3. Below the CT KUB of a potential 51-year-old kidney donor. No history of passing stone or UTI. Excellent kidney function with no other significant medical history.
- Please comment of the image shown above
- Council the potential donor regarding kidney donation
- Substantiate your answer
Dear All
Suppose he is a deceased donor, will you accept him?
He can be accepted after counceling the recipient and considering all the benefits and risks available as treatment of nephrolithiasis from a deceased donor can be carried out before transplantation by means ex-vivo pyelolithotomy or ex-vivo ureteroscopy .
In the post-transplantation term, renal transplanted stones can be managed with observation, shock wave lithotripsy, endoscopic, and percutaneous or open surgical approaches . But all of these choices have pros and cons and limitations so the type of the management must be individualised.
Chen CB etal demonstrated that transplantation of deceased donor stone-bearing kidneys can have comparable outcomes of deceased donor non-stone-bearing kidneys.
Reference
-Tonyali S, Aydin AM. Evaluation of Deceased Kidney Donors for Renal Stone Disease: Is Computed Tomography Needed? Curr Urol. 2018 Mar;11(3):113-116.
-Chen CB, Zhao L, Han M, Wang XP, Zhou J, Yuan XP, Wang CX. Renal Transplantation Using Stone-bearing Deceased Donor Kidneys-Experience of a Transplant Center in China. Urology. 2017 Sep;107:251-256.
Superb reply, Dr Doaa.
Moreover, as Prof Dawlat Belal points out, there is a need to involve urologists in doing on-bench ureteroscopy and Xray to ensure the complete removal of stone before transplantation.
Agree with Prof Sharma
_ If he is a deceased donor, I will accept him as small stones can be managed by pre-transplant exvivo pyelolithotomy or ureteroscopy.
_ counseling about post transplant care of preventive measures of stone recurrence in this graft (low salt and protein diet in addition to plenty of water intake).
_ post transplant follow up by US is important every 3_6 months for early detection of any stones and it’s treatment by ESWL, PCNL or even surgery.
_ it is interesting as the fear from such stones in living donor for the sake of the living donor for the concept that never to do harm to living donor. However, for deceased donor we can be accepted the kidney with lower risk of obstructed urolithiasis if strict adherence to preventive measures is done.
_ interestingly, for deceased donor CT must be done to exclude renal stones as large or obstructing stones are precluded for fear of progressive loss if graft function.
_ US screening has sensitivity arround 45% while CT up to 87%.,so it is recommended for deceased donor
Reference
Tonyali, Senol, and Ahmet M. Aydin. “Evaluation of Deceased Kidney Donors for Renal Stone Disease: Is Computed Tomography Needed?.” Current Urology 11.3 (2017): 113-116.
APA..
If you accept this case as deceased donor the urosurgeon has to deal with the ureter, or better take the other kidney and leave that one to both an unlikely recipient and surgeon!
Thanks dear professor, I mean to take the left kidney with less dilated renal pelvis and may be ureteroscopy to remove the stone in pelvis and I’d any other distal ureteric stones.
In this instance, kidney transplantation can be considered but with all the possible risks and complications during and post-transplantation of the kidney stones proper follow-up must be done.
If the recipient accepts the transplant, follow-ups have to be done and also proper investigating to ensure there is no new formation of stones or renal complications like hydronephrosis.
It must be noted that a study that was conducted by Chen et al, found that deceased donors with kidney stones can have comparable outcomes in relation to non-kidney stones deceased donors.
references:
Chen CB, Zhao L, Han M, Wang XP, Zhou J, Yuan XP, Wang CX. Renal Transplantation Using Stone-bearing Deceased Donor Kidneys-Experience of a Transplant Center in China. Urology. 2017 Sep;107:251-256.
How can anew stone develop in that kidney after transplanting it in a non stone forming recipient?
I will accept this donor as there are small stones that can be removed using ex-vivo uretroscopy
A study performed recently showed that the outcome of stone bearing deceased donor kidney transplantation was comparable to stone non-bearing kidneys, although the study was small including 32 patients, only 8 of them received deceased donor kidney harboring stones
REFERANCE
1- Chen CB, Zhao L, Han M, Wang XP, Zhou J, Yuan XP, et al. Renal Transplantation Using Stone-bearing Deceased Donor Kidneys-Experience of a Transplant Center in China. Urology. 2017 Sep;107:251-256.
Thankyou
if the stone s are retrievable and can be removed before transplantation, or otherwise after transplantation with lithotripsy along with optimization of the measures to prevent recurrence of the stone formation in the recipient by identifying the the risk factors that might linger in the recipient and manage accordingly.
So the answer is yes if its from a deceased donor.
I hope you mean recurrence in this non stone forming recipient might be due to anatomical factors!
if he is a deceased donor then will consider him for donation after discussion in MDT with the transplant surgeon to assess for possible renal arteries calcification and the urologist’s opinion for the possible intervention with the ureteroscopy and removal of the stones from the left one or directly remove the stone in the rt kidney which will be the easiest way.
Excellent for advising a MDT decision.
Study by Chen CB showed transplantation of deceased donor stone-bearing kidneys can have comparable outcomes of deceased donor non-stone-bearing kidneys.
So the left kidney will be taken for donation from the deceased donor.
Thankyou Theepa.
As my colleagues agreed, a living kidney donation is not acceptable in this case. something not to forget is: We are trying to save a life, but this should not be done by putting the donor at risk. This donor probably has lower glomerular filtration on the right side. regarding the hydronephrosis should be relieved because this is expected to affect both kidneys if not manipulated. The ultrasound will give us a clear evaluation of parenchyma, echogenicity, thinking etc.
In case this is a deceased donor, and I do not have the chance to evaluate the reason for such multiple bilateral stones, I may consider his kidneys for donation.
I do not know to which extent the kidney function is excellent, but an eGFR of more than 60 will be acceptable.
In case the eGFR is less than that, one could think of a double kidney donation. I need to evaluate the pelvic CT sections to evaluate whether the obstruction that resulted in this hydronephrosis may be fully relieved after stone removal. I think this is a grade 2 hydronephrosis
● Image showed
Bilateral kidney stons
Left pelvis and ureter hydronephrosis
Aortic calcifications
● So if he is a living donor I will exclude him because of bilateral stones Orientated to metabolic problems in the donor in addition to the high risk of recurrence
and donation will be high risk for donor
● But in case of deseased donor
I will accept him after urologic consultation for Possible therapeutic interventions before transplantation and vascular consultation for evaluating the vascular tree
Yes, can be accepted with management of nephrolithiasis by ex-vivo pyelolithotomy or ex-vivo ureteroscopy .Post transplantation, individualized approach including observation ,ESWL ,or other urological ;endoscopic, percutaneous or surgical ones.
Ref: Tonyali and Aydin,1918,Curr Urol 2018;Mar11(3):113-116.
if deceased donor iwill choose the less complicted and normal size kidney as the image showed asymmetrical kidney size so the largest one may be more complicated one and the recipent need follow up every 3 to 6 month, the best is to removed the stone pretransplantion
Yes.
With ex-vivo ureteroscopy prior to renal transplant
This is an abdominal CT which showed bilateral kidney stones hydrouretronephrosis on the right side and aortic calcification
This potential donor is not fit for donation as he has bilateral kidney stone , and leaving him with single kidney containing stone is risk factor for obstruction , AKI and infection
also this potential donor needs full metabolic work up to look for the cause of these stones
according to BTS 2018
People with bilateral kidney stones should in general not be considered as kidney
donors. This situation both suggests an inherent metabolic or anatomical
abnormality and would leave the individual with a single kidney containing a stone
placing them at significant risk of a future stone event in a solitary kidney.
Suppose he is a deceased donor, will you accept him?
thanks
In case this donor is deceased donor i will accept him
Management of nephrolithiasis from a deceased donor can be performed prior to transplantation by means ex-vivo pyelolithotomy or ex-vivo ureteroscopy .
transplantation of deceased donor kidneys with stones can have comparable outcomes to deceased donor kidneys without stones .
Urolithiasis in allograft kidneys is a rare entity. However, it can cause severe complications and result in deterioration of graft function. Transplanted stones from donors constitute up to 47% of all stones seen in renal transplant patients.
Senol Tonyali and Ahmet M. Aydin.Evaluation of Deceased Kidney Donors for Renal Stone Disease: Is Computed Tomography Needed?.Curr Urol.2018 Mar; 11(3): 113–116.
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.
Chen CB, Zhao L, Han M, Wang XP, Zhou J, Yuan XP, Wang CX. Renal Transplantation Using Stone-bearing Deceased Donor Kidneys-Experience of a Transplant Center in China. Urology. 2017 Sep;107:251-256.
Klingler HC, Kramer G, Lodde M, Marberger M. Urolithiasis in allograft kidneys. Urology. 2002;59:344–348.
In case of deceased donor , he can be accepted for donation. It would be sensible to involve stone surgeon and do on table flexible renoscopy and remove stone. Post transplant follow up with ultrasound is required to see any recurrence
It is possible to remove these small sized stone before transplantation by ex-vivo ureteroscopy. So, yes I agree with this transplantation from a deceased donor.
yes sir
because some study report a comparable result between a donor with or without stone .
the stone can be removed by ex- vivo uretroscopy before implantation.
Dear All, Very few noticed that the right renal pelvis is ABNORMAL
Dear All
I’m not impressed with the answers so far. We need to take an informed decision which I could not see in any of the comments below.
Image:
NCCT KUB showing:
Bilateral small calculi (or calcification) difficult to make out on Plain CT
Left Hydronephrosis
Aortic calcification
I would inform the donor that he is at very high risk of stone formation as bilateral stones are majority associated with metabolic abnormalities.
So, I would perform metabolic evaluation of the patient.
If the metabolic evaluation is normal and if these are both or unilateral parenchymal calcification (Randall’s plaques) on CT IVP, then he can be accepted as donor.
If these are bilateral stones, then I would reject this donor.
BTS guidelines 2018
KDIGO guidelines 2017
What about the hydroureter this can not be caused by calcifications.
CT abdomen shows bilateral renal stones with right hydronephrosis which can be due to ureteric stone.
Council the donor:
Excellent and clear answer.
Thank you sir
Dear Prof.
-Our potential donor is actually a patient who needs treatment, the imaging shows bilateral renal calculi both near the pelvis with left hydro ureter and renal fullness along with aortic calcifications , he needs :
-full metabolic profile
-24 hr urinary stone panel
-urine analysis + C&S
-Urosurgical consultation for possible intervention
He is not a suitable donor( increased risk of recurrent calculi , CVS risk )
Excellent and clear answer.
we can accept him but with metabolic screen to exclude causes of recurrent stones like hyperoxaluria
Image showing large stone
The patient should be counseled to have metabolic screening , if negative , stones should be removed and analyzed and then if stone is <1.5 , he can be accepted as a donor.
but both donor and recipient should be required to have frequent surveillance and follow ups regarding their renal function .
Please comment of the image shown above
CT scan of abdomen shows bilateral renal stones with back pressure in the right kidney .
Aortic calcification .
Donor with bilateral renal stones is not a candidate for kidney donation, instead he should be referenced for a urologist for further management of the hydronephrosis.
Donor with anatomical or bilateral renal stones cannot be used as a potential donor.
the image shows a heavily calcified aorta. with a bilateral small kidney stone. the right kidney show hydronephrosis with hydro-ureter.
this donor is at high risk of recurrence of renal stone. and should be counselled about this risk. so he should not be accepted for donation
CT images show bilateral small stones ranging from 1 to 3 mm and right moderate hydronephrosis (? due to ureteric calculus). I will not accept this donation if living donor even if no metabolic abnormality found
If he is a cadaveric donor, ex-vivo ureteroscopy and proceed for transplant
This image shows aortic calcification, bilateral renal stones with hydro-ureter and hydro-nephrosis on the right side
kidney donor is a healthy person with a low risk of ESRD which is the opposite regarding this case. He is a patient who needs to be treated and urgent referral for urology for assessment of right side obstruction.
I will not accept this patient for donation because of his high risk of recurrence, infection, and ESRD.
CT shows:
Ø bilateral renal stones
Ø Right hydronephrosis
Ø Aortic calcification
People with bilateral kidney stones should in general not be considered as kidney donors. This situation both suggests an inherent metabolic or anatomical abnormality and would leave the individual with a single kidney containing a stone placing them at significant risk of a future stone event in a solitary kidney.
Aortic calcification suggest vascular disaese and so more workup for atherosclerosis PVD is needed , either way he is not eligable for donation.
Detailed medical and dietary history, serum chemistries and urinalysis. Serum intact parathyroid hormone (PTH) concentration should be obtained as part of the screening evaluation. 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.
The image is CT KUB of a potential donor showing bilateral renal stone with right side hydronephrosis. there is aortic calcification .
as this patient has bilateral renal stone with right side hydronephrosis which suggest that the stone is not a simple one and could be a result of underlying metabolic disease especially there is associated with presence of aortic calcification.
Therefor this patient should be declined and not accepted as a donor.
this patient need
1- urology consultation.
2- investigation. GUE, 24H urine for stone profile.
3- searching for underlying cause and treat it
4- adequate treatment and measure to prevent recurrence .
This is an abdominal CT scan showing bilateral kidney stones and aortic calcification.
If he is a living donor, there is a high risk of stone formation and renal damage after donation. So, he is contraindicated for donation.
According to BTS guidelines, only unilateral kidney stones are considered for donation to leave the donor with a stone-free kidney.
Please comment of the image shown above
CT-KUB showing bilateral renal stones with right hydro-nephrosis.
Council the potential donor regarding kidney donation
This donor should be declined and referred to urology specialist for further management because of right hydronephrosis and obstructing stones.
He carries a high risk of recurrent stones, urinary tract infection and acute renal failure.
He should be worked up by complete metabolic stone work up (bilateral renal stones) and ruling out of urinary tract infection.
The CT-UT shows bilateral renal calculi, near the pelvis, left hydroureter and aortic calcification.
This donor should be excluded from donation, as he has bilateral current renal stones with risk of recurrent stones which may lead to obstruction or infection in both the donor and the recipient
metabolic cause should be excluded
24 hour urine sample to assess calcium, citrate, uric acid and oxalate excretion
The potential donor should be referred to urologist for further management.
Tatapudi VS, Goldfarb DS. Differences in American and International Guidelines Regarding Use of Kidney Stone Formers as Living Kidney Donors. Current opinion in nephrology and hypertension. 2019 Mar;28(2):140.
Please comment of the image shown above
The non-contrast CT-KUB image showed:
· Bilateral shadows in both kidneys suggesting nephrolithiasis
· RT sided hydrouretronephrosis , this may indicate a distal ureteric obstruction most probably due to stone
· Aortic calcification
Council the potential donor regarding kidney donation
· Bilateral ureteric stone preclude kidney donation as per BTS guide line
· This patient needs good urological evaluation as part of the multidiscipline team. Relieving obstruction is important to avoid worsening of the renal functions(a PCNN may be needed until the multidiscipline team decides further steps)
· Metabolic work-up is required to identify the cause of stones including urinary stone panel for oxalate, calcium, urate, phosphate and cysteine. Additionally, we need to check serum CA, Mg and uric acid levels.
Substantiate your answer
This potential kidney donor with bilateral renal stones should not be accepted for renal donation.
References:
1. Lentine KL et al. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017 Aug;101(8S Suppl 1):S1-S109
2. British Transplantation Society. Renal Association Guidelines for Living Donor Kidney Transplantation, 4th ed.; British Transplantation Society: Macclesfield, UK, 2018
The image shown illustrates a transverse cut abdominal CT scan without contrast, with marked aortic wall calcifications, bilateral renal stones, and the right kidney shows hydronephrosis with dilated pelvicalyceal system, with irregular outline indicating recurrent infections and inflammation as well as atherosclerotic vascular disease.
This 51 year old candidate donor must be counselled that his donation ought to be declined as he is not a healthy donor, the presence of bilateral renal stones with significant dilatation of right pelvicalyceal system as well as hydronephrosis poses him at high risk for recurrent infection, recurrent stone formation, metabolic profile disorders.as well as the presence of aortic calcification needs cardiological assessment and further management.
Full metabolic work up and screening is essential including 24 urinary calcium ,phosphorous ,citrate level ,serum uric acid ,serum uric acid , vitamin D level are all of value .
Urological consultation is necessary in such cases, he is now considered a patient rather than candidate donor. Dealing with these bilateral stones and unilateral hydronephrosis may require DJ or PCN stenting
According to urological decision. Also close follow up is needed for this patient.
According to KDIGO and the British Transplant Society recommendations, donors with bilateral renal stones, with evidence of obstruction should be prohibited from donation .this carries a greater risk of renal impairment and recurrent stones (50 % assumed risk).
proposing this case was for deceased donor ,the accepted kidney would be the left one after stone excision prior to renal transplantation according to the technique the urology team states ; as the outcomes of deceased kidney is much better than remaining on the waiting list or maintaining dialytic support.
Deceased donor can accepted for donation with stone. however, ex vivo stone removal (pyelolithotomy) should be done.
1) Please comment of the image shown above
Bilateral renal calculi
2)Council the potential donor regarding kidney donation
-Assess the etiology of renal calculi.
-Exclude urinary tract infection.
-Assess the risk of renal stone recurrent.
-MDT with uro surgeon regarding whether feasible to remove the kidney stone.
British Transplant Association 2018
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 )Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up.
3) Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease.
4) In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation provided vascular anatomy and split kidney function permitted.
this CT showed bilateral kidney stones
Asymptomatic renal stones are present in 5% of our donors. ExURS can be safely used to remove stones in these kidneys before transplantation, without the risk of subjecting the donor to an additional stone-removing procedure. Continued long-term follow-up of donors and recipients is still required to ensure the safety of this approach.
© 2012 The Authors. BJU International © 2012 BJU International.
CT KUB showing bilateral renal stones and left hydronephrosis renal pelvic + Calcification of aorta.
This patient can’tbe accepted as a donor
He needs further investigation to detect metabolic abnormalities ,hypercalciuria, hyperuricemia, hyperparathyroidism.
bilateral nephrolithiasis is associated with hypertension,infections, obstruction,and ESRD.
Urological Consultantaion is mandatory for stone mangment.
CT KUB of the donor shows bilateral nephrolithiasis with Right hydronephrosis possible due to right lower ureteric calculi…
According to BTS guidelines 2018, donors with bilateral renal stones should be counselled against donation because the chance of having a metabolic abnormality is high and the possibility of anatomical abnormalities with bilateral nephrolithiasis is higher..IT is prudent to understand that the life time risk of kidney stone recurrence in bilateral stone formers is high and the donor has life time recurrence of kidney stone in the solitary kidney….
I would not accept this patient as a live donor
If the decision is used for a cadaveric donor, then the urologist should take an opinion whether the kidney stone can be retrieved by ureteroscopy or PCN. The risk of post operative urosepsis must be cautioned in the recipient after transplant…It is difficult to take the right kidney with dilated system and would prefer the left kidney for harvesting in case of deceased donor….There have been studies from China which show that the deceased donor outcomes with nephrolithiasis have comparable outcomes to deceased donor non stone bearing outcomes
Aortic calcification, Bilateral kidney stones with right hydronephrosis, mostly due to another ureteric stone
As this potential donor has more than 1 stone and mostly symptomatic, risk of recurrence within 5 years about 50%.
Bilateral stones preclude donation as this suggests an inherent metabolic or anatomical abnormality and would leave the individual with a single kidney containing a stone placing them at significant risk of a future stone event in a solitary kidney
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
1- comment in this image
bilateral renal stones ,RT kidney is enlarged due to hydroureter
aortic wall calcification
regarding kidney donation will not accept this donor
iwill refer him to urologist for possible intervention and more investigation and management
refer for vascular as need to screening of other vessel involve and invstigate regarding other risk factor (DM ,HTN and smoking).
iwill not accept this donor as his rt kidney has complication from renal stone and even other is involoved and need to role any metabolic disorder .
Image shows bilateral renal stones ,rt hydroureter and aortic calcification .Bilateral renal stones precludes proceeding for donation..
Aortic calcification denotes severe vascular disease; making difficulty of
vascular implantation difficult. Counselling with the patient for need for metabolic assessment, urological care and precluding donation
Handbook of kidney transplantation,6 th edition
Please comment of the image shown above
Renal stones on both sites RT and LT with RT hydro ureter which indicates RT ureteric stone
Council the potential donor regarding kidney donation
According to the 2018 BTS Guidelines for Living Donor Kidney Transplantation, potential donors with a limited history of previous kidney stones or small stone(s) on imaging may be eligible to donate if they have no significant metabolic abnormalities. Notably, if metabolic abnormalities are detected, these guidelines recommend consulting with a kidney stone specialist. The BTS recommends transplantation of the stone-bearing kidney in appropriate donors with unilateral kidney stone(s), leaving the donor with a stone-free kidney, unless vascular anatomy and split renal function assessment preclude this. The BTS emphasizes the importance of post-donation follow-up and counseling for both the donor and the recipient about the risks and consequences of stone-related morbidity.
REF:
1. Tatapudi VS, Goldfarb DS. Differences in American and International Guidelines Regarding Use of Kidney Stone Formers as Living Kidney Donors. Current opinion in nephrology and hypertension. 2019 Mar;28(2):140.
Reply to Prof Ahmed Halawa
I will accept this potential deceased donor after counseling the recipient. The stones should be removed using ex-vivo ureteroscopy before transplantation. Xray should be performed to ensure the stones have been removed. Interestingly, a recent study has shown that deceased donor with kidney stone have a s similar outcomes than deceased donors without stones. However, this study included a small number of patient therefore the data are of limited value.
Reference:
Chen CB, Zhao L, Han M, Wang XP, Zhou J, Yuan XP, et al. Renal Transplantation Using Stone-bearing Deceased Donor Kidneys-Experience of a Transplant Center in China. Urology. 2017 Sep;107:251-256.
The image is CT scan of the abdomen, it shows bilateral renal stone and right hyrodnephronepjrosis. So, he is not suitable for kidney donation. Moreover, he should be investigated for the multiple stone causes. Serum calcium, uric acid and Parathyroid hormone in addition to urine for metabolic screen for renal stone including 24hours urine calcium, uric acid, oxalate, citrate, Sodium, sulphate, etc.
The image also showed calcification in the aorta.
This potential donor needs to know that some with multiple stone is risky specially with single kidney, If one stone is present post donation, it may cause obstruction in the single kidney which will lead to anuria if complete obstruction is there and if no intervention done early it will lead to irreversible kidney damage.
BTS stated that: 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.
So, in this case we will not be able to do that.
Refereces:
BTS guidelines 2018
# Please comment of the image shown above
*The CT-KUB showed bilateral renal stones and left hydroureteronephrosis
*According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018 recommendation, people with bilateral kidney stones should in general not be considered as kidney donors. This situation both suggests an inherent metabolic or anatomical abnormality and would leave the individual with a single kidney containing a stone placing them at significant risk of a future stone event in a solitary kidney.
# Council the potential donor regarding kidney donation
*He should be counseled about symptoms of renal/ureteric colic and anuria.
*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.
*Potential donors deemed unsuitable to donate because of stone disease should be
referred to a local urologist for further management.
# Substantiate your answer
BTS/RA Living Donor Kidney Transplantation Guidelines 2018.
if deceased donor , I will accept him and I will take the left one
CT KUB showing bilateral small kidney stones and right kidney hydronephrosis as there is obstruction distally.
I can not accept him as a kidney donor
as people with bilateral kidney stones should not be considered as kidney donor . as this suggest an inherent metabolic or anatomical abnormality and would leave the donor with a single kidney with stones with future significant risk.
CT-Scan show bilateral renal stone with right hydronephrosis and aortic calcification
1-We need to do (CT IVU which is useful in evaluating the presence of structural abnormality and A DMSA scan is useful if renal scarring suspected and to estimate split renal function.
2-24-hour urine collections for
(calcium, oxalate, citrate, urate, cystine, creatinine),
serum calcium, phosphorus, PTH, blood gas analysis
3-Need urosurgical consultation
I will not accept this donor
People with bilateral kidney stones should in general not be considered as kidney donors. This situation both suggests an inherent metabolic or anatomical abnormality and would leave the individual with a single kidney containing a stone placing them at significant risk of a future stone event in a solitary kidney.
Reference
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
in this case I will accept it if he is deceased donor ,it will need more work up with close follow up ,if the stone is approachable can be removed during surgery and send for analysis for preventive measures after transplant .
post renal transplant will need for regular follow up by Us for the graft every 6 month
In such case I would prefer to go for MDT approach for better outcome with the urologist .
>>> Please comment of the image shown above
CT KUB of a potential 51-year-old kidney donor with
>>> Council the potential donor regarding kidney donation
I will not accept such donor with bilateral kidney stones . We must to be safe doctors for both living donors and recipients.
MDT including nephrologist urologist cardiologist and vascular surgeon must be present during counseling .
Prospective donors with a history of a kidney stone must be advised of increased risk for recurrence (50% in 5 to 7 years).
The presence of underlying medical disorders associated with a high risk for recurrent stones such as cystinuria, primary or enteric hyperoxaluria, inflammatory bowel disease, and sarcoidosis contraindicates donation.
A history of struvite stones contraindicates donation because these stones are associated with infection that are difficult to eradicate.
A history of a single stone episode associated with treated primary hyperparathyroidism and normocalcemia does not necessarily preclude donation.
>>> Substitute your answer
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018 People with bilateral kidney stones should in general not be considered as kidney donors. This situation both suggests an inherent metabolic or anatomical abnormality and would leave the individual with a single kidney containing a stone placing them at significant risk of a future stone event in a solitary kidney.
SIXTH EDITION Handbook of Kidney Transplantation One of the absolute contraindications is Recurrent nephrolithiasis or bilateral stones
Even if deceased donor I will not accepting because of possible anatomical abnormalities
CT KUB showed
Urine examination and urine culture.
Metabolic screening.
urology consultation for evaluation, assessment and management.
I will not accept this donor
Bilateral kidney stove with anatomical abnormalities
This CT KUB show bilateral kidney stones and aortic calcification; in such age he need metabolic Workup and calcium scoring
by any means I will not accept him as potential donor
In the term of deceased donor I will took the kidney with smaller stone
CT shows very minimal specks of calcification in bilateral kidneys. the donor can be screened for metabolic workup and then I can accept him as a donor if other parameters are normal.the follow up of the donor should be aggressive and I would like to examine him every 6 months.
I can not accept this donor, both live or deceased!
AS a live donor: active renal stone disease is a contraindication to donation.
as a deceased donor the right kidney has dilated pelvis and the left has a proximal stone, I’m not in favour of the aggressive trials to remove those stones at back benching.
Moreover, the presence of bilateral proximal stones in a deceased donor should rise concerns.
Thank you.
Thank you.
The CT findings:
a) Bilateral kidney stones.
b) Right hydroureter ? impacted lower ureteric stone.
c) Aortic calcification.
The index donor is not suitable for donation;
a) Having bilateral renal stone with anatomical distortion, a problem precludes donation as per Amsterdam Forum and BTS 2018 guidelines.
b) This donor; for the sake of his health, needs work-up to rule out metabolic causes of nephrolithiasis as well as systemic causes of calcification which is evident by aortic calcification.
c) The right hydroureter, is possibly being obstructed by a lower impacted ureteric stone which may need urgent relieve to salvage the Rt kidney.
Thank you.
NCCT-KUB of 51 years old potential donor shows:
Bilateral renal stones
Right hydroureteronephrosis
Aortic calcification
The above man need urological counseltation to relieve the obstruction which is mostly in the distal ureter and to exclude infection by doing urinalysis and culture.
Full metabolic screen including 24 hours urinary stone panel ( ca, oxalate, uric acid , citrate,ph and cystine ) and serum ca . Uric acid, ph , oxalate and PTH
Exclude medical problems like IBD , short bowel syndrome, sarcoidosis, primary and enteric hyperoxaluria .
The donation is precluded because it’s bilateral renal stones with high risk of recurrence and infection with anatomical abnormalities. And it’s mostly metabolic cause.
Leaving a donor with single kidney with stone exposed him to recurrent infection with possible obstruction and AKI and finally increase the risk of ESKD
Thank you.
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
Are you sure Ben?
CT is showing small bilateral stones with hydroureter on right side which could be due to ureteric stone. He should be considered as donor .
Differences in American and International Guidelines Regarding Use of Kidney Stone Formers as Living Kidney DonorsVS Tatapudi and DS Goldfarb
Thank you.
CT KUB shows aortic calcification and bilateral renal stones. There is a right sided hydro nephrosis and hydro ureter and this could be due to ureteric stones.
I would refer this patient to the urologist as there is right sided hydronephrosis which may require an urgent intervention in order to resolve the obstruction (ureteroscopy to remove the stone or stones before transplantation).
I would also request a renal tubular screen (24 hours urinary test for oxalate, citrate, uric acid etc..) and metabolic screen. We need to know if there is any family history of metabolic disease. I would make him aware that he is at high risk of stone formation (as he has bilateral stones with complication, such as hyderonephrosis and hydroureter). He should have a splint renal function, because even if his kidney function is normal, we do not know the separate function, which means that one of the two kidney function may be below the target range for kidney donation.
In view of the above explanation I would not consider this patient a suitable candidate for donation
Thank you.
Please comment of the image shown above
This is an axial view on con contrast CT KUB showing Bilateral renal stones and a calcification on right side.
There dilatation of right pelvicalyceal system. There is no obvious perinephric stranding. There are some calcifications in Aorta.
It s not clear about the level of obstruction or right. Possibilities include PUJ obstruction or ureteric obstruction.
I will like whole CT scan to assess the level of obstruction.
Council the potential donor regarding kidney donation
I will counsel him that there are bilateral kidney stones. I will like to review his dietary habits, daily fluid intake, past history and family history of stones.
He will need urine analysis and culture. Assessment of serum calcium and uric acid and full 24 hour urine studies.
I will explain to the person that he cannot be accepted as donor due to bilateral kidney stones as there are higher risks of metabolic abnormality and post donation his left over kidney can be at risk due to risk of recurrence of stone even after treatment.
Substantiate your answer
Kidney donation should be avoided in those with bilateral stones as there can be risk of progression of stone disease post donation.
References-
1- Kim IK, Tan JC, Lapasia J, Elihu A,et al. Incidental kidney stones: a single center experience with kidney donor selection. Clin Transplant. 2012 Jul-Aug;26(4):558-63.
2- Lapasia JB, Kong SY, Busque S, et al. Living donor evaluation and exclusion: the Stanford experience. Clin Transplant. 2011 Sep-Oct;25(5):697-704.
Thank you. See my question above.
CT UT Showed Bilateral small renal stones with RT moderate hydronephrosis
with Aortic calcifications.
The Patient must be evaluated before descion of donation or not
With a history of whether he was stone passer or not, Symptomatic or not
with a metabolic profile including :
24 hrs urine assessment of oxalates,cysteine , ca, po4 and serum bicarbonate and uric acid , PTH, Ca , Po4 and excluding UTI
with good assessment, if there is anatomical abnormalities with an assessment of urologist for risk of recurrent and the possibility of stone extraction
And generally, it is accepted that bilateral renal stones is contraindicated for kidney donation due to the high risk of recurrence.
Ref :
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.
Thank you. Suppose his metabolic screening came back normal. Will you accept him as a kidney donor?
This no contrast CT abdomen shows evidence of bilateral renal stone with evidence of hydronephrosis in right kidney and calcifed aorta.
I will not accept for donation.
Pt need evaluation by urologist for urinary hypercalciuria / urine routine and metabolic study
Thank you. See my question above
Non contrasted CT abdomen showed
This donor should not considered as renal donor. He should be referred to a urologist. This donor need an urological evaluation, metabolic screening, urine analysis and urine cultures. The person needs intervention to relieve the obstruction.
Bilateral renal stones, and anatomical abnormality should excluded from kidney donation.
Thank you.
From the imaging one can identify that the patient has bilateral kidney stones with hydronephrosis. This patient is not classified as a suitable candidate for kidney donation.
He must be referred to a urologist for consultation and further investigations like:
1) Metabolic studies, like Ca, PO4, uric acid, oxalate, etc.
2) PTH level
3) Urine protein, urinalysis, urine culture
4) Urine excretion of Ca, uric acid excretion, etc.
So in my opinion he is not a good candidate for kidney transplantation
Thank you.
This CT abdomen shows bilateral kidneys and ureters in the given image with following findings:
a) Bilateral renal stones, near the pelvis.
b) Abnormally dilated right renal pelvis (probably due to a distal obstruction). We need lower CT cuts to know the status of the distal ureter.
c) Aortic calcification
This potential donor should not be taken up as a renal donor. Instead, a urologist should be involved in management of this person as the image points to a distal urinary tract obstruction. This subject needs urological evaluation, urine analysis, urine cultures, metabolic evaluation and probable intervention to relieve obstruction.
A potential renal donor with bilateral renal stones, and anatomical abnormality should not be taken up as renal donor (1-3).
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.
3) 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).
Thank you.
_ This axial non contrast CT shows bilateral renal stones with marked dilated right extrarenal pelvis ( mostly obstructed distal ureter) plus aortic calcification, so this potential living donor must be excluded.
_In addition, investigations to detect the cause of stones is essential as 24 h urinary stone panel for oxalate, calcium, urate, phosphate and cystine) in addition to serum CA, Mg and uric acid to identify etiology (metabolic cause).
_ Referral to urologist for treatment of obstructed urolithiasis ( if needs PCNL and drainage by PCN, further medical management to dissolve stones or make it easier to pass.
_ Exclusion of any overlying infection by urine analysis and culture, however it is is uncommon without fever and loin pain.
_ plenty of water intake up to 3 liters per day is essential to decrease risk of recurrence.
Thank you. Suppose the metabolic screening came back normal, will you consider him as a donor?
-Plain CT abdomen showing right renal pelvic stones with backpressure changes ,hydronephrosis due to variation of both kidney sizes and left renal pelvic stone with possible left adrenal lesion?? along with aortic calcifications detected.
-This donor is contraindicated to donate due to having bilateral renal stones and aortic calcifications indicative of the high possibility of having metabolic disturbances with high risk of stone recurrence and long term complications
This patient need to be refered to the urosurgeon and for further management.
– People with bilateral kidney stones mustn’t be considered as kidney donors due to possibility of having an inherent metabolic or anatomical abnormality leaving the donor with a single kidney carrying a stone keeping them at high risk of a future stone event in a solitary kidney.
Reference
BTS 2018 guidelines
Thank you.
By this CT there is a stone on both kidneys with evidence of RT sided moderate hydronephrosis! , and aortic calcifications.
I would not accept him as a potential donor any how, and he needs to do full metabolic work up to clarify his metabolic disease causing this bilateral renal stone and aortic calcification, then will send him for urological managment of his obstructive uropathy.
People with bilateral kidney stones should in general Not be considered as kidney donors, with referal to urologist for evaluation.
References :
Thank you.
*The above CT KUB: revealed : 1. Bilateral small renal stone , Right sided hydro-nephrosis , hydro-ureter. 2. Aortic calcification.
*Patient needs to do metabolic work-up ( serum ca, uric acid, 24hours urinary ca, po4, Mg, oxalate , creatinine).,exclude urinary tract infection with urine culture & sensitivity.
*Make urological consultation.
*This donor will not be accepted for kidney donation due to increased risk of stone recurrence because they are bilateral , multiple stones with increased incidence of inhertence or metabolic abnormalities.
References:
VS Tatapudi and DS Goldfarb.; Difference 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
Thank you.