 1.5cm in lower calyx is high risk for recurnce.
Referal to urologist.
Recurnce and ESKD it will high in case of donate
*Candidate donors with Small stone only (1-2mm) with normal metabolic panel can be accepted for donation after discussing risk with the donors and counselling them while ; large stone measure more than 1.5cm or small stone with metabolic abnormalities should be excluded from kidney donation.
*In this case , donor has large lower calyceal stone measures 1.7cm , which carries a higher risk so, we cannot accept this living donor.
*KDIGO Guidelines, 2017 , informed that ; stones discovered incidentally on imaging not a contraindication for kidney donation.
Regarding if deceased donor ; i would rather accept him for kidney donation if :
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 large stone at the lower calyx of the right kidney, which might obstruct the urinary tract and lead to chronic renal damage and is usually associated with infection or a significant metabolic abnormality and people with these stones should not be considered donors.
BTS guidelines
The patient is 47 years old, has 1.7cm stone in the lower calyx of the right kidney
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 patient has 1.7cm stone which put him at high risk of stone recurrence
I would not proceed with this transplantation
References
KDIGO LD guideline 2017