Accepting donor kidneys with stones remains a thorny issue

Sat, 12 Sep 2015

The decision to accept potential kidney donors with stone disease or a history of stone problems remains a difficult issue for urologists and the challenge involves not only a comprehensive check on both the donor and kidney recipient’s health records but also on the wishes of the involved parties.

Experts tackled the challenges of kidney transplants and stones in one of the concluding sessions of the 3rd EAU Section of Urolithiasis (EULIS) which ended today in Alicante, Spain.

Nephrologist Prof. David Goldsmith (GB) gave a comprehensivel overview on the issue during his lecture titled “Pathophysiology of de novo renal stones in the transplanted kidney,” wherein he examined the potential repercussions of a kidney stone-bearing organ in both recipient and donor.

“Fortunately, calculus or stone disease after transplantation has a low rate of incidence - about 1% of all allografts,” said Goldsmith. Calculi, according to Goldsmith, can be detected with imaging and that in many cases these calculi or stones can be removed prior to the transplant.

The challenge, however, remains as the possibility for the recipient to develop stones exists as with the recurrence of stone formation in the donor himself.

“It is prudent to remain vigilant at post-transplantation for both recipient and donor,” said Goldsmith. He said the decision to reject a potential donor due to kidney stone history is difficult due to the scarcity for suitable donors and the obligation to ensure health safety.

G. Gambaro (IT) picked up the discussion in the follow-up lecture and said asymptomatic stones in potential donors with no recurrence record should not be considered an obstacle for kidney donation. He underscored the importance of patient counselling in cases when the donor has a record of stone formation.

“The donor and recipient should be counselled extensively regarding the risk of donation. Where possible the stone-bearing kidney should be used for donation,” said Gambaro. He noted that donors with a kidney stone history should be evaluated on diet and fluid intake.

“Educating the donor is important to reduce the risk for the development of stone in the single kidney after donation,” he said, as he opined that personally he would treat the stone-bearing kidney before donation or transplantation.

Alberto Breda (ES) further deepened the discussion with his lecture on incidental renal stones in live kidney donors and reiterated the statements forwarded by the previous speakers. “A potential kidney donorwith a current single stone (less than 15mm) may be suitable if the donor is not at high risk for recurrence, and if the stone is potentially removable during transplantation,” said Breda.

During the Q&A, the concern that kidney recipients may missed out on a life-saving transplantation was stressed which prompted the speakers to note that crucial decisions are not easy to reach since recurrence of stones in donors may be minimal.

“I would rather recommend to involve the donor and the patient in the discussion, counsel them on the benefits and risks,” said Goldsmith as he mentioned that in some situations the concern may be hypothetical.

Gambaro focused on the importance of a proper health evaluation and the probability of stone recurrence. For his part, Breda said he would draw the line if the potential donor with kidney stones has a family history and of a young age, implying that recurrence in these type of donors is highly probable. He also added that with a single kidney, donor themselves are vulnerable, post-operatively, particularly when stone formation recurs.

“If you are operating on a donor, we are obliged to also give them the care,” he said whilst noting that follow-up is certainly recommended for the donors.