| Abstract|| |
A renal transplant recipient presented with abdominal pain and anuria secondary to multiple radio-opaque obstructing calculi. A ureteroscopy with ultrasonic disintegration was done, and the fragments were spontaneously passed later. The calculi had formed on a non-absorbable suture line. Although ureterolithiasis in the transplanted kidney is amongst the least common of the urological complications following renal transplantation, it is an important reversible cause of obstruction that should always be considered. Also, non-absorbable suture lines should not be used in the urinary tract because they may serve as a nidus for stone formation.
Keywords: Renal transplant, Lithiasis, Ureteric obstruction.
|How to cite this article:|
Hadidi M, Al-Akash N, Affarah H, El-Lozi M. Ureterolithiasis in a Renal Transplant Patient Secondary to Encrustation about a Suture Line. Saudi J Kidney Dis Transpl 1995;6:308-11
|How to cite this URL:|
Hadidi M, Al-Akash N, Affarah H, El-Lozi M. Ureterolithiasis in a Renal Transplant Patient Secondary to Encrustation about a Suture Line. Saudi J Kidney Dis Transpl [serial online] 1995 [cited 2013 May 19];6:308-11. Available from: http://www.sjkdt.org/text.asp?1995/6/3/308/40668
| Introduction|| |
Urinary tract lithiasis is an uncommon, but a well recognized complication in renal transplant patients , , the etiology and the management of which is similar to that in the non-transplanted patients ,,,, . Recently, in a retrospective analysis of 1000 renal transplant recipients, only two cases of uretery stones were identified  . Another study involving 1224 transplant recipients showed that stone formation is the least common of the urological complications, occurring in 6.6% of the cases  Despite its rarity, allograft lithiasis remains an important reversible cause of renal allograft functional detrioration ,, .
Several etiologic factors play a role in the formation and enlargement of renal or ureteric calculi in renal transplant recipients  . The most common etiology appears to be secondary hyperparathyroidism with the resultant disturbance in calcium and phosphorus metabolism ,, . Obstructive factors, such as periureteral fibrosis, lymphocele, and urinoma may lead to stagnation of urine and contribute to stone formation ,,, . Other causes include recurrent or persistent urinary tract infection especially when the organism is of the ureasplitting type ,,,, , or when the ureter is draining into an ileal loop  . Certain congenital metabolic defects such as primary oxalosis and cystinuria ,,, , or posttransplant renal tubular acidosis ,,,, could also play a role in the causation of stones. Donor-graft lithiasis is a particular form of renal calculus resulting from transplantation of a kidney and ureter with an unsuspected stone and is estimated to be present in about 0.5% of transplanted patients ,, . Also, the ingestion of large amounts of antacid containing magnesium trisilicate has been reported to have caused the formation of a silicon dioxide stone in a transplant patient  . The presence of a foreign body within the urinary system is another well recognized factor in stone formation ,,, , We herewith report a renal transplant recipient in whom renal stones were formed encrusted on a suture line.
| Case Report|| |
A 21 year old male patient, a known case of chronic glomerulonephritis since childhood, was placed on chronic hemodialysis in October 1982, and received a living-related kidney transplant from his brother in February 1985. The kidney was placed in the right iliac fossa with the ureter of the donor kidney anastomosed to the right ureter of the recipient in its lower third. He had a smooth post-operative course and was discharged with a serum creatinine of 97 µmol/L on prednisone and azathioprine.
He presented in November 1987 with sudden onset of colicky, non-radiating pain in the right iliac fossa with urgency and inability to pass urine for the past 16 hours. The patient denied history of fever, chills, previous history of urinary tract infection, and passage of kidney stones. His blood pressure was 180/120 mmHg, and the transplanted kidney was palpable and tender. A renal ultrasound, isotope scan, and intravenous pyelogram were highly suggestive of obstruction.
A percutaneous nephrostomy was performed to drain the transplanted kidney, and a nephrostogram showed multiple opaque stones in the lower end of the transplanted ureter with complete obstruction. Three days later, cystoscopy was performed under general anesthesia and the right ureter was dilated to 14 F. With the aid of a ureteroscope, the stones were seen and ultrasonic disintegration was performed.
Post-operatively, urine was drained through the nephrostomy tube as well as an indwelling Foley catheter. Ten days later, a repeat nephrostogram showed three stones at the upper part of the ureter causing partial obstruction and moderate dilatation of the pelvicalyceal system [Figure - 1]. The Foley catheter and the nephrostomy tube were removed and two weeks later, the patient spontaneously passed three calculi encrusted about a suture line [Figure - 2]. The stone fragments were white, spherical in shape, hard and with a rough surface. Stone analysis showed mainly calcium oxalate and traces of magnesium phosphate.
In February 1988, the patient was readmitted for evaluation. He was normotensive on no anti-hypertensive medications, with a serum creatinine of 106 µmol/L. Arterial blood gases, intravenous pyelogram, and 24 hour urine collection for protein, calcium, and uric acid were within normal limits.
| Discussion|| |
Renal transplant lithiasis is generally considered to be a late complication, occurring at least six months after transplantation  . Donor-graft lithiasis may present sooner, and has been reported even in the immediate post-operative period ,,, . The main presenting features are localized pain in the region of allograft, a sudden decrease in urinary output, fever, graft tenderness, an elevation in serum creatinine and radiologic evidence of urinary tract obstruction , .The complications may range from simple obstruction with hydronephrosis and the possibility of infection, to erosion of the stone through the ureter at the anastomotic site and consequent urinary extravasation  .
In our patient, a non-absorbable suture line served as a nidus for stone formation. It may be mentioned here that usage of nonabsorbable suture line in the urinary tract is not recommended. Motayne, et al reported the occurrence of lithiasis in seven renal transplant patients; in each of these cases the calculus formed on a tantalum staple used for uretero-ureteral anastomosis, and was positioned in a circular fashion at the anastomosis site and not within the lumen. However, with time the stones migrated into the lumen  .
The diagnosis of transplant urolithiasis depends on radiologic procedures including ultrasound and pyelography, as well as renal isotope scan  . The surgical management of calculi follows the same general principles which apply to native non-transplanted kidneys but with some modifications  . Non-operative management with endourological techniques have assumed a more important role in the treatment of early urological complications following transplantation because of theincreased risk of infection and impairment of wound healing in the immunosuppressed patient following open surgery , .
Percutaneous antegrade techniques allow adequate drainage of the transplanted kidney, and renal function recovery, and have also been very valuable in the observation and removal of calculi ,, . Large sized stones are disintegrated by ultrasonic lithotripsy and the fragments may be sucked out. Retrograde catheterization is more difficult because the neo-meatus is not easily accessible for cannulation , . In our patient, transurethral manipulation was possible because of the original ureteroureteric anastomosis. Nephrolithotomy may still be necessary for removal of stones, but it requires special technical considerations  . Preventive methods against allograft lithiasis are very important, and it is now routine to exclude kidney stones before transplantation in live-related donors. However, this may be difficult in cadaveric donors who are critically ill and unstable in intensive care units  .
Finally, patients who are at an increased risk for forming stones should be more closely observed for possible risk factors, and the appropriate preventive therapy should be initiated promptly.
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Department of Nephrology, King Hussein Medical Center, Amman
[Figure - 1], [Figure - 2]