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Extracorporeal Shock Wave Lithotripsy in A Renal Transplant Patient
0022-534 7/89 /1411-0098$2.00/0 THE JOURNAL OF UROLOGY
Vol. 141, January
Copyright © 1989 by The Williams & Wilkins Co.
Printed in U.S.A.
Pediatric Articles EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY IN A RENAL TRANSPLANT PATIENT EILEEN ELLIS, CHARLES WAGNER, WATSON ARNOLD, WILLIAM HULBERT TROY BARNETT
AND
From the Arkansas Children's Hospital, University of Arkansas for Medical Sciences and St. Vincent's Infirmary, Little Rock, Arkansas
ABSTRACT
We report a case of nephrolithiasis in a transplanted kidney that was treated successfully with extracorporeal shock wave lithotripsy. The patient experienced transient partial obstruction after lithotripsy and, thus, intense monitoring of the transplant patient is necessary. (J. Ural., 141: 9899, 1989) Development of renal calculi in a transplanted kidney is rare and it is most often related to hyperparathyroidism and hypercalcemia in the transplant recipient.' Previously, if the calculi did not pass spontaneously either open surgical or percutaneous endourological intervention often was required. 1 - 3 Furthermore, parathyroidectomy also was often required to alleviate the severe hyperparathyroidism. 1 With the advent of newer, nonsurgical management of nephrolithiasis, the need for an operation can be greatly reduced in patients with lithiasis in native kidneys. We report a case of a renal calculus in a 13-year-old renal transplant recipient, which was treated by extracorporeal shock wave lithotripsy (ESWL*). After treatment the patient experienced transient obstruction of the ureter by a stone fragment but she had no other complications.
schedule. A month after transplantation a urinary tract infection was noted and renal ultrasound revealed an unsuspected calculus in the upper pole of the newly transplanted kidney that had not been noted on the renal ultrasound immediately after the transplant. The calculus was radiopaque and measured 1 x 0.4 cm. The patient underwent ESWL with no ureteral catheter using the Dornier HM3 ESWL unit.* With the patient under general anesthesia, she was placed in the carrier of the lithotriptor unit in the standard position. The stone was 2 cm. below the iliac crest, necessitating visualization and focusing through the vertebral column by 1 camera. She received 1,500 shocks at 20 kV. The patient tolerated the procedure well and she was discharged from the hospital the next day while passing small gravel in the urine. No problems were noted on twice weekly outpatient followup until 1 month after lithotripsy when the serum creatinine increased from 0.8 to 1.2 mg./dl. Repeat ultrasound showed migration of a stone fragment to the ureterovesical junction associated with increasing hydronephrosis. After several days of vigorous hydration, stone fragments were found in the urine. Renal ultrasound showed that the stone was no longer present and the hydronephrosis was resolving. Renal function remains good at 10-month followup. Donor and recipient laboratory evaluations are shown in the table. The stone fragments were composed of calcium oxalate and apatite.
CASE REPORT
S. P. had a left flank mass, massive bilateral hydronephrosis with vesicoureteral reflux and a duplicated system on the left side when she was 5 days old. From infancy to age 3 years multiple surgical procedures were performed to correct the urinary tract abnormalities and she experienced renal insufficiency, voiding difficulties and chronic urinary tract infections. When she was 8 years old end stage renal disease supervened and chronic hemodialysis was started. A year later nephrectomy and renal transplantation, with her mother as the donor, were performed. Renal function was excellent for the next 3 years, although clean intermittent catheterization was required for complete bladder drainage. When the patient was 12 years old renal function deteriorated and end stage renal disease recurred despite treatment of rejection with methylprednisolone and antithymocyte globulin. After several months on continuous cycling peritoneal dialysis a second renal transplant, with her uncle as the donor, was performed. Her uncle was 49 years old with no history of nephrolithiasis. The donated left kidney had mild caliceal dilatation but it was otherwise normal on preoperative angiography and diuretic renography. The recipient was maintained on a post-transplant medication regimen of prednisone, cyclosporine A, furosemide, hydralazine and aluminum phosphate. She was not placed on a clean intermittent catheterization
DISCUSSION
The development of a renal stone in a transplanted kidney is uncommon, 1 • 4 - 6 and it is most often associated with severe hyperparathyroidism and hypercalcemia, although infection and renal tubular acidosis also can predispose to stone formation. Unsuspected cadaveric donor graft stones rarely have been noted to complicate the early post-transplant course. 6 Partial or complete obstruction of the transplanted ureter can occur and it has been reported to result in acute renal failure. 5 The etiology for stone formation in our patient is not entirely clear. It is doubtful that the stone was present in the donor kidney at transplantation, since arteriography before and renal ultrasound immediately after transplantation were normal. The recipient certainly had evidence of hyperparathyroidism, although hypercalcemia did not develop during the year before or at anytime after transplantation, nor did she have hypercalciuria. The patient was transiently hypophosphatemic after transplantation but this was resolved with aluminum phosphate
Accepted for publication May 12, 1988.
* Dornier Medical Systems, Inc., Marietta, Georgia. 98
99
Serum calcium (mg./dl.) Serum phosphorus (mg./dl.) N-terminal parathyroid hormone (pg./ml.) Serum uric acid (mg./dl.) Creatinine clearance (ml./min./1. 73 m.') Urine uric acid excretion (mg./kg./ day) Urine calcium excretion (mg./kg./day) Urine citrate excretion (mg./24 hrs.)
Normal Values*
Recipient PreTransplant
Recipient PostTransplant
8.5-10.4
8.9-10.0
9.5-10.8
9.6
2.7-4.5
3.3-7.5
1.6-4.2
4.0
8-24
340
14
2.6-5.6 95-122
5.3
Donor
9.7, 7.6 72
107
2-15
6.2
6.9
<4
1.0
2.5
322-1,239
108
transplant patient parallels these reports in that the stone v,as fragmented successfully without any major complications, although transient partial obstruction did occur 1 month after ESWL. Our patient experienced no pain at the time of partial obstruction as might be expected in the transplant situation. In addition to the usual careful monitoring, the use of renal ultrasound to differentiate obstruction from other causes of renal dysfunction in the transplanted kidney is particularly helpful. Other complications of ESWL have been noted, such as perirenal hematoma, subcapsular fluid collection, increase in kidney size and perirenal fascial thickening. 10 ESWL appears to be a successful method to treat renal calculi in the transplanted kidney; however, the transplant patient represents a higher risk and, thus, intense monitoring after ESWL is necessary.
7,440
* For 13-year-old girl. therapy. She never exhibited evidence of renal tubular acidosis. Although she had multiple urinary tract infections before the second transplant no urinary tract infection was detected after transplantation until the calculus was discovered. Nevertheless, several possible factors, including hyperparathyroidism and infection, probably relate to development of the calculus. During the last several years ESWL has become standard treatment of renal calculi, especially for smaller calculi when radiological localization is possible and there is no distal obstruction.7 Recently, the use of ESWL has been extended to children with nephrolithiasis 8 and to patients with a solitary kidney, 9 although to our knowledge its use in a child with a renal transplant has not been reported. The renal calculus developed in the upper pole of the transplanted kidney in our patient 1 month after transplantation and was treated successfully with ESWL. However, a month after treatment the patient did experience a transient increase in serum creatinine that was associated with migration of a stone fragment into the ureter and partial obstruction. ESWL appears to be safe and effective treatment in children with nephrolithiasis with a 93 per cent success rate without major complications;8 however, long-term effects on renal function and renal growth are unknown. A similar success rate has been achieved with the use of ESWL in adults with calculi in a solitary kidney.r1 In the patient with a solitary kidney it is crucial to monitor renal function, urine output and fragment size, since complete or partial obstruction with stone fragments has been reported in 8 per cent. 9 The experience with our
REFERENCES
1. Leapman, S. B., Vidne, B. A., Butt, K. M. H., Waterhouse, K. and
2. 3.
4. 5. 6.
7.
8.
9.
10.
Kountz, S. L.: Nephrolithiasis and nephrocalcinosis after renal transplantation: a case report and review of the literature. J. Urol., 115: 129, 1976. Schweizer, R. T., Bartus, S. A., Graydon, R. J. and Berlin, B. B.: Pyelolithotomy of a renal transplant. J. Urol., 117: 665, 1977. Hulbert, J.C., Reddy, P., Young, A. T., Hunter, D. W., CastanedaZuniga, W., Amplatz, K. and Lange, P. H.: The percutaneous removal of calculi from transplanted kidneys. J. Urol., 134: 324, 1985. Rosenberg, J. C., Arnstein, A. R., Ing, T. S., Pierce, J. M., Jr., Rosenberg, B., Silva, Y. and Walt, A. J.: Calculi complicating a renal transplant. Amer. J. Surg., 129: 326, 1975. Boyce, N. W., Holdsworth, S. R., Scott, D. and Atkins, R. C.: Acute renal transplant failure resulting from obstruction with a calculus. Transplant. Proc., 16: 1364, 1984. Van Gansbeke, D., Zalcman, M., Matos, C., Simon, J., Kinnaert, P. and Struyven, J.: Lithiasic complications of renal transplantation: the donor graft lithiasis concept. Urol. Rad., 7: 157; 1985. Webb, D.R., Payne, S. R. and Wickham, J.E. A.: Extracorporeal shockwave lithotripsy and percutaneous renal surgery. Comparisons, combinations and conclusions. Brit. J. Urol., 58: 1, 1986. Newman, D. M., Coury, T., Lingeman, J. E., Mertz, J. H. 0., Mosbaugh, P. G., Steele, R. E. and Knapp, P. M.: Extracorporeal shock wave lithotripsy experience in children. J. Urol., 136: 238, 1986. Kulb, T. B., Lingeman, J. E., Coury, T., Steele, R. E., Newman, D. M., Mertz, J.M. 0., Mosbaugh, P. G. and Knapp, P.: Extracorporeal shock wave !ithotripsy in patients with a solitary kidney. J. Urol., 136: 786, 1986. Rubin, J. I., Arger, P.H., Pollack, H. M., Banner, M. P., Coleman, B. G., Mintz, M. C. and Van Arsdalen, K. N.: Kidney changes after extracorporeal shock wave lithotripsy: CT evaluation. Radiology, 162: 21, 1987.
Vol. 141, January
Copyright © 1989 by The Williams & Wilkins Co.
Printed in U.S.A.
Pediatric Articles EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY IN A RENAL TRANSPLANT PATIENT EILEEN ELLIS, CHARLES WAGNER, WATSON ARNOLD, WILLIAM HULBERT TROY BARNETT
AND
From the Arkansas Children's Hospital, University of Arkansas for Medical Sciences and St. Vincent's Infirmary, Little Rock, Arkansas
ABSTRACT
We report a case of nephrolithiasis in a transplanted kidney that was treated successfully with extracorporeal shock wave lithotripsy. The patient experienced transient partial obstruction after lithotripsy and, thus, intense monitoring of the transplant patient is necessary. (J. Ural., 141: 9899, 1989) Development of renal calculi in a transplanted kidney is rare and it is most often related to hyperparathyroidism and hypercalcemia in the transplant recipient.' Previously, if the calculi did not pass spontaneously either open surgical or percutaneous endourological intervention often was required. 1 - 3 Furthermore, parathyroidectomy also was often required to alleviate the severe hyperparathyroidism. 1 With the advent of newer, nonsurgical management of nephrolithiasis, the need for an operation can be greatly reduced in patients with lithiasis in native kidneys. We report a case of a renal calculus in a 13-year-old renal transplant recipient, which was treated by extracorporeal shock wave lithotripsy (ESWL*). After treatment the patient experienced transient obstruction of the ureter by a stone fragment but she had no other complications.
schedule. A month after transplantation a urinary tract infection was noted and renal ultrasound revealed an unsuspected calculus in the upper pole of the newly transplanted kidney that had not been noted on the renal ultrasound immediately after the transplant. The calculus was radiopaque and measured 1 x 0.4 cm. The patient underwent ESWL with no ureteral catheter using the Dornier HM3 ESWL unit.* With the patient under general anesthesia, she was placed in the carrier of the lithotriptor unit in the standard position. The stone was 2 cm. below the iliac crest, necessitating visualization and focusing through the vertebral column by 1 camera. She received 1,500 shocks at 20 kV. The patient tolerated the procedure well and she was discharged from the hospital the next day while passing small gravel in the urine. No problems were noted on twice weekly outpatient followup until 1 month after lithotripsy when the serum creatinine increased from 0.8 to 1.2 mg./dl. Repeat ultrasound showed migration of a stone fragment to the ureterovesical junction associated with increasing hydronephrosis. After several days of vigorous hydration, stone fragments were found in the urine. Renal ultrasound showed that the stone was no longer present and the hydronephrosis was resolving. Renal function remains good at 10-month followup. Donor and recipient laboratory evaluations are shown in the table. The stone fragments were composed of calcium oxalate and apatite.
CASE REPORT
S. P. had a left flank mass, massive bilateral hydronephrosis with vesicoureteral reflux and a duplicated system on the left side when she was 5 days old. From infancy to age 3 years multiple surgical procedures were performed to correct the urinary tract abnormalities and she experienced renal insufficiency, voiding difficulties and chronic urinary tract infections. When she was 8 years old end stage renal disease supervened and chronic hemodialysis was started. A year later nephrectomy and renal transplantation, with her mother as the donor, were performed. Renal function was excellent for the next 3 years, although clean intermittent catheterization was required for complete bladder drainage. When the patient was 12 years old renal function deteriorated and end stage renal disease recurred despite treatment of rejection with methylprednisolone and antithymocyte globulin. After several months on continuous cycling peritoneal dialysis a second renal transplant, with her uncle as the donor, was performed. Her uncle was 49 years old with no history of nephrolithiasis. The donated left kidney had mild caliceal dilatation but it was otherwise normal on preoperative angiography and diuretic renography. The recipient was maintained on a post-transplant medication regimen of prednisone, cyclosporine A, furosemide, hydralazine and aluminum phosphate. She was not placed on a clean intermittent catheterization
DISCUSSION
The development of a renal stone in a transplanted kidney is uncommon, 1 • 4 - 6 and it is most often associated with severe hyperparathyroidism and hypercalcemia, although infection and renal tubular acidosis also can predispose to stone formation. Unsuspected cadaveric donor graft stones rarely have been noted to complicate the early post-transplant course. 6 Partial or complete obstruction of the transplanted ureter can occur and it has been reported to result in acute renal failure. 5 The etiology for stone formation in our patient is not entirely clear. It is doubtful that the stone was present in the donor kidney at transplantation, since arteriography before and renal ultrasound immediately after transplantation were normal. The recipient certainly had evidence of hyperparathyroidism, although hypercalcemia did not develop during the year before or at anytime after transplantation, nor did she have hypercalciuria. The patient was transiently hypophosphatemic after transplantation but this was resolved with aluminum phosphate
Accepted for publication May 12, 1988.
* Dornier Medical Systems, Inc., Marietta, Georgia. 98
99
Serum calcium (mg./dl.) Serum phosphorus (mg./dl.) N-terminal parathyroid hormone (pg./ml.) Serum uric acid (mg./dl.) Creatinine clearance (ml./min./1. 73 m.') Urine uric acid excretion (mg./kg./ day) Urine calcium excretion (mg./kg./day) Urine citrate excretion (mg./24 hrs.)
Normal Values*
Recipient PreTransplant
Recipient PostTransplant
8.5-10.4
8.9-10.0
9.5-10.8
9.6
2.7-4.5
3.3-7.5
1.6-4.2
4.0
8-24
340
14
2.6-5.6 95-122
5.3
Donor
9.7, 7.6 72
107
2-15
6.2
6.9
<4
1.0
2.5
322-1,239
108
transplant patient parallels these reports in that the stone v,as fragmented successfully without any major complications, although transient partial obstruction did occur 1 month after ESWL. Our patient experienced no pain at the time of partial obstruction as might be expected in the transplant situation. In addition to the usual careful monitoring, the use of renal ultrasound to differentiate obstruction from other causes of renal dysfunction in the transplanted kidney is particularly helpful. Other complications of ESWL have been noted, such as perirenal hematoma, subcapsular fluid collection, increase in kidney size and perirenal fascial thickening. 10 ESWL appears to be a successful method to treat renal calculi in the transplanted kidney; however, the transplant patient represents a higher risk and, thus, intense monitoring after ESWL is necessary.
7,440
* For 13-year-old girl. therapy. She never exhibited evidence of renal tubular acidosis. Although she had multiple urinary tract infections before the second transplant no urinary tract infection was detected after transplantation until the calculus was discovered. Nevertheless, several possible factors, including hyperparathyroidism and infection, probably relate to development of the calculus. During the last several years ESWL has become standard treatment of renal calculi, especially for smaller calculi when radiological localization is possible and there is no distal obstruction.7 Recently, the use of ESWL has been extended to children with nephrolithiasis 8 and to patients with a solitary kidney, 9 although to our knowledge its use in a child with a renal transplant has not been reported. The renal calculus developed in the upper pole of the transplanted kidney in our patient 1 month after transplantation and was treated successfully with ESWL. However, a month after treatment the patient did experience a transient increase in serum creatinine that was associated with migration of a stone fragment into the ureter and partial obstruction. ESWL appears to be safe and effective treatment in children with nephrolithiasis with a 93 per cent success rate without major complications;8 however, long-term effects on renal function and renal growth are unknown. A similar success rate has been achieved with the use of ESWL in adults with calculi in a solitary kidney.r1 In the patient with a solitary kidney it is crucial to monitor renal function, urine output and fragment size, since complete or partial obstruction with stone fragments has been reported in 8 per cent. 9 The experience with our
REFERENCES
1. Leapman, S. B., Vidne, B. A., Butt, K. M. H., Waterhouse, K. and
2. 3.
4. 5. 6.
7.
8.
9.
10.
Kountz, S. L.: Nephrolithiasis and nephrocalcinosis after renal transplantation: a case report and review of the literature. J. Urol., 115: 129, 1976. Schweizer, R. T., Bartus, S. A., Graydon, R. J. and Berlin, B. B.: Pyelolithotomy of a renal transplant. J. Urol., 117: 665, 1977. Hulbert, J.C., Reddy, P., Young, A. T., Hunter, D. W., CastanedaZuniga, W., Amplatz, K. and Lange, P. H.: The percutaneous removal of calculi from transplanted kidneys. J. Urol., 134: 324, 1985. Rosenberg, J. C., Arnstein, A. R., Ing, T. S., Pierce, J. M., Jr., Rosenberg, B., Silva, Y. and Walt, A. J.: Calculi complicating a renal transplant. Amer. J. Surg., 129: 326, 1975. Boyce, N. W., Holdsworth, S. R., Scott, D. and Atkins, R. C.: Acute renal transplant failure resulting from obstruction with a calculus. Transplant. Proc., 16: 1364, 1984. Van Gansbeke, D., Zalcman, M., Matos, C., Simon, J., Kinnaert, P. and Struyven, J.: Lithiasic complications of renal transplantation: the donor graft lithiasis concept. Urol. Rad., 7: 157; 1985. Webb, D.R., Payne, S. R. and Wickham, J.E. A.: Extracorporeal shockwave lithotripsy and percutaneous renal surgery. Comparisons, combinations and conclusions. Brit. J. Urol., 58: 1, 1986. Newman, D. M., Coury, T., Lingeman, J. E., Mertz, J. H. 0., Mosbaugh, P. G., Steele, R. E. and Knapp, P. M.: Extracorporeal shock wave lithotripsy experience in children. J. Urol., 136: 238, 1986. Kulb, T. B., Lingeman, J. E., Coury, T., Steele, R. E., Newman, D. M., Mertz, J.M. 0., Mosbaugh, P. G. and Knapp, P.: Extracorporeal shock wave !ithotripsy in patients with a solitary kidney. J. Urol., 136: 786, 1986. Rubin, J. I., Arger, P.H., Pollack, H. M., Banner, M. P., Coleman, B. G., Mintz, M. C. and Van Arsdalen, K. N.: Kidney changes after extracorporeal shock wave lithotripsy: CT evaluation. Radiology, 162: 21, 1987.