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anagement of Calculi in A Donor Kidney

. Trivedi, S. Patel, A. Devra, J. Rizvi, R. Goel, and P. Modi

ABSTRACT

Introduction. We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) andextracorporeal shock wave lithotripsy (ESWL) as means of rendering a donated kidneystone-free in living related and deceased donor renal transplantation.Material and methods. Three cases with calculi in donor kidneys were managed; 1 wasfrom a living related donor and 2 were from deceased donors. Immediately after coldperfusion, ExURS was performed with iced saline solution in 2 cases. Access to thecollecting system was via the ureteral stump. Calculi were fragmented with pneumaticintracorporeal lithotripsy and fragments were removed with forceps. PosttransplantationESWL was given to 1 patient for migration of a small lower caliceal calculus in the upperureter in 1 allograft of a dual-kidney transplantation.Results. Access to the renal collecting system and stone fragmentation was technicallysuccessful in both cases. Indwelling ureteral stents were kept during transplantation in allcases. There were no intraoperative or postoperative ureteral complications. FollowingESWL, stone was fragmented and cleared on its own within a week. At mean follow up of2.2 years no new stone formed in any recipient or donor.Conclusions. ExURS was technically feasible to render a stone-bearing kidney stone-free without compromising ureteral integrity or renal allograft function. ESWL could be

performed at a later date.

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ECEASED donor kidney transplantation programs indeveloping countries are still in the evolving phase.

here is a constant shortage of donors leading to inevitablese of marginal donors and kidneys. The incidence of donoridney lithiasis is approximately 0.37%.1 Lithiasis in theonor kidney has been considered a relative contraindica-ion to donation. But potential donors who have passednly 1 stone, have been free of stone disease for at least 10ears, display a low metabolic risk of future stone forma-ion, and have a normal antegrade pyelogram may beonsidered suitable candidates for donor nephrectomy.2 Atone in such a graft can be managed either ex vivommediately after harvesting or in vivo after transplanta-ion.

ATERIALS AND METHODS

e report our experience of 3 cases where renal grafts harboredtones. Two were subjected to ex vivo ureteroscopy (ExURS) stonereatment: 1 each in living related and deceased donor kidneysuring transplantation. Posttransplantation extracorporeal shockave lithotripsy (ESWL) was performed in 1 case of a deceased

onor kidney. In the living related case, a single 5-mm lower s

2007 by Elsevier Inc. All rights reserved.60 Park Avenue South, New York, NY 10010-1710

ransplantation Proceedings, 39, 761–762 (2007)

alyceal calculus was identified in the donor; ESWL followed byercutaneous nephrolithotomy failed. Immediately after donorephrectomy ExURS was done and stone was cleared.In the third case of dual-kidney transplantation where small

tones were present in both kidneys, the calculi in 1 kidney passedpontaneously and ESWL was given to a migrated calculus innother kidney during the third posttransplantation week. Renalunction was normal and urine culture was sterile. All recipientsere thoroughly counseled by the institutional transplantation

eam regarding stone formation by the transplanted allograft.

From the Department of Urology and Transplantation, Dr H.L.rivedi Institute Of Transplantation Sciences, Gulabben Rasiklaloshi and Kamlaben Mafatlal Mehta Institute Of Kidney Dis-ases & Research Center, Ahmedabad, Gujarat, India.Address reprint requests to Pranjal R. Modi, MS, DNB (Urol-

gy), Professor, Department of Urology and Transplantation, Dr.L. Trivedi Institute Of Transplantation Sciences, Gulabbenasiklal Doshi and Kamlaben Mafatlal Mehta Institute Of Kidneyiseases & Research Centre, Civil Hospital Campus, Asarwa,hmedabad- 380016, Gujarat, India. E-mail: ikdrcad1@

ancharnet.in

0041-1345/07/$–see front matterdoi:10.1016/j.transproceed.2007.01.059

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762 TRIVEDI, PATEL, DEVRA ET AL

echnique of ExURS

mmediately after harvesting the flushed kidney was prepared forransplantation. Ureteroscopy was performed through the ureterictump without ureteral dilatation, using an 8.5-French semirigidreteroscope. The kidney was cooled throughout the procedure inn iced saline bath with ice cold normal saline solution irrigationuid. All stones were visualized under direct vision; fluoroscopyas not used. Stones were fragmented with pneumatic energy and

he fragments were retrieved with forceps. Ureteroneo-cystostomyas performed over a JJ stent.

ESULTS

xURS was technically successful in both cases. Enteringll calices was possible by rotating the kidney. The post-ransplantation course was uneventful in both cases. Anndwelling ureteral stent was removed 2 weeks after trans-lantation. Recipient serum creatinines were 1.6 mg/dL and.2 mg/dL at 1 month posttransplantation and 1.2 mg/dLnd 0.99 mg/dL at 3 months, respectively. Follow-up of 5onths and 2 years showed no recurrence of calculi in any

ecipient.In the case of ESWL, complete clearance was achieved

ith no requirement for an ancillary procedure and noecurrence of calculi at 2 years follow-up.

ISCUSSION

ithiasis in the donor kidney is a difficult problem. Twoases have been described where a stone-bearing kidneyas transplanted; the recipient underwent subsequent suc-essful ESWL after transplantation.4 ExURS may be easiero perform in comparison with in vivo ureteroscopy, be-ause the ureter is free and short. In addition, the kidneyan be manipulated to vary the ureteropelvic angle toacilitate access to all calyces.5 The intervention may beerformed in a timely fashion with average additional cold

schemia time well within a period deemed safe for subse- N

uent transplantation. Because the transplanted kidney hadeen proven to be a stone former, there is concern that theecipient allograft is at risk for subsequent de novo stoneormation. It is well known from previous case series thathe stone rate in recipients is between 0.3% and 6.3%,hich is significantly lower than the normal population.6,7

o date, de novo nephrolithiasis has not developed in anyf our recipients. It has been speculated that the increasedlomerular filtration rate and urine output on a perephron basis that a transplant kidney experiences may beufficient to overcome any propensity of the kidney forubsequent stone formation.5

In conclusion, ExURS was a technically feasible means toender a stone-bearing kidney stone-free without compro-ising ureteral integrity or renal allograft function. ESWLas given successfully in the third posttransplantation week

o a third patient.3

EFERENCES

1. Van Gansbeke D, Zalcmon M, Matos C, et al: Lithiasicomplications of renal transplantation: the donor graft lithiasisoncept. Urol Radiol 7:157, 1985

2. Kasiske BL, Ravenscraft M, Ramos EL, et al: The evaluationf living renal transplant donors: clinical practice guidelines. J Amoc Nephrol 7:2288, 19963. Lu HF, Shekarriz B, Stoller LM: Donor gifted allograft

rolithiasis: early percutaneous management. Urology 59:25, 20024. Bhaduria RP, Ahlawat R, Kumar RV, et al: Donor gifted

llograft lithiasis: ESWL with over the table module using theithosatr Plus. Urol Int 55:51, 19955. Rashid MJ, Konnak JW, Wolf JS, et al: Ex vivo ureteroscopic

reatment of calculi in donor kidneys at renal transplantation.Urol 171:58, 20046. Harper JM, Samuel CT, Hallson PC, et al: Risk factors for

alculus formation in patients with renal transplants. Br J Urol4:147, 19947. Oztemel A, Yalcinkaya F, Duranay M, et al: Ureteropelvic

bstruction due to urinary calculi in transplanted kidney. Int Urol

ephrol 26:611, 1994