Please summarise these guidelines in your own words
Study compared the development of hypertension, proteinuria, and reduced eGFR in 227 kidney donors with kidney stones to 908 propensity score-matched donor controls without kidney stones
Ø 200 donors had kidney stones prior to donation, 21 had post-donation stones, and 6 had pre- and post-donation stones: details
1. Donors with pre-donation kidney stones and those with both pre- and post-donation stones were older than donors with post-donation stones only (43.5 vs. 45.5 vs. 34 years); donors with pre-donation kidney stones were less likely to be men and more likely to be white. The median time (IQR) from having a kidney stone to donation in those with pre-donation stones was 154 (50, 2478) days.
2. In the 6 donors with post-donation stones only, the interval from donation to stone was 89 days (65, 100).
3. Donors who had both pre- and post-donation stones had a higher BMI, a lower eGFR at donation and were more likely to have hyperlipidemia.
Ø Donors with stones were older, more likely to be Caucasian, less likely to be related to the recipient and had a higher fasting glucose.
Ø Outcome:
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD. There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones. At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922). Proteinuria, however, occurred more often in donors with kidney stones than those donors with no stones
Ø Summary:
1. After 16.5 ± 10.9 years (range 0–44 years) from donation to study close, no ESKD occurred in donors with stones. 2. The multivariable risks of hypertension, proteinuria, and reduced GFR were similar in donors with and without kidney stones. 3. No association demonstrated between stones and adverse renal outcomes in kidney donors, and the occurrence of post-donation stones
How these guidelines are different from the guidelines you follow at your workplace?
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone usually accepted as donor.
Amna Khalifa
2 years ago
Please summarise these guidelines in your own words
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD.
the development of hypertension, proteinuria, and reduced eGFR were compared in 227 kidney donors with kidney stones to 908 matched donor controls without kidney stones using data from The Renal and Lung Donor Evaluation (RELIVE) Study.
They studied intermediate and long-term outcomes of 8922 donors who donated between 1963 and 2007.
200 donors had kidney stones prior to donation, 21 had post-donation stones, and 6 had pre- and post-donation stones.
· Donors with stones were older.
· Caucasian
· not related to the recipient
· had higher fasting glucose
After 0 to 44 years from donation to study close: No ESKD occurred in donors with stones.
The multivariable risks of hypertension, proteinuria, and reduced GFR were similar in donors with and without kidney stones.
No association between stones and adverse renal outcomes in kidney donors were found, and the occurrence of post-donation stones was rare.
The author proposed that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
Excluding donors with multiple kidney stones, who have a benign urinary profile should be revisited These data may change the concept of excluding donors with kidney stones, hence increasing the donor pool.
How these guidelines are different from the guidelines you follow at your workplace?
At our place the donors with renal stones are excluded , this article may change our practice.
Mohamed Ghanem
2 years ago
This retrospective analysis compared the post-donation outcomes between donors with kidney stones and donors without kidney stones regarding HTN, proteinuria, and a decline in GFR using data from the RELIVE trial.
live donors were included in the RELIVE project from 1963 to 2007 at three major centres
There were 227 live donors who had kidney stones (200 have kidney stones predonation, 21 postdonation, and 6 pre and post)
The three hospitals did not accept donors with unilateral urolithiasis but did not accept patients with many or complex urolithiasis
At the study’s conclusion in 2007, it was discovered that both groups had a comparable risk of hypertension, cardiovascular events, and low GFR. Proteinuria was more prevalent in the kidney stone group
The authors argue that as long as potential donors are thoroughly examined for core metabolic problems, the majority of which may be treated with nutrition and/or pharmaceutical therapies, they shouldn’t be rejected from donation because they have kidney stones
Additionally, they think that it’s time to reconsider and continue research on the exclusion of donors with numerous kidney stones, especially distant donors with a benign urine profile
CARLOS TADEU LEONIDIO
2 years ago
Please summarise these guidelines in your own words
Despite the growth of patients on the waiting list for kidney transplantation, it is still common in large centers for patients with a history of kidney stones not to be accepted as donors. This is due to fear of future obstructions and the lack of confidence in current evidence that excludes an association between kidney stones and the development of Chronic Kidney Disease.
There are a wide variety of studies that suggest an association between kidney stones and the development of end-stage renal disease, but performed with different methods, populations and outcomes. This just shows how there is a variety of analyzes to be performed, in addition to the fact that patients with kidney stones often have a large number of comorbidities.
This study known as the Living Renal and Lung Donor Evaluation Study (RELIVE) was able to compare specific data for the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones with propensity score-matched donor controls without kidney stones.
In the results, it was noticed that the proportions of donors who developed hypertension, cardiovascular disease, loss of estimated glomerular filtration rate (at < 60, < 45 and < 30 ml/min/1.73 m2) were similar in donors with calculi to those observed in the larger group of donors without stones. Proteinuria, on the other hand, occurred more frequently in donors with kidney stones than in donors without stones. What drew the most attention was that in the 46 cases of progression to end-stage renal disease, none of them had a donor with a kidney stone.
Kidney donors with stones, occurring pre- or post-donation, were not at increased risk of developing hypertension, reduced eGFR, proteinuria, or end-stage renal disease. Most kidney stones occurred in older Caucasian donors who were not related to the recipient and who were also more likely to have a lower eGFR on donation. Despite this result, we cannot contemplate patients/donors with a history of complicated calculations, as this patient profile was not part of the study.
It is likely that studies that have shown an association between stones and chronic kidney disease in the general population have obtained this result due to the presence of predisposing factors that are almost always absent in kidney donors, as kidney donors rarely have comorbidities, do not show evidence of kidney disease , even subtle, usually do not take medication and have normal weight in most cases.
How these guidelines are different from the guidelines you follow at your workplace?
This guideline allows the use of organs from donors with a history of kidney stones when well evaluated.
Fatima AlTaher
2 years ago
Kidney stones is a common health issue in general population estimated to affect 11 of US population, but its impact on developement of CKD and ESRD in kidney donors is difficult to be assessed as most patients with renal stones usually have other comorbidities while kidney donors are selected from the healthiest individuals. Donors with renal stones whether past or current are usually excluded from donation due to fear of developing CKD or obstructing uropathy post donation that may require surgical interference, despite the fact that the 10 years stone recurrence rate is 30 %. The few transplant centers who accept donor with stone, usually accept only patients with past history of stone with no recurrence and normal metabolic screen for stones.
Previous studies suggested that presence of renal stone increase the risk of CKD and ESRD by two folds.
In this case – control study, the investigators compared e GFR, HPN and proteinuria in donors with renal stone (200 had stones before donation, 21 had post donation stones and 6 had both pre and post donation stones). The follow up period was around 16.5 y , the patients who had pre and both pre and post donation stones were more likely to be elderly, Caucasian. Renal stones were both asymptomatic (132 patients) and symptomatic in others.
Results of previous studies regarding stone recurrence post donation were reassuring as Thomas et al found that recurrence rate in donors was the same as non-donor controls and surgical intervention was needed only in 9/10000 patients.
The studies evaluating the link between renal stones and CKD and ESRD revealed conflicting results were some of them linked nephronophthisis with CKD but not ESRD while others show didn’t consider nephronophthisis as an independent risk factor for CKD, the same was present in current study Recommendations
1- patients with renal stones shouldn’t be excluded as donors except after careful history taking (unilateral or bilateral stone, symptomatic or incidentally discovered, family history of stones)
and metabolic screen investigations to assess the possibility of stone recurrence.
2- patients with single, remote episode of nephronophthisis can be safely considered for donation.
3- Some metabolic disorders can be effectively managed with diet and medications. Conclusion
Donors with renal stone shouldn’t be refused based on previous stone history alone but calculate their risk of recurrence and underlying metabolic disorders and many of them can donate safely.
In this study, development of renal stones was not associated with excess risk for decreased GFR, proteinuria or HPN
Nasrin Esfandiar
2 years ago
Q1- Summarization of the article: stone presence in donors and progression to ESKD were found correlated in studies done before. Associated comorbidities can have a role here, because of obstructive uropathy development concern in the kidney, post-donation. We can accept donors who have low burden kidney stones which might be unilateral, single, exclusion of metabolic stone panel abnormality, since follow-up in long periods of time showed results alike to donors who didn’t have stones considered declining GFR, hypertension, and proteinuria. The definition of Proteinuria was urine protein more than or equal to 2+ using dipstick, ratio of urine protein to creatinine more than 0.42 or 24-h protein more than 300 mg/day. The definition of hypertension was a BP more than 140/90 mmHg. We exclude patients who had multiple or bilateral stones. Having stones after the donation is unusual because of their attention to adequate screening for stones and ample evaluation of donors, having excluded irregularity from possible donors and hydration. We should study donors who have multiple stones well in order to adapt to the absolute contraindication category of them, meanwhile estimate the risk of recurrence. Q2- In our center, if there is only one available donor with a single stone and no other urine irregularity, we would transplant the kidney while closely following up the donor. Donors with recurrent, multiple, and bilateral stones are excluded.
Mohammed Sobair
2 years ago
INTRODUCTION
Many kidney donor candidates have a history of prior symptomatic kidney stones and as many as 11% have evidence of stones on renal imaging performed during the evaluation.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD.
In one study from Canada, one or more episodes of kidney stones were associated with a twofold higher risk of ESKD.
A National Health and Nutrition Examination Survey based study also reported that a history of kidney stones was associated with CKD and ESKD in women but not in men.
This study compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stone. MATERIALS AND METHODS
The Renal and Lung Living Donor Evaluation Study (RELIVE) was a National Institutes of Health sponsored effort that studied donor outcomes from the University of Minnesota, Mayo Clinic-Rochester and the University of Alabama-Birmingham, as previously described. Study population
There were 8922 live kidney donations at the study sites from 1963 to 2007. Results:
Donors with kidney stones were older (43 vs. 39 years), were more likely to be white (92.5% vs. 84.6%), less likely to be related to the recipient (71.8% vs. 81%), had a higher fasting plasma glucose (95 vs. 92 mg/dl) and a slightly lower eGFR (85.1 vs. 88.4 ml/min/1.73 m2 ), p < .05 for a Characteristics of donors with kidney stones In total, 227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones .
The majority (n = 119) had 1 stone, 28 donors had 2 stones, 3 donors.
Characteristics of donors with kidney stones In total, 227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones (Figure 1). The majority (n = 119) had 1 stone, 28 donors had 2 stones, 3 donors.
Donors who had both pre- and post-donation stones had a higher BMI, a lower eGFR at donation and were more likely to have hyperlipidemia. Study outcome:
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD. There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones.
At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922),
Proteinuria, however, occurred more often in donors with kidney stones than those donors with no stones (20% vs. 13.6%). DISCUSSION :
Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
A majority of kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation.
How these guidelines are different from the guidelines you follow at your workplace?
In our practice we don’t accept donors with history of stone .
Abdullah Raoof
2 years ago
Outcomes of kidney donors with pre- and post-donation kidney stones.
Q1- Please summarise these guidelines in your own words
INTRODUC TION
Many kidney donor have a history of prior symptomatic kidney stones and 11% have stones on renal imaging performed during the evaluation.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD.
kidney stones IN (ARIC) Study was not associated with a higher risk of CKD after multivariable adjustment.
This study compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to pro pensity score-matched donor controls without kidney stones
DISCUSSION
Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD. , very few donors reported kidney stones after donation. These data, , do not provide guidance on candidates with more complicated stone history .Symptomatic and incidentally discovered kidney stones in kidney donors are 3%–11%.
The development of a kidney stone in a kidney donor can cause obstructing the remaining kidney which may require surgical intervention. T there is a concerns about a possible association between kidney stones and CKD in some studies have resulted in wide variability among US transplant centers regarding the acceptance of kidney donors with stones.
Ø 23% of US transplant centers indicated they exclude donors with any kidney stones,
Ø 19% would accept those with a history of stones as long as none is present at the time of donation,
Ø 53% would accept donor candidates with a history of kidney stones provided none is currently present and metabolic studies are normal.
These practices are quite surprising considering that the 10-year recurrence rate of kidney stones is highly variable but is generally around 30% for all comers which means that 70% of donor with stones who are declined may never experience a second or a third episode of nephrolithiasis.
Kidney donors are not at a higher risk for kidney stones after donation. Thomas et al showed that kidney donors had similar hospital encounters for kidney stones as non-donor controls . The rate of kidney stones needing surgical intervention was similar in donors controls.
The evidence linking kidney stones to CKD and ESKD development has been mixed.
A recent meta-analysis of 7 studies concluded that a history of kidney stones was associated with a
47% higher likelihood of CKD . But in RELIVE study ESKD development in their cohort was rare. Interestingly, those with asymptomatic kidney stones incurred a higher risk of ESKD than those with recurrent stones. Kummer et al. did not find that nephrolithiasis was truly an independent risk factor for CKD development.
Ø This article propose that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
Ø excluding donors with multiple kidney stones, particularly remote ones, who have a benign urinary profile should be revisited and studied further.
Ø Risk of recurrence of kidney stones in donor can be reasonably quantified using the revised ROKS nomogram.
Ø Many with multiple kidney stones may have low recurrence rate and therefore maybe considered for donation provided they have no urinary mineral abnormalities.
These analyses have strengths.
Ø The population studied spans 50 years of kidney donations and follow-up is ethnically diverse and donors have ascertainable intermediate renal outcomes such as reduced GFR, proteinuria, and cardiovascular disease development which are not captured in national donor data sets.
Ø There were minimal missing data, and the propensity score matching produced a highly comparable kidney donor control group.
limitations of study .
Ø It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances that could lead to more kidney stones.
Ø Details regarding kidney stones size, unilateral
Øversus bilateral and in unilateral cases whether that kidney wasuniversally the donated one, and whether they were intervened upon pharmacologically or otherwise were not available in this data.
Conclusion :
Ø these data suggest that kidney donors with kidney stoneswho were allowed to donate do not have an increased risk of reducedeGFR, hypertension, or proteinuria when compared to kidney donorswith no kidney stones.
Ø excluding donors with anykidney stones by 25% of US transplant centers may not be justified.
Ø some candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered if the predicted recurrence rate is low.
Ø There is alimitations of models predicting stones recurrence and the limited ability of urinary stone profile and interventions to address its adverse components in predicting recurrence.
Q2-How these guidelines are different from the guidelines you follow at your workplace?
1) History of single stone which is not present know the donor can be accepted.
2) In the absence of a significant metabolic abnormality, history of stone a (small limited number) can be accepted for donation.
3) Potential donors with metabolic abnormalities detected on screening usually decline.
4) In appropriate donors , the stone-bearing kidney can be considered for donation .
rindhabibgmail-com
2 years ago
In this article it was found 3 to 11% renal stones in imaging during there evaluation. literation shows there is increased risk of CKD progression in future with stone disease.
According to RELIVE study it was found no much differences with stone and without stone disease if donors have no other comorbid condition. I think it will be biased as it does not encompasses the whole donor population.
If some one is found having renal stone that may be a recurrent stone former
We usually avoid donors with renal stones. we don’t have genetic testing to confirm the primary cause so for.
AMAL Anan
2 years ago
*About 11% of kidney stone is found on image of kidney donors during their evaluation
*Donors with stones either pre or post donation not are of high risk to be hypertension
proteinuric or decreased glomerular filtration rate and develop end stage renal diseases
*Developed stones in kidney donors may leads to emergency with surgical intervention
*Meta-analysis with seven studies resulted in that kidney stones can develop chronic kidney diseases by about 4%
References
1. Lorenz EC, Lieske JC, Vrtiska TJ, et al. Clinical characteristics of
potential kidney donors with asymptomatic kidney stones. Nephrol
Dial Transplant. 2011;26(8):2695.
2. Alexander RT, Brenda RH, Natasha W, et al. Kidney stones and kidney function loss: a cohort study. BMJ. 2012;345(7873):17.
3. Shoag J, Halpern J, Goldfarb DS, Eisner BH. Risk of chronic and
end stage kidney disease in patients with nephrolithiasis. J Urol.
2014;192(5):1440-1445.
Alyaa Ali
2 years ago
Symptomatic and incidentally discovered kidney stones in kidney donors are common about 3% to 11%.
Some studies suggested that history of kidney stones is associated with CKD , other studies showed that history of stones is not associated with an increased risk of CKD.
This study compared the development of HTN,proteinuria and reduced GFR in kidney stone donors with kidney stones to propensity score matched donor controls without kidney stones.
The study was done on 8922 live kidney donation from 1963 to 2007. From them 227 donors had kidney stones.
Kidney donors were classified by kidney stone history to none, pre-donation kidney stones, post-donation kidney stones or both pre- and post-donation stones.
227 donors with kidney stones ( 200 with pre-donation kidney stones, 21 post-donation and 6 pre and post donation )
Donors with kidney stones were older , more likely to be white ,less likely to be related to the recipient, had higher fasting plasma glucose and a slightly lower eGFR when compared with other donors in the study.
Outcome of study on 8922 donors after 16.5+/- 10.9 years from donation to study close
_ 13.8% of donors developed proteinuria, 36.9 % developed hypertension and 0.7% developed ESRD . there were 46 ESRD events after donation, none of them in donors with kidney stones
_ proportions of donors who developed HTN and cardiovascular events were similar in patient with history of kidney stones and whom with negative history.
There is no significant difference in the occurrence of proteinuria between two groups.
Kidney donors with stones ( pre-donation, post-donation or both) were not at higher risk for development of HTN, reduced GFR or proteinuria)
We don’t have kidney transplantation center
Filipe prohaska Batista
2 years ago
This is a study that uses the database of living donors from three transplant centers (Minnesota, Mayo, and Alabama) and is a retrospective cohort study between 1963 and 2007 comparing the status of nephrolithiasis and its clinical outcome related to kidney transplantation. There are data in other studies that suggest an increased risk of chronic disease and end-stage renal disease in donors with kidney stones.
This study was separated into four groups, where the patient had no stone, pre-donation (200 patients), post-donation (21 patients), pre- and post-donation (6 patients). Related to quantity, 119 patients had a single stone, 28 patients had two stones, 3 patients had five stones and the rest were not established.
Kidney stone donors were older, white, and had higher fasting glucose and mildly reduced eGFR response. Apparently, it was more related to the donor than the recipient. Patients with pre- and post-donation stones were more related to higher BMI, lower eGFR at donation, and a tendency to hyperlipidemia. Smoking appears to be related to kidney stone donors. Proteinuria is a more common finding in kidney stone donors compared to those without.
Undoubtedly few donors had stones after donation, probably as a result of the orientation of important post-donation water intake. Some American centers (23%) did not accept donors with kidney stones, while others were released after investigation for reversible metabolic causes. This study and that of Kummer et al do not suggest that nephrolithiasis is an independent factor for the development of chronic kidney disease.
Abnormal post-donation parathyroid hormone levels, especially in the first three years, may indicate gout medication. This study suggests that patients with kidney stones should not be excluded from donation protocols unless there are metabolic changes consistent with the condition, anatomical changes, or recurrent urinary infections, even in situations with multiple kidney stones.
Abubacarr Jagne
2 years ago
kidney stones are one the common recurrent renal diseases with an associated risk of other metabolic disorders. It has a complication of obstruction, infection and renal impairment.
This study set out to determine the risk of hypertension, proteinuria, and ESRD in donors
the study participants were 227 , with 200 participants with pre-transplant, 21 post-transplant stones, and 6 with both pre and post-transplant stone. the study period from 1963-2007
After an average follow-up period of 16.5 + 10.9years, apart from increased incidence of proteinuria in donors with stones, there was no increased incidence of hypertension, cardiovascular disease, or reduced GFR
The conclusion was that kidney donors with stones have no increased risk of hypertension, decrease GFR, or increased CVD risk.
my critique is the study didn’t take into account the type, size, complicated or none complicated stone, the site of the stone, and most importantly biochemical composition of the stone. which may establish the metabolic relationship between stones and hypertension and CVD risk
In my center, those donors who have stones are screened further and if they have any further risk of stones or complications of the stone, they are not allowed to donate
hussam juda
2 years ago
INTRODUCTION
· one or more episodes of kidney stones were associated with a twofold higher risk of ESKD (a Canadian study)
· In this case-controlled study, a comparison between kidney doner with kidney stones and matched doners without stones, in development of HTN, proteinuria and reduced GFR MATERIALS AND METHODS
· There were 8922 live kidney donations at the study sites from 1963 to 2007
· Family history of hypertension, diabetes mellitus (DM), kidney disease, stroke, or heart disease in donors’ first-degree relatives were recorded.
· A history and timing of kidney stones was obtained from medical record abstraction, imaging studies and by donor self-report
· post-donation events collected from donors by telephone and multiple mailings, and from centers records
· Definitions: HTN: s use of antihypertensive medications, a systolic blood pressure ≥140 mmHg, or a diastolic blood pressure ≥90 mmHg Cardiovascular disease: myocardial infarction, congestive heart failure, stroke, and need for coronary or peripheral arterial intervention. ESKD: the need for dialysis, receiving a kidney transplant or being listed for one. Proteinuria: urine protein by dipstick ≥2+, urine protein/osmolality >0.42 ratio, urine random protein >15 mg/dl, or 24-h protein >300 mg/day
· Exclusion criteria:1) donors with proteinuria, measured GFR, or creatinine clearance
2) candidates with multiple kidney stones (≥3–5)
RESULTS
· In total, 227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones
· Donors with pre-donation kidney stones and those with both pre- and post-donation stones were older than donors with post-donation stones only
· donors with pre-donation kidney stones were less likely to be men and more likely to be white
· Donors who had both pre- and post-donation stones had a higher BMI, a lower eGFR at donation and were more likely to have hyperlipidemia Study outcomes
· After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD
· At study close in 2007, there were no difference between donors with stones and those without stones in developing hypertension, cardiovascular disease, and reduced eGFR
· But proteinuria, was more frequent in donors with kidney stones than those donors with no stones DISCUSSION
· These analyses have strengths:
-The long time follow up (50 years) of kidney donations
-donors have intermediate renal outcomes such as reduced GFR, proteinuria, and cardiovascular disease development which are not captured in national donor data sets.
-There were minimal missing data
-the propensity score matching produced a highly comparable kidney donor control group
· Limitations:
-It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances that could lead to more kidney stones.
-There was no enough information about kidney stones size, site and intervention which was done
– the policies of the 3 RELIVE study centers may not be similar to other centers which may limit the generalizability of these findings.
-the RELIVE study did not capture bariatric surgery which can be predispose to kidney stones
CONCLUSION
kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones
How these guidelines are different from the guidelines you follow at your workplace?
We try to treat any donor with uncomplicated stone, but not recurrent, and exclude any metabolic disease. When we are sure the donor is stable and no recurrence of stone we accept the donor.
Eusha Ansary
2 years ago
This study includes 8922 live kidney donations from 1963 to 2007. In total, 227 donors had kidney stones: 200 donors with pre donation stones, 21 donors with post-donation stones, and 6 donors had both pre and post donation kidney stones.
This study suggests that kidney donors with renal stones do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no renal stones. Carefully evaluated candidates with stones with underlying metabolic disturbances can be accepted with dietary or pharmacological interventions.
Most kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation. Very few donors reported kidney stones after donation.
Kidney donors do not appear to be at a higher risk for kidney stones after donation and should not be excluded from donation for having kidney stones if they are carefully evaluated for underlying metabolic disturbances.
In our center we are not taking donors with kidney stones but now on it will be changed.
Abhijit Patil
2 years ago
Please summarise these guidelines in your own words
This study suggests that kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones.
Carefully evaluated candidates with stones with underlying metabolic disturbances amenable for dietary or pharmacological interventions can be accepted as donors.
Even donors with multiple stones with normal metabolic evaluation can be accepted after risk of stone recurrence is quantified using various nomograms esp ROKS nomogram.
How these guidelines are different from the guidelines you follow at your workplace?
We at our institute, do accept kidney donor with single or multiple small stones
We perform pre-donation stone clearance and evaluate complete stone clearance 2 weeks post stone clearance.
After stone clearance, we evaluate metabolic evaluation of donor. We proceed, if there is no abnormality or it is corrected with pharmacological intervention.
We routinely don’t put stent in kidney transplantation surgery. If there is a small stone in kidney donor, then we use a DJ stent during transplantation. the initial diuresis along with stent helps stone clearance of small stones.
We try to donate the stone bearing kidney to recipient and leave back the non-stone bearing kidney with the donor.
We keep such donors under strict surveillance to evaluate stone recurrence.
Mu'taz Saleh
2 years ago
Really this study will change my way in evaluating the potential donors , in our center we exclude any potential donor with renal stone or even history of stone due to increase risk of single kidney obstruction and needs urgent surgical intervention .
world wide 11 % of potential kidney donor have some renal stones .
This study was undertaken to study the effect of renal stones on kidney donor and subsequent development of HTN , CKD , ESRD ,CVD and protienurea .
in this study it is found that the risk for development of HTN , CKD is similar in both groups but the risk of protienurea is slightly high in donor with renal stones .
Donors with stones needs careful evaluation including the metabolic panel to assess the cause of stones , history of previous stones , symptomatic or incidentally finding , unilateral or bilateral , family history of stone
in this study it was concluded that careful selection of kidney donors with stones did not increase risk of low GFR, hypertension and proteinuria. Donors with kidney stones should not be excluded from donation with careful evaluation of underlying metabolic aspects which are modifiable by dietary and medical treatment Donors with multiple stones and normal urinary findings should have further evaluation.
Ahmed Omran
2 years ago
Around 11% potential kidney donors have some renal stone. 25 % US transplant centers exclude kidney stones donors to avoid future chronic kidney disease.
This study was undertaken to find possible relationship between renal stones in donor kidney and subsequent incidence of hypertension ,proteinuria and decline in GFR. Hypertension, proteinuria, eGFR < 60 ml/min/1.73 m2 and cardiovascular disease were compared in donors with kidney stones vs controls.
Post donation hypertension was defined as BP>140/90.
It was found that risk of hypertension, CV events and low GFR was similar in both groups but proteinuria was more in group with renal stones.
It was concluded that careful selection of kidney donors with stones did not increase risk of low GFR, hypertension and proteinuria.
Donors with kidney stones should not be excluded from donation with careful evaluation of underlying metabolic aspects which are modifiable by dietary and medical treatment
Donors with multiple stones and normal urinary findings should have further evaluation.
Strength points include long duration and ethnicity diversity
limitation points included lacking data regarding number of accepted donors of kidneys with stones and characters of stones.
Practically, donors with multiple and recurrent stones to be excluded..
Theepa Mariamutu
2 years ago
About 25% of the potential kidney donor is US are rejected because of findings of kidney stone for the fear of possible development of CKD after donation. Studies have reported a greater risk of developing CKD or ESRD among people with kidney stone, however others have also reported contrary to the finding.
This study is to compare the development of hypertension, proteinuria, and reduce GFR among donors with kidney stone to the matched control group.
8922 kidneys RELIVE donors between 1963-2007 data were recruited
Baseline demography and history were obtained
Donors were contacted for information between 2010-2012 through phone and mailing system
Median age, BMI, and GFR was 39 years, 25.8kg/m2, and 88.2ml/min/1.73m2
227 donors have kidney stones, and it was matched against 908 non kidney stone donors
200 out of the 227 donors have kidney stones before donation while 21 had post donation, and 6 had before and after donation
Donors with pre and post donation stone were found to have a higher BMI, reduce GFR at donation and hyperlipidaemia
The only difference between case and control were higher smoking rate, hyperlipidaemia and hypertension among donors with stones following 16.5+- years of follow up, hypertension, proteinuria, and ESRD was 36,9%, 13.8% and 0.7% respectively
kidney donors with stones were not at higher risk of developing hypertension, proteinuria, reduce GFR or ESRD smaller number of donors reported kidney stones after donation.
Conclusion
There was no significant increase of hypertension, proteinuria or ESRD among donors with kidney stones compared to the matched donor in this study, hence exempting potential donors from donating kidney because of stone may not be totally beneficial to the growth of kidney transplantation.
In our practise, we don’t take donor with renal stone as metabolic screening in our centre is not easily available.
Hoyam Elamin
2 years ago
Good evening,
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESR.
Past history of kidney stones was associated with CKD and ESRD in women but not in men in some studies.
Studying the potential association between kidney stones and future development of CKD is complicated due to associated multiple comorbidities
In this study, the development of hypertension, proteinuria, and reduced GFR was compared in kidney donors with kidney stones to matched donor controls without kidney stones.
Donors were stratified by kidney stone history: none, pre-donation kidney stones, post-donation kidney stones, or both pre- and post-donation stones. Donors with kidney stones were generally older, more likely to be white and non-related to the recipient, had a higher fasting plasma glucose and a slightly lower eGFR.
Kidney donors with stones, (pre- or post- donation), were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESRD.
Excluding donors with stones from donation led to the lower rate of stones in this group (about 3%–11%).
Potential donors with stones are usually excluded from donation due to the concern of obstructing the remaining kidney and the possible association between kidney stones and CKD in some studies.
Kidney donors do not appear to be at a higher risk for kidney stones after donation.
Some studies suggest that a history of kidney stones was associated with a 47% higher likelihood of CKD. . It is possible that these studies in the general population are highly confounded by the predisposing factors that are almost always absent in kidney donors.
The authors propose that potential kidney donors should not be excluded from donation due to kidney stones as long as they are carefully evaluated for underlying metabolic disturbances.
At our center, potential donors with renal stones at time of evaluation are excluded and referred to urologist. Those with past history of stones are accepted if their metabolic studies and imagings are normal.
Shereen Yousef
2 years ago
Please summarise these guidelines in your own words
Donors with kidney stones were usually excluded in many centres from donation to avoid potential risks of future obstructive consequences and the possible association between stones and CKD.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD.
In one study from Canada, one or more episodes of kidney stones were associated with a two fold higher risk of ESKD. And another study found the association more common in women.
recent meta-analysis of 7 studies concluded that a history of kidney stones was associated with a 47% higher likelihood of CKD. These findings were echoed by a study of individuals with former kidney stone(s) in Olmsted County, Minnesota .
Kummer et al. did not find that nephrolithiasis was truly an independent risk factor for CKD development in 10 678 ARIC study participants of whom 856 had a history of stones and an additional 322 who developed stones over a mean follow-up of 12 years.
Also,it was found that history of kidney stones among 10,678 participants in the Atherosclerosis Risk in Communities (ARIC) Study was not associated with a higher risk of CKD after multivariable adjustment.
Renal and Lung Donor Evaluation (RELIVE) Study studied intermediate and long-term outcomes of 8922 donors who donated between 1963 and 2007. 200 donors had kidney stones prior to donation, 21 had post-donation stones, and 6 had pre-and post-donation stones.
227 kidney donors with kidney stones were compared to 908 propensity score-matched donor controls without kidney stones regarding development of hypertension, proteinuria, and reduced eGFR .
results
After 16.5 ± 10.9 years (range 0–44 years) from donation to study close, -no ESKD occurred in donors with stones. -no association between stones and adverse renal outcomes in kidney donors. – post-donation stones was rare. Thomas et al also showed that kidney donors had similar hospital encounters for kidney stones as non-donor controls.
-risks of hypertension, proteinuria, and reduced GFR were similar in donors of both groups.
These findings are highly consistent with the data from Kummer et al.
It is possible that studies demonstrating an association between stones and CKD in the general population are highly confounded by the presence of predisposing factors that are almost always absent in kidney donors, as kidney donors rarely have comorbidities, have no evidence of even subtle renal disease, are generally on no medications, and have normal weight in the majority of cases.
These data may provide a rationale for possibly a wider acceptance of donor candidates with low kidney stones burden after carefull evaluation for underlying metabolic disturbances .
How these guidelines are different from the guidelines you follow at your workplace?
in My work place potential donors with current or repeated kidney stones are excluded
Donors with past history of stones usually excluded
although i find it logic that they might be accepted after full evaluation of the cause ,family history of stones, metabolic abnormalities ,current kidney function.
fakhriya Alalawi
2 years ago
This study (The Renal and Lung Living Donor Evaluation Study (RELIVE)) was a National Institutes of Health sponsored effort that studied donor outcomes from the University of Minnesota.
There were 8922 live kidney donations at the study sites from 1963 to 2007. A history and timing of kidney stones was obtained from medical record abstraction, imaging studies and by donor self-report. In total, 227 donors had kidney stones: 200 donors with pre-do[1]nation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones.
Study outcomes:
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD.
There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones. At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922).
Proteinuria occurred more often in donors with kidney stones than those donors with no stones (20% vs. 13.6%), p = .01, however, the difference in proteinuria was no longer significant (15.6% vs. 20%), p = .06. The method of proteinuria assessment (24-h urine vs. dipstick vs. urinary albumin/creatinine ratio) after donation was similar in stone and non-stone formers.
The estimated 10-, 20-, and 30-year cumulative incidence of outcomes per 10 000 donors in donors with and without stones were almost identical.
Most kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation. Very few donors reported kidney stones after donation.
Kidney donors do not appear to be at a higher risk for kidney stones after donation.
In conclusion: donor candidates should not be excluded from donation for having kidney stones if they are carefully evaluated for underlying metabolic disturbances.
Many with multiple kidney stones may have low recurrence rate and therefore maybe considered for the donation provided they have no urinary mineral abnormalities.
Kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones.
In our centre we are not taking donors with kidney stones for fear of possible adverse long-term outcomes on kidney.
Batool Butt
2 years ago
Patients with kidney stones generally have many comorbid conditions that’s why it is difficult to study and predict about the development of CKD in the future in these patients. This article also clarifies few concepts about the risks of hypertension, GFR decline ,proteinuria and ESRD later in kidney stone donation patients.
This study included 8922 live kidney donations from three different centers. Results revealed hypertension to be present in 36.9% of donors , proteinuria in 13.8% and ESRD in 0.75% donors with a follow up period of 16.5 ± 10.9 years. Moreover, 30% chance of recurrence of kidney stones ,also donors with stones were white and non-related , had high fasting glucose levels ,higher BMI and hyperlipidemia .
In conclusion, no difference was found between donors with and without kidney stones in terms of outcome i.e., hypertension, proteinuria, ESRD. Donors with kidney stones with no metabolic abnormality should not be excluded. And patients with uncomplicated multiple stones ,positive family history ,raised BMI ,male gender should be assessed with ROKS nomogram and donation should be done only if less chance of recurrence.
Strength: Propensity score matching was done to produce comparable kidney donor, follow up of patients was diverse and also long..
However, limitations of the study included uncertainity about the acceptance of donors with pre-donation stones. No detail was provided about the size of kidney stone, whether it is unilateral or bilateral or whether any surgical or medical intervention done before.
At our center ,we evaluate patients according to KDIGO 2017 guidelines and include urinalysis followed by Ultrasound abdomen ,CT angiography of renal vessels. We do not reject patients with unilateral stones with negative metabolic profile but with proper counseling and close follow up. However, patients with recurrent and bilateral kidney stones are rejected.
.
Huda Saadeddin
2 years ago
INTRODUCTION
Many kidney donor candidates have a history of prior symptomatic kidney stones and as many as 11% have evidence of stones on renal imaging performed during the evaluation.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD. In one study from Canada, one or more episodes of kidney stones were associated with a twofold higher risk of ESKD
Studying the potential association between kidney stones and future development of chronic kidney disease is quite complicated as many people with kidney stones have multiple comorbid conditions.
Herein, we compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
MATERIALS AND METHODS
Post-donation hypertension was defined as use of antihypertensive medications, a systolic blood pressure (SBP) ≥140 mmHg, or a diastolic blood pressure (DBP) ≥90 mmHg. Cardiovascular disease (CVD) was defined by any of the followings: myocardial infarction, congestive heart failure, stroke, and need for coronary or peripheral arterial intervention. ESKD was defined by need for dialysis, receiving a kidney transplant or being listed for one. Proteinuria was defined as one or more of the following: urine protein by dipstick ≥2+, urine protein/osmolality >0.42 ratio, urine random protein >15 mg/dl, or 24-h protein >300 mg/day.
The three centers generally excluded candidates with multiple kidney stones (≥3–5) particularly recent episodes
This study was exempt from institutional review board approval as it used only de-identified data from the publicly available RELIVE study data set.
RESULTS
Characteristics of donors with kidney stones
In total, 227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones .
Study outcomes
There were 46 ESKD events that occurred
18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones. At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m 2 were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922), Proteinuria, however, occurred more often in donors with kidney stones than those donors with no stones (20% vs. 13.6%).
DISCUSSION
Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
very few donors reported kidney stones after donation
Kidney donors do not appear to be at a higher risk for kidney stones after donation.
Certainly, the low rates of post-donation stones might be related to screening-out candidates who were deemed to have a high stone recurrence potential at the time of donor evaluation in addition to the general recommendation given to kidney donors to stay “well hydrated”.
A recent meta-analysis of 7 studies concluded that a history of kidney stones was associated with a 47% higher likelihood of CKD.
Interestingly, those with asymptomatic kidney stones incurred a higher risk of ESKD than those with recurrent stones. In contrast, in a more recent study with a similar length of follow-up to that of the Olmstead County study but in a more ethnically diverse population, Kummer et al. did not find that nephrolithiasis was truly an independent risk factor for CKD development in 10 678 ARIC study participants of whom 856 had a history of stones and an additional 322 who developed stones over a mean follow-up of 12 years. 4 Our findings are highly consistent with the data from Kummer et al.
We propose that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
It also identified BMI, male, family history of kidney stones, asymptomatic and suspected kidney stone episodes before the symptomatic event and pregnancy at last stone episode as important predictors of recurrence.
In all, these data suggest that kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones.
Moreover, even some candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered if the predicted recurrence rate is low.
On our center the donor assessed for kidney stones and evaluated by urologist and nephrologist for the risk of recurrence.
Mohamed Mohamed
2 years ago
I. Outcomes of kidney donors with pre-and post-donation kidney stones Please summarise these guidelines in your own words Introduction
Kidney stones are common among potential kidney donors; stones are seen on 11% of imaging done during pre-transplant workup.
Some studies linked between kidney stones & the increased risk of CKD & ESRD (Study from Canada), especially in female (National Health & Nutrition Examination Survey based study).
In other studies (ARIC Study), H/O kidney stones was not associated with a higher risk of CKD.
The aim of this current study (RELIVE Study) was to know the effects of kidney stones on the occurrence of reduced GFR, proteinuria, & HTN in kidney donors who have minimal to no confounders.
Materials & Methods
The total number of live kidney donations from 1963 2007 was 8922; done in 3 centers in the USA.
They compared the occurrence of HTN, proteinuria, & reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
Individuals with multiple kidney stones (.3–5) were excluded.
The kidney with a stone was taken for donation in cases of unilateral stones. Results
Donors with kidney stones were:
Older (43 vs 39 yr)
More likely to be white (92.5% vs. 84.6%)
Less related to the recipient (71.8% vs. 81%)
Higher FBG (95 vs. 92 mg/dl)
Lower eGFR (85.1 vs 88.4 ml/min/1.73
P < 0.05 for all.
A 227 donors had stones (200 pre-donation, 21 post-donation, & 6 had both pre- & post-donation kidney stones); the majority (119) had 1 stone, 28 had 2 stones, 3 donors had 5 stones, & the number of was unknown in the remainders.
Donors with both pre- & post-donation stones were less likely to be Caucasian but otherwise highly comparable.
Outcomes after 16.5 ± 10.9 yrs from donation to study:
– 36.9% of donors developed HTN
– 13.8% developed proteinuria
– 0.7% had ESRD (46 events occurred 18.5 ± 10.5 yrs
after donation & none of these occurred in donors
with kidney stones).
Development of HTN, CVD, eGFR < 60, eGFR < 45, eGFR < 30 ml/min were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922).
Proteinuria was more in donors with stones than donors with no stones (20% vs. 13.6%), p = .01, however with propensity score-matching, the difference in proteinuria was no longer significant (15.6% vs. 20%), p = 0.06.
Discussion
Donors with stones were not at a higher risk for HTN, reduced eGFR, proteinuria, or ESRD.
A majority of stones were in older Caucasian donors who were unrelated to the recipient & who were more likely to have a lower eGFR at donation.
Very few donors had stones after donation (candidates with H/O more complicated stone were excluded from donation).
Symptomatic & incidental stones in kidney donors not uncommon(3%–11%); the lower rate may be explained by the practice of excluding donors with stones from donation.
A 23% of US transplant centers exclude donors with any kidney stones, 19% would accept them if none is present at the time of donation, & 53% would accept if none is currently present & metabolic studies are normal.
The 10-year recurrence rate of stones is variable (generally around 30%); 70% of donor with stones who are excluded may never have a 2nd or a 3rd stone.
Kidney donors are not at a higher risk for stones after donation (Thomas et al).
The rate of stones needing surgical intervention was similar in donors controls.
These results are consistent with the very few stones reported in RELIVE donors after donation.
The low rates of post-donation stones might be explained by the practice of exclusion of those with high risk of recurrent stones; the general advice given to kidney donors to stay “well hydrated” may also be a contributing factor.
ROKS nomogram (Rule et al.) can be used to quantify risk of recurrence of kidney stones in potential donors.
In conclusion, kidney donors with stones who were allowed to donate do not have an increased risk of reduced eGFR, HTN, or proteinuria when compared to donors with no kidney stones.
The authors believe that excluding donors with any kidney stones may not be justified. ============================== How these guidelines are different from the guidelines you follow at your workplace?
Our local guidelines are not much different from these guidelines.
We exclude from donation those with bilateral or multiple stones irrespective to the type of the stone.
We do not commonly do evaluation for metabolic risk of stone formation in our center.
We accept donors with unilateral stone (small non obstructive); and of course the kidney with the stone is taken for donation. And our surgical teams successfully removed some of such stones before grafting without the need for inappropriate manipulation of the kidney.
We, also do not accept any donors with proteinuria, measured GFR, or creatinine clearance <85 ml/min. Here, we are more conservative and use a level <85 ml/min rather than what stated in these guidelines.
Abdul Rahim Khan
2 years ago
Please summarise these guidelines in your own words
About 11% potential kidney donors may have some sort of renal stone at the time of assessment. There has been an association of kidney stones with chronic kidney disease. 25 % US transplant centres exclude donors with kidney stones with fear future chronic kidney disease.
In this study the authors have studied the relationship of renal stones in donor kidney with subsequent development of hypertension, Proteinuria and decline in GFR.
They compared kidney donors with stones with control donors without stones. They looked at development of hypertension, proteinuria and reduced GFR.
Kidney donors with stone -227
Propensity matched donors without stones – 908
Methodology
The renal and lung living donor evaluation – RELIEVE Study studies the donor outcomes at the University of Minnesota , Mayo clinic and university of Alabama and evaluated 8922 live donations from1963 -2007. Baseline demographic and laboratory record was abstracted from central record. Hypertension, proteinuria, eGFR < 60 ml/min/1.73 m2 and cardiovascular disease were compared in donors with kidney stones (cases) versus those who no kidney stones (controls)
To assess of post-donation events, donors were contacted between 2010 and 2012 via telephone and multiple mailings for health updates, QOL surveys, and any laboratory data that took place after donation. Post donation hypertension was defined as blood pressure >140/90.
Total donors with stones were 227.
21 had post donation stones and 200 had pre donation stone.
Results.
At the end of study in 2007 it was found that risk of hypertension, cardiovascular events and low GFR was similar in both groups Proteinuria was more in group with renal stones.
Conclusion
Carefully selected kidney donation with stones does not increase the risk of low GFR, hypertension and proteinuria.
Donors with kidney stones should not be excluded from donation if they are carefully evaluated for underlying metabolic problems which are amenable to dietary and medical treatment
Those with multiple stones who have normal urinary profile should be revisited and evaluated further
Strengths of study
Long study span
Ethnicity -diverse
Limitations
Unclear how many donors with stones were accepted
Not much details about stone characteristics
Policy of 3 RELIVE centre may be different
How these guidelines are different from the guidelines you follow at your workplace?
At my centre we do accept potential donors with solitary unilateral stones . However this is subject to satisfactory metabolic evaluation.
We refuse those with multiple stones, recurrent stones and large stone burden.
I like your list of strengths and limitations of this study, dear Dr Abdul Rahim Khan. Moreover, I appreciate the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine. Ajay
Marius Badal
2 years ago
Outcomes of kidney donors with pre-and post-donation kidney stones
This article is about kidney donor candidates with a history of having kidney stones. Some centers do not include kidney stones as part of donors for transplantations due to the possible future obstruction and there may be an association between kidney stones and CKD. Due to the above, there is controversy in allowing these patients to be donors because they may have another comorbidity that may prevent them from being a donor.
The aim of this article is to see the relation between two groups one with a kidney stone and the other without kidney stones and to see which develops proteinuria, HTN, and a reduction of GFR.
The study was conducted in the US by RELIVE, from a period of 1963 to 2007. There was a total of 227 donors with kidney stones of which 200 had pre-donation stones and 21 post-donation stones and a total of 6 with both. It was compared with a 908 propensity score matched control without stones.
It was observed that the donors with stones were older likely predominantly white, with a higher serum plasma glucose and with a decrease in GFR. Between the two groups, it was found that individuals that were found with kidney stones had a history of smoking, hyperlipidemia, and a first-degree relative with HTN.
The study was a good study due to the fact that it had a study span of 50 years, the follow-up is ethnically diverse, data missing was minimal and the propensity score matching produced a highly comparable kidney donor control group.
However, the study had some limitations like how donors with stones were accepted after having metabolic screening, there was nothing to show if it was unilateral or bilateral kidney stones, and the possible sizes.
In the study, it was concluded that patient kidney donors with stones before or after transplantation were not at a higher risk for developing hypertension, proteinuria, a decrease in GFR, and kidney failure. So it can be said that kidney stones patients may be donors for kidney transplants but there is no clear cut as to the severity of the kidney stone.
Actually, in my workplace, there are no guidelines as yet but I would like to implement the same and what I was thinking of is to have or avoid patients with kidney stones not to be part of donating.
That is very pleasing to note, dear Dr Marius Badal, that this article inspires you to make protocols in your department.
Muntasir Mohammed
2 years ago
Please summarise these guidelines in your own words
INTRODUC TION
11% of potential donors have stone or history of stone with some concern about future CKD or obstructive uropathy. A National Health and Nutrition Examination Survey based study also reported that a history of kidney stones was associated with CKD and ESKD in women but not in men. Contradicting to this, Kidney stones among 10,678 participants in the Atherosclerosis Risk in Communities (ARIC) Study was not associated with a higher risk of CKD after multivariable adjustment. Studying this in the healthy donors with no comorbidities may improve our understanding. In this study we compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
MATERIALS AND METHODS The Renal and Lung Living Donor Evaluation Study (RELIVE) was a National Institutes of Health sponsored effort that studied donor outcomes from the University of Minnesota, Mayo Clinic-Rochester and the University of Alabama-Birmingham, as previously described. There were 8922 live kidney donations at the study sites from 1963 to 2007.
RESULTS
Characteristics of RELIVE study donors:
1. Median age was 39 years.
2. 56.2% were women
3. 84.8% were non-Hispanic whites, 9.5% were non-Hispanic black, 1.8% were Hispanic, 0.9% were Asian, and 3% were categorized as other.
4. The majority (80.8%) donated to a family member.
Characteristics of donors with kidney stones
· 227 donors had kidney stones
· 200 donors with pre-donation stones
· 21 donors with post-donation stones, and
· 6 donors had both pre- and post-donation kidney stones
· The majority (n = 119) had 1 stone, 28 donors had 2 stones, 3 donors had 5 stones, and the number of stones in the remainder was unknown.
For the 227 donors with kidney stones, 908 controls without stones were selected.
The only differences noted between cases and controls after PS matching were a higher prevalence of smoking, hyperlipidemia and having a first-degree relative with hypertension in donors with kidney stones. Study outcomes
Outcomes were ascertainable in 97% of the cohort except for proteinuria data which was missing in 10.7%.
After 16.5 ± 10.9 years from donation to study close:
1. 36.9% of donors developed hypertension
2. 13.8% developed proteinuria.
3. 0.7% had ESKD.
4. There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones.
Proteinuria, however, occurred more often in donors with kidney stones than those donors with no stones (20% vs. 13.6%), p = .01. The proportions of donors reaching the different outcomes in the 2 groups were also similar in the propensity score-matched cohort, and the difference in proteinuria was no longer significant (15.6% vs. 20%), p = .06..
DISCUSSION
Kidney donors with stones, were not at a higher risk for developing hypertension, reduced
eGFR, proteinuria, or ESKD. Most of kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation.
Of note very few donors reported kidney stones after donation.
Strength of the study:
1-Large sample size.
2-Long follow up period
3-very good matching of control group
4-Outcomes were ascertainable in 97%.
Weakness of the study:
1-Most of donors were Caucasians
2-Data about proteinuria were not available in some donors.
3-Retrospective nature of the study.
Conclusion
These data suggest that kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones. Hence excluding all kidney stone former is not justified. Moreover, even some candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered if the predicted recurrence rate is low.
How these guidelines are different from the guidelines you follow at your workplace?
It is not much different. We accept cases of single kidney stone and normal 24hours urine for stone chemistry. We take the kidney with stone for donation. Potential kidney donors with multiple, bilateral stones or high risk of recurrence are excluded.
I like your list of strengths and limitations of this study, dear Dr Muntasir. Moreover, I appreciate the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine. Ajay
saja Mohammed
2 years ago
Outcomes of kidney donors with pre- and post-donation kidney stone.
INTRODUCTION
The incidental finding of kidney stones by renal imaging was reported in around 11% during transplant workup and based on evidence. There is a concern about the increased risk of CKD and ESRD among kidney donors, one study from Canada advocates donors with one or two episodes of symptomatic kidney stones are at a twofold higher risk of ESKD (2). Another national survey data confirms more risk of CKD in women rather than men (3) while another big study (ARIC) confirmed no increase in such risk after multivariate adjustment.
Aim of this study
linked the incidence of proteinuria, hypertension, and drop of GFR in kidney donors with a history of stones to the matched donor control group without a history of kidney stones.
Materials and setting
the Renal and Lung Living Donor Evaluation Study RELIVE, part of a national health institution donor outcome study from different centers
9882donors were included from 1963-2007and all donor’s baseline demographics and investigations placid from their electronic medical records, post donation events recorded between 2010-2012 from institution medical records, and multiple donor phone calls and emails for updated health with QOL survey
Hypertension was recorded with an average of three visits and defined as the Bp > 140/90 or patients on medications
CVD referred to MI, heart failure, stroke, or the need for coronary or peripheral vascular intervention
ESKD is demarcated as the need for dialysis or transplantation or being registered for one of them
Proteinuria definition as one or more of the following: urine protein by dipstick ≥2+, urine protein/osmolality >0.42 ratio,
urine random protein >15 mg/dl, or 24-h protein >300 mg/day.
They exclude donors with proteinuria and measured GFR < 80ml/min, in three centers additional exclusion of the donors with recent episodes of kidney stones > 3-5 but no further details about associated metabolic disorders.
Propensity score matching 1 case -4 control for age, gender, ethnicity, and years of donation.
Results
RELIVE donors’ characteristics
The median age of the RELIVE study was 39 years, 56.2% were women, 84.8% were white, 9.5% were non-Hispanic black, 1.8% were Hispanic, 0.9% were Asian, and 3% were categorized as other.
About (80.8%) donated to a family member.
71% had positive FH of CKD (first-degree relative)
41.0% had positive FH of hypertension (first-degree relative).
Median BMI 25.8
Median GFR *88ml/min/1.73m2
Donors with kidney stones are older, white, and with higher fasting blood sugar non related donors with slightly lower GFR 85ml/min/1.73m2
Donors with kidney stones
The total number of donors with kidney stones was 227, 200 pre-donation, 21 post-donation stores, and another 6 donors with both pre and post-donations, asymptomatic kidney stones with incidental findings by a renal image found in 132 cases, donors with pre and post-donation risk of kidney stones they are older age in their 40s compared to control group more in the white population, they have higher BMI, lower baseline GFR, and dyslipidemia and after adjustment variable risk factors by propensity score(PS ), they found a significant association of recurrence of kidney stones posts donation in donors with a history of smoking, dyslipidemia and FH of hypertension in a first-degree relative.
There is missing data on proteinuria in 10.7%. After meaning fu of 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, and 13.8% developed proteinuria, but the cumulative incidence of proteinuria was of no significance between the two groups.
and 0.7% had ESKD
Strength of the study
A big sample size of donor pool over 50 years of FU, varied populations
Few missing data
Well-matched control group
Clearly identifies the renal outcome Limitation
no clear screening for metabolic risk factors in donors with pre-donation stones history
no details about kidney stone type and size, uni or bilateral, and which kidney have been donated in case of unilateral stones
no information about the treatment or intervention for donors with kidney stones.
The difference in 3 RETVIL center policies limits the generalizability of these results
No information about the history of bariatric surgery Conclusion
The data from this study confirm the safety of donation from potential donors with kidney stones compared to a donor control group with no stones with no associated risk of proteinuria, hypertension, or low GFR.and they believe its indefensible that some centers in the US declined donors with kidney stones such decisions should be revisited by further studies and donors with associated modifiable metabolic risk factors should be treated before including them in transplant work up.
ROCK nomogram and modified Rock nomogram its useful tool for donors with symptomatic and kidney stone recurrence score assessment tools developed by Rule and colleagues (10). And revised by Vaughan et al.
Predictors for symptomatic stone recurrence include the type of the stones, FH of kidney stone associated metabolic risks like dyslipidemia, obesity, gender (male), and stone in pregnancy.
In our local protocol, we exclude donors with a history of kidney stones, as one of the major concerns is the exposure to recurrence of obstructive stone in singlefunctioning kidneys after reviewing this study i think we should take care of donors with metabolic syndrome and may exclude them from donation with medical advise to improve lifestyle ,stop smoking , reduce wt and treat dyslipidemia , control of Bloodpressure and sugar addressing family history in the first degree and apply the ROCKnomogram the reconsider their fitness for donation.
I like your list of strengths and limitations of this study, dear Dr Saja. Moreover, I appreciate the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine. Ajay
Jamila Elamouri
2 years ago
Summary
Many kidney donor candidates have a history of prior symptomatic kidney stones and as many as 11% have evidence of stones on renal imaging performed during the evaluation. Some study demonstrate association between renal stone and CKD and ESRD.
Many transplant centers exclude donor with kidney stones, because of possibility of future obstruction and CKD.
The study compared the development of HTN, proteinuria, and reduced eGFR in 227 kidney donors with kidney stones to 908 donors without kidney stones.
After 16.5 ± 10.9 years from donation to study close, no ESRD occurred in donors with stones. The multivariable risks of hypertension, proteinuria, and reduced GFR were similar
in donors with and without kidney stones. The study could not demonstrate an association between stones and adverse renal outcomes in kidney donors, and the occurrence of post-donation stones was distinctly rare. Donors with stones were older, more likely to be Caucasian, less likely to be
related to the recipient and had a higher fasting glucose.
Some candidates with multiple kidney stones who have a favourable and correctable urinary stone profile can be considered if the predicted recurrence rate is low. Nevertheless, one has to be very aware of the limitations of models predicting stone recurrence and the limited ability of urinary stone profile and interventions to address its adverse components in predicting recurrence.
These data may provide a rationale for possibly a wider acceptance of donor candidates with low kidney stones burden.
in our centre, we do not accept donor with kidney stone whatever the condition.
Would this article influence your practice, Dr Jamila?
Mohammad Alshaikh
2 years ago
Please summarise these guidelines in your own words
Kidney stones in donors is not an absolute contraindications of living kidney donation,
Transplant team should be aware of the models predicting stone recurrence, and the limited ability of urinary stone profile.
In all transplant centers the donors is thoroughly evaluated and all the modifiable risk factors identified so the potential donors supposed to be healthy not diabetic and of average weight(BMI)., so they are at low risk of having recurrent kidney stones.
Obesity, smoking history, diabetes mellitus history, family history of DM , kidney stones, or personal history of kidney stones should be identifies, screened and managed.
Kidney stone former donors are not at increased risk of developing HTN, proteinuria ,CKD, or ESRD.
70% of potential donors whom had a history of kidney stone will never experience second or third episode of kidney stones.
ROKS nomogram should be applied to detect the risk of recurrence of kidney stones in all potential donors(ROKS – Recurrence Of Kidney Stone (2014) | Calculate by QxMD | QxMD).
How these guidelines are different from the guidelines you follow at your workplace?
In our center we do full work up by urinalysis and ultrasound abdomen as well as renal CT angiography, and the donors are fully evaluated according to KDIGO 2017 guidelines,
we do not decline donors with renal stones, unless complicated stone events and strong family history, and bilateral stones. and we get the kidney with stone for the recipient.
We do 24 hours urine metabolic panel in recurrent stone formers, and in some cases we do genetic studies if hyperoxaluria or cystinurea suspected.
From this article i learned how to have a systemic risk assessment in kdieny stone potential donor using ROKS nomogram.
It seems using the ROKS nomogram will influence your practice.
Sahar elkharraz
2 years ago
Outcomes of kidney
donors with pre-and
post-donation kidney stones
Please summarise these guidelines in your own words:
Kidney donors with stones, whether occurring pre- or post- donation are not associated with higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
Most of cases, kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation.
There’s some countries like US kidney transplant centers excluded donor with history of renal stone and some centers accept donor with renal stone but normal metabolic studies.
Many studies shows kidney donor not having risk of renal stone post donation.
Cases with predonation renal stone have low rate of renal stone recurrence post donation.
Despite low rate of recurrence post donation but kidney donor renal stone have 47% incidence of CKD post donation and low risk of ESRD.
Kidney donor Renal stone with multiple renal stone and positive family history of renal stone and abnormal urinary metabolic rate should excluded from donation.
Consider kidney donor with one renal stone and no metabolic disturbance with normal body weight.
Strength of this study is wide population spans 50 years of kidney donations and regular follow-up with available data as reduced GFR, proteinuria, and cardiovascular disease.
There were minimal missing data.
Limitations: It’s unclear how many donors with predonation accepted and details regarding kidney stones size, unilateral versus bilateral and in unilateral.
• How these guidelines are different from the guidelines you follow at your workplace?
In our center we excluded all cases with history of recurrent renal stone and positive family history of nephrolithiasis, raised BMI and old male age.
This retrospective study used the data of RELIVE study to compare the post donation outcome between the donors with kidney stones and donors without kidney stones regarding HTN, proteinuria and decrease in GFR.
RELIVE study contained 8922 living donors from 1963-2007 in three large centers.
The living donors with kidney stones were 227 (200 have kidney stones predonation, 21 postdonation, and 6 pre and post).
The three centers excluded patients with multiple and complicated kidney stones but accepted donors with unilateral kidney stone.
Donors with stone were older, smoker, hyperlipidaemic, having 1st degree relative with HTN, not related to recipient, with higher fasting blood sugar and more likely to be Caucasian.
After 16.5+10.9 ys from donation, 39.9% of donors developed HTN, 13.8% developed proteinuria and 0.7% developed ESRD.
Development of HTN, proteinuria, and CKD was the same between donors with or without kidney stones.
After 18.5 + 10.5 ys, 46 donors developed ESRD with none of them was donors with kidney stones.
Conclusion: There is no difference between donors with kidney stones (pre- post or both) and donors without kidney stones in post donation outcome regarding HTN, proteinuria, CKD or ESRD.
Donors with kidney stones with no metabolic abnormality should not be excluded.
Donors with multiple stones with no urinary abnormality, family history of stones, increase of BMI, male gender or any other risk factor of stone recurrence should evaluated using ROKS nomogram and if low rate of recurrence, they could be considered for donation.
11% of living donors show stones during their routine evaluation (CT imaging)
Some evidences report that LD with kidney stone has higher risk for CKD after donation (2 fold or higher!)
The goal of this study is to compare the development of hypertension- proteinuria – and reduced GFR between LD with and without stones
Population
277 LD with kidney stones
908 without kidney stones (after criteria of exclusion and after propensity score matching)
4:1
Average age 39
Female 56%
84% white
80% related LD
71% related stage I has kidney stone
41% related stage I has BP
Average BMI 25
Average GFR 88
Duration of Follow-up
Average 12.9 in LD with stones
13.6 In LD without stones
IN GENERAL in the study
13.9% had hypertension
13.8% had proteinuria
0.7% ESRD
ESRD didn’t happen in LD with stone
Incidence rate of Hypertension- CVD- eGFR <60- eGFR <40- eGFR <30 is similar LD with or without stones
Even proteinuria incidence rate has no significant importance between the two groups
Presence of stones was higher in older- caucasian- non related living donor
In the past , there was caution of accepting LD with stone because this may lead to AKI then CKD
So there was difference in strategies between kidney transplantation centers in US
20% accept LD when the stones is not exist during evaluation for donation
20% refuse any living donor with stone
If we remember that the recurrence rate of kidney stone is 30%, so 70% of living donors with stone were denied in vain
Kummer et al study concluded that kidney stones were not an independent risk factor for CKD
The explanation of studies results , which approved the correlation between LK stones and CKD , is that the control group is from general population so they have risk factors that were usually absence in LD group
The limitation of this study is
1- excluding LD with multiple stones or recurrent stones therefore it may correlate to CkD
2- the strategies of RELIVE study non identical to other centers…it is not able to generalization
Conclusion
LD with kidney stone has no higher risk for reducing GFR- increasing proteinuria- hypertension
And the strategy of US centers in excluding LD with stone is unnecessary
And we should reconsider LD with multiple stones if they have low risk of recurrence after management
In our central we exclude
Multiple and recurrent stone
Stones with positive 24 h urine study (hyperoxaluria- cystinuria….)
I like your list of strengths and limitations of this study, dear Dr Ghalia. Moreover, I appreciate the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine. Ajay
So nice of you for a prompt acknowledgment, Dr Ghalia
Zahid Nabi
2 years ago
In this article Murad and collaegues have tried to look into an interesting question regarding effect of kidney stone presence in donors and subsequent development of hypertension, proteinuria and reduced GFR They compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
The Renal and Lung Living Donor Evaluation Study (RELIVE) was a National Institutes of Health sponsored effort that studied donor outcomes from the University of Minnesota, Mayo Clinic-Rochester and the University of Alabama-Birmingham, as previously described.There were 8922 live kidney donations at the study sites from 1963 to 2007.
For ascertainment of post-donation events, donors were contacted between 2010 and 2012 via telephone and multiple mail- ings for health updates, QOL surveys, and any laboratory data that took place after donation.
In total, 227 donors had kidney stones: 200 donors with pre-do- nation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD.
At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones Proteinuria, however, occurred more often in donors with kidney stones than those do- nors with no stones (20% vs. 13.6%),
Kidney donors with stones, whether occurring pre- or post- dona- tion, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD. A majority of kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation.
Most transplant centers have their own guidelines regarding accepting such donors. As mentioned in this paper around 25% of US centers exclude donors with kidney stones however there is no strong evidence favoring such policy.
The authors propose that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions. Furthermore, we believe that excluding donors with multiple kidney stones, particularly remote ones, who have a benign urinary profile should be revisited and studied further.
We at our center have adopted the same policy and don’t refuse donors with unilateral kidney stones. We do work them for any metabolic abnormality and at times treat these stones before declaring these donors fit .
Hi Dr Nabi,
I like the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine.
Ajay
Abdulrahman Ishag
2 years ago
Please summarise these guidelines in your own words;
1- These guidelines suggest that, kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones.
2-These guidelines recommend that, donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
3-These guidelines suggest that ,candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered if the predicted recurrence rate is low.
4-These guidelines suggest that ,risk of recurrence of kidney stones in potential donor candidates can be quantified using the ROKS nomogram developed by Rule and colleagues. This tool developed in those with symptomatic kidney stones is particularly useful when considering candidates with multiple kidney stones, known stone type, location, and family history of stones.
How these guidelines are different from the guidelines you follow at your workplace?
1-These guidelines increases the pool of donation.
2-kidney donor with multiple kidney stones with low risk of recurrence, can be allowed to donate .
2-It give us a tool to quantify the risk of recurrence
Hi Dr Ishag,
Would you change your department’s practice based on this article?
Ajay
Mohamed Saad
2 years ago
Outcomes of kidney donors with pre- and post-donation kidney stones. Introduction: History of kidney stones might have risk of CKD but still controversial as those group of people had history of other co-morbidities, but here we are taking about potential donors who supposed to have normal renal function at time of donation. In this study they compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to matched donor control without kidney stones. Material/method and result. The Renal and Lung Living Donor Evaluation Study (RELIVE) studied donor outcomes from three centers, There were 8922 live kidney donations at the study sites from 1963 to 2007. Stratified our donors to : A-227 donors had kidney stones. B- 200 donors with pre-donation stones. C-21 donors with post-donation stones. D- 6 donors had both pre- and post-donation kidney stones. They were119 donors had 1 stone, 28 donors had 2 stones, 3 donors had 5 stones. The propensity score (PS)-matched cohort (227 donors with kidney stones and 908 controls without stones) The differences noted between cases and controls after PS matching were a higher prevalence of smoking, hyperlipidemia and having a first-degree relative with hypertension in donors with kidney stones. The proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones . Conclusion: kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones. Acceptance of donors with history of stone formation is center policy dependent, for example 23% of US transplant centers exclude donors with any kidney stones which is not justified, 19% would accept those with a history of stones as long as none is present at the time of donation, and 53% would accept donor candidates with a history of kidney stones provided none is currently present and metabolic studies are normal. How these guidelines are different from the guidelines you follow at your workplace? We exclude donors with history of multiple recurrence of renal stone or with metabolic urinary abnormalities. Incidental urinary stone with negative work up of metabolic-urinary causes can be accepted for donation .
Dear Dr Saad,
I like the scientific content of this write-up. Please type headings and sub-headings in bold or underline, so that it makes it easier to read.
Ajay
Assafi Mohammed
2 years ago
Outcomes of kidney donors with pre-and post-donation kidney stones
Summary of the Article
This is a retrospective study of 227 kidney donors with kidney stone(200 donors with pre-donation stone, 21 with post-donation stone and 6 donors with pre- and post-donation stone) in the period from 1963 and 2007 in the Renal and Lung Living Donor Evaluation Study (RELIVE)-USA. The study compared the development of HTN, Proteinuria and reduced GFR in kidney donors with stone to donor control without stone.
Characteristics of Donors with stone:
a) More likely to beolder
b) More likely to be white(Caucasian).
c) Less likely to be related to the recipient.
d) Had a higher fasting glucose.
e) A slightly lower eGFR.
Study outcomes
1. Outcomes were ascertainable in 97% of the cohort except for proteinuria(missing data).
2. The proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those without stones. Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
3. The difference in proteinuria was no longer significant between stone former and non-stone former.
4. Kidney donors do not appear to be at a higher risk for kidney stones after donation.
5. The low rates of post-donation stones might be related to screening-out candidates who were potential to have stone recurrence in addition to the advices given to the donors to keep drinking water and to stay well hydrated.
6. The link of low CKD rates in donors with stone can be justified by study’s policy of excluding complicated kidney stones from donation.
Study’s strengths
a) The population studied spans 50 years of kidney donations.
b) Follow-up is ethnically diverse.
c) Donors have ascertainable intermediate renal outcomes such as reduced GFR, proteinuria, and cardiovascular disease development.
d) There were minimal missing data.
e) The propensity score matching produced a highly comparable kidney donor control group.
Study’s limitations
a) It is unclear how many donors with pre-donation stones were accepted.
b) There are no available details about regarding kidney stones size, unilateral versus bilateral and in unilateral cases whether that kidney was universally the donated one, and whether they were intervened upon pharmacologically or otherwise.
c) The policies of the 3 RELIVE study centers may not be similar to other centers which may limit the generalizability of these findings.
d) The RELIVE study did not capture bariatric surgery which can be predispose to kidney stones.
Study’ conclusion
a) The study’s data suggest that kidney donors with stones do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors without kidney stones.
b) Some candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered for donation if the predicted recurrence rate is low.
How these guidelines are different from the guidelines you follow at your workplace?
In my workplace we do reject all potential kidney donors with kidney stone(s) or history of kidney stone.
I like your list of strengths and limitations of this study, dear Dr Assafi.
Ibrahim Omar
2 years ago
Please summarise these guidelines in your own words
11% of potential kidney donors were found as having renal stones on imaging studies.
some data reported that stones may be associated with an increased risk of CKD/ESRD.
one study was carried out in Canada and revealed that 1 or more episode of renal stones were associated with a 2 fold increase in the risk of ESRD.
the National Health and Nutritional Examination Survey (NHNES)- based study revealed similar results but in women, not in men
25% of transplant centers in US, exclude donor candidates with renal stone for the fear of developing CKD.
this article was for a study that compared 227 kidney donors with renal stones versus 908 kidney donors without kidney stones, for the outcome of hypertension, proteinuria and decreased GFR. it used data from the RELIVE study that included 8922 living kidney donations that were managed in 1963-2007. 200 donors had renal stones pre-nephrectomy, 21 doors developed renal post-nephrectomy and 6 donors developed renal stones both pre and post-nephrectomy.
the results were as following :
1- donors with renal stones were older, more of caucasian race and having an increase in blood sugar.
2- there was no incidence of ESRD in donors with kidney stones over a period of 16.5 +/- 10.9 years of follow-up.
3- the multi-variable risks of hypertension, proteinuria and decreased GFR, were similar in both groups of donors.
4- there was no association between renal stones and adverse renal outcome in kidney donors.
the conclusion were :
1- kidney donors with kidney stones have no increased risk of hypertension, proteinuria or decreasing GFR.
2- kidney donor candidates with kidney stones shouldn’t be excluded from donation provided that they are carefully evaluated for underlying metabolic disturbances as most of these disturbances can be managed with dietary modifications or pharmacologic interventions.
3- kidney donor candidates with multiple kidney stones who have favorite and correctable urinary stone profile can be considered for donation if the recurrence rate is low.
4- the risk of recurrence of renal stones in potential kidney donors can be reasonably quantified with ROKS nomogram, developed by Rule and colleagues.
How these guidelines are different from the guidelines you follow at your workplace?
these guideline allow for more acceptance of donors including those with current or past history of renal stones.
Re-evaluation of previously rejected donors can be done to accept them for donation.
Yes Dr Omar,
That is very good that you wish to reevaluate your policy based on this article.
Ajay
Yashu Saini
2 years ago
Kidney stones in kidney donors are quite common. [RATHER VERY COMMON IN MY STATE IN INDIA BUT VERY LESS PERCENTAGE OF METABOLIC CAUSES]
At many centers these candidates are excluded from the list of potential donors due to many anticipated risks associated with kidney stones: Obstructive, Infective, Metabolic and likely possibility of development of proteinuria and ESRD later in life post donation.
However, its still remains a controversial topic that whether to exclude all such potential donors with kidney stones straightaway or have common assessment policy.
Current study is a multi-centric (Involving 3 US centers) case control study with controls being the potential donors without kidney stones and not the general population. It had long follow up ranging from 13 to 20 years
Aim of Study: Development of hypertension, proteinuria, and reduced GFR after kidney donation was compared between donors with stones and propensity score-matched controls without kidney stones who were also potential donors.
Donors were grouped into three categories as per the kidney stone history:
pre-donation kidney stones
post-donation kidney stones
both pre- and post-donation stones.
227 donors had kidney stones who were compared to 908 propensity score (PS)-matched controls without stones.
The only differences noted between cases and controls after PS matching were a higher prevalence of smoking, hyperlipidemia and having a first-degree relative with hypertension in donors with kidney stones Outcomes of study
Donors with kidney stones were older, more likely white, had a higher fasting plasma glucose and a slightly lower eGFR.
Death, CVD, new onset hypertension, proteinuria, eGFR < 60 and <45 ml/ min/1.73 m2 that were statistically similar in donors with history of kidney stones as compared to controls.
Strength:
Population studied spans 50 years of kidney donation and follow up.
Ethnically diverse follow up.
There were minimal missing data
highly comparable kidney donor control were produced by propensity score matching
Limitations:
It was unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances that could lead to more kidney stones.
Kidney stone size were not available.
The three study centers included might have different policies regarding donation with kidney stones
Overall, the authors proposed that donor candidates should not be excluded straightaway from donation until detailed metabolic evaluation has been done and ROKS normogram should be used for assessment of risk of recurrence of kidney stones in potential donors
This was a case-control study looking at outcomes of kidney donors with pre- and post-donation kidney stones.
Many potential kidney donors have a history of renal calculi and are exempted from donating due to the potential risk of developing a kidney stone in the remaining kidney which may cause obstruction and consequent CKD. A study in Canada demonstrated that patients with kidney stones had a 2-fold higher risk of developing CJD and ESK. The NHANES survey also showed an increased risk developing CKD in female patients with kidney stones. However, the ARIC study did not demonstrate an increased risk of CKD in patients with kidney stones.
The possible reason for the the development of CKD and ESKD in patients with kidney stones is postulated to be due to the many comorbidities these patients also have.
Kidney donors are a special cohort of patients with no comorbidities, therefore their risk of developing CKD or ESKD should not be high.
This study looked at all the kidney donors from 1963-2007 at three centers. They compared kidney donors who had kidney stones pre-donation, pre- and post donation and those who developed kidney stones post-donation to propensity score-matched control donors without kidney stones.
They looked at 8922 kidney donors out of which 8695 had no kidney stones and 227 had kidney stones.
The 227 kidney donors with kidney stones were compared to 908 propensity score-matched control donors without kidney stones.
The outcome measures being looked at were
Development of hypertension
Development of proteinuria
Reduced GFR
Baseline demographics and laboratory investigation results were obtained from the centers where the donors had undergone nephrectomy. A history and timing of kidney stones was obtained from the records and by donor-self report. Post-donation events were obtained from the medical records which included post-donation hypertension, CVD, proteinuria and ESKD.
HTN, proteinuria, eGFR < 60 mls/min and < 45 mls/min and CVD was compared in donors with stones to donors without stones.
200 donors had kidney stones pre-donation, 6 had kidney stones pre- and post-donation and 21 had developed stones post-donation.
The characteristics of donors with stones included:
Older age
Caucasian
Less likely to be related to the recipient
Higher fasting plasma glucose
The study showed that the risk of developing HTN. proteinuria or reducing GFR was similar in donors with kidney stones and donors without kidney stones.
The findings are similar to a study by Kummer et al.
The reason for the higher incidence of developing CKD/ESKD in non-donors with kidney stones is that these patients have multiple other comorbidities that can predispose them to develop CKD/ESKD and CVD, while the kidney donors are a highly selected cohort of patients with no comorbidities and hence their risk is much lower.
The authors propose that the criteria for disqualifying potential kidney donors with kidney stones should be re-looked in to.
In my center, our guidelines disqualify patients with history of recurrent renal calculi or presence of renal calculi during the work up. If the patient has had one episode of renal calculi, a full stone work up is done and if no cause is found then the patient is allowed to proceed with donation after counseling. However, the donor is under closer follow up
1-Summary ofoutcomes of kidney donors with pre-and post-donation kidney stones:Some studies concluded kidney stone may be associated with a higher risk of ckd and ESRD but presence of multiple morbid condition made the result of these studies is quite complicated.
In this study compared the development of HTN ,proteinuria and reduced eGFR in kidney donor with kidney stone to donor( control )without kidney stone.
material and methods:
At the RELIVE study there were 8922 live kidney donation at the study from 1963 to 2007.with updating information between 2010 to 2012.
Family history of HTN ,DM ,kidney disease ,stroke or heart disease in donors first degree relatives were recorded.
Report in this study included HTN ,proteinuria ,eGFR,60 and ,45ml/min1.7 m2and cvs were compered in donors with kidney stones versus those who had no kidney stone(control).
Result
Donor with kidney stone were older ,white and non related to recipient had a higher fasting plasma glucose 95 vs 92 mg/dl and a higher lower eGFR (85.1 vs88.4) p <.05 for all.
There were 227 donors had kidney stone 200 donors with pre donation stones,21 post donation stones ,and 6 donors had pre and post donation stones.
higher BMI were found in the in pre and post donation group.
lower eGFR and hyperlipdemia in stone at donation group.
Study outcome
there were 36.9% of donors develop HTN and 13.8% develop proteinuria and 0.7%had ESRD.
Death ,CVS, new onset HTN ,proteinuria ,eGFR <60and <45 were not statistically different in donors with history of stone and control groups.
no evidence of stone postdonation
Discussion
kidney donors pre or post donation ,were not at a higher, reduced eGFR ,proteinuria or ESRD risk for developing HTN .
Strength of this study
1-50 years of follow up of kidney donation..
2- donor have intermediate result out come such as reduced eGFR ,proteinuria ,cvs disease development .
3- minimal missing data .
4-The propensity score matching provide a highly comparer kidney donor and control .group.
Limitaion of the study
The number of donors with pre-donation stone that were accepted after they passed screening for metabolic disturbance is unclear .
Conculision
Kidney donor with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR ,HTN or proteinuria who compered to kidney donor with no kidney stone
2-In our centre any donor with multiple ,recurrent stone and metabolic disorder is declined from the donation.
Professor Ahmed Halawa
Admin
2 years ago
Dear All I was pleased to read your comments. There is some variation of practice which is normal. Some of you exclude all potential donors with a history of a single stone. We need to know the basics of this exclusion.
Regarding those who accept potential donors with a history of a single small stone (including all UK centres). What criteria should be fulfilled before accepting them?
I really enjoyed the reflection and it is a good opportunity to learn from each other NB Ibrahim et al is a well-known figure in this respect and all his articles are landmarks in kidney donation.
Donors with history of renal stones are not at increased risk of renal adverse outcomes and should not be excluded form donation if metabolic work up is negative, and no current renal stones at the time of evaluation
The recurrence rate can be reduced by either dietary and/ or pharmacological intervention (such as treatment of hyperuricemia)
Guidelines for Living Donor Kidney Transplantation stated that :
Patient with history of renal stones can donate provided it is not recurrent and after exclusion of metabolic abnormality like hyperoxalosis, hypercalciuria, hyperuricosuria, hypocitruria
This means that indication of exclusion of patient with history of renal stones include
Recurrent stones
Current stone
Stones associated with metabolic abnormalities
Hence a patient with a single episode of renal stone can donate
But some will be reluctant to accept donor even with a single episode or renal stone on the base that a patient with history of renal stone has a 10-30 % recurrence rate at 3 years, 35-40 % at 5 years and 50% chance of recurrence at 10 years. (1-5) and this will be problematic in case of a single kidney
For me I will accept a donor with single episode or renal stone if no current stone and no metabolic abnormalities after educating the patient about the dietary life style to prevent recurrence.
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.
According to KDIGO guideline
The acceptance of a donor with prior or recurrent kidney stones should be based
on assessment of stone recurrence risk
Knowledge of the possible consequences of kidney stones after donation
Donor with kidney stone should have counseling (evidence based prevention of recurrent stones)
Detailed evaluation: time of the previous stone – location- all investigations (CT…)
Laboratory evaluation should be done
PTH …24h urine collection for Ca-UA- OXALATE- CITRATE- AND OTHERS….
Kidney function evaluation (GFR)
And exclude urology abnormalities
some factors carry low risk
>40 years
Stone less than 1.5 cm
Solitary
Unilateral
No family history
So with negative evaluation and a low risk of recurrence we consider accepting donor with
Stone provided that he will be followed up by specialist to prevent the occurrence of stones
MOHAMMED GAFAR medi913911@gmail.com
2 years ago
Studying the potential association between kidney stones and future development of chronic kidney disease is quite complicated as many people with kidney stones have multiple comorbid conditions.
Kidney donors with stones, whether occurring pre or post donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
Symptomatic and incidentally discovered kidney stones in kidney donors are not uncommon; 3%–11%.
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, and 53% would accept donor candidates with a history of kidney stones provided none is currently present and metabolic studies are normal.
10-year recurrence rate of kidney stones is highly variable but is generally around 30% for all comers which means that 70% of donor candidates with stones who are declined may never experience a second or a third episode of nephrolithiasis.
donors candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions. Furthermore, excluding donors with multiple kidney stones, particularly remote ones, who have a benign urinary profile should be revisited and studied further.
How these guidelines are different from the guidelines you follow at your workplace?
if the kidney stone stone is incidental finding with now history of reccurent stones no family historty of stone formation , no any metbolic screen abnormaity we can accept him as adonor.
if there is a history of recurrent kidney stone with any metboic screen abonormaities we will decline him.
Please summarise these guidelines in your own words
Incidentally discovered kidney stones in kidney donors are not uncommon. Transplant centers tend to exclude candidates with kidney stones fearing future obstructive consequences and the possible association between stones and CKD. However, there is controversy regarding this relation as the potential association is quite complicated as many people with kidney stones have multiple comorbid conditions.
Study aim: compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
Study population: living kidney donors who involved at RELIVE study in 3 US transplant centers from 1963 to 2007. For post-donation events, donors were contacted between 2010 and 2012 via telephone and multiple mailings for health updates.
Donors were stratified by kidney stone history: none, pre-donation kidney stones, post-donation kidney stones or both pre- and post-donation stones.
In total, 227 donors had kidney stones (200; pre-donation stones, 21;post-donation stones, and 6; both pre- and post-donation kidney stones) compared to 908 propensity score (PS)-matched controls without stones.
Donors with kidney stones were older, more likely to be white, less likely to be related to the recipient, had a higher fasting plasma glucose, and a slightly lower eGFR.
The only differences noted between cases and controls after PS matching were a higher prevalence of smoking, hyperlipidemia and having a first-degree relative with hypertension in donors with kidney stones
Study outcomes
The logistic regression model yielded adjusted odds ratios for death, CVD, new onset hypertension, proteinuria, eGFR < 60 and <45 ml/ min/1.73 m2 that were not statistically different in donors with any history of kidney stones compared to propensity score-matched controls.
Strength:
The population studied spans 50 years of kidney donation.
Follow-up is ethnically diverse.
Donors have ascertainable intermediate renal outcomes which are not captured in national donor data sets.
There were minimal missing data
The propensity score matching produced a highly comparable kidney donor control group
Limitation:
It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances that could lead to more kidney stones.
Details regarding kidney stone size, unilateral versus bilateral and in unilateral cases whether that kidney was universally the donated one, and whether they were intervened upon pharmacologically or otherwise.
the policies of the 3 RELIVE study centers may not be similar to other centers which may limit the generalizability of these findings.
the RELIVE study did not capture bariatric surgery which can be predisposed to kidney stones.
Study Conclusion;
Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
These data may provide a rationale for possibly a wider acceptance of donor candidates with low kidney stones burden These findings, however, do not provide guidance on candidates with more complicated stone history as those have been generally excluded from donation.
How these guidelines are different from the guidelines you follow at your workplace?
Potential donors with kidney stone and family history of kidney stone, abnormal metabolic screen or bilateral stone are usually excluded.
However, those with asymptomatic, unilateral, small stone, normal metabolic screen, and no family history of stone will be accepted for donation.
It is estimated that around 25% of US transplant centers exclude donor candidates with kidney stones. This is because of possible recurrence of kidney stone in the transplanted allograft with subsequent obstructive consequences and the possible association between stones and CKD.
The relationship between kidney stones and kidney disease post-kidney donation is controversial. Some studies reported that a history of kidney stones was associated with CKD and ESKD in women but not in men, however another study reported no association with higher risk of CKD after multivariable adjustment.
Results of RELIVE (Renal and Lung Living Donor Evaluation) Study
– After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD.
– There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones.
– The logistic regression model yielded adjusted odds ratios for death, CVD, new onset hypertension, proteinuria, eGFR < 60 and <45 ml/ min/1.73 m2 that were not statistically different in donors with any history of kidney stones compared to propensity score-matched controls.
In conclusion, Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD. Kidney donors do not appear to be at a higher risk for kidney stones after donation.
It is proposed that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
Please summarise these guidelines in your own words
Approximately 25% of renal donor candidates are rejected due to renal stones in view of a probable association with CKD. This study was conducted to evaluate kidney donors with stones with respect to development of hypertension, proteinuria, and reduction in eGFR.
This study was based on data from RELIVE (Renal and Lung Living Donor Evaluation) Study which involved 8922 donors from 3 transplant centres. A total of 227 donors had renal stones (200 had pre-donation stones, 21 had post-donation stones, while 6 had both pre- and post-donation stones). They were compared with 908 matched donors. Donors with >2 stones pre-donation were excluded.
Donors with stones were more likely to be whites, were older, less likely to be related to the recipient, had higher fasting blood sugars, and had slightly lower eGFR. Majority had single kidney stone. The median time from donation to stone detection was 89 days. Donors with both pre- and post-donation stones had higher BMI, dyslipidemia and lower eGFR at the time of donation.
Hypertension, reduction in GFR, ESKD and proteinuria were similar in the two groups.
The strengths of the study include: long-term data involving follow-up of diverse ethnic background donors, availability of complete data, and a highly comparable control group. The limitations of the study were that the data for kidney stone characteristics, metabolic screening of the donors and regarding bariatric surgery was missing.
Hence the study group recommended that the donor candidate should not be rejected in presence of renal stones, unless they have been evaluated for underlying metabolic abnormalities
How these guidelines are different from the guidelines you follow at your workplace?
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 in them is recommended.
By metabolic abnormalities, I meant was serum levels of calcium, phosphorus, uric acid, in addition to 24 hour urine collection for calcium, uric acid, citrate, oxalate, creatinine, sodium and magnesium.
The results of these tests can give us a clue regarding the cause of stone formation.
Isaac Abiola
2 years ago
SUMMARY
Introduction
It is estimated that about 25% of the potential kidney donor is US are declined because of findings of kidney stone for the fear of possible development of CKD after donation. Also, some studies have reported a greater risk of developing CKD or ESRD among people with kidney stone, but others have also reported contrary to this finding.
Aim of the Study:
-to compare the development of hypertension, proteinuria, and reduce GFR among donors with kidney stone to the matched control group.
Material and Method:
8922 kidneys RELIVE donors between 1963-2007 data were recruited
baseline demography and history were obtaine
donors were contacted for information between 2010-2012 via phone and mailing system
definitions of post donation hypertension, proteinuria, CVD event, and reduce GFR were set
institutional board review approval was obtained
Results
the median age, BMI, and GFR was 39 years, 25.8kg/m2, and 88.2ml/min/1.73m2
227 donors have kidney stones, and it was matched against 908 non donors
200 out of the 227 donors have kidney stones before donation while 21 had after donation, and 6 had before and after donation
donors with pre and post donation stone were found to have a higher BMI, reduce GFR at donation and hyperlipidemia
the only observed difference between case and control were higher smoking rate, hyperlipidemia and hypertension among donors with stones
following 16.5+- years of follow up, hypertension, proteinuria, and ESRD was 36,9%, 13.8% and 0.7% respectively
kidney donors with stones were not at higher risk of developing hypertension, proteinuria, reduce GFR or ESRD
smaller number of donors reported kidney stones after donation.
Conclusion
There was no significant increase of hypertension, proteinuria or ESRD among donors with kidney stones compared to the matched donor in this study, hence exempting potential donors from donating kidney because of stone may not be totally beneficial to the growth of kidney transplantation.
In my centre, we do take donor with one stone after evaluating for possible etiology of the stone, but we usually reject those with two or more stones.
Please summarise these guidelines in your own words
Many studies suggest that there is an association between kidney stones and CKD. This study compared HTN, proteinuria , reduced eGFR and CV disease in kidney donors with kidney stones to matched controlled donor without kidney stones (ratio 1:4)
They used data of the Renal and Lung Living Donor Evaluation Study (RELIVE). Donors with proteinuria, eGFR < 80 and multiple kidney stones (3-5) were excluded
Donors with kidney stones were older, most of them were Caucasian, less likely to be related to recipients and higher fasting glucose
227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones. The majority (119) had 1 stone, 28 donors had 2 stones, 3 donors had 5 stones, and the number of stones in the remainder was unknown
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed HTN, 13.8% developed proteinuria, and 0.7% had ESKD. Proteinuria occurred more in the case group but not significant. These results were similar to control group. Death, CVD, HTN, proteinuria, eGFR < 60 and <45 ml/ min were not statistically different in donors with any history of kidney stones compared to matched control group
Limitations of the study: It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances. Kidney stones size, unilateral versus bilateral and in unilateral cases which kidney was donated
These data concluded that kidney donors may be allowed to donate as there is no increase risk of proteinuria, reduced GFR or HTN
How these guidelines are different from the guidelines you follow at your workplace?
We exclude almost all donors with kidney stones (high risk of kidney disease). This article changes our mind as there is no increase risk of kidney diseases and other adverse outcomes regarding no metabolic abnormalities
Thank you Mohamed for your reflection on your practice.
Mahmoud Wadi
2 years ago
Please summarise these guidelines in your own words
– Many kidney donor candidates have a history of prior symptomatic kidney stones and around 11% have evidence of stones on renal imaging performed during the evaluation.
– Some data suggest that kidney stones may be associated with a higher risk of CKD
and ESKD.
– Studying the potential association between kidney stones and future development of chronic kidney disease is quite complicated as many people with kidney stones have multiple comorbid conditions.
-This study compared the development of hypertension, proteinuria, and reduced
eGFR in 227 kidney donors with kidney stones to 908 to matched donor controls without kidney stones using data from The Renal and Lung Donor Evaluation (RELIVE) Study. M ATE R I A L S A N D M E TH O DS
– Data was collected from RELIVE study which included 8922 living kidney donors from 1963-2007.
– 908 matched donors with no history of renal stones
– 227 kidney donors with stones
– Post-donation data was collected from 2010-2012 by contacting the donors through telephone and mailing.
– Post-donation events were also supplemented from centers records.
###Exclusion criteria: candidates with multiple stones especially recent onset.
-Candidates with complicated stones.
– Results:
– 200 donors had kidney stones before donation.
– 21 had post-donation stones.
– 6 had pre- and post-donation stones.
###Donors with stones were older, more likely to be Caucasian, less likely to be related to the recipient and had a higher fasting glucose.
– After 16.5 ± 10.9 years from donation, no ESKD occurred in donors with stones.
-46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones.
-The multivariable risks of hypertension, proteinuria, and reduced GFR were similar in
– donors with and without kidney stones. Discussion
– Donors with stone pre or post were not at higher risk of developing HTN, decrease eGFR, proeteinuria, and ESKD.
-Also noticed decrease rate of stone , may be due to exclusion of donors with stone during evaluation.
– CKD post donation associated with kidney stone in some studies.
The development of a kidney stone in a kidney donor can have the serious consequence of obstructing the remaining kidney which may require emergency surgical intervention.
The population studied spans 50 years of kidney donations and follow-up is ethnically diverse and donors have ascertainable intermediate renal outcomes such as reduced GFR, proteinuria, and cardiovascular disease development
which are not captured in national donor data sets.
There were minimal missing data, and the propensity score matching produced a highly comparable kidney donor group .
limitations.
It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances that could lead to more kidney stones.
Details regarding kidney stones size, unilateral versus bilateral and in unilateral cases whether that kidney was universally the donated one, and whether they were intervened upon pharmacologically or otherwise were not available in this public data set.
Policies of the 3 RELIVE study centers may not be similar to other centers which may limit the generalizability of these findings.
Lastly, the RELIVE study did not capture bariatric surgerywhich can be predispose to kidney stones.
Conclusion
– pre – post-donation stones were distinctly rare.
kidney donor are not associated with an increased risk of kidney adverse effects and CV disease.
How these guidelines are different from the guidelines you follow at your workplace?
In our center donors with kidney stones are excluded from donation,espicially ( family history of reccurent kidney stones ,metabolic,bialateral kidney stones).
Study compared the development of hypertension, proteinuria, and reduced eGFR in 227 kidney donors with kidney stones to 908 propensity score-matched donor controls without kidney stones
Ø 200 donors had kidney stones prior to donation, 21 had post-donation stones, and 6 had pre- and post-donation stones: details
1. Donors with pre-donation kidney stones and those with both pre- and post-donation stones were older than donors with post-donation stones only (43.5 vs. 45.5 vs. 34 years); donors with pre-donation kidney stones were less likely to be men and more likely to be white. The median time (IQR) from having a kidney stone to donation in those with pre-donation stones was 154 (50, 2478) days.
2. In the 6 donors with post-donation stones only, the interval from donation to stone was 89 days (65, 100).
3. Donors who had both pre- and post-donation stones had a higher BMI, a lower eGFR at donation and were more likely to have hyperlipidemia.
Ø Donors with stones were older, more likely to be Caucasian, less likely to be related to the recipient and had a higher fasting glucose.
Ø Outcome:
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD. There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones. At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922). Proteinuria, however, occurred more often in donors with kidney stones than those donors with no stones
Ø Summary:
1. After 16.5 ± 10.9 years (range 0–44 years) from donation to study close, no ESKD occurred in donors with stones.
2. The multivariable risks of hypertension, proteinuria, and reduced GFR were similar in donors with and without kidney stones.
3. No association demonstrated between stones and adverse renal outcomes in kidney donors, and the occurrence of post-donation stones
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone usually accepted as donor.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD.
the development of hypertension, proteinuria, and reduced eGFR were compared in 227 kidney donors with kidney stones to 908 matched donor controls without kidney stones using data from The Renal and Lung Donor Evaluation (RELIVE) Study.
They studied intermediate and long-term outcomes of 8922 donors who donated between 1963 and 2007.
200 donors had kidney stones prior to donation, 21 had post-donation stones, and 6 had pre- and post-donation stones.
· Donors with stones were older.
· Caucasian
· not related to the recipient
· had higher fasting glucose
After 0 to 44 years from donation to study close: No ESKD occurred in donors with stones.
The multivariable risks of hypertension, proteinuria, and reduced GFR were similar in donors with and without kidney stones.
No association between stones and adverse renal outcomes in kidney donors were found, and the occurrence of post-donation stones was rare.
The author proposed that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
Excluding donors with multiple kidney stones, who have a benign urinary profile should be revisited These data may change the concept of excluding donors with kidney stones, hence increasing the donor pool.
At our place the donors with renal stones are excluded , this article may change our practice.
This retrospective analysis compared the post-donation outcomes between donors with kidney stones and donors without kidney stones regarding HTN, proteinuria, and a decline in GFR using data from the RELIVE trial.
live donors were included in the RELIVE project from 1963 to 2007 at three major centres
There were 227 live donors who had kidney stones (200 have kidney stones predonation, 21 postdonation, and 6 pre and post)
The three hospitals did not accept donors with unilateral urolithiasis but did not accept patients with many or complex urolithiasis
At the study’s conclusion in 2007, it was discovered that both groups had a comparable risk of hypertension, cardiovascular events, and low GFR. Proteinuria was more prevalent in the kidney stone group
The authors argue that as long as potential donors are thoroughly examined for core metabolic problems, the majority of which may be treated with nutrition and/or pharmaceutical therapies, they shouldn’t be rejected from donation because they have kidney stones
Additionally, they think that it’s time to reconsider and continue research on the exclusion of donors with numerous kidney stones, especially distant donors with a benign urine profile
Despite the growth of patients on the waiting list for kidney transplantation, it is still common in large centers for patients with a history of kidney stones not to be accepted as donors. This is due to fear of future obstructions and the lack of confidence in current evidence that excludes an association between kidney stones and the development of Chronic Kidney Disease.
There are a wide variety of studies that suggest an association between kidney stones and the development of end-stage renal disease, but performed with different methods, populations and outcomes. This just shows how there is a variety of analyzes to be performed, in addition to the fact that patients with kidney stones often have a large number of comorbidities.
This study known as the Living Renal and Lung Donor Evaluation Study (RELIVE) was able to compare specific data for the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones with propensity score-matched donor controls without kidney stones.
In the results, it was noticed that the proportions of donors who developed hypertension, cardiovascular disease, loss of estimated glomerular filtration rate (at < 60, < 45 and < 30 ml/min/1.73 m2) were similar in donors with calculi to those observed in the larger group of donors without stones. Proteinuria, on the other hand, occurred more frequently in donors with kidney stones than in donors without stones. What drew the most attention was that in the 46 cases of progression to end-stage renal disease, none of them had a donor with a kidney stone.
Kidney donors with stones, occurring pre- or post-donation, were not at increased risk of developing hypertension, reduced eGFR, proteinuria, or end-stage renal disease. Most kidney stones occurred in older Caucasian donors who were not related to the recipient and who were also more likely to have a lower eGFR on donation. Despite this result, we cannot contemplate patients/donors with a history of complicated calculations, as this patient profile was not part of the study.
It is likely that studies that have shown an association between stones and chronic kidney disease in the general population have obtained this result due to the presence of predisposing factors that are almost always absent in kidney donors, as kidney donors rarely have comorbidities, do not show evidence of kidney disease , even subtle, usually do not take medication and have normal weight in most cases.
This guideline allows the use of organs from donors with a history of kidney stones when well evaluated.
Kidney stones is a common health issue in general population estimated to affect 11 of US population, but its impact on developement of CKD and ESRD in kidney donors is difficult to be assessed as most patients with renal stones usually have other comorbidities while kidney donors are selected from the healthiest individuals. Donors with renal stones whether past or current are usually excluded from donation due to fear of developing CKD or obstructing uropathy post donation that may require surgical interference, despite the fact that the 10 years stone recurrence rate is 30 %. The few transplant centers who accept donor with stone, usually accept only patients with past history of stone with no recurrence and normal metabolic screen for stones.
Previous studies suggested that presence of renal stone increase the risk of CKD and ESRD by two folds.
In this case – control study, the investigators compared e GFR, HPN and proteinuria in donors with renal stone (200 had stones before donation, 21 had post donation stones and 6 had both pre and post donation stones). The follow up period was around 16.5 y , the patients who had pre and both pre and post donation stones were more likely to be elderly, Caucasian. Renal stones were both asymptomatic (132 patients) and symptomatic in others.
Results of previous studies regarding stone recurrence post donation were reassuring as Thomas et al found that recurrence rate in donors was the same as non-donor controls and surgical intervention was needed only in 9/10000 patients.
The studies evaluating the link between renal stones and CKD and ESRD revealed conflicting results were some of them linked nephronophthisis with CKD but not ESRD while others show didn’t consider nephronophthisis as an independent risk factor for CKD, the same was present in current study
Recommendations
1- patients with renal stones shouldn’t be excluded as donors except after careful history taking (unilateral or bilateral stone, symptomatic or incidentally discovered, family history of stones)
and metabolic screen investigations to assess the possibility of stone recurrence.
2- patients with single, remote episode of nephronophthisis can be safely considered for donation.
3- Some metabolic disorders can be effectively managed with diet and medications.
Conclusion
Donors with renal stone shouldn’t be refused based on previous stone history alone but calculate their risk of recurrence and underlying metabolic disorders and many of them can donate safely.
In this study, development of renal stones was not associated with excess risk for decreased GFR, proteinuria or HPN
Q1- Summarization of the article: stone presence in donors and progression to ESKD were found correlated in studies done before. Associated comorbidities can have a role here, because of obstructive uropathy development concern in the kidney, post-donation.
We can accept donors who have low burden kidney stones which might be unilateral, single, exclusion of metabolic stone panel abnormality, since follow-up in long periods of time showed results alike to donors who didn’t have stones considered declining GFR, hypertension, and proteinuria.
The definition of Proteinuria was urine protein more than or equal to 2+ using dipstick, ratio of urine protein to creatinine more than 0.42 or 24-h protein more than 300 mg/day.
The definition of hypertension was a BP more than 140/90 mmHg.
We exclude patients who had multiple or bilateral stones.
Having stones after the donation is unusual because of their attention to adequate screening for stones and ample evaluation of donors, having excluded irregularity from possible donors and hydration.
We should study donors who have multiple stones well in order to adapt to the absolute contraindication category of them, meanwhile estimate the risk of recurrence.
Q2- In our center, if there is only one available donor with a single stone and no other urine irregularity, we would transplant the kidney while closely following up the donor. Donors with recurrent, multiple, and bilateral stones are excluded.
INTRODUCTION
Many kidney donor candidates have a history of prior symptomatic kidney stones and as many as 11% have evidence of stones on renal imaging performed during the evaluation.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD.
In one study from Canada, one or more episodes of kidney stones were associated with a twofold higher risk of ESKD.
A National Health and Nutrition Examination Survey based study also reported that a history of kidney stones was associated with CKD and ESKD in women but not in men.
This study compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stone.
MATERIALS AND METHODS
The Renal and Lung Living Donor Evaluation Study (RELIVE) was a National Institutes of Health sponsored effort that studied donor outcomes from the University of Minnesota, Mayo Clinic-Rochester and the University of Alabama-Birmingham, as previously described.
Study population
There were 8922 live kidney donations at the study sites from 1963 to 2007.
Results:
Donors with kidney stones were older (43 vs. 39 years), were more likely to be white (92.5% vs. 84.6%), less likely to be related to the recipient (71.8% vs. 81%), had a higher fasting plasma glucose (95 vs. 92 mg/dl) and a slightly lower eGFR (85.1 vs. 88.4 ml/min/1.73 m2 ), p < .05 for a Characteristics of donors with kidney stones In total, 227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones .
The majority (n = 119) had 1 stone, 28 donors had 2 stones, 3 donors.
Characteristics of donors with kidney stones In total, 227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones (Figure 1). The majority (n = 119) had 1 stone, 28 donors had 2 stones, 3 donors.
Donors who had both pre- and post-donation stones had a higher BMI, a lower eGFR at donation and were more likely to have hyperlipidemia.
Study outcome:
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD. There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones.
At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922),
Proteinuria, however, occurred more often in donors with kidney stones than those donors with no stones (20% vs. 13.6%).
DISCUSSION :
Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
A majority of kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation.
In our practice we don’t accept donors with history of stone .
Outcomes of kidney donors with pre- and post-donation kidney stones.
Q1- Please summarise these guidelines in your own words
INTRODUC TION
Many kidney donor have a history of prior symptomatic kidney stones and 11% have stones on renal imaging performed during the evaluation.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD.
kidney stones IN (ARIC) Study was not associated with a higher risk of CKD after multivariable adjustment.
This study compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to pro pensity score-matched donor controls without kidney stones
DISCUSSION
Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD. , very few donors reported kidney stones after donation. These data, , do not provide guidance on candidates with more complicated stone history .Symptomatic and incidentally discovered kidney stones in kidney donors are 3%–11%.
The development of a kidney stone in a kidney donor can cause obstructing the remaining kidney which may require surgical intervention. T there is a concerns about a possible association between kidney stones and CKD in some studies have resulted in wide variability among US transplant centers regarding the acceptance of kidney donors with stones.
Ø 23% of US transplant centers indicated they exclude donors with any kidney stones,
Ø 19% would accept those with a history of stones as long as none is present at the time of donation,
Ø 53% would accept donor candidates with a history of kidney stones provided none is currently present and metabolic studies are normal.
These practices are quite surprising considering that the 10-year recurrence rate of kidney stones is highly variable but is generally around 30% for all comers which means that 70% of donor with stones who are declined may never experience a second or a third episode of nephrolithiasis.
Kidney donors are not at a higher risk for kidney stones after donation. Thomas et al showed that kidney donors had similar hospital encounters for kidney stones as non-donor controls . The rate of kidney stones needing surgical intervention was similar in donors controls.
The evidence linking kidney stones to CKD and ESKD development has been mixed.
A recent meta-analysis of 7 studies concluded that a history of kidney stones was associated with a
47% higher likelihood of CKD . But in RELIVE study ESKD development in their cohort was rare. Interestingly, those with asymptomatic kidney stones incurred a higher risk of ESKD than those with recurrent stones. Kummer et al. did not find that nephrolithiasis was truly an independent risk factor for CKD development.
Ø This article propose that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
Ø excluding donors with multiple kidney stones, particularly remote ones, who have a benign urinary profile should be revisited and studied further.
Ø Risk of recurrence of kidney stones in donor can be reasonably quantified using the revised ROKS nomogram.
Ø Many with multiple kidney stones may have low recurrence rate and therefore maybe considered for donation provided they have no urinary mineral abnormalities.
These analyses have strengths.
Ø The population studied spans 50 years of kidney donations and follow-up is ethnically diverse and donors have ascertainable intermediate renal outcomes such as reduced GFR, proteinuria, and cardiovascular disease development which are not captured in national donor data sets.
Ø There were minimal missing data, and the propensity score matching produced a highly comparable kidney donor control group.
limitations of study .
Ø It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances that could lead to more kidney stones.
Ø Details regarding kidney stones size, unilateral
Øversus bilateral and in unilateral cases whether that kidney wasuniversally the donated one, and whether they were intervened upon pharmacologically or otherwise were not available in this data.
Conclusion :
Ø these data suggest that kidney donors with kidney stoneswho were allowed to donate do not have an increased risk of reducedeGFR, hypertension, or proteinuria when compared to kidney donorswith no kidney stones.
Ø excluding donors with anykidney stones by 25% of US transplant centers may not be justified.
Ø some candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered if the predicted recurrence rate is low.
Ø There is alimitations of models predicting stones recurrence and the limited ability of urinary stone profile and interventions to address its adverse components in predicting recurrence.
Q2-How these guidelines are different from the guidelines you follow at your workplace?
1) History of single stone which is not present know the donor can be accepted.
2) In the absence of a significant metabolic abnormality, history of stone a (small limited number) can be accepted for donation.
3) Potential donors with metabolic abnormalities detected on screening usually decline.
4) In appropriate donors , the stone-bearing kidney can be considered for donation .
In this article it was found 3 to 11% renal stones in imaging during there evaluation. literation shows there is increased risk of CKD progression in future with stone disease.
According to RELIVE study it was found no much differences with stone and without stone disease if donors have no other comorbid condition. I think it will be biased as it does not encompasses the whole donor population.
If some one is found having renal stone that may be a recurrent stone former
We usually avoid donors with renal stones. we don’t have genetic testing to confirm the primary cause so for.
*About 11% of kidney stone is found on image of kidney donors during their evaluation
*Donors with stones either pre or post donation not are of high risk to be hypertension
proteinuric or decreased glomerular filtration rate and develop end stage renal diseases
*Developed stones in kidney donors may leads to emergency with surgical intervention
*Meta-analysis with seven studies resulted in that kidney stones can develop chronic kidney diseases by about 4%
References
1. Lorenz EC, Lieske JC, Vrtiska TJ, et al. Clinical characteristics of
potential kidney donors with asymptomatic kidney stones. Nephrol
Dial Transplant. 2011;26(8):2695.
2. Alexander RT, Brenda RH, Natasha W, et al. Kidney stones and kidney function loss: a cohort study. BMJ. 2012;345(7873):17.
3. Shoag J, Halpern J, Goldfarb DS, Eisner BH. Risk of chronic and
end stage kidney disease in patients with nephrolithiasis. J Urol.
2014;192(5):1440-1445.
Symptomatic and incidentally discovered kidney stones in kidney donors are common about 3% to 11%.
Some studies suggested that history of kidney stones is associated with CKD , other studies showed that history of stones is not associated with an increased risk of CKD.
This study compared the development of HTN,proteinuria and reduced GFR in kidney stone donors with kidney stones to propensity score matched donor controls without kidney stones.
The study was done on 8922 live kidney donation from 1963 to 2007. From them 227 donors had kidney stones.
Kidney donors were classified by kidney stone history to none, pre-donation kidney stones, post-donation kidney stones or both pre- and post-donation stones.
227 donors with kidney stones ( 200 with pre-donation kidney stones, 21 post-donation and 6 pre and post donation )
Donors with kidney stones were older , more likely to be white ,less likely to be related to the recipient, had higher fasting plasma glucose and a slightly lower eGFR when compared with other donors in the study.
Outcome of study on 8922 donors after 16.5+/- 10.9 years from donation to study close
_ 13.8% of donors developed proteinuria, 36.9 % developed hypertension and 0.7% developed ESRD . there were 46 ESRD events after donation, none of them in donors with kidney stones
_ proportions of donors who developed HTN and cardiovascular events were similar in patient with history of kidney stones and whom with negative history.
There is no significant difference in the occurrence of proteinuria between two groups.
Kidney donors with stones ( pre-donation, post-donation or both) were not at higher risk for development of HTN, reduced GFR or proteinuria)
We don’t have kidney transplantation center
This is a study that uses the database of living donors from three transplant centers (Minnesota, Mayo, and Alabama) and is a retrospective cohort study between 1963 and 2007 comparing the status of nephrolithiasis and its clinical outcome related to kidney transplantation. There are data in other studies that suggest an increased risk of chronic disease and end-stage renal disease in donors with kidney stones.
This study was separated into four groups, where the patient had no stone, pre-donation (200 patients), post-donation (21 patients), pre- and post-donation (6 patients). Related to quantity, 119 patients had a single stone, 28 patients had two stones, 3 patients had five stones and the rest were not established.
Kidney stone donors were older, white, and had higher fasting glucose and mildly reduced eGFR response. Apparently, it was more related to the donor than the recipient. Patients with pre- and post-donation stones were more related to higher BMI, lower eGFR at donation, and a tendency to hyperlipidemia. Smoking appears to be related to kidney stone donors. Proteinuria is a more common finding in kidney stone donors compared to those without.
Undoubtedly few donors had stones after donation, probably as a result of the orientation of important post-donation water intake. Some American centers (23%) did not accept donors with kidney stones, while others were released after investigation for reversible metabolic causes. This study and that of Kummer et al do not suggest that nephrolithiasis is an independent factor for the development of chronic kidney disease.
Abnormal post-donation parathyroid hormone levels, especially in the first three years, may indicate gout medication. This study suggests that patients with kidney stones should not be excluded from donation protocols unless there are metabolic changes consistent with the condition, anatomical changes, or recurrent urinary infections, even in situations with multiple kidney stones.
kidney stones are one the common recurrent renal diseases with an associated risk of other metabolic disorders. It has a complication of obstruction, infection and renal impairment.
This study set out to determine the risk of hypertension, proteinuria, and ESRD in donors
the study participants were 227 , with 200 participants with pre-transplant, 21 post-transplant stones, and 6 with both pre and post-transplant stone. the study period from 1963-2007
After an average follow-up period of 16.5 + 10.9years, apart from increased incidence of proteinuria in donors with stones, there was no increased incidence of hypertension, cardiovascular disease, or reduced GFR
The conclusion was that kidney donors with stones have no increased risk of hypertension, decrease GFR, or increased CVD risk.
my critique is the study didn’t take into account the type, size, complicated or none complicated stone, the site of the stone, and most importantly biochemical composition of the stone. which may establish the metabolic relationship between stones and hypertension and CVD risk
In my center, those donors who have stones are screened further and if they have any further risk of stones or complications of the stone, they are not allowed to donate
INTRODUCTION
· one or more episodes of kidney stones were associated with a twofold higher risk of ESKD (a Canadian study)
· In this case-controlled study, a comparison between kidney doner with kidney stones and matched doners without stones, in development of HTN, proteinuria and reduced GFR
MATERIALS AND METHODS
· There were 8922 live kidney donations at the study sites from 1963 to 2007
· Family history of hypertension, diabetes mellitus (DM), kidney disease, stroke, or heart disease in donors’ first-degree relatives were recorded.
· A history and timing of kidney stones was obtained from medical record abstraction, imaging studies and by donor self-report
· post-donation events collected from donors by telephone and multiple mailings, and from centers records
· Definitions:
HTN: s use of antihypertensive medications, a systolic blood pressure ≥140 mmHg, or a diastolic blood pressure ≥90 mmHg
Cardiovascular disease: myocardial infarction, congestive heart failure, stroke, and need for coronary or peripheral arterial intervention.
ESKD: the need for dialysis, receiving a kidney transplant or being listed for one.
Proteinuria: urine protein by dipstick ≥2+, urine protein/osmolality >0.42 ratio, urine random protein >15 mg/dl, or 24-h protein >300 mg/day
· Exclusion criteria:1) donors with proteinuria, measured GFR, or creatinine clearance
2) candidates with multiple kidney stones (≥3–5)
RESULTS
· In total, 227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones
· Donors with pre-donation kidney stones and those with both pre- and post-donation stones were older than donors with post-donation stones only
· donors with pre-donation kidney stones were less likely to be men and more likely to be white
· Donors who had both pre- and post-donation stones had a higher BMI, a lower eGFR at donation and were more likely to have hyperlipidemia
Study outcomes
· After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD
· At study close in 2007, there were no difference between donors with stones and those without stones in developing hypertension, cardiovascular disease, and reduced eGFR
· But proteinuria, was more frequent in donors with kidney stones than those donors with no stones
DISCUSSION
· These analyses have strengths:
-The long time follow up (50 years) of kidney donations
-donors have intermediate renal outcomes such as reduced GFR, proteinuria, and cardiovascular disease development which are not captured in national donor data sets.
-There were minimal missing data
-the propensity score matching produced a highly comparable kidney donor control group
· Limitations:
-It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances that could lead to more kidney stones.
-There was no enough information about kidney stones size, site and intervention which was done
– the policies of the 3 RELIVE study centers may not be similar to other centers which may limit the generalizability of these findings.
-the RELIVE study did not capture bariatric surgery which can be predispose to kidney stones
CONCLUSION
kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones
How these guidelines are different from the guidelines you follow at your workplace?
We try to treat any donor with uncomplicated stone, but not recurrent, and exclude any metabolic disease. When we are sure the donor is stable and no recurrence of stone we accept the donor.
This study includes 8922 live kidney donations from 1963 to 2007. In total, 227 donors had kidney stones: 200 donors with pre donation stones, 21 donors with post-donation stones, and 6 donors had both pre and post donation kidney stones.
This study suggests that kidney donors with renal stones do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no renal stones. Carefully evaluated candidates with stones with underlying metabolic disturbances can be accepted with dietary or pharmacological interventions.
Most kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation. Very few donors reported kidney stones after donation.
Kidney donors do not appear to be at a higher risk for kidney stones after donation and should not be excluded from donation for having kidney stones if they are carefully evaluated for underlying metabolic disturbances.
In our center we are not taking donors with kidney stones but now on it will be changed.
Please summarise these guidelines in your own words
How these guidelines are different from the guidelines you follow at your workplace?
Really this study will change my way in evaluating the potential donors , in our center we exclude any potential donor with renal stone or even history of stone due to increase risk of single kidney obstruction and needs urgent surgical intervention .
world wide 11 % of potential kidney donor have some renal stones .
This study was undertaken to study the effect of renal stones on kidney donor and subsequent development of HTN , CKD , ESRD ,CVD and protienurea .
in this study it is found that the risk for development of HTN , CKD is similar in both groups but the risk of protienurea is slightly high in donor with renal stones .
Donors with stones needs careful evaluation including the metabolic panel to assess the cause of stones , history of previous stones , symptomatic or incidentally finding , unilateral or bilateral , family history of stone
in this study it was concluded that careful selection of kidney donors with stones did not increase risk of low GFR, hypertension and proteinuria.
Donors with kidney stones should not be excluded from donation with careful evaluation of underlying metabolic aspects which are modifiable by dietary and medical treatment
Donors with multiple stones and normal urinary findings should have further evaluation.
Around 11% potential kidney donors have some renal stone. 25 % US transplant centers exclude kidney stones donors to avoid future chronic kidney disease.
This study was undertaken to find possible relationship between renal stones in donor kidney and subsequent incidence of hypertension ,proteinuria and decline in GFR. Hypertension, proteinuria, eGFR < 60 ml/min/1.73 m2 and cardiovascular disease were compared in donors with kidney stones vs controls.
Post donation hypertension was defined as BP>140/90.
It was found that risk of hypertension, CV events and low GFR was similar in both groups but proteinuria was more in group with renal stones.
It was concluded that careful selection of kidney donors with stones did not increase risk of low GFR, hypertension and proteinuria.
Donors with kidney stones should not be excluded from donation with careful evaluation of underlying metabolic aspects which are modifiable by dietary and medical treatment
Donors with multiple stones and normal urinary findings should have further evaluation.
Strength points include long duration and ethnicity diversity
limitation points included lacking data regarding number of accepted donors of kidneys with stones and characters of stones.
Practically, donors with multiple and recurrent stones to be excluded..
About 25% of the potential kidney donor is US are rejected because of findings of kidney stone for the fear of possible development of CKD after donation. Studies have reported a greater risk of developing CKD or ESRD among people with kidney stone, however others have also reported contrary to the finding.
This study is to compare the development of hypertension, proteinuria, and reduce GFR among donors with kidney stone to the matched control group.
8922 kidneys RELIVE donors between 1963-2007 data were recruited
Baseline demography and history were obtained
Donors were contacted for information between 2010-2012 through phone and mailing system
Median age, BMI, and GFR was 39 years, 25.8kg/m2, and 88.2ml/min/1.73m2
227 donors have kidney stones, and it was matched against 908 non kidney stone donors
200 out of the 227 donors have kidney stones before donation while 21 had post donation, and 6 had before and after donation
Donors with pre and post donation stone were found to have a higher BMI, reduce GFR at donation and hyperlipidaemia
The only difference between case and control were higher smoking rate, hyperlipidaemia and hypertension among donors with stones following 16.5+- years of follow up, hypertension, proteinuria, and ESRD was 36,9%, 13.8% and 0.7% respectively
kidney donors with stones were not at higher risk of developing hypertension, proteinuria, reduce GFR or ESRD smaller number of donors reported kidney stones after donation.
Conclusion
There was no significant increase of hypertension, proteinuria or ESRD among donors with kidney stones compared to the matched donor in this study, hence exempting potential donors from donating kidney because of stone may not be totally beneficial to the growth of kidney transplantation.
In our practise, we don’t take donor with renal stone as metabolic screening in our centre is not easily available.
Good evening,
At our center, potential donors with renal stones at time of evaluation are excluded and referred to urologist. Those with past history of stones are accepted if their metabolic studies and imagings are normal.
Donors with kidney stones were usually excluded in many centres from donation to avoid potential risks of future obstructive consequences and the possible association between stones and CKD.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD.
In one study from Canada, one or more episodes of kidney stones were associated with a two fold higher risk of ESKD.
And another study found the association more common in women.
recent meta-analysis of 7 studies concluded that a history of kidney stones was associated with a 47% higher likelihood of CKD.
These findings were echoed by a study of individuals with former kidney stone(s) in Olmsted County, Minnesota .
Kummer et al. did not find that nephrolithiasis was truly an independent risk factor for CKD development in 10 678 ARIC study participants of whom 856 had a history of stones and an additional 322 who developed stones over a mean follow-up of 12 years.
Also,it was found that history of kidney stones among 10,678 participants in the Atherosclerosis Risk in Communities (ARIC) Study was not associated with a higher risk of CKD after multivariable adjustment.
Renal and Lung Donor Evaluation (RELIVE) Study studied intermediate and long-term outcomes of 8922 donors who donated between 1963 and 2007.
200 donors had kidney stones prior to donation, 21 had post-donation stones, and 6 had pre-and post-donation stones.
227 kidney donors with kidney stones were compared to 908 propensity score-matched donor controls without kidney stones regarding development of hypertension, proteinuria, and reduced eGFR .
results
After 16.5 ± 10.9 years (range 0–44 years) from donation to study close,
-no ESKD occurred in donors with stones.
-no association between stones and adverse renal outcomes in kidney donors.
– post-donation stones was rare.
Thomas et al also showed that kidney donors had similar hospital encounters for kidney stones as non-donor controls.
-risks of hypertension, proteinuria, and reduced GFR were similar in donors of both groups.
These findings are highly consistent with the data from Kummer et al.
It is possible that studies demonstrating an association between stones and CKD in the general population are highly confounded by the presence of predisposing factors that are almost always absent in kidney donors, as kidney donors rarely have comorbidities, have no evidence of even subtle renal disease, are generally on no medications, and have normal weight in the majority of cases.
These data may provide a rationale for possibly a wider acceptance of donor candidates with low kidney stones burden after carefull evaluation for underlying metabolic disturbances
.
in My work place potential donors with current or repeated kidney stones are excluded
Donors with past history of stones usually excluded
although i find it logic that they might be accepted after full evaluation of the cause ,family history of stones, metabolic abnormalities ,current kidney function.
This study (The Renal and Lung Living Donor Evaluation Study (RELIVE)) was a National Institutes of Health sponsored effort that studied donor outcomes from the University of Minnesota.
There were 8922 live kidney donations at the study sites from 1963 to 2007. A history and timing of kidney stones was obtained from medical record abstraction, imaging studies and by donor self-report. In total, 227 donors had kidney stones: 200 donors with pre-do[1]nation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones.
Study outcomes:
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD.
There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones. At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922).
Proteinuria occurred more often in donors with kidney stones than those donors with no stones (20% vs. 13.6%), p = .01, however, the difference in proteinuria was no longer significant (15.6% vs. 20%), p = .06. The method of proteinuria assessment (24-h urine vs. dipstick vs. urinary albumin/creatinine ratio) after donation was similar in stone and non-stone formers.
The estimated 10-, 20-, and 30-year cumulative incidence of outcomes per 10 000 donors in donors with and without stones were almost identical.
Most kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation. Very few donors reported kidney stones after donation.
Kidney donors do not appear to be at a higher risk for kidney stones after donation.
In conclusion: donor candidates should not be excluded from donation for having kidney stones if they are carefully evaluated for underlying metabolic disturbances.
Many with multiple kidney stones may have low recurrence rate and therefore maybe considered for the donation provided they have no urinary mineral abnormalities.
Kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones.
In our centre we are not taking donors with kidney stones for fear of possible adverse long-term outcomes on kidney.
Patients with kidney stones generally have many comorbid conditions that’s why it is difficult to study and predict about the development of CKD in the future in these patients. This article also clarifies few concepts about the risks of hypertension, GFR decline ,proteinuria and ESRD later in kidney stone donation patients.
This study included 8922 live kidney donations from three different centers. Results revealed hypertension to be present in 36.9% of donors , proteinuria in 13.8% and ESRD in 0.75% donors with a follow up period of 16.5 ± 10.9 years. Moreover, 30% chance of recurrence of kidney stones ,also donors with stones were white and non-related , had high fasting glucose levels ,higher BMI and hyperlipidemia .
In conclusion, no difference was found between donors with and without kidney stones in terms of outcome i.e., hypertension, proteinuria, ESRD. Donors with kidney stones with no metabolic abnormality should not be excluded. And patients with uncomplicated multiple stones ,positive family history ,raised BMI ,male gender should be assessed with ROKS nomogram and donation should be done only if less chance of recurrence.
Strength: Propensity score matching was done to produce comparable kidney donor, follow up of patients was diverse and also long..
However, limitations of the study included uncertainity about the acceptance of donors with pre-donation stones. No detail was provided about the size of kidney stone, whether it is unilateral or bilateral or whether any surgical or medical intervention done before.
At our center ,we evaluate patients according to KDIGO 2017 guidelines and include urinalysis followed by Ultrasound abdomen ,CT angiography of renal vessels. We do not reject patients with unilateral stones with negative metabolic profile but with proper counseling and close follow up. However, patients with recurrent and bilateral kidney stones are rejected.
.
INTRODUCTION
Many kidney donor candidates have a history of prior symptomatic kidney stones and as many as 11% have evidence of stones on renal imaging performed during the evaluation.
Some data suggest that kidney stones may be associated with a higher risk of CKD and ESKD. In one study from Canada, one or more episodes of kidney stones were associated with a twofold higher risk of ESKD
Studying the potential association between kidney stones and future development of chronic kidney disease is quite complicated as many people with kidney stones have multiple comorbid conditions.
Herein, we compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
MATERIALS AND METHODS
Post-donation hypertension was defined as use of antihypertensive medications, a systolic blood pressure (SBP) ≥140 mmHg, or a diastolic blood pressure (DBP) ≥90 mmHg. Cardiovascular disease (CVD) was defined by any of the followings: myocardial infarction, congestive heart failure, stroke, and need for coronary or peripheral arterial intervention. ESKD was defined by need for dialysis, receiving a kidney transplant or being listed for one. Proteinuria was defined as one or more of the following: urine protein by dipstick ≥2+, urine protein/osmolality >0.42 ratio, urine random protein >15 mg/dl, or 24-h protein >300 mg/day.
The three centers generally excluded candidates with multiple kidney stones (≥3–5) particularly recent episodes
This study was exempt from institutional review board approval as it used only de-identified data from the publicly available RELIVE study data set.
RESULTS
Characteristics of donors with kidney stones
In total, 227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones .
Study outcomes
There were 46 ESKD events that occurred
18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones. At study close in 2007, the proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m 2 were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922), Proteinuria, however, occurred more often in donors with kidney stones than those donors with no stones (20% vs. 13.6%).
DISCUSSION
Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
very few donors reported kidney stones after donation
Kidney donors do not appear to be at a higher risk for kidney stones after donation.
Certainly, the low rates of post-donation stones might be related to screening-out candidates who were deemed to have a high stone recurrence potential at the time of donor evaluation in addition to the general recommendation given to kidney donors to stay “well hydrated”.
A recent meta-analysis of 7 studies concluded that a history of kidney stones was associated with a 47% higher likelihood of CKD.
Interestingly, those with asymptomatic kidney stones incurred a higher risk of ESKD than those with recurrent stones. In contrast, in a more recent study with a similar length of follow-up to that of the Olmstead County study but in a more ethnically diverse population, Kummer et al. did not find that nephrolithiasis was truly an independent risk factor for CKD development in 10 678 ARIC study participants of whom 856 had a history of stones and an additional 322 who developed stones over a mean follow-up of 12 years. 4 Our findings are highly consistent with the data from Kummer et al.
We propose that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
It also identified BMI, male, family history of kidney stones, asymptomatic and suspected kidney stone episodes before the symptomatic event and pregnancy at last stone episode as important predictors of recurrence.
In all, these data suggest that kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones.
Moreover, even some candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered if the predicted recurrence rate is low.
On our center the donor assessed for kidney stones and evaluated by urologist and nephrologist for the risk of recurrence.
I. Outcomes of kidney donors with pre-and post-donation kidney stones
Please summarise these guidelines in your own words
Introduction
Kidney stones are common among potential kidney donors; stones are seen on 11% of imaging done during pre-transplant workup.
Some studies linked between kidney stones & the increased risk of CKD & ESRD (Study from Canada), especially in female (National Health & Nutrition Examination Survey based study).
In other studies (ARIC Study), H/O kidney stones was not associated with a higher risk of CKD.
The aim of this current study (RELIVE Study) was to know the effects of kidney stones on the occurrence of reduced GFR, proteinuria, & HTN in kidney donors who have minimal to no confounders.
Materials & Methods
The total number of live kidney donations from 1963 2007 was 8922; done in 3 centers in the USA.
They compared the occurrence of HTN, proteinuria, & reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
Individuals with multiple kidney stones (.3–5) were excluded.
The kidney with a stone was taken for donation in cases of unilateral stones.
Results
Donors with kidney stones were:
Older (43 vs 39 yr)
More likely to be white (92.5% vs. 84.6%)
Less related to the recipient (71.8% vs. 81%)
Higher FBG (95 vs. 92 mg/dl)
Lower eGFR (85.1 vs 88.4 ml/min/1.73
P < 0.05 for all.
A 227 donors had stones (200 pre-donation, 21 post-donation, & 6 had both pre- & post-donation kidney stones); the majority (119) had 1 stone, 28 had 2 stones, 3 donors had 5 stones, & the number of was unknown in the remainders.
Donors with both pre- & post-donation stones were less likely to be Caucasian but otherwise highly comparable.
Outcomes after 16.5 ± 10.9 yrs from donation to study:
– 36.9% of donors developed HTN
– 13.8% developed proteinuria
– 0.7% had ESRD (46 events occurred 18.5 ± 10.5 yrs
after donation & none of these occurred in donors
with kidney stones).
Development of HTN, CVD, eGFR < 60, eGFR < 45, eGFR < 30 ml/min were similar in donors with stones to those observed in the larger donor group without stones (n = 7888–8922).
Proteinuria was more in donors with stones than donors with no stones (20% vs. 13.6%), p = .01, however with propensity score-matching, the difference in proteinuria was no longer significant (15.6% vs. 20%), p = 0.06.
Discussion
Donors with stones were not at a higher risk for HTN, reduced eGFR, proteinuria, or ESRD.
A majority of stones were in older Caucasian donors who were unrelated to the recipient & who were more likely to have a lower eGFR at donation.
Very few donors had stones after donation (candidates with H/O more complicated stone were excluded from donation).
Symptomatic & incidental stones in kidney donors not uncommon(3%–11%); the lower rate may be explained by the practice of excluding donors with stones from donation.
A 23% of US transplant centers exclude donors with any kidney stones, 19% would accept them if none is present at the time of donation, & 53% would accept if none is currently present & metabolic studies are normal.
The 10-year recurrence rate of stones is variable (generally around 30%); 70% of donor with stones who are excluded may never have a 2nd or a 3rd stone.
Kidney donors are not at a higher risk for stones after donation (Thomas et al).
The rate of stones needing surgical intervention was similar in donors controls.
These results are consistent with the very few stones reported in RELIVE donors after donation.
The low rates of post-donation stones might be explained by the practice of exclusion of those with high risk of recurrent stones; the general advice given to kidney donors to stay “well hydrated” may also be a contributing factor.
ROKS nomogram (Rule et al.) can be used to quantify risk of recurrence of kidney stones in potential donors.
In conclusion, kidney donors with stones who were allowed to donate do not have an increased risk of reduced eGFR, HTN, or proteinuria when compared to donors with no kidney stones.
The authors believe that excluding donors with any kidney stones may not be justified.
==============================
How these guidelines are different from the guidelines you follow at your workplace?
Our local guidelines are not much different from these guidelines.
We exclude from donation those with bilateral or multiple stones irrespective to the type of the stone.
We do not commonly do evaluation for metabolic risk of stone formation in our center.
We accept donors with unilateral stone (small non obstructive); and of course the kidney with the stone is taken for donation. And our surgical teams successfully removed some of such stones before grafting without the need for inappropriate manipulation of the kidney.
We, also do not accept any donors with proteinuria, measured GFR, or creatinine clearance <85 ml/min. Here, we are more conservative and use a level <85 ml/min rather than what stated in these guidelines.
Please summarise these guidelines in your own words
About 11% potential kidney donors may have some sort of renal stone at the time of assessment. There has been an association of kidney stones with chronic kidney disease. 25 % US transplant centres exclude donors with kidney stones with fear future chronic kidney disease.
In this study the authors have studied the relationship of renal stones in donor kidney with subsequent development of hypertension, Proteinuria and decline in GFR.
They compared kidney donors with stones with control donors without stones. They looked at development of hypertension, proteinuria and reduced GFR.
Kidney donors with stone -227
Propensity matched donors without stones – 908
Methodology
The renal and lung living donor evaluation – RELIEVE Study studies the donor outcomes at the University of Minnesota , Mayo clinic and university of Alabama and evaluated 8922 live donations from1963 -2007. Baseline demographic and laboratory record was abstracted from central record. Hypertension, proteinuria, eGFR < 60 ml/min/1.73 m2 and cardiovascular disease were compared in donors with kidney stones (cases) versus those who no kidney stones (controls)
To assess of post-donation events, donors were contacted between 2010 and 2012 via telephone and multiple mailings for health updates, QOL surveys, and any laboratory data that took place after donation. Post donation hypertension was defined as blood pressure >140/90.
Total donors with stones were 227.
21 had post donation stones and 200 had pre donation stone.
Results.
At the end of study in 2007 it was found that risk of hypertension, cardiovascular events and low GFR was similar in both groups Proteinuria was more in group with renal stones.
Conclusion
Carefully selected kidney donation with stones does not increase the risk of low GFR, hypertension and proteinuria.
Donors with kidney stones should not be excluded from donation if they are carefully evaluated for underlying metabolic problems which are amenable to dietary and medical treatment
Those with multiple stones who have normal urinary profile should be revisited and evaluated further
Strengths of study
Long study span
Ethnicity -diverse
Limitations
Unclear how many donors with stones were accepted
Not much details about stone characteristics
Policy of 3 RELIVE centre may be different
How these guidelines are different from the guidelines you follow at your workplace?
At my centre we do accept potential donors with solitary unilateral stones . However this is subject to satisfactory metabolic evaluation.
We refuse those with multiple stones, recurrent stones and large stone burden.
I like your list of strengths and limitations of this study, dear Dr Abdul Rahim Khan. Moreover, I appreciate the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine.
Ajay
Outcomes of kidney donors with pre-and post-donation kidney stones
This article is about kidney donor candidates with a history of having kidney stones. Some centers do not include kidney stones as part of donors for transplantations due to the possible future obstruction and there may be an association between kidney stones and CKD. Due to the above, there is controversy in allowing these patients to be donors because they may have another comorbidity that may prevent them from being a donor.
The aim of this article is to see the relation between two groups one with a kidney stone and the other without kidney stones and to see which develops proteinuria, HTN, and a reduction of GFR.
The study was conducted in the US by RELIVE, from a period of 1963 to 2007. There was a total of 227 donors with kidney stones of which 200 had pre-donation stones and 21 post-donation stones and a total of 6 with both. It was compared with a 908 propensity score matched control without stones.
It was observed that the donors with stones were older likely predominantly white, with a higher serum plasma glucose and with a decrease in GFR. Between the two groups, it was found that individuals that were found with kidney stones had a history of smoking, hyperlipidemia, and a first-degree relative with HTN.
The study was a good study due to the fact that it had a study span of 50 years, the follow-up is ethnically diverse, data missing was minimal and the propensity score matching produced a highly comparable kidney donor control group.
However, the study had some limitations like how donors with stones were accepted after having metabolic screening, there was nothing to show if it was unilateral or bilateral kidney stones, and the possible sizes.
In the study, it was concluded that patient kidney donors with stones before or after transplantation were not at a higher risk for developing hypertension, proteinuria, a decrease in GFR, and kidney failure. So it can be said that kidney stones patients may be donors for kidney transplants but there is no clear cut as to the severity of the kidney stone.
Actually, in my workplace, there are no guidelines as yet but I would like to implement the same and what I was thinking of is to have or avoid patients with kidney stones not to be part of donating.
That is very pleasing to note, dear Dr Marius Badal, that this article inspires you to make protocols in your department.
INTRODUC TION
11% of potential donors have stone or history of stone with some concern about future CKD or obstructive uropathy. A National Health and Nutrition Examination Survey based study also reported that a history of kidney stones was associated with CKD and ESKD in women but not in men. Contradicting to this, Kidney stones among 10,678 participants in the Atherosclerosis Risk in Communities (ARIC) Study was not associated with a higher risk of CKD after multivariable adjustment. Studying this in the healthy donors with no comorbidities may improve our understanding. In this study we compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
MATERIALS AND METHODS
The Renal and Lung Living Donor Evaluation Study (RELIVE) was a National Institutes of Health sponsored effort that studied donor outcomes from the University of Minnesota, Mayo Clinic-Rochester and the University of Alabama-Birmingham, as previously described. There were 8922 live kidney donations at the study sites from 1963 to 2007.
RESULTS
Characteristics of RELIVE study donors:
1. Median age was 39 years.
2. 56.2% were women
3. 84.8% were non-Hispanic whites, 9.5% were non-Hispanic black, 1.8% were Hispanic, 0.9% were Asian, and 3% were categorized as other.
4. The majority (80.8%) donated to a family member.
Characteristics of donors with kidney stones
· 227 donors had kidney stones
· 200 donors with pre-donation stones
· 21 donors with post-donation stones, and
· 6 donors had both pre- and post-donation kidney stones
· The majority (n = 119) had 1 stone, 28 donors had 2 stones, 3 donors had 5 stones, and the number of stones in the remainder was unknown.
For the 227 donors with kidney stones, 908 controls without stones were selected.
The only differences noted between cases and controls after PS matching were a higher prevalence of smoking, hyperlipidemia and having a first-degree relative with hypertension in donors with kidney stones.
Study outcomes
Outcomes were ascertainable in 97% of the cohort except for proteinuria data which was missing in 10.7%.
After 16.5 ± 10.9 years from donation to study close:
1. 36.9% of donors developed hypertension
2. 13.8% developed proteinuria.
3. 0.7% had ESKD.
4. There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones.
Proteinuria, however, occurred more often in donors with kidney stones than those donors with no stones (20% vs. 13.6%), p = .01. The proportions of donors reaching the different outcomes in the 2 groups were also similar in the propensity score-matched cohort, and the difference in proteinuria was no longer significant (15.6% vs. 20%), p = .06..
DISCUSSION
Kidney donors with stones, were not at a higher risk for developing hypertension, reduced
eGFR, proteinuria, or ESKD. Most of kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation.
Of note very few donors reported kidney stones after donation.
Strength of the study:
1-Large sample size.
2-Long follow up period
3-very good matching of control group
4-Outcomes were ascertainable in 97%.
Weakness of the study:
1-Most of donors were Caucasians
2-Data about proteinuria were not available in some donors.
3-Retrospective nature of the study.
Conclusion
These data suggest that kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones. Hence excluding all kidney stone former is not justified. Moreover, even some candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered if the predicted recurrence rate is low.
It is not much different. We accept cases of single kidney stone and normal 24hours urine for stone chemistry. We take the kidney with stone for donation. Potential kidney donors with multiple, bilateral stones or high risk of recurrence are excluded.
I like your list of strengths and limitations of this study, dear Dr Muntasir. Moreover, I appreciate the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine.
Ajay
Outcomes of kidney donors with pre- and post-donation kidney stone.
INTRODUCTION
The incidental finding of kidney stones by renal imaging was reported in around 11% during transplant workup and based on evidence. There is a concern about the increased risk of CKD and ESRD among kidney donors, one study from Canada advocates donors with one or two episodes of symptomatic kidney stones are at a twofold higher risk of ESKD (2). Another national survey data confirms more risk of CKD in women rather than men (3) while another big study (ARIC) confirmed no increase in such risk after multivariate adjustment.
Aim of this study
linked the incidence of proteinuria, hypertension, and drop of GFR in kidney donors with a history of stones to the matched donor control group without a history of kidney stones.
Materials and setting
the Renal and Lung Living Donor Evaluation Study RELIVE, part of a national health institution donor outcome study from different centers
9882donors were included from 1963-2007and all donor’s baseline demographics and investigations placid from their electronic medical records, post donation events recorded between 2010-2012 from institution medical records, and multiple donor phone calls and emails for updated health with QOL survey
Hypertension was recorded with an average of three visits and defined as the Bp > 140/90 or patients on medications
CVD referred to MI, heart failure, stroke, or the need for coronary or peripheral vascular intervention
ESKD is demarcated as the need for dialysis or transplantation or being registered for one of them
Proteinuria definition as one or more of the following: urine protein by dipstick ≥2+, urine protein/osmolality >0.42 ratio,
urine random protein >15 mg/dl, or 24-h protein >300 mg/day.
They exclude donors with proteinuria and measured GFR < 80ml/min, in three centers additional exclusion of the donors with recent episodes of kidney stones > 3-5 but no further details about associated metabolic disorders.
Propensity score matching 1 case -4 control for age, gender, ethnicity, and years of donation.
Results
RELIVE donors’ characteristics
The median age of the RELIVE study was 39 years, 56.2% were women, 84.8% were white, 9.5% were non-Hispanic black, 1.8% were Hispanic, 0.9% were Asian, and 3% were categorized as other.
About (80.8%) donated to a family member.
71% had positive FH of CKD (first-degree relative)
41.0% had positive FH of hypertension (first-degree relative).
Median BMI 25.8
Median GFR *88ml/min/1.73m2
Donors with kidney stones are older, white, and with higher fasting blood sugar non related donors with slightly lower GFR 85ml/min/1.73m2
Donors with kidney stones
The total number of donors with kidney stones was 227, 200 pre-donation, 21 post-donation stores, and another 6 donors with both pre and post-donations, asymptomatic kidney stones with incidental findings by a renal image found in 132 cases, donors with pre and post-donation risk of kidney stones they are older age in their 40s compared to control group more in the white population, they have higher BMI, lower baseline GFR, and dyslipidemia and after adjustment variable risk factors by propensity score(PS ), they found a significant association of recurrence of kidney stones posts donation in donors with a history of smoking, dyslipidemia and FH of hypertension in a first-degree relative.
There is missing data on proteinuria in 10.7%. After meaning fu of 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, and 13.8% developed proteinuria, but the cumulative incidence of proteinuria was of no significance between the two groups.
and 0.7% had ESKD
Strength of the study
A big sample size of donor pool over 50 years of FU, varied populations
Few missing data
Well-matched control group
Clearly identifies the renal outcome
Limitation
no clear screening for metabolic risk factors in donors with pre-donation stones history
no details about kidney stone type and size, uni or bilateral, and which kidney have been donated in case of unilateral stones
no information about the treatment or intervention for donors with kidney stones.
The difference in 3 RETVIL center policies limits the generalizability of these results
No information about the history of bariatric surgery
Conclusion
The data from this study confirm the safety of donation from potential donors with kidney stones compared to a donor control group with no stones with no associated risk of proteinuria, hypertension, or low GFR.and they believe its indefensible that some centers in the US declined donors with kidney stones such decisions should be revisited by further studies and donors with associated modifiable metabolic risk factors should be treated before including them in transplant work up.
ROCK nomogram and modified Rock nomogram its useful tool for donors with symptomatic and kidney stone recurrence score assessment tools developed by Rule and colleagues (10). And revised by Vaughan et al.
Predictors for symptomatic stone recurrence include the type of the stones, FH of kidney stone associated metabolic risks like dyslipidemia, obesity, gender (male), and stone in pregnancy.
In our local protocol, we exclude donors with a history of kidney stones, as one of the major concerns is the exposure to recurrence of obstructive stone in singlefunctioning kidneys after reviewing this study i think we should take care of donors with metabolic syndrome and may exclude them from donation with medical advise to improve lifestyle ,stop smoking , reduce wt and treat dyslipidemia , control of Bloodpressure and sugar addressing family history in the first degree and apply the ROCKnomogram the reconsider their fitness for donation.
I like your list of strengths and limitations of this study, dear Dr Saja. Moreover, I appreciate the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine.
Ajay
Summary
Many kidney donor candidates have a history of prior symptomatic kidney stones and as many as 11% have evidence of stones on renal imaging performed during the evaluation. Some study demonstrate association between renal stone and CKD and ESRD.
Many transplant centers exclude donor with kidney stones, because of possibility of future obstruction and CKD.
The study compared the development of HTN, proteinuria, and reduced eGFR in 227 kidney donors with kidney stones to 908 donors without kidney stones.
After 16.5 ± 10.9 years from donation to study close, no ESRD occurred in donors with stones. The multivariable risks of hypertension, proteinuria, and reduced GFR were similar
in donors with and without kidney stones. The study could not demonstrate an association between stones and adverse renal outcomes in kidney donors, and the occurrence of post-donation stones was distinctly rare. Donors with stones were older, more likely to be Caucasian, less likely to be
related to the recipient and had a higher fasting glucose.
Some candidates with multiple kidney stones who have a favourable and correctable urinary stone profile can be considered if the predicted recurrence rate is low. Nevertheless, one has to be very aware of the limitations of models predicting stone recurrence and the limited ability of urinary stone profile and interventions to address its adverse components in predicting recurrence.
These data may provide a rationale for possibly a wider acceptance of donor candidates with low kidney stones burden.
in our centre, we do not accept donor with kidney stone whatever the condition.
Would this article influence your practice, Dr Jamila?
Please summarise these guidelines in your own words
Kidney stones in donors is not an absolute contraindications of living kidney donation,
Transplant team should be aware of the models predicting stone recurrence, and the limited ability of urinary stone profile.
In all transplant centers the donors is thoroughly evaluated and all the modifiable risk factors identified so the potential donors supposed to be healthy not diabetic and of average weight(BMI)., so they are at low risk of having recurrent kidney stones.
Obesity, smoking history, diabetes mellitus history, family history of DM , kidney stones, or personal history of kidney stones should be identifies, screened and managed.
Kidney stone former donors are not at increased risk of developing HTN, proteinuria ,CKD, or ESRD.
70% of potential donors whom had a history of kidney stone will never experience second or third episode of kidney stones.
ROKS nomogram should be applied to detect the risk of recurrence of kidney stones in all potential donors(ROKS – Recurrence Of Kidney Stone (2014) | Calculate by QxMD | QxMD).
How these guidelines are different from the guidelines you follow at your workplace?
In our center we do full work up by urinalysis and ultrasound abdomen as well as renal CT angiography, and the donors are fully evaluated according to KDIGO 2017 guidelines,
we do not decline donors with renal stones, unless complicated stone events and strong family history, and bilateral stones. and we get the kidney with stone for the recipient.
We do 24 hours urine metabolic panel in recurrent stone formers, and in some cases we do genetic studies if hyperoxaluria or cystinurea suspected.
From this article i learned how to have a systemic risk assessment in kdieny stone potential donor using ROKS nomogram.
It seems using the ROKS nomogram will influence your practice.
Outcomes of kidney
donors with pre-and
post-donation kidney stones
Please summarise these guidelines in your own words:
Kidney donors with stones, whether occurring pre- or post- donation are not associated with higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
Most of cases, kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation.
There’s some countries like US kidney transplant centers excluded donor with history of renal stone and some centers accept donor with renal stone but normal metabolic studies.
Many studies shows kidney donor not having risk of renal stone post donation.
Cases with predonation renal stone have low rate of renal stone recurrence post donation.
Despite low rate of recurrence post donation but kidney donor renal stone have 47% incidence of CKD post donation and low risk of ESRD.
Kidney donor Renal stone with multiple renal stone and positive family history of renal stone and abnormal urinary metabolic rate should excluded from donation.
Consider kidney donor with one renal stone and no metabolic disturbance with normal body weight.
Strength of this study is wide population spans 50 years of kidney donations and regular follow-up with available data as reduced GFR, proteinuria, and cardiovascular disease.
There were minimal missing data.
Limitations: It’s unclear how many donors with predonation accepted and details regarding kidney stones size, unilateral versus bilateral and in unilateral.
• How these guidelines are different from the guidelines you follow at your workplace?
In our center we excluded all cases with history of recurrent renal stone and positive family history of nephrolithiasis, raised BMI and old male age.
I agree, Dr Sahar
This retrospective study used the data of RELIVE study to compare the post donation outcome between the donors with kidney stones and donors without kidney stones regarding HTN, proteinuria and decrease in GFR.
RELIVE study contained 8922 living donors from 1963-2007 in three large centers.
The living donors with kidney stones were 227 (200 have kidney stones predonation, 21 postdonation, and 6 pre and post).
The three centers excluded patients with multiple and complicated kidney stones but accepted donors with unilateral kidney stone.
Donors with stone were older, smoker, hyperlipidaemic, having 1st degree relative with HTN, not related to recipient, with higher fasting blood sugar and more likely to be Caucasian.
After 16.5+10.9 ys from donation, 39.9% of donors developed HTN, 13.8% developed proteinuria and 0.7% developed ESRD.
Development of HTN, proteinuria, and CKD was the same between donors with or without kidney stones.
After 18.5 + 10.5 ys, 46 donors developed ESRD with none of them was donors with kidney stones.
Conclusion:
There is no difference between donors with kidney stones (pre- post or both) and donors without kidney stones in post donation outcome regarding HTN, proteinuria, CKD or ESRD.
Donors with kidney stones with no metabolic abnormality should not be excluded.
Donors with multiple stones with no urinary abnormality, family history of stones, increase of BMI, male gender or any other risk factor of stone recurrence should evaluated using ROKS nomogram and if low rate of recurrence, they could be considered for donation.
would this article change your practice?
11% of living donors show stones during their routine evaluation (CT imaging)
Some evidences report that LD with kidney stone has higher risk for CKD after donation (2 fold or higher!)
The goal of this study is to compare the development of hypertension- proteinuria – and reduced GFR between LD with and without stones
Population
277 LD with kidney stones
908 without kidney stones (after criteria of exclusion and after propensity score matching)
4:1
Average age 39
Female 56%
84% white
80% related LD
71% related stage I has kidney stone
41% related stage I has BP
Average BMI 25
Average GFR 88
Duration of Follow-up
Average 12.9 in LD with stones
13.6 In LD without stones
IN GENERAL in the study
13.9% had hypertension
13.8% had proteinuria
0.7% ESRD
ESRD didn’t happen in LD with stone
Incidence rate of Hypertension- CVD- eGFR <60- eGFR <40- eGFR <30 is similar LD with or without stones
Even proteinuria incidence rate has no significant importance between the two groups
Presence of stones was higher in older- caucasian- non related living donor
In the past , there was caution of accepting LD with stone because this may lead to AKI then CKD
So there was difference in strategies between kidney transplantation centers in US
20% accept LD when the stones is not exist during evaluation for donation
20% refuse any living donor with stone
If we remember that the recurrence rate of kidney stone is 30%, so 70% of living donors with stone were denied in vain
Kummer et al study concluded that kidney stones were not an independent risk factor for CKD
The explanation of studies results , which approved the correlation between LK stones and CKD , is that the control group is from general population so they have risk factors that were usually absence in LD group
The limitation of this study is
1- excluding LD with multiple stones or recurrent stones therefore it may correlate to CkD
2- the strategies of RELIVE study non identical to other centers…it is not able to generalization
Conclusion
LD with kidney stone has no higher risk for reducing GFR- increasing proteinuria- hypertension
And the strategy of US centers in excluding LD with stone is unnecessary
And we should reconsider LD with multiple stones if they have low risk of recurrence after management
In our central we exclude
Multiple and recurrent stone
Stones with positive 24 h urine study (hyperoxaluria- cystinuria….)
I like your list of strengths and limitations of this study, dear Dr Ghalia. Moreover, I appreciate the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine.
Ajay
Thank you professor
So nice of you for a prompt acknowledgment, Dr Ghalia
In this article Murad and collaegues have tried to look into an interesting question regarding effect of kidney stone presence in donors and subsequent development of hypertension, proteinuria and reduced GFR
They compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
The Renal and Lung Living Donor Evaluation Study (RELIVE) was a National Institutes of Health sponsored effort that studied donor outcomes from the University of Minnesota, Mayo Clinic-Rochester and the University of Alabama-Birmingham, as previously described.There were 8922 live kidney donations at the study sites from 1963 to 2007.
For ascertainment of post-donation events, donors were contacted between 2010 and 2012 via telephone and multiple mail- ings for health updates, QOL surveys, and any laboratory data that took place after donation.
In total, 227 donors had kidney stones: 200 donors with pre-do- nation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD.
At study close in 2007, the proportions of donors
developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones
Proteinuria, however, occurred more often in donors with kidney stones than those do- nors with no stones (20% vs. 13.6%),
Kidney donors with stones, whether occurring pre- or post- dona- tion, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD. A majority of kidney stones occurred in older Caucasian donors who were unrelated to the recipient and who were also more likely to have a lower eGFR at donation.
Most transplant centers have their own guidelines regarding accepting such donors. As mentioned in this paper around 25% of US centers exclude donors with kidney stones however there is no strong evidence favoring such policy.
The authors propose that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions. Furthermore, we believe that excluding donors with multiple kidney stones, particularly remote ones, who have a benign urinary profile should be revisited and studied further.
We at our center have adopted the same policy and don’t refuse donors with unilateral kidney stones. We do work them for any metabolic abnormality and at times treat these stones before declaring these donors fit .
Hi Dr Nabi,
I like the way you compare this article with your own departmental practice. That is a good example of evidence-based medicine.
Ajay
Please summarise these guidelines in your own words;
1- These guidelines suggest that, kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones.
2-These guidelines recommend that, donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
3-These guidelines suggest that ,candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered if the predicted recurrence rate is low.
4-These guidelines suggest that ,risk of recurrence of kidney stones in potential donor candidates can be quantified using the ROKS nomogram developed by Rule and colleagues. This tool developed in those with symptomatic kidney stones is particularly useful when considering candidates with multiple kidney stones, known stone type, location, and family history of stones.
How these guidelines are different from the guidelines you follow at your workplace?
1-These guidelines increases the pool of donation.
2-kidney donor with multiple kidney stones with low risk of recurrence, can be allowed to donate .
2-It give us a tool to quantify the risk of recurrence
Hi Dr Ishag,
Would you change your department’s practice based on this article?
Ajay
Outcomes of kidney donors with pre- and post-donation kidney stones.
Introduction:
History of kidney stones might have risk of CKD but still controversial as those group of people had history of other co-morbidities, but here we are taking about potential donors who supposed to have normal renal function at time of donation.
In this study they compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to matched donor control without kidney stones.
Material/method and result.
The Renal and Lung Living Donor Evaluation Study (RELIVE) studied donor outcomes from three centers, There were 8922 live kidney donations at the study sites from 1963 to 2007.
Stratified our donors to :
A-227 donors had kidney stones.
B- 200 donors with pre-donation stones.
C-21 donors with post-donation stones.
D- 6 donors had both pre- and post-donation kidney stones.
They were119 donors had 1 stone, 28 donors had 2 stones, 3 donors had 5 stones.
The propensity score (PS)-matched cohort (227 donors with kidney stones and 908 controls without stones)
The differences noted between cases and controls after PS matching were a higher prevalence of smoking, hyperlipidemia and having a first-degree relative with hypertension in donors with kidney stones.
The proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those observed in the larger donor group without stones .
Conclusion:
kidney donors with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors with no kidney stones.
Acceptance of donors with history of stone formation is center policy dependent, for example 23% of US transplant centers exclude donors with any kidney stones which is not justified, 19% would accept those with a history of stones as long as none is present at the time of donation, and 53% would accept donor candidates with a history of kidney stones provided none is currently present and metabolic studies are normal.
How these guidelines are different from the guidelines you follow at your workplace?
We exclude donors with history of multiple recurrence of renal stone or with metabolic urinary abnormalities.
Incidental urinary stone with negative work up of metabolic-urinary causes can be accepted for donation .
Dear Dr Saad,
I like the scientific content of this write-up. Please type headings and sub-headings in bold or underline, so that it makes it easier to read.
Ajay
Outcomes of kidney donors with pre-and post-donation kidney stones
Summary of the Article
This is a retrospective study of 227 kidney donors with kidney stone(200 donors with pre-donation stone, 21 with post-donation stone and 6 donors with pre- and post-donation stone) in the period from 1963 and 2007 in the Renal and Lung Living Donor Evaluation Study (RELIVE)-USA. The study compared the development of HTN, Proteinuria and reduced GFR in kidney donors with stone to donor control without stone.
Characteristics of Donors with stone:
a) More likely to be older
b) More likely to be white(Caucasian).
c) Less likely to be related to the recipient.
d) Had a higher fasting glucose.
e) A slightly lower eGFR.
Study outcomes
1. Outcomes were ascertainable in 97% of the cohort except for proteinuria(missing data).
2. The proportions of donors developing hypertension, cardiovascular disease, eGFR < 60, eGFR < 45, eGFR < 30 ml/min/1.73 m2 were similar in donors with stones to those without stones. Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
3. The difference in proteinuria was no longer significant between stone former and non-stone former.
4. Kidney donors do not appear to be at a higher risk for kidney stones after donation.
5. The low rates of post-donation stones might be related to screening-out candidates who were potential to have stone recurrence in addition to the advices given to the donors to keep drinking water and to stay well hydrated.
6. The link of low CKD rates in donors with stone can be justified by study’s policy of excluding complicated kidney stones from donation.
Study’s strengths
a) The population studied spans 50 years of kidney donations.
b) Follow-up is ethnically diverse.
c) Donors have ascertainable intermediate renal outcomes such as reduced GFR, proteinuria, and cardiovascular disease development.
d) There were minimal missing data.
e) The propensity score matching produced a highly comparable kidney donor control group.
Study’s limitations
a) It is unclear how many donors with pre-donation stones were accepted.
b) There are no available details about regarding kidney stones size, unilateral versus bilateral and in unilateral cases whether that kidney was universally the donated one, and whether they were intervened upon pharmacologically or otherwise.
c) The policies of the 3 RELIVE study centers may not be similar to other centers which may limit the generalizability of these findings.
d) The RELIVE study did not capture bariatric surgery which can be predispose to kidney stones.
Study’ conclusion
a) The study’s data suggest that kidney donors with stones do not have an increased risk of reduced eGFR, hypertension, or proteinuria when compared to kidney donors without kidney stones.
b) Some candidates with multiple kidney stones who have a favorable and correctable urinary stone profile can be considered for donation if the predicted recurrence rate is low.
How these guidelines are different from the guidelines you follow at your workplace?
In my workplace we do reject all potential kidney donors with kidney stone(s) or history of kidney stone.
I like your list of strengths and limitations of this study, dear Dr Assafi.
Please summarise these guidelines in your own words
1- donors with renal stones were older, more of caucasian race and having an increase in blood sugar.
2- there was no incidence of ESRD in donors with kidney stones over a period of 16.5 +/- 10.9 years of follow-up.
3- the multi-variable risks of hypertension, proteinuria and decreased GFR, were similar in both groups of donors.
4- there was no association between renal stones and adverse renal outcome in kidney donors.
1- kidney donors with kidney stones have no increased risk of hypertension, proteinuria or decreasing GFR.
2- kidney donor candidates with kidney stones shouldn’t be excluded from donation provided that they are carefully evaluated for underlying metabolic disturbances as most of these disturbances can be managed with dietary modifications or pharmacologic interventions.
3- kidney donor candidates with multiple kidney stones who have favorite and correctable urinary stone profile can be considered for donation if the recurrence rate is low.
4- the risk of recurrence of renal stones in potential kidney donors can be reasonably quantified with ROKS nomogram, developed by Rule and colleagues.
How these guidelines are different from the guidelines you follow at your workplace?
Yes Dr Omar,
That is very good that you wish to reevaluate your policy based on this article.
Ajay
Kidney stones in kidney donors are quite common. [RATHER VERY COMMON IN MY STATE IN INDIA BUT VERY LESS PERCENTAGE OF METABOLIC CAUSES]
At many centers these candidates are excluded from the list of potential donors due to many anticipated risks associated with kidney stones: Obstructive, Infective, Metabolic and likely possibility of development of proteinuria and ESRD later in life post donation.
However, its still remains a controversial topic that whether to exclude all such potential donors with kidney stones straightaway or have common assessment policy.
Current study is a multi-centric (Involving 3 US centers) case control study with controls being the potential donors without kidney stones and not the general population. It had long follow up ranging from 13 to 20 years
Aim of Study: Development of hypertension, proteinuria, and reduced GFR after kidney donation was compared between donors with stones and propensity score-matched controls without kidney stones who were also potential donors.
Donors were grouped into three categories as per the kidney stone history:
227 donors had kidney stones who were compared to 908 propensity score (PS)-matched controls without stones.
The only differences noted between cases and controls after PS matching were a higher prevalence of smoking, hyperlipidemia and having a first-degree relative with hypertension in donors with kidney stones
Outcomes of study
Strength:
Limitations:
Overall, the authors proposed that donor candidates should not be excluded straightaway from donation until detailed metabolic evaluation has been done and ROKS normogram should be used for assessment of risk of recurrence of kidney stones in potential donors
I like your list of strengths and limitations of this study, dear Dr Saini.
Thanks sir
This was a case-control study looking at outcomes of kidney donors with pre- and post-donation kidney stones.
Many potential kidney donors have a history of renal calculi and are exempted from donating due to the potential risk of developing a kidney stone in the remaining kidney which may cause obstruction and consequent CKD. A study in Canada demonstrated that patients with kidney stones had a 2-fold higher risk of developing CJD and ESK. The NHANES survey also showed an increased risk developing CKD in female patients with kidney stones. However, the ARIC study did not demonstrate an increased risk of CKD in patients with kidney stones.
The possible reason for the the development of CKD and ESKD in patients with kidney stones is postulated to be due to the many comorbidities these patients also have.
Kidney donors are a special cohort of patients with no comorbidities, therefore their risk of developing CKD or ESKD should not be high.
This study looked at all the kidney donors from 1963-2007 at three centers. They compared kidney donors who had kidney stones pre-donation, pre- and post donation and those who developed kidney stones post-donation to propensity score-matched control donors without kidney stones.
They looked at 8922 kidney donors out of which 8695 had no kidney stones and 227 had kidney stones.
The 227 kidney donors with kidney stones were compared to 908 propensity score-matched control donors without kidney stones.
The outcome measures being looked at were
Baseline demographics and laboratory investigation results were obtained from the centers where the donors had undergone nephrectomy. A history and timing of kidney stones was obtained from the records and by donor-self report. Post-donation events were obtained from the medical records which included post-donation hypertension, CVD, proteinuria and ESKD.
HTN, proteinuria, eGFR < 60 mls/min and < 45 mls/min and CVD was compared in donors with stones to donors without stones.
200 donors had kidney stones pre-donation, 6 had kidney stones pre- and post-donation and 21 had developed stones post-donation.
The characteristics of donors with stones included:
The study showed that the risk of developing HTN. proteinuria or reducing GFR was similar in donors with kidney stones and donors without kidney stones.
The findings are similar to a study by Kummer et al.
The reason for the higher incidence of developing CKD/ESKD in non-donors with kidney stones is that these patients have multiple other comorbidities that can predispose them to develop CKD/ESKD and CVD, while the kidney donors are a highly selected cohort of patients with no comorbidities and hence their risk is much lower.
The authors propose that the criteria for disqualifying potential kidney donors with kidney stones should be re-looked in to.
In my center, our guidelines disqualify patients with history of recurrent renal calculi or presence of renal calculi during the work up. If the patient has had one episode of renal calculi, a full stone work up is done and if no cause is found then the patient is allowed to proceed with donation after counseling. However, the donor is under closer follow up
Very good thankyou
1-Summary ofoutcomes of kidney donors with pre-and post-donation kidney stones:Some studies concluded kidney stone may be associated with a higher risk of ckd and ESRD but presence of multiple morbid condition made the result of these studies is quite complicated.
In this study compared the development of HTN ,proteinuria and reduced eGFR in kidney donor with kidney stone to donor( control )without kidney stone.
material and methods:
At the RELIVE study there were 8922 live kidney donation at the study from 1963 to 2007.with updating information between 2010 to 2012.
Family history of HTN ,DM ,kidney disease ,stroke or heart disease in donors first degree relatives were recorded.
Report in this study included HTN ,proteinuria ,eGFR,60 and ,45ml/min1.7 m2and cvs were compered in donors with kidney stones versus those who had no kidney stone(control).
Result
Donor with kidney stone were older ,white and non related to recipient had a higher fasting plasma glucose 95 vs 92 mg/dl and a higher lower eGFR (85.1 vs88.4) p <.05 for all.
There were 227 donors had kidney stone 200 donors with pre donation stones,21 post donation stones ,and 6 donors had pre and post donation stones.
higher BMI were found in the in pre and post donation group.
lower eGFR and hyperlipdemia in stone at donation group.
Study outcome
there were 36.9% of donors develop HTN and 13.8% develop proteinuria and 0.7%had ESRD.
Death ,CVS, new onset HTN ,proteinuria ,eGFR <60and <45 were not statistically different in donors with history of stone and control groups.
no evidence of stone postdonation
Discussion
kidney donors pre or post donation ,were not at a higher, reduced eGFR ,proteinuria or ESRD risk for developing HTN .
Strength of this study
1-50 years of follow up of kidney donation..
2- donor have intermediate result out come such as reduced eGFR ,proteinuria ,cvs disease development .
3- minimal missing data .
4-The propensity score matching provide a highly comparer kidney donor and control .group.
Limitaion of the study
The number of donors with pre-donation stone that were accepted after they passed screening for metabolic disturbance is unclear .
Conculision
Kidney donor with kidney stones who were allowed to donate do not have an increased risk of reduced eGFR ,HTN or proteinuria who compered to kidney donor with no kidney stone
2-In our centre any donor with multiple ,recurrent stone and metabolic disorder is declined from the donation.
Dear All
I was pleased to read your comments. There
is some variation of practice which is normal. Some of you exclude all
potential donors with a history of a single stone. We need to know the basics of this exclusion.
Regarding those who accept potential donors
with a history of a single small stone (including all UK centres). What criteria should be fulfilled before accepting them?
I really enjoyed the reflection and it is a good opportunity to learn from each other
NB
Ibrahim et al is a well-known figure in this respect and all his articles are landmarks in kidney donation.
Ibrahim et al concluded that :
Guidelines for Living Donor Kidney Transplantation stated that :
This means that indication of exclusion of patient with history of renal stones include
Hence a patient with a single episode of renal stone can donate
But some will be reluctant to accept donor even with a single episode or renal stone on the base that a patient with history of renal stone has a 10-30 % recurrence rate at 3 years, 35-40 % at 5 years and 50% chance of recurrence at 10 years. (1-5) and this will be problematic in case of a single kidney
For me I will accept a donor with single episode or renal stone if no current stone and no metabolic abnormalities after educating the patient about the dietary life style to prevent recurrence.
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.
According to KDIGO guideline
The acceptance of a donor with prior or recurrent kidney stones should be based
Donor with kidney stone should have counseling (evidence based prevention of recurrent stones)
Detailed evaluation: time of the previous stone – location- all investigations (CT…)
Laboratory evaluation should be done
PTH …24h urine collection for Ca-UA- OXALATE- CITRATE- AND OTHERS….
Kidney function evaluation (GFR)
And exclude urology abnormalities
some factors carry low risk
So with negative evaluation and a low risk of recurrence we consider accepting donor with
Stone provided that he will be followed up by specialist to prevent the occurrence of stones
Very good, Thanks.
Incidentally discovered kidney stones in kidney donors are not uncommon. Transplant centers tend to exclude candidates with kidney stones fearing future obstructive consequences and the possible association between stones and CKD. However, there is controversy regarding this relation as the potential association is quite complicated as many people with kidney stones have multiple comorbid conditions.
Study aim: compared the development of hypertension, proteinuria, and reduced GFR in kidney donors with kidney stones to propensity score-matched donor controls without kidney stones.
Study population: living kidney donors who involved at RELIVE study in 3 US transplant centers from 1963 to 2007. For post-donation events, donors were contacted between 2010 and 2012 via telephone and multiple mailings for health updates.
Donors were stratified by kidney stone history: none, pre-donation kidney stones, post-donation kidney stones or both pre- and post-donation stones.
In total, 227 donors had kidney stones (200; pre-donation stones, 21;post-donation stones, and 6; both pre- and post-donation kidney stones) compared to 908 propensity score (PS)-matched controls without stones.
Donors with kidney stones were older, more likely to be white, less likely to be related to the recipient, had a higher fasting plasma glucose, and a slightly lower eGFR.
The only differences noted between cases and controls after PS matching were a higher prevalence of smoking, hyperlipidemia and having a first-degree relative with hypertension in donors with kidney stones
Study outcomes
The logistic regression model yielded adjusted odds ratios for death, CVD, new onset hypertension, proteinuria, eGFR < 60 and <45 ml/ min/1.73 m2 that were not statistically different in donors with any history of kidney stones compared to propensity score-matched controls.
Strength:
The population studied spans 50 years of kidney donation.
Follow-up is ethnically diverse.
Donors have ascertainable intermediate renal outcomes which are not captured in national donor data sets.
There were minimal missing data
The propensity score matching produced a highly comparable kidney donor control group
Limitation:
It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances that could lead to more kidney stones.
Details regarding kidney stone size, unilateral versus bilateral and in unilateral cases whether that kidney was universally the donated one, and whether they were intervened upon pharmacologically or otherwise.
the policies of the 3 RELIVE study centers may not be similar to other centers which may limit the generalizability of these findings.
the RELIVE study did not capture bariatric surgery which can be predisposed to kidney stones.
Study Conclusion;
Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD.
These data may provide a rationale for possibly a wider acceptance of donor candidates with low kidney stones burden These findings, however, do not provide guidance on candidates with more complicated stone history as those have been generally excluded from donation.
Potential donors with kidney stone and family history of kidney stone, abnormal metabolic screen or bilateral stone are usually excluded.
However, those with asymptomatic, unilateral, small stone, normal metabolic screen, and no family history of stone will be accepted for donation.
Very good, Hadeel, Thanks.
It is estimated that around 25% of US transplant centers exclude donor candidates with kidney stones. This is because of possible recurrence of kidney stone in the transplanted allograft with subsequent obstructive consequences and the possible association between stones and CKD.
The relationship between kidney stones and kidney disease post-kidney donation is controversial. Some studies reported that a history of kidney stones was associated with CKD and ESKD in women but not in men, however another study reported no association with higher risk of CKD after multivariable adjustment.
Results of RELIVE (Renal and Lung Living Donor Evaluation) Study
– After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed hypertension, 13.8% developed proteinuria, and 0.7% had ESKD.
– There were 46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones.
– The logistic regression model yielded adjusted odds ratios for death, CVD, new onset hypertension, proteinuria, eGFR < 60 and <45 ml/ min/1.73 m2 that were not statistically different in donors with any history of kidney stones compared to propensity score-matched controls.
In conclusion, Kidney donors with stones, whether occurring pre- or post- donation, were not at a higher risk for developing hypertension, reduced eGFR, proteinuria, or ESKD. Kidney donors do not appear to be at a higher risk for kidney stones after donation.
It is proposed that donor candidates should not be excluded from donation for having kidney stones as long as they are carefully evaluated for underlying metabolic disturbances most of which are amenable to dietary and/or pharmacological interventions.
Very good, Thanks.
Approximately 25% of renal donor candidates are rejected due to renal stones in view of a probable association with CKD. This study was conducted to evaluate kidney donors with stones with respect to development of hypertension, proteinuria, and reduction in eGFR.
This study was based on data from RELIVE (Renal and Lung Living Donor Evaluation) Study which involved 8922 donors from 3 transplant centres. A total of 227 donors had renal stones (200 had pre-donation stones, 21 had post-donation stones, while 6 had both pre- and post-donation stones). They were compared with 908 matched donors. Donors with >2 stones pre-donation were excluded.
Donors with stones were more likely to be whites, were older, less likely to be related to the recipient, had higher fasting blood sugars, and had slightly lower eGFR. Majority had single kidney stone. The median time from donation to stone detection was 89 days. Donors with both pre- and post-donation stones had higher BMI, dyslipidemia and lower eGFR at the time of donation.
Hypertension, reduction in GFR, ESKD and proteinuria were similar in the two groups.
The strengths of the study include: long-term data involving follow-up of diverse ethnic background donors, availability of complete data, and a highly comparable control group. The limitations of the study were that the data for kidney stone characteristics, metabolic screening of the donors and regarding bariatric surgery was missing.
Hence the study group recommended that the donor candidate should not be rejected in presence of renal stones, unless they have been evaluated for underlying metabolic abnormalities
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 in them is recommended.
Very good, Thanks.
What do you mean by metabolic abnormalties?
By metabolic abnormalities, I meant was serum levels of calcium, phosphorus, uric acid, in addition to 24 hour urine collection for calcium, uric acid, citrate, oxalate, creatinine, sodium and magnesium.
The results of these tests can give us a clue regarding the cause of stone formation.
SUMMARY
Introduction
It is estimated that about 25% of the potential kidney donor is US are declined because of findings of kidney stone for the fear of possible development of CKD after donation. Also, some studies have reported a greater risk of developing CKD or ESRD among people with kidney stone, but others have also reported contrary to this finding.
Aim of the Study:
-to compare the development of hypertension, proteinuria, and reduce GFR among donors with kidney stone to the matched control group.
Material and Method:
Results
Conclusion
There was no significant increase of hypertension, proteinuria or ESRD among donors with kidney stones compared to the matched donor in this study, hence exempting potential donors from donating kidney because of stone may not be totally beneficial to the growth of kidney transplantation.
In my centre, we do take donor with one stone after evaluating for possible etiology of the stone, but we usually reject those with two or more stones.
Very good, Thanks.
Please summarise these guidelines in your own words
Many studies suggest that there is an association between kidney stones and CKD. This study compared HTN, proteinuria , reduced eGFR and CV disease in kidney donors with kidney stones to matched controlled donor without kidney stones (ratio 1:4)
They used data of the Renal and Lung Living Donor Evaluation Study (RELIVE). Donors with proteinuria, eGFR < 80 and multiple kidney stones (3-5) were excluded
Donors with kidney stones were older, most of them were Caucasian, less likely to be related to recipients and higher fasting glucose
227 donors had kidney stones: 200 donors with pre-donation stones, 21 donors with post-donation stones, and 6 donors had both pre- and post-donation kidney stones. The majority (119) had 1 stone, 28 donors had 2 stones, 3 donors had 5 stones, and the number of stones in the remainder was unknown
After 16.5 ± 10.9 years from donation to study close, 36.9% of donors developed HTN, 13.8% developed proteinuria, and 0.7% had ESKD. Proteinuria occurred more in the case group but not significant. These results were similar to control group. Death, CVD, HTN, proteinuria, eGFR < 60 and <45 ml/ min were not statistically different in donors with any history of kidney stones compared to matched control group
Limitations of the study: It is unclear how many donors with pre-donation stones were accepted only after they passed screening for metabolic disturbances. Kidney stones size, unilateral versus bilateral and in unilateral cases which kidney was donated
These data concluded that kidney donors may be allowed to donate as there is no increase risk of proteinuria, reduced GFR or HTN
How these guidelines are different from the guidelines you follow at your workplace?
We exclude almost all donors with kidney stones (high risk of kidney disease). This article changes our mind as there is no increase risk of kidney diseases and other adverse outcomes regarding no metabolic abnormalities
Thank you Mohamed for your reflection on your practice.
Please summarise these guidelines in your own words
– Many kidney donor candidates have a history of prior symptomatic kidney stones and around 11% have evidence of stones on renal imaging performed during the evaluation.
– Some data suggest that kidney stones may be associated with a higher risk of CKD
and ESKD.
– Studying the potential association between kidney stones and future development of chronic kidney disease is quite complicated as many people with kidney stones have multiple comorbid conditions.
-This study compared the development of hypertension, proteinuria, and reduced
eGFR in 227 kidney donors with kidney stones to 908 to matched donor controls without kidney stones using data from The Renal and Lung Donor Evaluation (RELIVE) Study.
M ATE R I A L S A N D M E TH O DS
– Data was collected from RELIVE study which included 8922 living kidney donors from 1963-2007.
– 908 matched donors with no history of renal stones
– 227 kidney donors with stones
– Post-donation data was collected from 2010-2012 by contacting the donors through telephone and mailing.
– Post-donation events were also supplemented from centers records.
###Exclusion criteria: candidates with multiple stones especially recent onset.
-Candidates with complicated stones.
– Results:
– 200 donors had kidney stones before donation.
– 21 had post-donation stones.
– 6 had pre- and post-donation stones.
###Donors with stones were older, more likely to be Caucasian, less likely to be related to the recipient and had a higher fasting glucose.
– After 16.5 ± 10.9 years from donation, no ESKD occurred in donors with stones.
-46 ESKD events that occurred 18.5 ± 10.5 years after donation and none of these occurred in donors with kidney stones.
-The multivariable risks of hypertension, proteinuria, and reduced GFR were similar in
– donors with and without kidney stones.
Discussion
– Donors with stone pre or post were not at higher risk of developing HTN, decrease eGFR, proeteinuria, and ESKD.
-Also noticed decrease rate of stone , may be due to exclusion of donors with stone during evaluation.
– CKD post donation associated with kidney stone in some studies.
which are not captured in national donor data sets.
limitations.
Conclusion
– pre – post-donation stones were distinctly rare.
How these guidelines are different from the guidelines you follow at your workplace?
In our center donors with kidney stones are excluded from donation,espicially ( family history of reccurent kidney stones ,metabolic,bialateral kidney stones).
Very good, Thanks.