EXPANDING THE LIVING RELATED DONOR POOL IN RENAL TRANSPLANTATION:: USE OF MARGINAL DONORS

Outcomes in Living Donor Kidney Transplantation: The Role of Donor's Kidney Function

INTRODUCTION

Living donor kidney transplant (LDKT) is one of the best therapeutic options for end-stage kidney disease (ESKD). Guidelines identify different estimated glomerular filtration rate (eGFR) thresholds to determine the eligibility of donors. The aim of our study was to evaluate whether pretransplant donor eGFR was associated with kidney function in the recipient.

METHODS

We retrospectively studied LDKT recipients who received a kidney graft between September 1, 2005, and June 30, 2016 in the same transplant center in France and that had eGFR data available at 3, 12, 24, and 36 months posttransplant.

RESULTS

We studied 90 donor-recipient pairs. The average age at time of transplant was 51.47 ± 10.95 for donors and 43.04 ± 13.52 years for recipients. Donors' average eGFR was 91.99 ± 15.37 mL/min/1.73 m2. Donor's age and eGFR were significantly correlated (p < 0.0001, r2 0.023). Donor's age and eGFR significantly correlated with recipient's eGFR at 3, 12, and 24 months posttransplant (age: p < 0.001 at all intervals; eGFR p = 0.001, 0.003, and 0.016, respectively); at 36 months, only donor's age significantly correlated with recipient's eGFR. BMI, gender match, and year of kidney transplant did not correlate with graft function. In the multivariable analyses, donor's eGFR and donor's age were found to be associated with graft function; correlation with eGFR was lost at 36 months; and donor's age retained a strong correlation with graft function at all intervals (p < 0.001).

CONCLUSIONS

Donor's eGFR and age are strong predictors of recipient's kidney function at 3 years. We suggest that donor's eGFR should be clinically balanced with other determinants of kidney function and in particular with age.

[Analysis of living related kidney donors and their postoperative course]

Lack of cadaveric organs for transplantation resulted in increased number of living related kidney donors examinations and consequent transplantations in our Department. Donor procedure, selection, drop-outs and final results for living related donors (LRD) were retrospectively analyzed in this paper. Between 1987 and 1994 202 potential LRD were examined. Most of them were females (59%) and about 30% were older than 60 years. The family relation between LRD and recipients were: parents (95%), siblings (3%), grandmother/grandfather (1.5%) and uncle (0.5%). Potential LRD were informed on risks, advantages and procedure of living donor transplantation. After primary information 26% of potential LRD gave up further examinations. Following immunological and clinical evaluations 48% of LRD actually donated a kidney. The other 26% were excluded during the selection procedure. High immunological risks including ABO incompatibility, HLA mismatches and positive cross match test were the reasons for drop outs of 35 potential LRD (17%). Five more donors were excluded for medical reasons: one because of low creatinine clearance and four because of neoplasms, discovered during examination (kidney, laryngeal, lung). Fourteen transplantation were not realized due to different recipient reasons: 5 of them had clinical contraindications, two died and in 7 cadaveric kidney transplantations were performed. Mild hypertension, coronary disease and diabetes mellitus type 2 were presented in 5 LRD accepted for transplantation. Five more had to be operated before donation (abdominal or urological operation). Early complications after donor nephrectomy were acute renal failure, stress ulcus, pleuropneumonia in three and thromboflebitis in two donors. In conclusion, although kidney transplantation from LRD is highly successful, careful examination during selection procedure is indispensable.

Laparoscopy-assisted live donor nephrectomy: a modified cost-effective approach for developing countries

BACKGROUND AND PURPOSE

Because of the prohibitive cost of laparoscopic disposable instruments such as the PneumoSleeve, Endocatch, and vascular staples, laparoscopic live-donor nephrectomy has not gained wide acceptance in many developing countries. To circumvent this problem, we have developed a cost-saving approach, which is described herein and compared with the open method.

PATIENTS AND METHODS

Forty-nine patients underwent laparoscopic live-donor nephrectomy at our institute, of which two were performed by the hand-assisted technique, five by the technique described by Fabrizio et al and forty-two by our modified cost-saving laparoscopy-assisted technique (LD). The latter patients were compared with 50 patients who had a standard open donor nephrectomy (OD) through a rib-resecting (12th rib) flank incision. Our technique is similar to the procedure described by Fabrizio et al except for a 6- to 8-cm incision placed in the subcostal region to retrieve the kidney after the renal vessels are cut and ligated as in the open procedure. The costs of the various techniques at our institute were compared.

RESULTS

The LD and OD groups were similar in terms of age, weight, side of nephrectomy, and number of renal vessels. The operative time was longer in the LD group than in the OD group (180.7 +/- 18 minutes v 101.5 +/- 10.4 minutes), whereas the mean intraoperative blood loss was less (85.5 +/- 21.35 v 220 +/- 22.5 mL; P < 0.001). Warm ischemia time and recipient outcomes were comparable in the two groups. Patients in the LD group had lower postoperative narcotic (tramadol hydrochloride) requirement (155.3 +/- 53.3 mg v 251.8 +/- 63.1 mg; P < 0.001) and earlier discharge from the hospital (3.14 v 5.7 days; P < 0.001). The mean expense incurred was US$175 v US$160 in the LD and OD groups, respectively. The cost of the hand-assisted and standard laparoscopic techniques was significantly higher than that of our modified technique.

CONCLUSIONS

Our modified technique of laparoscopy-assisted live-donor nephrectomy avoids the use of costly disposables yet offers the advantages of lesser morbidity and small incision of LD. It is cost effective and is an alternative to open nephrectomy in the developing world.