Analysis of 33,616 urinary stone cases: novel findings on renal transplantation impact, comorbidity profiles, and composition patterns

Background Urinary stone composition in renal transplant recipients remains poorly characterized, despite their distinct metabolic and urological profiles. Understanding stone composition patterns in this population is crucial for targeted management and recurrence prevention strategies. Methods This retrospective observational study analyzed 33,616 urinary stone samples from two hospitals in Southern China (April 2014-December 2024). We compared stone composition between 69 renal transplant recipients with nephrolithiasis and 33,547 non-transplant stone-forming controls using Fourier Transform-Infrared Spectrometry. Propensity score matching (1:2) was performed to balance baseline characteristics. Logistic regression with progressive adjustment and comprehensive subgroup analyses were conducted to assess associations between transplantation and stone composition. Results After propensity score matching, transplant recipients with nephrolithiasis demonstrated markedly different stone composition patterns compared to controls. Before matching, carbonate apatite stones were substantially more prevalent among stone formers in the transplant group (37.7% vs. 16.4%, p<0.001), while calcium oxalate monohydrate stones were less common (39.1% vs. 63.7%). After matching with 139 controls, these differences persisted and intensified (carbonate apatite: 37.7% vs. 15.8%; calcium oxalate monohydrate: 39.1% vs. 66.9%, p=0.001). Renal transplantation with nephrolithiasis was associated with significantly lower proportion of calcium oxalate stones compared to non-transplant stone formers (OR 0.32, 95% CI: 0.17-0.57, p<0.001) and significantly higher odds of carbonate apatite stones (OR 3.22, 95% CI: 1.66-6.32, p<0.001).These associations remained robust across sensitivity analyses with progressive adjustment for confounders (adjusted OR for carbonate apatite: 2.82, 95% CI: 1.37-5.82) and multiple subgroups stratified by age, sex, and comorbidities. Additional factors associated with carbonate apatite included renal atrophy (OR 4.37, 95% CI: 1.49-13.17, p=0.007) and urinary tract stricture (OR 2.50, 95% CI: 1.06-5.75, p=0.032). Transplant recipients with nephrolithiasis also exhibited higher proportions of mixed stone composition (58.0% vs. 39.6%, p=0.018) and urological complications. Conclusions Renal transplantation fundamentally alters urinary stone pathogenesis in patients who develop stones, with distinct compositional shifts toward carbonate apatite and away from calcium oxalate stones. These findings suggest the need for transplant-specific stone prevention protocols.