The man who gained a stone

John Beckly1, Sunil Bhandari1,2,, Josette Eris1 and John Horvath1

1 Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia and 2 Hull and East Yorkshire NHS Trust, Hull Royal Infirmary, Kingston upon Hull, UK

Keywords: pyelolithotomy; renal calculi; transplant; ultrasound scan

A 62-year-old male, previously on continuous ambulatory peritoneal dialysis for 1 year, received a cadaveric renal transplant. His renal failure was due to nephritis of undetermined cause. Past history consisted of hypertension and gout. He denied any history of renal stone disease or urinary infections. There was no family history of renal disease.

The donated left kidney came from a 60-year-old male, white Caucasian smoker with a history of hypertension. There was no history of renal stone disease. HLA matching was three out of six with 0% panel reactive antibodies, and a negative T- and B-cell cross-match. The donor kidney had a single renal artery with mild atheroma and an intrarenal aortic aneurysm. Biopsy showed minor acute tubular necrosis (ATN). No glomeruli were sclerosed. Cold and warm ischaemic times were 8 h 45 min and 35 min, respectively, before revascularization. Inspection of the graft prior to its placement in the recipient showed no evidence of renal calculi.

Surgery was uncomplicated with the graft vessels anastamosed end to side to the right external iliac vessels with good instantaneous renal perfusion. The ureteric anastomosis was submucosally tunnelled to a mucosal nipple made in the bladder.

At day 0 post-operatively, urine flow was poor. Routine allograft ultrasound scan (USS) demonstrated hydronephrosis secondary to a 2 cm calculus in the renal pelvis (Figure 1Go). The tortuous ureteric course and large adherent pelvic calculus prevented the successful placement of a transplant ureteric stent (Figure 2Go). Subsequent successful pyelolithotomy, with removal of a 1.5x2 cm oval mixed calcium phosphate/oxalate calculus, and repair of the ureteric anastamosis was carried out.



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Fig. 1.  Trans-abdominal ultrasound showing renal calculi (indicated by two+marks) lodged in renal pelvis of the donor kidney.

 


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Fig. 2.  Retrograde ureterogram showing tortuous dilated ureter and renal pelvis with the presence of a renal calculi.

 
He remained well despite a single episode of steroid responsive cellular rejection and cyclosporin toxicity. He was discharged on day 19 post-operatively after repeat biopsy showed improved rejection and cyclosporin changes. Serum creatinine had improved to 160 µmol/l. Immunosuppressives on discharge were mycophenolate 3 g daily, cyclosporin 350 mg daily and prednisone 30 mg daily.

Renal calculi are a rare urological complication of renal transplantation, developing, in <2% of allografts post-transplantation [1,2]. The incidence of detected transplanted renal calculi is much lower with few reported cases [15]. The clinical presentation of renal transplant calculi is non-specific resembling acute rejection [6], ATN, obstruction or sepsis and is complicated by the absence of renal colic due to renal denervation [7]. In donor graft lithiasis often the diagnosis is made by routine post-operative imaging [3].

Treatment of renal graft calculi follows the same principals as for native kidneys. Therapeutic choice is influenced by several important factors including: the size, volume, composition, location and morphology of the offending stone; the location (i.e. transplant, native or ectopic) of the kidney and whether there are any malformations within either the kidney or urinary tract. Three potential methods of stone removal are normally available: extracorporeal shock wave lithotripsy (ESWL) (for pelvic or calyceal calculi <2.5 cm), percutaneous nephrolithotomy (for calculi >2.5 cm) and ureteroscopy. ESWL is normally a safe and effective method of stone removal in the majority of patients with calculi in native kidneys. However, when using ESWL deleterious effects on renal function occur if base creatinine exceeds 300 µmol/l. There is an increased risk of hypertension, steinstrasse (stone fragments), urinary sepsis, peri-renal haematoma, subcapsular fluid collection, increase in kidney size and peri-renal fascia thickening [1,3]. The use of endo-urological techniques may be technically difficult due to the location of the transplant ureteral orifice and in our case the vulnerable ureteric anastamosis. Several authors advocate a percutaneous approach as the treatment of choice (irrespective of stone size) and, in particular, the use of percutaneous electrohydraulic lithotripsy [3,4].

Presence of a solitary renal calculi should not be a contraindication for renal harvesting and indeed if the calculus is in the renal calyces it is possible to transplant without removing it [1,4]. When stones are found elsewhere in the kidney prior to transplantation, these should be removed during kidney preparation using endoscopic techniques [4].

Direct X-ray of the abdomen with additional renal sonography is both sensitive and specific (89–100%) with a negative predictive value—excluding the presence of a stone—of ~95%. These two investigations together provide useful information on the presence and nature of stones and the extent of obstruction. Therefore, routine abdominal X-ray coupled with inspection and palpation of the graft is helpful in avoiding donor graft lithiasis [5]. The addition of routine renal USS of the donor kidney pre-transplantation [4] may allow removal of non-calyceal stones, thus reducing the risk of urological procedures in the early post-transplant period. It would thus seem prudent to USS all transplanted kidneys early post-operatively and consider renal calculi as a cause of renal transplant delayed function or deterioration.

Acknowledgments

We would like to thank the urology department and Mr J. Eissenger.

Notes

Correspondence and offprint requests to: Dr Sunil Bhandari, Hull and East Yorkshire NHS Trust, Hull Royal Infirmary, Anlaby Road, Kingston upon Hull HU3 2JZ, UK. Email: sunil.bhandari{at}hey.nhs.uk Back

References

  1. Benoit G, Blanchet P, Eschwege P, Jardin A, Charpentier B. Occurrence and treatment of kidney graft lithiasis in a series of 1500 patients. Clin Transplant1996; 10:176–180[ISI][Medline]
  2. Cho DK, Zackson DA, Cheigh J, Stubenbord WT, Stenzel KH. Urinary calculi in renal transplant recipients. Transplantation1988; 45:899[ISI][Medline]
  3. Kar PM, Popili S, Hatch D. Renal transplantation: donor with renal stone disease. Clin Nephrol1994; 42:347–348[ISI][Medline]
  4. Citterio F, Grassetti F, Nanni G, Azzaretto M, Avolio AW, Castagneto M. Accidental transplantation of a kidney with stones: case report. Transplant Proc1991; 23:2650[ISI][Medline]
  5. Lerut J, Lerut T, Gruwez JA, Michielsen P. Case profile: donor graft lithiasis—unusual complication of renal transplantation. Urology1979; XIV:627–628[CrossRef]
  6. Donnelly PK, Farndon JR. Donor ureteric calculus presenting as acute rejection in a renal transplant recipient. Br Med J1984; 288:1961–1962[ISI][Medline]
  7. Greif F, Dreznick Z, Jacob ET. Calculus in 16-year-old cadaveric kidney transplant: a unique case and literature review. Nephron1990; 55:423–428[ISI][Medline]
Received for publication: 19. 6.02
Accepted in revised form: 19. 9.02





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