Multimodal management of urolithiasis in renal transplantation

Abstract

OBJECTIVE To report the largest single series of renal transplant patients (adults and children) with urolithiasis, assess the risk factors associated with urolithiasis in renal transplant recipients, and report the outcome of the multimodal management by endourological and open procedures. PATIENTS AND METHODS The records of all patients undergoing renal transplantation between 1977 and 2003 were reviewed. In all, 2085 patients had a renal transplant at our centre and 21 (17 adults and four children) developed urinary tract calculi. Their mode of presentation, investigations, treatments, complications and outcomes were recorded. Investigations included one or more of the following; ultrasonography (US), plain abdominal X‐ray, intravenous urography, nephrostogram and computed tomography. Management of these calculi involved extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy and in situ lithotripsy, percutaneous nephrolithotomy (PCNL), open pyelolithotomy and open cystolitholapaxy. RESULTS Thirteen patients had renal calculi, seven had ureteric calculi and one had bladder calculi. The incidence of urolithiasis was 21/2085 (1.01%) in the series. Urolithiasis was incidentally discovered on routine US in six patients, six presented with oliguria or anuria, including one with acute renal failure, four with a painful graft, three with haematuria, one with sepsis secondary to obstruction and infection and in one, urolithiasis was found after failure to remove a stent. Ten patients (63%) had an identifiable metabolic cause for urolithiasis, two by obstruction, two stent‐related, one secondary to infection and in six no cause was identifiable. Thirteen required more than one treatment method; 13 (69%) were treated by ESWL, eight of whom required multiple sessions; eight required ureteric stent insertion before a second procedure and four required a nephrostomy tube to relieve obstruction. Two patients had flexible ureteroscopy and stone extraction, three had a PCNL and one had open cystolithotomy. PCNL failed in one patient who subsequently had successful open pyelolithotomy. All patients were rendered stone‐free when different treatments were combined. CONCLUSIONS The incidence of urolithiasis in renal transplant patients is low. There is a high incidence of metabolic causes and therefore renal transplant patients with urolithiasis should undergo comprehensive metabolic screening. Management of these patients requires a multidisciplinary approach by renal physicians, transplant surgeons and urologists.

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“…In general, a radioopaque nonobstructing calculus of less than 15 mm is suitable for SWL. 5,26 Even in cases of graft obstruction, a rapid relief with PCN followed by SWL appears to be optimal for stone clearance. 5 Retrograde access to the transplanted ureter is technically demanding because of the domal location of ureteral orifice.…”

“…5 In addition, the superficial location of a renal allograft to the abdominal wall might contribute to an easier procedure. Furthermore, PNL has been performed in the early postoperative period with minimal morbidity.…”

“…1 Urolithiasis is an uncommon sequela after renal transplant with a varying incidence of up to 3%. [2][3][4][5][6][7][8][9] Stones in the allograft may be donor gifted or de novo, which develop after transplant. A donor with a stone-bearing kidney is no longer a contrain dication for donation provided that certain criteria are met, 10 a term called "donor-gifted nephrolithiasis."…”

Tubeless percutaneous nephrolithotomy (pcnl) in renal allografts: a case report and mini-review

“…[10][11][12][13][14] Many series have reported the mean time of posttransplantation lithiasis between 1.6 to 3.6 years. 4,15,16 As, this complication is usually asymptomatic, the diagnosis is often made incidentally by ultrasound examination followed by symptoms such as hematuria, oliguria/anuria, fever, elevated creatinine level, and positive urine culture. 3,17 Traditionally, open surgery has been used for allograft calculus treatment which may lead to substantial morbidity and mortality.…”

Urological challenges in renal transplantation

“…The majority of calculi are less than 1 cm in diameter, with staghorn calculi being an unusual occurrence. As in the native urinary tract, the majority of calculi can be treated with shock wave lithotripsy (ESWL), percutaneous nephrolithotomy or flexible ureteroscopy and lithotrity (42). Localization during SWL can be a little more difficult than in the native kidney.…”