Laparoscopic donor nephrectomy increases the supply of living donor kidneys: a center-specific microeconomic analysis

The Mayo Adhesive Probability score can help predict intra- and postoperative complications in patients undergoing laparoscopic donor nephrectomy

PURPOSE

Living donor nephrectomy is a high-stake procedure involving healthy individuals, therefore every effort should be made to define each patient's individualized risk and improve potential donors' information. The aim of this study was to evaluate the interest of the Mayo adhesive probability (MAP) score, an imaging-based score initially designed to estimate the risk of adherent perinephric fat in partial nephrectomy, to predict intra- and postoperative complications of living donor nephrectomy.

MATERIALS AND METHODS

We retrospectively reviewed the imaging, clinical, and follow-up data of 452 kidney donors who underwent laparoscopic donor nephrectomy in two academic centers.

RESULTS

Imaging and follow-up data were available for 307 kidney donors, among which 44 (14%) had a high MAP score (≥ 3). Intraoperative difficulties were encountered in 50 patients (16%), including difficult dissection (n = 35) and bleeding (n = 17). Conversion to open surgery was required for 13 patients (4.2%). On multivariate analysis, a MAP score ≥ 3 was significantly associated with the risk of intraoperative difficulty [OR 14.12 (5.58-35.7), p < 0.001] or conversion to open surgery [OR 18.96 (3.42-105.14), p = 0.0042]. Postoperative complications were noted in 99 patients (32%), including 12 patients (3.9%) with Clavien-Dindo grade III-IV complications. On multivariate analysis, a high MAP score was also associated with the risk of postoperative complications [OR 2.55 (1.20-5.40), p = 0.01].

CONCLUSIONS

In this retrospective bicentric study, a high MAP score was associated with the risk of intra- and postoperative complications of laparoscopic donor nephrectomy. The MAP score appears of interest in the living donor evaluation process to help improve donors' information and outcomes.

Prescription patterns of opioids and non-steroidal anti-inflammatory drugs in the first year after living kidney donation: An analysis of U.S. Registry and Pharmacy fill records

We examined a novel database linking national donor registry identifiers to records from a US pharmaceutical claims warehouse (2007-2015) to describe opioid and NSAID prescription patterns among LKDs during the first year postdonation, divided into three periods: 0-14 days, 15-182 days, and 183-365 days. Associations of opioid and NSAID prescription fills with baseline factors were examined by logistic regression (adjusted odds ratio, LCL aORUCL ). Among 23,565 donors, opioid prescriptions were highest during days 0-14 (36.6%), but 12.6% of donors filled opioids during days 183-365. NSAID prescriptions rose from 0.5% during days 0-14 to 3.3% during days 183-365. Women filled opioids more commonly than men, and black donors filled both opioids and NSAIDs more commonly than white donors. After covariate adjustment, significant correlates of opioid prescription fills during days 183-365 included obesity (aOR,1.24 1.381.53 ), less than college education (aOR,1.19 1.311.43 ), smoking (aOR,1.33 1.451.58 ), and nephrectomy complications (aOR,1.11 1.291.49 ). NSAID prescription fills in year 1 were not associated with differences in estimated glomerular filtration rate, incidence of proteinuria or new-onset hypertension at the first and second year postdonation. Prescription fills for opioids and NSAIDs for LKDs varied with demographic and clinic traits. Future work should examine longer-term outcome implications to help inform safe analgesic regimen choices after donation.

Comparison of transversus abdominis plane block and intrathecal morphine for laparoscopic donor nephrectomy: Randomised controlled trial

Background and Aims:

Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures.

Methods:

The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 μg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software.

Results:

Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement (P = 0.01) and postoperative fentanyl requirement until 24 h (P = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment (P = 0.000).

Conclusion:

ITM 5 μg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.

Living Donor Liver Transplantation: Technical Innovations

Living donor liver transplantation (LDLT) has found a place to serve the end-stage liver disease community as the donor safety and recipient suitability has been elucidated. Donor safety is of paramount importance and transplant programs must continue endeavors to maintain the highest possible standards. At the same time, adequacy of grafts based on recipient clinical status via their model for end-stage liver disease (MELD) score and volumetric studies to achieve a GRBWR >0.8, along with special attention to anatomic tailoring and portal venous flow optimization are necessary for successful transplantation. Technical innovations have improved sequentially the utility and availability of LDLT.

Minimally Invasive Surgery for Live Kidney Donors: Techniques and Challenges

Live kidney donation is assuming an increasingly prominent role in kidney transplantation programs. The traditional operative approach has been through an incision in the upper quadrant of the abdomen or in the loin, with the attendant potential postoperative complications associated with a large surgical wound. These problems may act as disincentives to prospective donors. The introduction of laparoscopic donor surgery in 1995 heralded a new era offering reduced postoperative pain and improved cosmetic result. It is hoped that these benefits may counter some disincentives and thereby increase donation rates. Three minimal-access approaches and their advantages and disadvantages are described: classical laparoscopic, hand-assisted laparoscopic, and retroperitoneoscopic surgery. Published reports indicate extensive experience with the first 2 of these approaches and less experience with the latter. All 3 approaches present technical, physiological, and anatomical challenges in the context of retrieving an organ that is fit for transplantation. For minimal-access surgery to be accepted as the procedure of choice for live kidney donors, it must be demonstrated that morbidity is not transferred from donor to recipient when these techniques are used. Some concerns about these procedures are addressed. High-level evidence in the form of randomized controlled trials is generally lacking, but experiences of surgeons and patients suggest that, with appropriate modifications, these techniques are safe for both donors and allografts and also benefit donors' recovery.

Laparoscopic donor nephrectomy: The Middle East experience

OBJECTIVES

To summarize the experience of the Middle East in laparoscopic donor nephrectomy (LDN), to discuss the associated advantages and salient problems, to examine the learning curve encountered compared with that of the pioneering centres in the West, and the contribution of the regional centres to the worldwide experience.

METHODS

We searched Medline and PubMed for all centres performing LDN in the Middle East. Questionnaires were e-mailed to the regional transplantation centres, and programme directors, and leading urological and transplant surgeons were contacted by telephone.

RESULTS

LDN in the Middle East was first introduced in 2000; this approach has been pioneered and practised at seven transplant centres within five countries in the region, and was restricted to only three Arab countries, i.e. Lebanon, Egypt and Kuwait. Data collection yielded a total of 888 procedures over one decade, representing only 2% of the total of ≈50,000 transplants during the same period. Despite variability of accurate reporting the overall outcomes were similar to those of open DN. The spectrum of complications was comparable to that from major centres in the USA during their learning curve.

CONCLUSIONS

The introduction of LDN in the Middle East has been gratifying. The relative hesitancy in introducing LDN in the rest of the Arab Middle East is multifaceted. The advantages conferred to the donor underscore the need for further expansion of this approach for kidney retrieval.

Morbidity of 200 consecutive cases of hand-assisted laparoscopic living donor nephrectomies: a single-center experience

Background. Recipients of laparoscopically procured kidneys have been reported to have delayed graft function, a slower creatinine nadir, and potential significant complications. As the technique has evolved laparoscopic donor nephrectomy technique is becoming the gold standard for living donation. Study Design. We retrospectively reviewed the data of the first 200 hand-assisted laparoscopic living donor nephrectomies performed between January 2003 and February 2009. The initial 41 donors and their recipients (Group 1) were compared to the next 159 donors and their recipients (Group 2). The estimated blood loss, serum creatinine at discharge and 6 months, and the incidence of delayed graft function and perioperative complications were analyzed. Results. The median donor serum creatinine at discharge and 6 months was 1.2 mg/dL in each group. None of the laparoscopic procedures required conversion to an open procedure, and none of the donors required perioperative blood transfusion. The median recipient serum creatinine at 6 months after transplant was 1.2 mg/dL for each group. No ischemic ureteral complications related to the laparoscopic technique were seen. Conclusions. HALDN with meticulous surgical technique allows kidney procurement with very low morbidity and no mortality. This improved safety and decreased invasiveness from laparoscopic approach may further decrease morbidity of the procedure and increase organ donation.

Retrospective evaluation of donor pain and pain management after laprascopic nephrectomy

PURPOSE

The purpose of this study was to evaluate donor pain and pain management beginning immediately postoperatively until hospital discharge.

METHODS

All kidney donors were included from 2008 and 2009. Demographic data, operative data, pain scores in the postanesthesia care unit, and visual analog pain scale (VAS) scores were collected for each patient. Standardization for comparison was made by converting doses to intravenous morphine equivalents (ME).

RESULTS

Eighty-five patients were identified as donors, all of which underwent laparoscopic nephrectomy. Daily analgesic requirement was significantly reduced from postoperative day 1 to postoperative day 2 (42.2 mg ME versus 19.7 mg ME, P < .0001). The use of patient-controlled analgesia (PCA) did not demonstrate improved pain management with similar VAS scores for users and nonusers on the day of operation (5.4 vs 5.6, P = .87), postoperative day 1 (4.9 vs 5.4, P = .5), and postoperative day 2 (4.7 vs 4.5, P = .65), respectively. Even though similar VAS scores were found for PCA users and nonusers, PCA users had significantly higher opioid use on the day of operation (P = .007) and postoperative day 1 (P = .004).

CONCLUSIONS

The average VAS score on the day of operation was 5.5, with patients experiencing a significant reduction in VAS score on postoperative day 1. PCA delivery did not provide any additional benefit in pain relief in this cohort.

Mini-donor nephrectomy: a viable and effective alternative

Live kidney donation is an excellent way of increasing the donor pool. The introduction of the laparoscopic donor nephrectomy has resulted in an increase in live organ donation in the western hemisphere. There is no data on its impact on organ donation in India. However attractive as it may seem, the procedure is associated with a definite learning curve and does compromise donor safety. The procedure is also expensive in terms of the equipment required. The mini-donor nephrectomy is an excellent alternative, has no learning curve and is ideally suited for donors in India who have a low BMI. The procedure is also relatively inexpensive. We are in need of a donor registry rather than reports from single institutions to fully evaluate the risks and benefits of both procedures.

Open and laparoscopic donor nephrectomy: activity and outcomes from all Australasian transplant centers

BACKGROUND

Laparoscopic donor nephrectomy (LapDN) has been widely adopted despite a lack of randomized trials comparing recipient outcomes with open surgery. Review of registry data now seems the most realistic mechanism to compare outcomes. The Australia and New Zealand Dialysis and Transplant Registry prospectively captures data on all renal transplants performed in Australia and New Zealand including long-term follow-up of recipients. AIM.: To compare graft outcomes among recipient of kidneys from donors undergoing nephrectomy using open and laparoscopic techniques, through analysis of the Australia and New Zealand Dialysis and Transplant Registry after the introduction of laparoscopic donor surgery in Australia and New Zealand in 1997.

METHODS

Operative technique data for live donor transplants were collected from all surgeons performing live kidney donation procedures from May 1997 to December 2003; the outcomes of all live donor transplants were examined with follow-up to December 2007. Donor and recipient demographic variables and graft outcomes were compared between the laparoscopic and the open donor groups.

RESULTS

One thousand four hundred seventy-four live donor transplants were performed in 27 transplant centers. Of these, 315 (21%) were performed laparoscopically in 11 centers. Nineteen laparoscopic cases (6%) were converted to open. Total ischemic time was longer in the LapDN group (3.16 hr) than in the open donor group (1.61 hr, P<0.0001). The LapDN group experienced a lower incidence of rejection episodes (29.2% vs. 38.6%, P=0.002). Delayed graft function and technical failure rates were statistically equal across the groups. There were a total of 242 graft failures (175 graft losses and 67 deaths with a functioning graft, NS). Among surviving grafts, there was no consistent difference in serum creatinine at any time point. Graft and patient survivals were similar in both groups during 10-year follow-up.

CONCLUSION

This study suggests that there is no difference in short- or long-term recipient outcomes for open and laparoscopic live donor nephrectomy.

Laparo-endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison

BACKGROUND

Laparo-endoscopic single site (LESS) surgery is a recent development in minimally invasive surgery. Presented herein is the initial comparison of LESS donor nephrectomy (LESS-DN) and standard laparoscopic living donor nephrectomy (LLDN).

OBJECTIVE

To determine whether LESS-DN provides any measurable benefit over LLDN during the perioperative period and subsequent convalescence.

DESIGN, SETTING, AND PARTICIPANTS

Between November 2007 and November 2008, 18 consecutive patients underwent LESS-DN (17 left DN, 1 right DN). A contemporary matched-pair cohort of 17 patients undergoing standard LLDN was selected for retrospective comparison.

INTERVENTIONS

LESS-DN was performed through an intraumbilical novel multichannel port. The kidney was extracted through a slightly extended umbilical incision.

MEASUREMENTS

All data were prospectively accrued in an institutional review board-approved database. Convalescence data included visual analog pain scores and questionnaires containing patient-reported time to recovery end points.

RESULTS AND LIMITATIONS

One right-sided donor was converted to standard laparoscopy and excluded from analysis. Baseline demographics, operating time, blood loss, and hospital stay were comparable between groups. Compared to LLDN, patients undergoing LESS-DN had similar in-hospital analgesic requirements and mean visual analog scores at discharge. After discharge, patient-reported convalescence was faster in the LESS-DN group, including days on oral pain medication (20 vs 6; p=0.01), days off work (46 vs 18; p=0.0009), and days to 100% physical recovery (83 vs 29; p=0.03). Mean warm ischemia time was longer in the LESS-DN group (3 vs 6.1 min; p<0.0001); however, allograft function was immediate and comparable between groups. One allograft in the LESS-DN group thrombosed postoperatively. Regardless of laparoscopic approach, patients' global satisfaction with kidney donation and willingness to recommend their procedure to others were favorable and equivalent between groups.

CONCLUSIONS

This retrospective matched-pair comparison between LESS-DN and LLDN suggests that the single-port approach may be associated with quicker convalescence. In this initial series, LESS-DN had longer ischemia time, yet early allograft outcomes were comparable.

Laparoscopic live donor nephrectomy: Are ten cases per year enough to reach the quality standards? A report from a single small-volume transplant center

BACKGROUND

Laparoscopic live donor nephrectomy is the preferred method of kidney donation in high-volume US transplant centers, but for small transplant programs the question of the minimal case load per year necessary to reach the quality standards is open.

PATIENTS AND METHODS

From 1996 to 2007 we performed 130 live kidney donations including 93 laparoscopic donor nephrectomies followed by transplantation in a community hospital with an average case load of 10 laparoscopic cases per year. We compared the results after 37 open and 93 laparoscopic live donor operations with respect to operating time, conversion rate, complications, and recipients' outcome.

RESULTS

There were no significant differences in terms of safe outcome of donor patients after open or laparoscopic donor nephrectomy. The mean operating time was significantly shorter (p < 0.001) in the open group (125 min, OG) than in the laparoscopic group (150 min, LG). Mean hospital stay was significantly shorter (p < 0.001) in LG (6.8 days) versus OG (9.7 days). The conversion rate was 3.2% in the LG. Postoperative complication of donors consisted of temporary nerve irritation (two patients) and retroperitoneal hematoma (one patient) in the LG, and wound infection followed by hernia formation (one patient) and ileus 1 year after organ donation (one patient) in the OG. Safe outcome of the recipients after open (RaOD) or laparoscopic donation (RaLD) was similar. Uneventful transplantation occurred in 94.6% of the RaOD and in 92.5% of the RaLD. One kidney was lost due to renal vein thrombosis (RaLD). Mean postoperative creatinine after 4 weeks showed no difference between RaOD (1.6 mg/dl) and RaLD (1.7 mg/dl).

CONCLUSION

Approximately ten cases per year may be enough to ensure safety and quality of laparoscopic live donor nephrectomy.

The detrimental effect of poor early graft function after laparoscopic live donor nephrectomy on graft outcomes

We undertook this study to assess the rate of poor early graft function (EGF) after laparoscopic live donor nephrectomy (lapNx) and to determine whether poor EGF is associated with diminished long-term graft survival. The study population consisted of 946 consecutive lapNx donors/recipient pairs at our center. Poor EGF was defined as receiving hemodialysis on postoperative day (POD) 1 through POD 7 (delayed graft function [DGF]) or serum creatinine >/= 3.0 mg/dL at POD 5 without need for hemodialysis (slow graft function [SGF]). The incidence of poor EGF was 16.3% (DGF 5.8%, SGF 10.5%), and it was stable in chronologic tertiles. Poor EGF was independently associated with worse death-censored graft survival (adjusted hazard ratio (HR) 2.15, 95% confidence interval (CI) 1.34-3.47, p = 0.001), worse overall graft survival (HR 1.62, 95% CI 1.10-2.37, p = 0.014), worse acute rejection-free survival (HR 2.75, 95% CI 1.92-3.94, p < 0.001) and worse 1-year renal function (p = 0.002). Even SGF independently predicted worse renal allograft survival (HR 2.54, 95% CI 1.44-4.44, p = 0.001). Risk factors for poor DGF included advanced donor age, high recipient BMI, sirolimus use and prolonged warm ischemia time. In conclusion, poor EGF following lapNx has a deleterious effect on long-term graft function and survival.

2509 living donor nephrectomies, morbidity and mortality, including the UK introduction of laparoscopic donor surgery

The worldwide expansion of laparoscopic, at the expense of open, donor nephrectomy (DN) has been driven on the basis of faster convalescence for the donor. However, concerns have been expressed over the safety of the laparoscopic procedure. The UK Transplant National Registry collecting mandatory information on all living kidney donations in the country was analyzed for donations between November 2000 (start of living donor follow-up data reporting) to June 2006 to assess the safety of living DN, after the recent introduction of the laparoscopic procedure in the United Kingdom. Twenty-four transplant units reported data on 2509 donors (601 laparoscopic, 1800 open and 108 [4.3%] unspecified); 46.5% male; mean donor age: 46 years. There was one death 3 months postdischarge and a further five deaths beyond 1 year postdischarge. The mean length of stay was 1.5 days less for the laparoscopic procedure (p < 0.001). The risk of major morbidity for all donors was 4.9% (laparoscopic = 4.5%, open = 5.1%, p = 0.549). The overall rate of any morbidity was 14.3% (laparoscopic = 10.3%, open = 15.7%, p = 0.001). Living donation has remained a safe procedure in the UK during the learning curve of introduction of the laparoscopic procedure. The latter offers measurable advantages to the donor in terms of reduced length of stay and morbidity.

Single-Surgeon Laparoscopic Donor Nephrectomy and Renal Transplantation

OBJECTIVES

To demonstrate the feasibility of single-surgeon performance of laparoscopic donor nephrectomy and recipient living renal transplantation.

METHODS

Fifteen consecutive donor-recipient pairs were performed from August 2003 and July 2004 by a single surgeon at one institution. Routine donor and recipient outcome measures were prospectively assessed.

RESULTS

The mean donor height and weight was 66 in. and 151 lb, respectively. All donors underwent left nephrectomy. Renal arteries were paired in 3 (20%) of 15 donors. No donors underwent conversion or transfusion. No donor complications occurred. The mean operating room time, estimated blood loss, and hospital stay was 195 minutes, 200 mL, and 2 days, respectively. The mean recipient height and weight was 65 in. and 158 lb, respectively. The mean recipient age was 46 years (range 21 to 69). Of the 15 recipients, 3 (20%) had previously undergone transplantation. The mean operating room time, blood loss, and hospital stay for the recipients was 155 minutes, 100 mL, and 4.5 days, respectively. No recipient operative complications occurred. All allografts functioned immediately. The median recipient creatinine nadir was 1.1 mg/dL. Of the 15 recipients, 3 (20%) had postoperative complications during follow-up, including reintubation in 1, pneumonia in 1, and acute rejection in 1. The patient and graft survival rate were both 100%, and the mean serum creatinine was 1.16 mg/dL at a mean and median follow-up of 187 and 164 days (range 18 to 350), respectively.

CONCLUSIONS

We report the first series evaluating the performance of single-surgeon laparoscopic donor nephrectomy and living renal transplantation. Single-surgeon performance of both laparoscopic donor nephrectomy and living renal transplantation is technically feasible and logistically straightforward. The donor and recipient outcomes are consistent with those reported in published reports.

Laparoscopic vs open living donor nephrectomy: a contemporary series from one centre

OBJECTIVE

To report our experience of laparoscopic living donor nephrectomy (LDN) vs open donor nephrectomy (ODN), as LDN offers potential advantages to the donor and has become a routine procedure for live kidney procurement worldwide.

PATIENTS AND METHODS

Between February 2000 and August 2005 we performed 183 donor-recipient operations at our institution (ODN, 83; LDN, 100). We prospectively collected information on all donors and recipients for the same period to audit our experience with the first 100 LDNs. Patients made their operative choice after discussions that included unit experience and published information. We present our findings with the emphasis on donor operative details and early recipient graft outcome.

RESULTS

Donor and recipient age, gender, body mass index, human leukocyte antigen mismatches, and vascular anastomotic times did not differ significantly between the groups. There were two conversions to an open operation in the LND group; neither affected recipient-graft outcome. The mean (sd) operative duration was 178 (38) min for the LDN and 159 (34) min for the ODN (P < 0.05). The mean (sd) hospital stay was 4.7 (1.2) days in the LND group and 6.8 (1.5) days in the ODN group (P < 0.05). There was one case of delayed graft function in both groups. Serum creatinine levels at 1, 6 and 12 months after transplantation did not differ significantly between the groups.

CONCLUSIONS

Our contemporaneous series shows the safe introduction of a laparoscopic living-donor programme without compromising donor patient safety or allograft outcome.

Impact of laparoscopic donor nephrectomy on allograft function in pediatric renal transplant recipients: a single-center report

Laparoscopic donor nephrectomy (LDN) is rapidly becoming the preferred technique for the procurement of living donor kidneys. An association of this technique with delayed graft function and higher risk for rejection has been reported in pediatric recipients. We reviewed our experience of 17 pediatric patients who received a living donor kidney, from 2002 to 2004, procured by LDN, and compared it with a matched group that received living donor kidneys harvested by the open technique. Patient demographics, etiology of renal failure, intra-operative events, length of stay, serum creatinine decline, and graft function were reviewed. Our experience confirmed the findings of earlier reports specifically in small pediatric recipients. The LDN group showed a significantly slower decline in creatinine in the immediate post-operative period and longer intra-operative time. However, there was no difference between the two groups in the length of hospital stay, and creatinine clearances at discharge, six, 12 and 24 months post-operatively. The incidence of acute rejection was similar in both groups. LDN is a safe procurement modality for pediatric patients. The risk for prolonged OR time and delay graft function has to be considered during the evaluation process.

The direct and indirect economic costs incurred by living kidney donors-a systematic review

BACKGROUND

Despite the many benefits of living donor kidney transplantation, economic consequences can result for donors. We reviewed studies which quantified the direct and indirect costs incurred by living kidney donors, in order to understand the strengths and limitations of existing literature.

METHODS

We identified relevant studies in MEDLINE, EMBASE and ECONOLIT bibliographic databases, in the Science Citation Index and study reference lists. Any study which reported at least one cost relevant to donors was included. The accuracy of abstracted data was verified by two reviewers and reported in year 2004 US dollars.

RESULTS

Thirty-five studies from 12 countries described costs incurred by individuals who donated between the years 1964 and 2003. No study comprehensively quantified all relevant expenses-the sum of select costs considered in one US study averaged Dollars 837 per donor and ranged from Dollars 0 to 28,906. Travel and/or accommodation costs were incurred by 9-99% of donors, and were higher in countries with a larger land mass. Post-discharge analgesics were required by 4-24% of donors, but prescription costs were not reported. Between 14 and 30% of donors incurred costs for lost income, with an average loss of Dollars 3386 in one study from the UK and Dollars 682 in another study from the Netherlands. Costs for dependent care were incurred by 9-44% of donors, while costs for domestic help were incurred by 8% of donors.

CONCLUSIONS

Donors incur many types of costs attributable to kidney donation and the total costs are certainly higher than previously reported. To guide informed consent and fair reimbursement policies, further data on all relevant costs, preferably from a detailed prospective multi-centre cohort study, are required.

Steroid-free tacrolimus monotherapy after pretransplantation thymoglobulin or Campath and laparoscopy in living donor renal transplantation

Living donor renal transplantation was performed under a regimen of recipient pretreatment and low-dose postoperative immunosuppression with subsequent weaning. From October 9, 2002, to December 31, 2004, 196 consecutive, unselected laparoscopic live donor nephrectomies resulting in 196 living donor renal transplantations were performed. Recipients were pretreated with rabbit antithymocyte globulin (thymoglobulin; 24 patients or [12%]) or Campath 1H (alemtuzumab; 166 patients [85%]), or were not in protocol (6 patients [3%]), and were given postoperative steroid-free low-dose tacrolimus immunosuppressive monotherapy with subsequent weaning. There was no donor mortality. Major and minor donor morbidities were 2.6% and 4.2%, respectively. Laparoscopic live donor nephrectomy recipient outcomes with a mean follow-up of 401 days included (1) recipient and graft survival of 99.0% and 97.4%, respectively; (2) no ureteral stenosis; (3) 0.5% delayed graft function, from recurrent focal segmental glomerulosclinosis; and (4) no vascular thrombosis. The incidence of acute rejection at 30, 90, and 401 days was 1.5%, 3.8%, and 11.2% (all 196 recipients), 0%, 25%, and 29.2% (thymoglobulin recipients), and 1.8%, 3.9%, and 8.4% (Campath 1H recipients), respectively. Sixty-six patients (33.7%) are receiving spaced-dose immunosuppressive monotherapy. The mean creatinine concentration in all recipients was 1.5 +/- 1.1 mg/dL. There were no instances of cytomegalovirus tissue invasive disease or posttransplantation lymphoproliferative disease. The incidence of new-onset posttransplantation insulin-dependent diabetes was 0.5%. At current follow-up, the use of Campath 1H rather than thymoglobulin for pretreatment seems to have significantly improved the efficacy of our regimen.

Improving the prediction of donor kidney quality: deceased donor score and resistive indices

BACKGROUND

The deceased donor score (DDS), expanded criteria donor (ECD) definition, and resistive index (RI) were developed for pretransplant evaluation of donors. DDS and ECD are determined by a calculation of risk from donor variables, while RI is determined from flow characteristics of kidneys during machine preservation (MP). This study was designed to compare DDS, ECD status, and RI as predictors of outcome after deceased donor transplantation. We were also interested to see if DDS or ECD could identify kidneys most likely to benefit from MP.

METHODS

We retrospectively reviewed 48,952 deceased donor renal transplants reported to UNOS from 1997-2002. DDS (0-39 pts.), ECD status (+ or -), and preservation technique (MP vs. cold storage [CS]) were determined in all cases. RI during MP was studied in a single-center cohort of 425 transplants.

RESULTS

DDS was superior to ECD status and RI in its correlation with early and late renal function after transplantation. DDS identified a subgroup of ECD- kidneys, those with DDS > or = 20 pts, that functioned significantly below expectation and similar to ECD+ kidneys. Benefits of MP, which include improved early graft function and a trend towards longer graft survival, were greatest in the group of kidneys with DDS > or = 20 pts.

CONCLUSIONS

DDS was the best predictor of outcome after deceased donor renal transplantation and may be useful in identifying kidneys most likely to benefit from MP.

Health-related quality of life of living kidney donors: review of the short form 36-health questionnaire survey

Kidney transplantation is the ultimate goal and the best treatment for most patients with end-stage renal disease. Organ shortage and steadily growing waiting time for a cadaver kidney transplant have forced the medical community to look for alternatives, such as living kidney donation. However, available data examining health-related quality of life (QOL) issues of living donors are currently limited. In addition, little information regarding factors associated with health-related QOL in living kidney donors is currently available and this issue remains controversial. This review article aims to summarize the data regarding health-related QOL of living kidney donors by using the Medical Outcomes Study Short Form.

Laparoscopy for living donor nephrectomy - particularities of the currently applied techniques

Today, laparoscopic donor nephrectomy (LDN) in many centers features the standard approach for kidney retrieval in living donors. More than 60% of the centers in the USA currently perform LDN and numbers are rising in Europe as well. Today's variety of laparoscopic approaches reflects the evolution in the field of LDN. Multiple modifications have been made for the laparoscopic approach, with consequences for intraoperative handling of the kidney, operating and ischemic times and with impact on donor, organ, and recipient. We reviewed the literature from 1995 to 2004 and critically evaluated the different technical modifications, their specific advantages and disadvantages and their impact for the operation. The article aims to help the surgeon choose the technique he feels most safe with for performing laparoscopic kidney retrieval safely and with good results for donor and recipient.

Comparison of hand-assisted laparoscopic and open donor nephrectomy: a single-center experience from South Korea

PURPOSE

We report our experience with hand-assisted laparoscopic donor nephrectomy (HALDN) and compare to our results with conventional open donor nephrectomy (ODN).

PATIENTS AND METHODS

From February 2000 to January 2003, 100 patients (M:F 54:46) underwent HALDN at the Kangnam St. Mary's hospital. These patients were divided into early (1st 50 cases) and late (2nd 50 cases) groups. These cohorts were compared with 40 patients (M:F 26:14) who underwent ODN via a flank incision from January 1999 to January 2003 at the same institution. Patient data were obtained from medical record review and personal and telephone interviews.

RESULTS

The HALDN was completed successfully in 99 donors. The mean operative times (minutes) were 225 (140-425), 178 (135-250), and 188 (140-260) in the early HALDN, late HALDN, and ODN groups, respectively (P<0.05). The mean warm ischemia times (seconds) of the ODN (135+/-52.4) and late HALDN (150+/-76.7) groups were shorter than that of the early HALDN group (207+/-88.5) (P<0.05). On average, a regular diet was resumed after 2.1, 1.89, and 2.05 days, respectively. (P<0.05), and patients were discharged home 4.12, 4.04, and 6.8 days (P<0.05) after surgery in the early HALDN, late HALDN, and ODN groups. Analgesic use was significantly reduced in the HALDN group in comparison with ODN (P<0.05). Complications consisted of two cases of chyloperitoneum and one case each of open conversion, transfusion, prolonged ileus, liver enzyme elevation, and recipient ureteral necrosis in the early HALDN group; one case of subcutaneous emphysema in the late HALDN group; and one case each of transfusion and liver enzyme elevation in the ODN group. The mean donor (1 and 30 days) and recipient (6 months) serum creatinine concentrations did not differ among the groups (P>0.05).

CONCLUSIONS

The HALDN appears to be a safe, technically feasible, and effective alternative to conventional ODN. The procedure may offer several advantages over conventional ODN in terms of less postoperative pain, shorter convalescence, and minimal cosmetic disfigurement. The recipient graft function is similar to that after ODN.

Laparoscopic versus Open Donor Nephrectomy in Germany: Impact on Donor Health-Related Quality of Life and Willingness to Donate

INTRODUCTION

Laparoscopic living donor nephrectomy (LDN) offers multiple advantages to the donor. Since 1999 LDN has become the only surgical approach for living kidney donation in our department. To our knowledge a donor health-related quality of life (QoL) has not yet been performed with standardized and validated questionnaires to compare laparoscopic with open nephrectomy. We therefore performed a study with two questionnaires (SF-36/GBB-24) and one set of open questions for all donors in our department.

METHODS

Questionnaires were sent out to all donors between 1983 and 2001 with at least a 1-year follow-up. To exclude a bias a maximum response rate was sought; donors who did not answer were recontacted as well as their recipients or their physicians to motivate them for participation.

RESULTS

The response rate was (89.8%). Except for less limb pain in the laparoscopy group, no difference could be detected for donors QoL with respect to the surgical method. Willingness to donate again was not affected by the surgical method. Nevertheless if asked again today, most donors want laparoscopic kidney retrieval.

CONCLUSIONS

Donors health-related QoL is not affected by the surgical method when queried retrospectively. Nevertheless, most donors today would favor laparoscopy, if they could chose again. How laparoscopy affects a reluctant donor to step forward must be determined in a prospective study.

Controle dos vasos renais usando clips vasculares e fio cirúrgico em nefrectomias vídeo-assistidas de doadores vivos

OBJETIVO: A nefrectomia laparoscópica em doadores vivos para transplante renal vem assumindo um papel importante na era das cirurgias minimamente invasivas, acarretando menor morbidade aos doadores, e resultados semelhantes à técnica aberta no que se refere ao enxerto renal. O objetivo do presente artigo é relatar a experiência do nosso serviço utilizando a técnica de controle dos vasos renais usando fio cirúrgico e clips vasculares. MÉTODO: Foram realizadas 45 nefrectomias utilizando a técnica vídeo-assistida, com ligadura dos vasos renais com clips de titânio (LT-300) e fio cirúrgico. As variáveis analisadas foram tempo cirúrgico, perda sangüínea, tempo de isquemia quente, permanência hospitalar, necessidade de conversão e complicações. RESULTADOS: O procedimento foi realizado com sucesso em todos os casos. O tempo cirúrgico médio foi de 118 minutos, com perda sangüínea estimada em 84ml e tempo de isquemia quente de 4,3 minutos. Dois casos de íleo prolongado, uma lesão de veia gonadal, um escape de artéria renal e uma necrose de ureter foram observados. A permanência hospitalar média foi de 3,7 dias. O uso de clips vasculares e fio cirúrgico reduziu a perda de tecido venoso comparado à técnica com staplers e gerou redução de custos. CONCLUSÕES: A nefrectomia vídeo-assistida com a técnica descrita é factível e mostrou ser efetiva na contenção de gastos e na redução de tecido venoso perdido.

Laparoscopic live donor nephrectomy

BACKGROUND

The demand for renal transplants is greater than the available kidneys. Live donation is one way of increasing the supply. Laparoscopic removal of the donor kidney appears to reduce morbidity for the donors. Some who are hesitant because of the morbidity associated with open nephrectomy are willing to consider the laparoscopic donor nephrectomy.

METHODS

Laparoscopic donor nephrectomy was offered to all but three donors since the commencement of the programme in 1997. Data were collected both prospectively and retrospectively for the first 120 donors. Venous and arterial anatomy was assessed preoperatively by computed tomographic angiography.

RESULTS

All but four donor procedures were completed laparoscopically. Three of these were for bleeding that could not be safely controlled laparoscopically and the fourth was a planned conversion to deal with the renal vessels, in the first right nephrectomy. Two kidneys were lost due to arterial thrombosis and two underwent segmental infarction after the loss of one of two or three separately anastomosed vessels. Three recipients had delayed function and two of them required dialysis postoperatively. Other minor complications occurred but were uncommon.

CONCLUSIONS

Laparoscopic live donor nephrectomy is safe for the donor and the transplant kidney. It offers the advantage of decreased morbidity for the donor, with a shorter hospital stay, earlier return to normal activity and, for some, early return to work.

Laparoscopic live donor nephrectomy: a risk factor for delayed function and rejection in pediatric kidney recipients? A UNOS analysis

The impact of laparoscopic (vs. open) donor nephrectomy on early graft function and survival in pediatric kidney recipients (< or =18 years) is unknown. We studied 995 pediatric live donor txs reported to UNOS from January 2000 to June 2002, in two recipient age groups: 0-5 years (n = 212, 44% laparoscopic donors [LapD]) and 6-18 years (n = 783, 50% LapD). Delayed graft function (DGF) rates were higher for LapD versus open donor (OpD) txs (0-5 years, 12.8% vs. 2.5% [p = 0.004]; 6-18 years, 5.9% vs. 2.8% [p = 0.03]). Acute rejection incidence for LapD versus OpD txs was higher at 6 months for recipients 0-5 years (18.6% vs. 5.9%, p = 0.01) and 6-18 years (22.5% vs. 15.6%, p = 0.03), and 1 year for recipients 0-5 years (24.3% vs. 7.9%, p = 0.004). In multivariate analyses, significant independent risk factors for rejection at 6 months and 1 year were recipient age 6-18 years, pretx dialysis, LapD nephrectomy and DGF. Graft survival was similar for LapD versus OpD txs. In this retrospective UNOS database analysis, LapD procurement was associated with increased DGF and an independent risk factor for rejection during the first year, particularly for recipients 0-5-years old. Future investigations must confirm these findings and identify strategies to optimize procurement and pediatric recipient outcome.

The nondirected living donor program: a model for cooperative donation, recovery and allocation of living donor kidneys

We describe an altruistic nondirected (ND) and live donor/deceased donor list exchange (LE) donor program administered by an organ procurement organization (OPO) in the Washington, DC area. Screening eliminated 25 donors (17 NE; 8 LE) from the 97 donor applications (62 ND; 35 LE) completed. Twenty-one donors (16 ND; 5 LE) failed to follow through with the psychiatric evaluation, which eliminated 13 donors (9 ND; 4 LE). Two donors dropped out and 12 (9 ND; 3 LE) were medically unsuitable after final clinical evaluation. Twenty donor procedures were performed (10 ND; 10 LE) with four pending (2 ND; 2 LE). This resulted in a modest 3-5% increase in the OPO-procured kidney organ pool. The average cold ischemia time of the grafts not transported between transplant centers was 205 +/- 66 min compared with 243 +/- 48 min for transported grafts. With no documented adverse outcomes, donors had a hospital stay of length 2.9 days and at home recuperation of 12.3 days. Three- and 6-month creatinines were 1.44 +/- 1.36 and 1.68 +/- 0.61 for grafts not transported between transplant centers, and 1.6 +/- 0.27 and 1.6 +/- 0.44 for transported grafts. An OPO-administered altruistic donor program can serve as a model for cooperative donation, recovery and allocation of living donor kidneys.

An audit over 2 years’ practice of open and laparoscopic live-donor nephrectomy at renal transplant centres in the UK and Ireland

OBJECTIVE

To collate information on the practice of live-donor nephrectomy and compare this with the published British Transplantation Society (BTS) guidelines for best practice, using two questionnaires sent to all renal transplant centres in the UK and Ireland to cover practice for the years 2000 and 2002.

METHODS

A postal questionnaire was sent to all surgical kidney transplant consultants in the UK and Ireland, including questions on the practice of live-donor nephrectomy in the year 2000 (the questionnaire was sent in 2001) and 2002 (questionnaire sent in 2003).

RESULTS

All 28 centres responded fully for both years; 27 centres used live kidney donation in 2000, decreasing to 24 in 2002. Consultants reported 356 operations in 2000, representing 19% of all kidney transplants, and 403 in 2002, representing 23% of all kidney transplants. Three centres offered laparoscopic donor nephrectomy in 2000, and five did so in 2002. Most centres organize donor and recipient operations synchronously, and most have a consultant anaesthetist present for the donor procedure. There were variations in the use of analgesia and thromboprophylaxis, and in donor follow-up.

CONCLUSIONS

There is widespread application of live-donor nephrectomy in the UK but BTS guidelines are not closely followed. Minimal access donor nephrectomy is offered at a few centres but many have plans to introduce this into their practice.

Right retroperitoneal versus left transperitoneal laparoscopic live donor nephrectomy

OBJECTIVES

To describe our preferred method of right laparoscopic live donor nephrectomy (LDN) using a retroperitoneoscopic approach to determine the indications for, and overall rate of, right LDN and to compare the donor and recipient early outcomes of right retroperitoneal LDN to those of left transperitoneal LDN in a consecutive single-institution series.

METHODS

At our institution, LDN for allotransplantation was performed in 143 consecutive patients. The indications for right LDN (n = 29) included multiple left renal vessels (n = 18), early branching of the left renal artery (n = 1), left renal vein anomaly (n = 2), right renal arterial fibromuscular dysplasia (n = 2), right renal cyst (n = 3), mild right hydronephrosis with delay on renal scan (n = 1), or right nephrolithiasis (n = 2).

RESULTS

Right LDN was performed in 29 (20.3%) of 143 patients using a retroperitoneal approach in all but the first case. Right retroperitoneal LDN was associated with decreased blood loss and operative time compared with left transperitoneal LDN. The hospital stay, analgesic use, and donor serum creatinine at discharge were similar in both groups. Despite a statistically significantly increased warm ischemia time and decreased renal vein length, right retroperitoneal LDN was associated with recipient functional outcomes at 5 and 30 days after transplant that were no different from those after left transperitoneal LDN.

CONCLUSIONS

Right retroperitoneal laparoscopic LDN provides similar donor and recipient outcomes when compared with the left transperitoneal approach and obviates most of the technical challenges encountered with a right transperitoneal approach.

Recipient outcome following living donor kidney transplantation using kidneys procured laparoscopically

BACKGROUND

Laparoscopic live donor nephrectomy is becoming increasingly popular as it has been shown to minimize donor morbidity, length of hospital stay and length of time to return to work. Initial experience suggested that kidneys procured laparoscopically had higher rates of delayed graft function and ureteric complications but with increasing experience, these complications have become less common.

METHODS

Retrospective chart review of all patients who underwent living donor kidney transplant using kidneys procured laparoscopically at our centre was performed. From the initiation of the laparoscopic donor nephrectomy programme at our institution in November 1998 until February 2002, we performed 71 living donor kidney transplants (69 kidneys procured laparoscopically and two procured by open donor nephrectomy after failed laparoscopic approach). Donor left kidney was used in all except in one patient. Mean duration of warm ischaemia time was 206 +/- 79 s.

RESULTS

The mean age of the recipients was 42 +/- 15 years (range 1-68) including five paediatric recipients (age < 18 years). There were 48 males and 23 females. Nine (13%) were retransplants (seven second transplants and one each of third and fourth transplants). Two patients died with functioning grafts and four patients lost the graft (three thrombosis, one anastomotic rupture). No patient developed ureteric complications. The incidence of delayed graft function (need for dialysis in the first week post-transplant) was 4%. Patient and graft survival rates (actual) were 97% and 91%, respectively. Mean length of hospital stay was 9 +/- 7 days (median 7 days).

CONCLUSIONS

Recipient outcome is not compromised and excellent results can be achieved with living donor kidney transplantation using laparoscopically procured kidneys.

Laparoscopic (vs open) live donor nephrectomy: a UNOS database analysis of early graft function and survival

The impact of laparoscopic (lap) live donor nephrectomy on early graft function and survival remains controversial. We compared 2734 kidney transplants (tx) from lap donors and 2576 tx from open donors reported to the U.S. United Network for Organ Sharing from 11/1999 to 12/2000. Early function quality (>40 mL urine and/or serum creatinine [creat] decline >25% during the first 24 h post-tx) and delayed function incidence were similar for both groups. Significantly more lap (vs. open) txs, however, had discharge creats greater than 1.4 mg/dL (49.2% vs. 44.9%, p = 0.002) and 2.0 mg/dL (21.8% vs. 19.5%, p = 0.04). But all later creats, early and late rejection, as well as graft survival at 1 year (94.4%, lap tx vs. 94.1%, open tx) were similar for lap and open recipients. Our data suggests that lap nephrectomy is associated with slower early graft function. Rejection rates and short-term graft survival, however, were similar for lap and open graft recipients. Further prospective studies with longer follow up are necessary to assess the potential impact of the laparoscopic procurement mode on early graft function and long-term outcome.

Demographics of 353 laparoscopic renal donor and recipient pairs at the Johns Hopkins Medical Institutions

BACKGROUND AND PURPOSE

The demographics of laparoscopic donor nephrectomy (LDN) have not been characterized in detail. The aim of this study was to review our LDN experience with respect to donor and recipient demographic characteristics and trends.

PATIENTS AND METHODS

Over a 6-year period, 353 patients underwent LDN. A retrospective chart review was performed to identify the donor and recipient demographic characteristics and trends associated with the procedure.

RESULTS

Among the donors, the mean age was 41 years, with a predominance of females (59.2%), whites (76.2%), and blood relations (72%). Siblings were the most common related-donor-to-recipient relationship, and spouses were the most common unrelated relationships. Among the recipients, the mean age was 43 years, with a predominance of males (58.4%), whites (73.7%), and dialysis-dependent patients (55%). Diabetes mellitus and hypertension were the most common causes of end-stage renal failure. With the introduction of laparoscopy, there was a nearly twofold increase in the total number of live renal donations, and there was a significant expansion in the unrelated-donor pool.

CONCLUSIONS

Laparoscopic harvest of donated kidneys is associated with new trends that may help alleviate the current organ shortage.

Quality of life, pain and return to normal activities following laparoscopic donor nephrectomy versus open mini-incision donor nephrectomy

PURPOSE

We evaluated pain, convalescence and health related quality of life in patients undergoing laparoscopic and open mini-incision donor nephrectomy.

MATERIALS AND METHODS

We compared the records of consecutive patients who underwent laparoscopic and mini-incision open donor nephrectomy from our donor nephrectomy data base in retrospective fashion using 2 questionnaires. The first questionnaire evaluated postoperative pain, return to functioning time and satisfaction. The second questionnaire was the RAND 36-Item Health Survey, version 2, a standardized and validated health survey quality of life assessment tool. Mean patient sex, age and followup were similar for the 2 groups. All data were analyzed using the 2-tailed t test for independent variables with commercially available statistical analysis software.

RESULTS

Pain in the laparoscopic group was significantly less than in the mini-incision group at all followup time points (p <0.05). Statistically significant differences demonstrated that laparoscopy led to more rapid recovery time in certain categories, including walking, discontinuation of prescribed oral pain relievers, return to driving, and resumption of normal work and home daily activities. More subjective questions in the survey showed high levels of acceptance for the 2 procedures. Using the RAND 36-Item Health Survey, version 2 health related quality of life was significantly higher in the laparoscopy group in 3 domains that measure bodily pain, physical functioning and emotional role functioning. However, each group scored at or above age matched American averages in all domains.

CONCLUSIONS

The laparoscopy group had significantly less postoperative pain and required less time to return to normal functional activities than the mini-incision group. In addition, the laparoscopic group showed significantly higher quality of life scores than the mini-incision group in 3 domains.