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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 1995  |  Volume : 6  |  Issue : 3  |  Page : 308-311
Ureterolithiasis in a Renal Transplant Patient Secondary to Encrustation about a Suture Line


King Hussein Medical Center, Amman, Jordan

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   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 2020 Jun 4];6:308-11. Available from: http://www.sjkdt.org/text.asp?1995/6/3/308/40668

   Introduction Top


Urinary tract lithiasis is an uncommon, but a well recognized complication in renal transplant patients [1],[2] , the etiology and the management of which is similar to that in the non-transplanted patients [3],[4],[5],[6],[7] . Recently, in a retrospective analysis of 1000 renal transplant recipients, only two cases of uretery stones were identified [8] . 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 [9] Despite its rarity, allograft lithiasis remains an important reversible cause of renal allograft functional detrioration [10],[11],[12] .

Several etiologic factors play a role in the formation and enlargement of renal or ureteric calculi in renal transplant recipients [2] . The most common etiology appears to be secondary hyperparathyroidism with the resultant disturbance in calcium and phos­phorus metabolism [4],[6],[13] . Obstructive factors, such as periureteral fibrosis, lymphocele, and urinoma may lead to stagnation of urine and contribute to stone formation [2],[5],[12],[13] . Other causes include recurrent or persistent urinary tract infection especially when the organism is of the urea­splitting type [3],[5],[13],[14],[15] , or when the ureter is draining into an ileal loop [16] . Certain congenital metabolic defects such as primary oxalosis and cystinuria [3],[5],[6],[17] , or post­transplant renal tubular acidosis [3],[5],[6],[13],[17] 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 [1],[5],[18] . 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 [17] . The presence of a foreign body within the urinary system is another well recognized factor in stone formation [1],[5],[11],[18] , We herewith report a renal transplant recipient in whom renal stones were formed encrusted on a suture line.


   Case Report Top


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 Top


Renal transplant lithiasis is generally considered to be a late complication, occurring at least six months after transplantation [1] . Donor-graft lithiasis may present sooner, and has been reported even in the immediate post-operative period [1],[5],[10],[18] . 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 [2],[19] .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 [20] .

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 [19] .

The diagnosis of transplant urolithiasis depends on radiologic procedures including ultrasound and pyelography, as well as renal isotope scan [12] . The surgical management of calculi follows the same general princi­ples which apply to native non-transplanted kidneys but with some modifications [13] . 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 [6],[7] .

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 [6],[7],[11] . 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 [5],[7] . 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 [17] . 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 [1] .

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.

 
   References Top

1.Van Gansbeke D, Zalcman M, Matos C, Simon J, Kinnaert P, Struyven J. Lithiasis complications of renal transplantation: The donor graft lithiasis concept. Urol Radiol 1985;7:157-60.  Back to cited text no. 1  [PUBMED]  
2.De Vecchi A. Donor ureteric calculus presenting as cute rejection in a renal transplant recipient. Br Med J Clin Res Ed 1984;289:1079-80.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Narayana AS, Loening S, Culp DA. Kidney stones and renal transplantation. Urology 1978;12:61-3.  Back to cited text no. 3  [PUBMED]  
4.Leapman SB, Vidne BA, Butt KM, Waterhouse K, Kountz SL. Nephrolithiasis and nephrocalcinosis after renal transplantation: A case report and review of the literature. J Urol 1976;115:129-32.  Back to cited text no. 4  [PUBMED]  
5.Shackford S, Collins GM, Kaplan G, Harbach L. Idiopathic ureterolithiasis in a renal transplant patient. J Urol 1976;116:660-l.   Back to cited text no. 5  [PUBMED]  
6.Hulbert JC, Reddy P, Young AT, et al. The percutaneous removal of calculi from transplanted kidneys. J Urol 1985;134:324-6.  Back to cited text no. 6  [PUBMED]  
7.Benoit G, Icard P, Bensadoun H, et al. Value of antegrade ureteral dilation for late ureter obstru­ction in renal transplants. Transpl Int 1989;2:33-5. 8. Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1000 consecutive renal transplant recipients. J Urol 1995;153(1): 18-21.  Back to cited text no. 7  [PUBMED]  
8.Thiounn N, Benoit G, Osphal C, et al. Urological complications in renal transplantation. Prog Urol 1991;l(4):531-8.  Back to cited text no. 8    
9.Donnelly PK, Farndon JR, Roy RR. Donor ureteric calculus presenting as acute rejection in a renal transplant recipient. Br Med J Clin Res Ed 1984;288:1961-2.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Fisher MF, Haaga JR, Persky L, Eckel RE, LiPuma J. Renal stone extraction through a percutaneous nephrostomy in a renal transplant patient. Radiology 1982;144:95-6.   Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Qunibi WY, Chavez A, Guerriero WG, Suki WN. Renal transplant ureteric obstruction by periureteric fibrosis. Am J Nephrol 1982;2:91-4.   Back to cited text no. 11  [PUBMED]  
12.Lucas BS, Castro JE. Calculi in renal transplants. Br J Urol 1978;50:302-6.   Back to cited text no. 12  [PUBMED]  
13.Caralps A, Lloveras J, Masramon J, Andreu J, Brulles A, Gilvernet JM. Urinary calculi after renal transplantation. Lancet 1977;1:544.   Back to cited text no. 13    
14.Hess B, Metzger RM, Ackermann D, Montandon A, Jaeger P. Infection-induced stone formation in a renal allograft. Am J Kidney Dis 1994;24:868-72.   Back to cited text no. 14  [PUBMED]  
15.Rattiazzi LC, Simmons RL, Markland C, Casali R, Kjellstrand CM, Najarian JS. Calculi complicating renal transplantation into ileal conduits. Urology 1975;5:29-31.   Back to cited text no. 15  [PUBMED]  
16.Schweizer RT, Bartus SA, Graydon RJ, Berlin BB. Pyelolithotomy of a renal transplant. J Urol 1977;117:665-6.  Back to cited text no. 16  [PUBMED]  
17.Lerut J, Lerut T, Gruwez JA, Michielsen P. Case profile: donor graft lithiasis-unusual complication of renal transplantation. Urology 1979;14:627-8.  Back to cited text no. 17  [PUBMED]  
18.Motayne GG, Jindal SL, Irvine AH, Abele RP. Calculus formation in renal transplant patients. J Urol 1984;132:448-9.   Back to cited text no. 18  [PUBMED]  
19.Starzl TE, Groth CG, Putnam CW, et al. Urological complications in 216 human recipients of renal transplants. Ann Surg 1970; 172:1-22.   Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Petrek J, Tilney NL, Smith EH, Williams JS, Vineyard GC. Ultrasound in renal transplantation. Ann Surg 1977;185:441-7.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Nabil Al-Akash
Department of Nephrology, King Hussein Medical Center, Amman
Jordan
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    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures
 

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