Background: The acceptance of living kidney donor candidates with nephrolithiasis varies across transplant programs. Although radiographic stone burden and prior symptomatic episodes frequently influence donor selection, the prognostic role of urinary metabolic abnormalities in predicting symptomatic stone recurrence after donor evaluation remains insufficiently characterized. Objective: To determine whether metabolic abnormalities identified during living donor evaluation are associated with symptomatic kidney stone events after evaluation among candidates with a personal history or radiographic evidence of nephrolithiasis. Methods: We designed a retrospective cohort study of adult living kidney donor candidates evaluated at a tertiary transplant center between 2012 and 2024. Eligible candidates had either a prior symptomatic kidney stone history, asymptomatic radiographic nephrolithiasis on donor imaging, or both. Baseline variables included demographics, body mass index, prior stone history, radiographic stone burden, laterality, maximum stone diameter, and 24-hour urine metabolic parameters. Donation outcome was classified as donated, not donated because of kidney stone-related concerns, or not donated for other reasons. The primary outcome was a symptomatic kidney stone event after donor evaluation. Univariable and multivariable logistic regression models were used to identify factors associated with non-donation due to stone disease and with post-evaluation symptomatic stone recurrence. Results: Among 284 donor candidates with nephrolithiasis, 146 (51.4%) donated, 68 (23.9%) did not donate due to kidney stone-related concerns, and 70 (24.6%) did not donate for other reasons. Low urine volume, hypocitraturia, hypercalciuria, and higher radiographic stone burden were more frequent among candidates who were declined because of stone-related risk. During a median follow-up of 5.2 years, 49 candidates (17.3%) experienced a symptomatic kidney stone event after donor evaluation. In multivariable analysis, younger age (aOR 0.94 per year, 95% CI 0.91-0.98, p=0.003), two or more stones on baseline imaging (aOR 2.84, 95% CI 1.52-5.31, p=0.001), hypocitraturia (aOR 2.67, 95% CI 1.39-5.12, p=0.003), and low urine volume (aOR 2.41, 95% CI 1.26-4.60, p=0.008) were independently associated with symptomatic recurrence, whereas donation itself was not independently associated with post-evaluation symptomatic stone events. Conclusions: In living kidney donor candidates with nephrolithiasis, urinary metabolic abnormalities appear to refine recurrence risk beyond radiographic stone burden alone. Standardized metabolic evaluation may improve donor risk stratification and support more consistent transplant committee decision-making.