Minimizing morbidity of organ donation: analysis of factors for perioperative complications after living-donor nephrectomy in the United States

Outcomes of Living Kidney Donors Following Donor Nephrectomy in Aotearoa New Zealand

Introduction

Living donor kidney transplantation is the optimal treatment for people with kidney failure (KF). Because living donors do not derive health benefits from donation, contemporary relevant information on post donation outcomes need to inform decision-making. Studies of donor outcomes are largely restricted to donations in the USA and Europe. We studied donors over a 30-year period in Aotearoa New Zealand (NZ) to investigate short-term and long-term outcomes.

Methods

This was a retrospective observational cohort study of all living kidney donors in NZ (1988-2018). The primary outcome was the incidence of KF. Secondary outcomes were death, cardiovascular disease (CVD), and the incidence of complications within 90 days after nephrectomy. Donors were identified using multiple data sources: the NZ Blood Service, the Ministry of Health (MoH), hospital records, and the Australia and New Zealand Live Kidney Donor Registry. Outcomes were determined via data linkage with the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry and the MoH. Follow-up was until December 31, 2019.

Results

A total of 1339 people donated a kidney from 1988 to 2018. During 16,272 person-years of follow-up, 5 people developed KF, an incidence of 3 per 10,000 person-years (95% confidence interval [CI]:1.3-7.4). Patient survival was 99% (98.2%-99.5%) at 10 years; 30 people died during follow-up. The incidence of CVD was 11.6 (95% CI: 7.4-19.2) per 10,000 person-years; 292 donors (22%) experienced a complication following donor nephrectomy and 69 (5%) required intervention.

Conclusion

There is a low risk of KF and other complications among living kidney donors in NZ. These findings represent important contemporary data to support decision making.

Early Complications in Kidney Donors and Course of Health-related Quality of Life 12 mo After Donation: An Analysis of the Swiss Organ Living-Donor Health Registry

Background

Since 1998, the Swiss Organ Living-Donor Health Registry (SOL-DHR) has recorded peri- and postoperative complications of living kidney (LK) donors, as reported by all Swiss transplant centers and has collected follow-up data prospectively.

Methods

We analyzed the early complications of 2379 consecutive individuals who donated a kidney between January 1998 and June 2022 and assessed their health-related quality of life (HRQoL) 1 y after donation.

Results

In total, 447 early complications in 404/2379 LK donors (17.0%) were reported to the SOL-DHR. The frequency of donors with major complications (ie, Dindo-Clavien classification 3/4) was 2.4%. In total, 31 donors needed reoperation, and in 13/31 (42%), donors reoperation was necessary because of bleeding complications. Independent risk factors for major early complications were older donor age (P = 0.005) and type of surgical approach (ie, the laparoscopic retroperitoneal compared with laparoscopic transabdominal surgery; P = 0.01), but not sex. We observed a U-shaped association of body mass index, where very low/high body mass indexes had higher odds of major early complications, without reaching statistical significance. Although HRQoL was affected by kidney donation, 96.5% of donors indicated that they would donate their kidney again. The only independent risk factor for low HRQoL based on mental health scores was worsening EB after living kidney donation (P < 0.0001).

Conclusions

Overall, living kidney donation is a safe procedure, however, donor age and type of surgical approach affect the risk of complications. A decline in emotional bonding with the recipient after donation may worsen the quality of life of the donor.

Impact of donor smoking history on kidney transplant recipient outcomes: A systematic review and meta-analysis

BACKGROUND

Impact of donor smoking history on kidney transplant recipient outcomes is undefined.

METHODS

We systematically searched, critically appraised, and summarized associations between donor smoking and primary outcomes of death-censored and all-cause graft failure (DCGF, ACGF), and secondary outcomes of allograft histology, delayed graft function, serum creatinine, estimated glomerular filtration rate, and mortality. We searched MEDLINE, Embase, and Cochrane Databases from 2000 to 2023. Risk of bias was assessed using Risk of Bias in Non-randomized Studies - of Exposure tool. Quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation Working Group recommendations. We pooled results using inverse variance, random-effects model and reported hazard ratios for time-to-event outcomes or binomial proportions. Statistical heterogeneity was assessed with I2 statistic.

RESULTS

From 1785 citations, we included 17 studies. Donor smoking was associated with modestly increased DCGF (HR 1.05 (95% CI: 1.01, 1.09); I2 = 0%; low quality of evidence), predominantly in deceased donors, and ACGF in adjusted analyses (HR 1.12 (95% CI: 1.06, 1.19); I2 = 20%; very low quality of evidence). Other outcomes could not be pooled meaningfully.

CONCLUSIONS

Kidney donor smoking history was associated with modestly increased risk of death-censored graft failure and all-cause graft failure. This review emphasizes the need for further research, standardized reporting, and thoughtful consideration of donor factors like smoking in clinical decision-making on kidney utilization and allocation.

Inconsistency in the Reporting Terminology of Adverse Events and Complications in Hallux Valgus Reconstruction: A Systematic Review

Surgical complications are inevitable in any surgical subspecialty. Throughout the years, many classification systems have been developed to better understand and report such complications. The aim of this systematic review is to investigate the variability and frequency of reporting terms used to describe adverse events and complications in hallux valgus reconstruction. We hypothesized that the terms used would be highly inconsistent, which further promotes a need for a standardized terminology reporting system. Studies related to hallux valgus reconstruction outcomes that met our predetermined inclusion criteria were investigated to identify and report the related adverse terms and complications. Adverse terms and complications were grouped into 9 categories. Of the 142 studies included, 376 distinct terms that described adverse events or complications related to hallux valgus reconstruction were identified. Of these, 73.4% (276/376) were mentioned only once in their respective studies. Five of 376 terms were mentioned in at least 25% of the papers, and only 2 of 376 were mentioned in at least 50%. The most frequently reported adverse events were "Recurrence," mentioned in 77 of 142 studies (54%), followed by "Nonunion," mentioned in 76 of 142 studies (53%). The most reported category was "Bone/Joint" with 135 related terms, mentioned in 135 of 376 of the papers (95.1%). The terminology used in reporting adverse events and complications in surgical hallux valgus correction was highly inconsistent and variable. This represents yet another barrier in accurate reporting of these terms, and subsequently a difficult analysis of the outcomes related to hallux valgus reconstruction. To overcome these challenges, we suggest developing a standardized terminology reporting system.Levels of Evidence: Level III; systematic review of Level III studies and above.

Comprehensive Surgical Audit of Live-Related Donor Nephrectomy: Procedural Parameters, Demographics, Health Assessments, Complications, and Postoperative Outcomes

BACKGROUND AND OBJECTIVES

End-stage renal disease (ESRD) rates are on the rise globally, including in India. However, the affordability of dialysis treatment remains a significant challenge for many, with costs varying across different regions. Although cost-effective, kidney transplantation faces challenges like a surgeon shortage, lack of infrastructure, and lack of logistic support. The study examines Indian laparoscopic nephrectomy outcomes and their benefits for donor recovery. It covers kidney donor procedural details, demographics, preoperative health evaluations, complications, and one-month follow-up.

METHODS

Ethical approval was obtained, and the study involved 102 cases at the Indira Gandhi Institute of Medical Science, Patna, Bihar, India, from 2019 to 2023. Detailed preoperative assessments, postoperative complications, and one-month follow-up analyses were conducted. Statistical analysis employed SPSS version 17 (IBM Corp., Armonk, NY).

RESULTS

The results revealed an average surgery time of 152.3 min, blood loss of 205 ± 42 ml, and a hospital stay of 4.6 ± 2.2 days. The study found a female predominance (80.39%), with a mean donor age of 35.9 ± 5.2 years. Preoperative assessments showed robust patient health, with glomerular filtration rate (GFR) exceeding the expected threshold and normal urea levels, creatinine, electrolytes, liver enzymes, bilirubin, albumin, and total protein. Post-nephrectomy complications were reported, with females experiencing more difficulties than males.

CONCLUSION

This study underscores the efficiency and safety of laparoscopic nephrectomy in the Indian context, providing valuable insights into donor demographics, preoperative health assessments, complications, and postoperative outcomes. The findings contribute to understanding laparoscopic nephrectomy outcomes and associated risk factors despite certain limitations.

An Unexpected Catastrophe-Renal Artery Thrombosis in a Living Donor: A Case Report

BACKGROUND

Renal artery thrombosis is a devastating complication if not detected early. Cardioembolic disease or surgical and technical complications are frequent causes of renal artery thrombosis. There are some reports of renal artery thrombosis in a renal allograft, but to our knowledge, this is the first case of renal artery thrombosis reported in a kidney donor.

How Long Does It Take to Acquire Mastery of Performance in Laparoscopic Living Donor Nephrectomy? A Center-Based and Surgeon-Based Operative Time CUSUM Analysis

BACKGROUND

The safety of laparoscopic donor nephrectomy (LDN) has been widely documented, but its challenging learning curve (LC) requires an insightful assessment to expand its application. The aim of this study was to evaluate LC of LDN in a high-volume transplant center.

METHODS

Three hundred forty-three LDNs performed from 2001 to 2018 were evaluated. CUSUM analysis based on the operative time was used to assess the number of cases required to reach mastery in the technique for both the entire surgical team and for the 3 main surgeons considered separately. Analysis of association between demographics, perioperative characteristics, and complications within the different LC phases was conducted.

RESULTS

Mean operative time was 228.9 minutes. Mean length of stay was 3.8 days and mean warm ischemia time (WIT) was 170.8 seconds. Surgical and medical complication rates were 7.3% and 6.4%, respectively. The CUSUM-LC showed a requirement of 157 cases (for surgical team) and 75 cases (for single surgeons) to reach competence in the procedure. Patient baseline characteristic showed no differences among the LC phases. Compared with the initial LC phase, hospital stay was significantly lower at the end of the LC whereas WIT results were longer in the LC descendent phase.

CONCLUSIONS

This study confirms the safety and efficacy of LDN, with a low rate of complications. This analysis suggests that about 75 procedures are required to reach competence and 93 cases to achieve mastery level of skill for a single surgeon. It can be hypothesized that, in a high-volume transplant enter, the time to guarantee training in LDN is compatible with the duration of a clinical fellowship.

Modified Clavien-Dindo-Sink system is reliable for classifying complications following surgical treatment of early-onset scoliosis

PURPOSE

Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien-Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons.

METHODS

Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement.

RESULTS

11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56-0.94], indicating substantial agreement, and 0.84 [95% CI 0.70-0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74-0.95) between the first and second surveys, indicating nearly perfect agreement .

CONCLUSION

The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes.

LEVEL OF EVIDENCE

Level V.

Donor obesity and weight gain after transplantation: two still overlooked threats to long-term graft survival

The effect of donor obesity on kidney transplantation success has long been an overlooked clinical research area. Even though there is no strict guideline in most countries prohibiting donation from obese individuals, most candidates with a body mass index >35-40 kg/m² are rejected due to concerns regarding long-term renal functional deterioration in the donor. The effects of excessive fat mass on renal function and allograft survival have been analysed by several longitudinal and follow-up studies. These studies have documented the deleterious effect on long-term graft outcomes of excessive body mass in living kidney donors and de novo obesity or pre-existing obesity worsening after transplantation on kidney outcomes. However, there is a paucity of clinical trials aimed at countering overweight and obesity in living and deceased kidney donors and in transplant patients. In this review we will briefly discuss the mechanism whereby fat excess induces adverse kidney outcomes and describe the effects on graft function and survival in living obese donors.

The Association between Body Composition Measurements and Surgical Complications after Living Kidney Donation

Obesity is considered a risk factor for peri- and postoperative complications. Little is known about this risk in overweight living kidney donors. The aim of this study was to assess if anthropometric body measures and/or surgical determinants are associated with an increased incidence of peri- and postoperative complications after nephrectomy. We included 776 living kidney donors who donated between 2008 and 2018 at the University Medical Center Groningen. Prenephrectomy measures of body composition were body mass index (BMI), body surface area (BSA), waist circumference, weight, and waist-hip ratio. Incidence and severity of peri- and postoperative complications were assessed using the Comprehensive Complication Index. Mean donor age was 53 ± 11 years; 382 (49%) were male, and mean BMI at donor screening was 26.2 ± 3.41 kg/m2. In total, 77 donors (10%) experienced peri- and postoperative complications following donor nephrectomy. Male sex was significantly associated with fewer surgical complications (OR 0.59, 0.37-0.96 95%CI, p = 0.03) in binomial logistic regression analyses. Older age (OR: 1.03, 1.01-1.05 95%CI, p = 0.02) and a longer duration of surgery (OR: 1.01, 1.00-1.01 95%CI, p = 0.02) were significantly associated with more surgical complications in binomial logistic regression analyses. Multinomial logistic regression analyses did not identify any prenephrectomy measure of body composition associated with a higher risk of surgical complications. This study shows that higher prenephrectomy BMI and other anthropometric measures of body composition are not significantly associated with peri- and postoperative complications following living donor nephrectomy.

Long-term Surgical Outcome and Risk Factors in Living Kidney Donors

CONTEXT

Studies on the surgical outcome in living kidney donors mainly report perioperative complications with short follow-up.

OBJECTIVE

The objectives of this study are to evaluate the long-term surgical outcome in living kidney donors and to identify donors with an increased risk for a complicated postoperative course.

BASIC PROCEDURES

A prospectively collected database of 496 living kidney donors at the Department of General, Visceral, and Transplantation Surgery of the Ruprecht Karls University Heidelberg was retrospectively analyzed in a retrospective, observational single-center study.

RESULTS

The median follow-up time was 37 months. The perioperative severe complication (Clavien-Dindo IIIb) rate was 2.8%, the early postoperative (PO) severe complication rate (1-3 months post operation) was 0.7%, and the late PO severe complication rate (> 3 months post operation) was 8.4%. In multivariate analyses, male sex was associated with higher overall perioperative complication rate (odds ratio [OR], 1.930; P = .005) as well as higher rate of late PO complications (OR, 2.243; P = .014). An increased body mass index was associated with a higher late and severe (Clavien-Dindo ≥ IIIb) PO complication rate (OR, 1.107; P = .009 and OR, 1.105; P = .008, respectively).

CONCLUSIONS AND RELEVANCE

Long-term surgery-associated severe complications occur in 8.4% of kidney donors. Older age is associated with an increased operative time, greater intraoperative blood loss, and longer PO hospital stay. Male donors and donors with an increased body mass index have a higher risk for a complicated PO course after kidney donation. Within a shared decision-making process before living kidney donation, special awareness should be brought to these facts.

Perioperative Complications During Living Donor Nephrectomy: Results From a Multicenter Cohort Study

BACKGROUND

While living kidney donation is considered safe in healthy individuals, perioperative complications can occur due to several factors.

OBJECTIVE

We explored associations between the incidence of perioperative complications and donor characteristics, surgical technique, and surgeon's experience in a large contemporary cohort of living kidney donors.

DESIGN

Living kidney donors enrolled prospectively in a multicenter cohort study with some data collected retrospectively after enrollment was complete (eg, surgeon characteristics).

SETTING

Living kidney donor centers in Canada (n = 12) and Australia (n = 5).

PATIENTS

Living kidney donors who donated between 2004 and 2014 and the surgeons who performed the living kidney donor nephrectomies.

MEASUREMENTS

Operative and hospital discharge medical notes were collected prospectively, with data on perioperative (intraoperative and postoperative) information abstracted from notes after enrollment was complete. Complications were graded using the Clavien-Dindo system and further classified into minor and major. In 2016, surgeons who performed the nephrectomies were invited to fill an online survey on their training and experience.

METHODS

Multivariable logistic regression models with generalized estimating equations were used to compare perioperative complication rates between different groups of donors. The effect of surgeon characteristics on the complication rate was explored using a similar approach. Poisson regression was used to test rates of overall perioperative complications between high- and low-volume centers.

RESULTS

Of the 1421 living kidney donor candidates, 1042 individuals proceeded with donation, where 134 (13% [95% confidence interval (CI): 11%-15%]) experienced 142 perioperative complications (55 intraoperative; 87 postoperative). The most common intraoperative complication was organ injury and the most common postoperative complication was ileus. No donors died in the perioperative period. Most complications were minor (90% of 142 complications [95% CI: 86%-96%]); however, 12 donors (1% of 1042 [95% CI: 1%-2%]) experienced a major complication. No statistically significant differences were observed between donor groups and the rate of complications. A total of 43 of 48 eligible surgeons (90%) completed the online survey. Perioperative complication rates did not vary significantly by surgeon characteristics or by high- versus low-volume centers.

LIMITATIONS

Operative and discharge reporting is not standardized and varies among surgeons. It is possible that some complications were missed. The online survey for surgeons was completed retrospectively, was based on self-report, and has not been validated. We had adequate statistical power only to detect large effects for factors associated with a higher risk of perioperative complications.

CONCLUSIONS

This study confirms the safety of living kidney donation as evidenced by the low rate of major perioperative complications. We did not identify any donor or surgeon characteristics associated with a higher risk of perioperative complications.

TRIAL REGISTRATIONS

NCT00319579: A Prospective Study of Living Kidney Donation (https://clinicaltrials.gov/ct2/show/NCT00319579)NCT00936078: Living Kidney Donor Study (https://clinicaltrials.gov/ct2/show/NCT00936078).

Should donors who have used marijuana be considered candidates for living kidney donation?

BACKGROUND

The use of marijuana in the USA has been steadily increasing over the last 10 years. This study is the first to investigate the effect of marijuana use by live kidney donors upon outcomes in both donors and recipients.

METHODS

Living kidney donor transplants performed between January 2000 and May 2016 in a single academic institution were retrospectively reviewed. Donor and recipient groups were each divided into two groups by donor marijuana usage. Outcomes in donor and recipient groups were compared using t-test, Chi-square and mixed linear analysis (P < 0.05 considered significant).

RESULTS

This was 294 living renal donor medical records were reviewed including 31 marijuana-using donors (MUD) and 263 non-MUDs (NMUD). It was 230 living kidney recipient records were reviewed including 27 marijuana kidney recipients (MKRs) and 203 non-MKRs (NMKR). There was no difference in donor or recipient perioperative characteristics or postoperative outcomes based upon donor marijuana use (P > 0.05 for all comparisons). There was no difference in renal function between NMUD and MUD groups and no long-term difference in kidney allograft function between NMKR and MKR groups.

CONCLUSIONS

Considering individuals with a history of marijuana use for living kidney donation could increase the donor pool and yield acceptable outcomes.

Analysis of Postoperative Complications in Spinal Surgery, Hospital Length of Stay, and Unplanned Readmission: Application of Dindo-Clavien Classification to Spine Surgery

STUDY DESIGN

Retrospective study. Level of evidence III.

OBJECTIVE

Postoperative complications in spine surgery are associated with increased morbidity, hospital length of stay, and health care costs. Registry of complications in orthopedics and the spine surgery is heterogeneous.

METHODS

Between July 2016 and June 2017, 274 spinal surgeries were performed, the presence of postoperative complications was analyzed at 90 days (according to the classification of Dindo-Clavien, grades I-V), hospital length of stay, surgical complexity (low, medium, and high), unplanned readmission, and risk factors were evaluated.

RESULTS

A total of 79 patients suffered a complication (28.8%), of them 21 (26.7%) were grade I, 24 (30.3%) were grade II, 4 (5.7%) were grade IIIA, and 29 (37.3%) were grade IIIB. There were no IV and V grade cases. The most frequent complication was excessive pain followed by deep wound infection and anemia. Surgical complexity and surgical time were significantly associated with the risk of developing a complication. The average number of hospital length of stay in patients without and with complications were 2.7 and 10.6, respectively, and the unplanned readmission rate was 11%.

CONCLUSIONS

Registry of postoperative complications allows the correct standardization and risk factors required to establish measures to decrease them, the application of Dindo-Clavien classification was useful for the purpose of our study.

Short-term complication rate following orthopedic surgery in a tertiary care center in Argentina

INTRODUCTION

Registration of adverse events following orthopedic surgery has a critical role in patient safety and has received increasing attention. The purpose of this study was to determine the prevalence and severity of postoperative complications in the department of orthopedic unit in a tertiary hospital.

METHODS

A retrospective review from the postoperative complication registry of a cohort of consecutive patients operated in the department of orthopedic surgery from May 2015 to June 2016 was performed. Short-term complications (3 months after surgery), age gender, types of surgery (elective, scheduled urgency, non-scheduled urgency, and emergency), operative time, surgical start time (morning, afternoon or evening), American Society of Anesthesiologists score and surgeon's experience were assessed. Complications were classified based on their severity according to Dindo-Clavien system: Grade I complications do not require alterations in the postoperative course or additional treatment; Grade II complications require pharmacological treatment; Grade III require surgical, endoscopic, or radiological interventions without (IIIa) or with (IIIb) general anesthesia; Grade IV are life-threatening with single (IVa) or multi-organ (IVb) dysfunction(s), and require ICU management; and Grade V result in death of the patient. Complications were further classified in minor (Dindo I, II, IIIa) and major (Dindo IIIb, IVa, IVb and V), according to clinical severity.

RESULTS

1960 surgeries were performed. The overall 90-day complication rate was 12.7% (249/1960). Twenty-three complications (9.2 %) were type I, 159 (63.8%) type II, 9 (3.6%) type IIIa, 42 (16.8%) type IIIb, 7 (2.8%) type IVa and 9 (3.6%) were grade V according to Dindo-Clavien classification (DCC). The most frequent complication was anemia that required blood transfusion (27%) followed by wound infection (15.6%) and urinary tract infection (6%).

DISCUSSION

The overall complication rate after orthopedic surgery in our department was 12.7%. The implementation of the DCC following orthopedic surgery was an important tool to measure the standard of care.

Validation of Living Donor Nephrectomy Codes

Background:

Use of administrative data for outcomes assessment in living kidney donors is increasing given the rarity of complications and challenges with loss to follow-up.

Objective:

To assess the validity of living donor nephrectomy in health care administrative databases compared with the reference standard of manual chart review.

Design:

Retrospective cohort study.

Setting:

5 major transplant centers in Ontario, Canada.

Patients:

Living kidney donors between 2003 and 2010.

Measurements:

Sensitivity and positive predictive value (PPV).

Methods:

Using administrative databases, we conducted a retrospective study to determine the validity of diagnostic and procedural codes for living donor nephrectomies. The reference standard was living donor nephrectomies identified through the province’s tissue and organ procurement agency, with verification by manual chart review. Operating characteristics (sensitivity and PPV) of various algorithms using diagnostic, procedural, and physician billing codes were calculated.

Results:

During the study period, there were a total of 1199 living donor nephrectomies. Overall, the best algorithm for identifying living kidney donors was the presence of 1 diagnostic code for kidney donor (ICD-10 Z52.4) and 1 procedural code for kidney procurement/excision (1PC58, 1PC89, 1PC91). Compared with the reference standard, this algorithm had a sensitivity of 97% and a PPV of 90%. The diagnostic and procedural codes performed better than the physician billing codes (sensitivity 60%, PPV 78%).

Limitations:

The donor chart review and validation study was performed in Ontario and may not be generalizable to other regions.

Conclusions:

An algorithm consisting of 1 diagnostic and 1 procedural code can be reliably used to conduct health services research that requires the accurate determination of living kidney donors at the population level.

A retrospective analysis of complications of laparoscopic left donor nephrectomy using the Kocak's modification of Clavien-Dindo system

INTRODUCTION

Kocak described a modification of Clavien-Dindo classification system (CDCS) for reporting procedure-related complications in laparoscopic donor nephrectomy (LDN). We used the Kocak modification in grading and reporting the severity of complications in patients who underwent LDN and in evaluating various parameters that predict them.

METHODS

In all, 1430 patients who underwent left LDN from 2000 to 2016 were included in this study. All data was retrospectively collected and analyzed for complications occurring in the postoperative period. All complications were classified according to the four grades of Kocak-modified CDCS.

RESULTS

124 patients (8.6%) suffered a total of 235 postoperative complications. Most of the complications were Grade I and Grade II (Grade I: 79.5% [n = 187] and Grade II 16.2% [n = 38]), 2.5% of the complications were Grade III (n = 6) and Kocak Grade IVa complications occurred in three patients. There was one death (Grade IVb: 0.4%, overall mortality rate: 0.06%). The incidence of complications was significantly greater for male patients, those with body mass index ≥25 kg/m2, and if the operating surgeon had ≤ 1 year of experience in performing LDN surgery.

CONCLUSION

LDN is a safe procedure with low morbidity. The rate of complications is 8.6% and most of these complications are of low grade. The use of a standardized system for reporting the complications of LDN allows appropriate comparison between reported data.

A retrospective study to assess the evaluation of living related kidney donors and their outcomes following nephrectomy at Kenyatta National Hospital

Background

Kidney transplantation is the renal replacement therapy of choice for end stage renal disease. To ensure safety regular audit of the donation process is necessary. The aim of this study was to assess the evaluation of potential living related kidney donors and document their outcomes following nephrectomy.

Methods

This was a retrospective descriptive study involving all living related kidney donors seen at Kenyatta National Hospital (KNH) renal unit from 2010 to 2014.

Upon approval by KNH/ERC, the records of all kidney donors were retrieved. Demographic characteristics, number of potential and actual donors, their clinical, laboratory and radiological data as well as documented complications and deaths were recorded. SPSS version 17(Chicago, Ilinois) was used for data entry and analysis. Chi square test and Mann Whitney U test were used as tests of association for categorical and continuous data respectively, with P value set at <0.05.

Results

Median age of the donors was 34 years (IQR 31–39). First-degree relatives were majority(84.5%). Renal function assessment was done using mean glomerular filtration rate (GFR) from the radionuclide scan (DTPA) and serum creatinine levels. The donors had a mean GFR of 99.2 ± SD 6.6. All the haematological and biochemical tests were within normal. Majority(42.9%) were HLA compatible, but data on HLA typing was missing for 22% of the patients records. On CT angiogram, single renal artery and single renal vein were found in 94 and 88% respectively. Immediate complications included excessive bleeding(2%) and breach of other cavities (4%). Paralytic ileus (32%) and atelectasis (27%) were the most common early postoperative complications. There was no mortality.

Conclusion

Our study reports no fatality but significant post-operative complications. These are significant findings that may be used to review and improve care and to educate potential kidney donors on the safety of this procedure in our centre, in a bid to widen the pool of potential living kidney donors.

Predonation Prescription Opioid Use: A Novel Risk Factor for Readmission After Living Kidney Donation

Implications of opioid use in living kidney donors for key outcomes, including readmission rates after nephrectomy, are unknown. We integrated Scientific Registry of Transplant Recipients data with records from a nationwide pharmacy claims warehouse and administrative records from an academic hospital consortium to quantify predonation prescription opioid use and postdonation readmission events. Associations of predonation opioid use (adjusted odds ratio [aOR]) in the year before donation and other baseline clinical, procedural, and center factors with readmission within 90 days postdonation were examined by using multivariate logistic regression. Among 14 959 living donors, 11.3% filled one or more opioid prescriptions in the year before donation. Donors with the highest level of predonation opioid use (>305 mg/year) were more than twice as likely as nonusers to be readmitted (6.8% vs. 2.6%; aOR 2.49, 95% confidence interval 1.74-3.58). Adjusted readmission risk was also significantly (p < 0.05) higher for women (aOR = 1.25), African Americans (aOR = 1.45), spouses (aOR = 1.42), exchange participants (aOR = 1.46), uninsured donors (aOR = 1.40), donors with predonation estimated glomerular filtration rate <60 mL/min/1.73 m² (aOR = 2.68), donors with predonation pulmonary conditions (aOR = 1.54), and after robotic nephrectomy (aOR = 1.68). Predonation opioid use is independently associated with readmission after donor nephrectomy. Future research should examine underlying mechanisms and approaches to reducing risks of postdonation complications.

Cigarette Smoking and Its Hazards in Kidney Transplantation

Cigarette smoking affects many organs. It causes vasoconstriction through activation of sympathetic nervous system which leads to elevation of blood pressure and reduction in glomerular filtration rate and filtration pressure. It also causes thickening of renal arterioles. Cigarette smoking increases the risk of microalbuminuria and accelerates progression of microalbuminuria to macroalbuminuria. Furthermore, it causes rapid loss of glomerular filtration rate in chronic kidney disease patients. After kidney donation, these factors may be injurious to the solitary kidney. Kidney donors with history of cigarette smoking are prone to develop perioperative complications, pneumonia, and wound infection. Postkidney transplantation various stressors including warm and cold ischemia time, delayed graft function, and exposure to calcineurin inhibitors may result in poor graft function. Continuation of cigarette smoking in kidney transplant recipients will add further risk. In this review, we will specifically discuss the effects of cigarette smoking on normal kidneys, live kidney donors, and kidney transplant recipients. This will include adverse effects of cigarette smoking on graft and patient survival, cardiovascular events, rejection, infections, and cancers in kidney transplant recipients. Lastly, the impact of kidney transplantation on behavior and smoking cessation will also be discussed.

Delays in Prior Living Kidney Donors Receiving Priority on the Transplant Waiting List

BACKGROUND AND OBJECTIVES

Prior living donors (PLDs) receive very high priority on the Organ Procurement and Transplantation Network (OPTN) kidney waiting list. Program delays in adding PLDs to the waiting list, setting their status to active, and submitting requests for PLD priority can affect timely access to transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used the OPTN and the Centers for Medicare and Medicaid Services data to examine timing of (1) listing relative to start of dialysis, (2) activation on the waiting list, and (3) requests for PLD priority relative to listing date. There were 210 PLDs (221 registrations) added to the OPTN kidney waiting list between January 1, 2010 and July 31, 2015.

RESULTS

As of September 4, 2015, 167 of the 210 PLDs received deceased donor transplants, six received living donor transplants, two died, five were too sick to transplant, and 29 were still waiting. Median waiting time to deceased donor transplant for PLDs was 98 days. Only 40.7% of 221 PLD registrations (n=90) were listed before they began dialysis; 68.3% were in inactive status for <90 days, 17.6% were in inactive status for 90-365 days, 8.6% were in inactive status for 1-2 years, and 5.4% were in inactive status for >2 years. Median time of PLDs waiting in active status before receiving PLD priority was 2 days (range =0-1450); 67.4% of PLDs received PLD priority within 7 days after activation, but 15.4% waited 8-30 days, 8.1% waited 1-3 months, 4.1% waited 3-12 months, and 5.0% waited >1 year in active status for PLD priority. After receiving priority, most were transplanted quickly. Median time in active status with PLD priority before deceased donor transplant was 23 days.

CONCLUSIONS

Fewer than one half of listed PLDs were listed before starting dialysis. Most listed PLDs are immediately set to active status and receive PLD priority quickly, but a substantial number spends time in active status without PLD priority or a large amount of time in inactive status, which affects access to timely transplants.

Perioperative Complications After Living Kidney Donation: A National Study

We integrated the US transplant registry with administrative records from an academic hospital consortium (97 centers, 2008-2012) to identify predonation comorbidity and perioperative complications captured in diagnostic, procedure, and registry sources. Correlates (adjusted odds ratio, aOR) of perioperative complications were examined with multivariate logistic regression. Among 14 964 living kidney donors, 11.6% were African American. Nephrectomies were predominantly laparoscopic (93.8%); 2.4% were robotic and 3.7% were planned open procedures. Overall, 16.8% of donors experienced a perioperative complication, most commonly gastrointestinal (4.4%), bleeding (3.0%), respiratory (2.5%), surgical/anesthesia-related injuries (2.4%), and "other" complications (6.6%). Major Clavien Classification of Surgical Complications grade IV or higher affected 2.5% of donors. After adjustment for demographic, clinical (including comorbidities), procedure, and center factors, African Americans had increased risk of any complication (aOR 1.26, p = 0.001) and of Clavien grade II or higher (aOR 1.39, p = 0.0002), grade III or higher (aOR 1.56, p < 0.0001), and grade IV or higher (aOR 1.56, p = 0.004) events. Other significant correlates of Clavien grade IV or higher events included obesity (aOR 1.55, p = 0.0005), predonation hematologic (aOR 2.78, p = 0.0002) and psychiatric (aOR 1.45, p = 0.04) conditions, and robotic nephrectomy (aOR 2.07, p = 0.002), while annual center volume >50 (aOR 0.55, p < 0.0001) was associated with lower risk. Complications after live donor nephrectomy vary with baseline demographic, clinical, procedure, and center factors, but the most serious complications are infrequent. Future work should examine underlying mechanisms and approaches to minimizing the risk of perioperative complications in all donors.

Living Donor Kidney Transplantation: Facilitating Education about Live Kidney Donation--Recommendations from a Consensus Conference

The Best Practice in Live Kidney Donation Consensus Conference held in June of 2014 included the Best Practices in Living Donor Education Workgroup, whose charge was to identify best practice strategies in education of living donors, community outreach initiatives, commercial media, solicitation, and state registries. The workgroup's goal was to identify critical content to include in living kidney donor education and best methods to deliver educational content. A detailed summary of considerations regarding educational content issues for potential living kidney donors is presented, including the consensus that was reached. Educational topics that may require updating on the basis of emerging studies on living kidney donor health outcomes are also presented. Enhancing the educational process is important for increasing living donor comprehension to optimize informed decision-making.

Correlations between a dedicated orthopaedic complications grading system and early adverse outcomes in joint arthroplasty

BACKGROUND

Reliable classification of postoperative complications is important for quality improvement efforts. In 2014, The Knee Society proposed a grading system for complications after TKA, but to our knowledge, a relationship between complication grades and surgical outcomes has not yet been established.

QUESTIONS/PURPOSES

We attempted to determine (1) whether an association exists between complication grade and early adverse outcomes after TKA and THA, and (2) what proportion of the variability in complications could be associated with the classification grade (a metric of potential predictive value of the grading schema).

METHODS

A total of 210 primary THAs and TKAs in 201 patients performed at one center from January 1, 2011 to December 31, 2011 were reviewed; of those, 188 patients (94%; 197 procedures) had complete 90-day postoperative data and were evaluated retrospectively for postoperative complications. We defined and graded complications according to the classification system proposed by Iorio et al. and The Knee Society. Early adverse outcomes assessed included length of hospital stay and unplanned readmissions or reoperations. A total of 254 complications were documented in 135 patients (137 procedures); 53 patients (60 procedures) had no complications. Bivariate analyses were conducted to identify associations between complication grade and early adverse outcomes and patient variables; analyses considered patient variables including age, sex, status as a state prisoner (yes or no), American Society of Anesthesiologists score, BMI, and procedure (TKA or THA). Multiple regression and logistic regression analyses were conducted to determine the association between complication grade and early adverse outcomes (length of stay [LOS] and unplanned readmission or reoperations) adjusted for confounding patient variables. Alpha was set at 0.05 for two-sided tests.

RESULTS

Maximum complication grade (range, from 0-4) was associated with a longer LOS (for each point increase of maximum grade, LOS increased 0.105 ± 0.024 days, p < 0.001) and more readmissions or reoperations (odds ratio [OR], 3.79; 95% CI, 1.91-7.54; p < 0.001). Total grade (range, 0-22) also was associated with increased LOS (for each point increase of total grade, LOS increased 0.032 ± 0.006 days, p < 0.001) and increased readmissions or reoperations (OR, 1.34; 95% CI, 1.18-1.53; p < 0.001). Total grade could account for 38% of the variation in LOS and readmissions or reoperations (C-statistic = 0.94; 95% CI, 0.90-0.98); whereas maximum complication grade could account for 35% of the variation in LOS and readmissions or reoperations (C-statistic = 0.35; 95% CI, 0.88-0.96). Thus, we found total grade to be a slightly better predictor of LOS and readmissions or reoperations than maximum grade.

CONCLUSIONS

We found that the proposed grading system is applicable to TKA and THA in terms of documentation of complication severity and as an indicator of increased LOS and increased unplanned readmissions or reoperation rates. That total complication grade was a better predictor of LOS than maximum grade suggests that multiple complications of a lesser grade can be just as important as a single higher grade complication in terms of effect on outcomes.

Increasing the supply of kidneys for transplantation by making living donors the preferred source of donor kidneys

At the present time, increasing the use of living donors offers the best solution to the organ shortage problem. The clinical questions raised when the first living donor kidney transplant was performed, involving donor risk, informed consent, donor protection, and organ quality, have been largely answered. We strongly encourage a wider utilization of living donation and recommend that living donation, rather than deceased donation, become the first choice for kidney transplantation. We believe that it is ethically sound to have living kidney donation as the primary source for organs when the mortality and morbidity risks to the donor are known and kept extremely low, when the donor is properly informed and protected from coercion, and when accepted national and local guidelines for living donation are followed.

The Outcomes of Living Kidney Donation from Medically Complex Donors: Implications for the Donor and the Recipient

Living kidney donation is an important option for patients with end-stage renal disease (ESRD), and has improved life expectancy and quality for patients otherwise requiring maintenance dialysis or deceased-donor transplantation. Given the favorable outcomes of live donation and the shortage of organs to transplant, individuals with potentially unfavorable demographic and clinical characteristics are increasingly being permitted to donate kidneys. While this trend has successfully expanded the live donor pool, it has raised concerns as to which acceptance criteria are safe. This review aims to summarize the existing literature on the outcomes of transplantation from medically complex, living kidney donors, including both donor and recipient outcomes when available.

Stratification of standardized TKA complications and adverse events: a brief communication

BACKGROUND

The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of Clinical Orthopaedics and Related Research (®), the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system.

QUESTIONS/PURPOSES

The purpose of this article was to stratify the previously published standardized list of TKA adverse events and complications.

METHODS

A modified version of the Sink adaptation of the Clavien-Dindo Surgical Complication Classification was applied to the list of standardized TKA complications and adverse events.

RESULTS

The proposed stratified classifications of TKA complications were reviewed and endorsed by the Knee Society.

CONCLUSIONS

Stratification of TKA complications will allow more in-depth and detailed outcome reporting for surgeons, hospitals, third-party payers, government agencies, joint replacement registries, and orthopaedic researchers. This improvement in reporting of TKA complications will also improve the quality of orthopaedic literature.

Obesity and metabolic syndrome in kidney transplantation

The epidemic of obesity and metabolic syndrome (MS) contributes to the rapid growth of chronic kidney disease (CKD) and end-stage renal disease (ESRD). There is a reverse epidemiology, known as the "obesity paradox," in ESRD patients receiving maintenance dialysis. Obese patients are routinely referred for kidney transplant, and they have more surgical and medical complications than non-obese patients. However, compared to dialysis, kidney transplant provides a survival benefit for obese patients. After kidney transplant, obese patients tend to gain more body weight, and non-obese patients can develop new-onset obesity/MS. Obesity/MS is not only associated with serious morbidities, but also compromises the long-term graft and patient survival. The immunosuppressive drugs commonly used as maintenance therapy, including corticosteroids, calcineurin inhibitors and mammalian target-of-rapamycin inhibitors, contribute to obesity/MS. Development of novel immunosuppressive drugs free of metabolic adverse effects is needed, so that the full potential and benefits of kidney transplantation can be realized.

Comorbidity burden and perioperative complications for living kidney donors in the United States

BACKGROUND AND OBJECTIVES

Since 1998, 35% of kidney transplants in the United States have been derived from living donors. Research suggests minimal long-term health consequences after donation, but comprehensive studies are limited. The primary objective was to evaluate trends in comorbidity burden and complications among living donors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The National Inpatient Sample (NIS) was used to identify donors from 1998 to 2010 (n=69,117). Comorbid conditions, complications, and length of stay during hospitalization were evaluated. Outcomes among cohorts undergoing appendectomies, cholecystectomies and nephrectomy for nonmetastatic carcinoma were compared, and sample characteristics were validated with the Scientific Registry of Transplant Recipients (SRTR). Survey regression models were used to identify risk factors for outcomes.

RESULTS

The NIS captured 89% (69,117 of 77,702) of living donors in the United States. Donor characteristics were relatively concordant with those noted in SRTR (mean age, 40.1 versus 40.3 years [P=0.18]; female donors, 59.0% versus 59.1% [P=0.13]; white donors, 68.4% versus 69.8% [P<0.001] for NIS versus SRTR). Incidence of perioperative complications was 7.9% and decreased from 1998 to 2010 (from 10.1% to 7.6%). Men (adjusted odds ratio [AOR], 1.37; 95% confidence interval [CI], 1.20 to 1.56) and donors with hypertension (AOR, 3.35; 95% CI, 2.24 to 5.01) were more likely to have perioperative complications. Median length of stay declined over time (from 3.7 days to 2.5 days), with longer length of stay associated with obesity, depression, hypertension, and pulmonary disorders. Presence of depression (AOR, 1.08; 95% CI, 1.04 to 1.12), hypothyroidism (AOR, 1.07; 95% CI, 1.04 to 1.11), hypertension (AOR, 1.38; 95% CI, 1.27 to 1.49), and obesity (AOR, 1.07; 95% CI, 1.03 to 1.11) increased over time. Complication rates and length of stay were similar for patients undergoing appendectomies and cholecystectomies but were less than those with nephrectomies for carcinoma.

CONCLUSIONS

The NIS is a representative sample of living donors. Complications and length of stay after donation have declined over time, while presence of documented comorbid conditions has increased. Patients undergoing appendectomy and cholecystectomy have similar outcomes during hospitalization. Monitoring the health of living donors remains critically important.

Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation

Obese patients with end-stage renal disease (ESRD) are often excluded from kidney transplantation due to concerns about surgical site infections. To reduce infections, we developed a robotic kidney transplantation method for obese recipients. From June 2009-December 2011, a prospective cohort of 39 obese patients underwent robotic kidney transplantation at a single center. The outcomes of patients with at least six months of follow-up (n=28) were compared to a frequency-matched retrospective cohort of obese patients who underwent open kidney transplantation from 2004-2009 (n=28). The 28 robotic patients were predominately African-American (46.4%) or Hispanic (35.7%), with a mean age of 47.9±10.7 years, similar to the control group. BMI in the robotic group was 42.6±7.8 kg/m2 compared to 38.1±5.4 kg/m2 in the control group (p=0.02). There were no surgical site infections in the robotic group (0/28), while 28.6% (8/28) in the control group developed an infection (p=0.004). Six-month creatinine (1.5±0.4 vs.1.6±0.6 mg/dL; p=0.47), and patient and graft survival (100%) were comparable between the two groups. Outcomes following robotic surgery compared favorably to conventional transplantation. Robotic surgery may therefore enable obese patients with ESRD to access kidney transplantation and may thereby reduce health disparities in groups with a high prevalence of obesity and ESRD.

Inguinal incision as a successful route to extract the kidney during laparoscopic retroperitoneal live-donor nephrectomy

OBJECTIVES

We sought to evaluate the advantages of an inguinal incision in extracting the kidney during retroperitoneal laparoscopic live-donor nephrectomy.

MATERIALS AND METHODS

From May 2008 to June 2011, fifty-eight cases of retroperitoneal live-donor nephrectomy were performed at our hospital; all data were analyzed retrospectively. All donors were grouped in a test group (n=32, inguinal incision) or a control group (n=26, lumbar incision) according to the selected graft retrieval incision. Donors were compared with regard to operative time and warm ischemia time, operative blood loss, hospital stay, cosmetic satisfaction, and incision complications.

RESULTS

All 58 cases of retroperitoneal live-donor nephrectomy were successfully accomplished, without donor death, serious complications, and conversion to open surgery. There were no differences in mean operative time, mean blood loss, mean warm ischemic time, graft function, and 1-year graft survival rate between the groups. However, in a test group, the mean hospital stay was shorter (P < .01), and the satisfaction with cosmesis was higher (P < .01). The incidence rates of abdomen asymmetry (9/28), incision hernia (4/28), wound infection (5/28), and wound faulty union (6/28) were higher in the control group than they were in the test group.

CONCLUSIONS

Inguinal incision is a safe and practical graft retrieval incision in retroperitoneal laparoscopic donor nephrectomy and can be generally applied.

Bayesian modeling of pretransplant variables accurately predicts kidney graft survival

INTRODUCTION

Machine learning can enable the development of predictive models that incorporate multiple variables for a systems approach to organ allocation. We explored the principle of Bayesian Belief Network (BBN) to determine whether a predictive model of graft survival can be derived using pretransplant variables. Our hypothesis was that pretransplant donor and recipient variables, when considered together as a network, add incremental value to the classification of graft survival.

METHODS

We performed a retrospective analysis of 5,144 randomly selected patients (age ≥18, deceased donor kidney only, first-time recipients) from the United States Renal Data System database between 2000 and 2001. Using this dataset, we developed a machine-learned BBN that functions as a pretransplant organ-matching tool.

RESULTS

A network of 48 clinical variables was constructed and externally validated using an additional 2,204 patients of matching demographic characteristics. This model was able to predict graft failure within the first year or within 3 years (sensitivity 40%; specificity 80%; area under the curve, AUC, 0.63). Recipient BMI, gender, race, and donor age were amongst the pretransplant variables with strongest association to outcome. A 10-fold internal cross-validation showed similar results for 1-year (sensitivity 24%; specificity 80%; AUC 0.59) and 3-year (sensitivity 31%; specificity 80%; AUC 0.60) graft failure.

CONCLUSION

We found recipient BMI, gender, race, and donor age to be influential predictors of outcome, while wait time and human leukocyte antigen matching were much less associated with outcome. BBN enabled us to examine variables from a large database to develop a robust predictive model.

Rates and correlates of health maintenance behaviors after living kidney donation

CONTEXT AND OBJECTIVE

Donating a kidney may provide an opportunity for donors to reevaluate their health maintenance behaviors (eg, regular exercise, smoking cessation, medical checkups). Although the effect of donation on donors' health, quality of life, and financial outcomes has received growing attention, no studies have examined whether donation is related to changes in health maintenance behaviors. The study aims were to (1) describe and compare kidney donors' health maintenance behaviors before and after donation, and (2) determine the correlates of health maintenance behaviors after donation. DESIGN, SETTING, PARTICIPANTS AND MEASURES: We conducted a telephone-interview study with 85 randomly selected laparoscopic kidney donors in a major US transplant center to assess health behaviors before and after donation, postdonation characteristics (eg, quality of life, postsurgical pain), and demographics.

RESULTS

Sample demographics included a median age of 48 years; 55% were female, 82% were white, 71% were married, and 52% were college graduates. Few health behaviors changed significantly from before to after donation. Only the rate of medical checkups increased after donation (P< .001). Logistic regression was used to examine the association of demographics and postdonation characteristics with postdonation health maintenance behaviors, after adjusting for predonation behavior. Older age, higher income, less postsurgical pain, and better physical functioning were associated with more exercise after donation. Longer time since donation was associated with a higher prevalence of obesity.

CONCLUSIONS

These results may help identify donors who are at greater risk for poor health maintenance behaviors after donation and suggest areas of health behavior that should be the focus of education sessions before donation.

Reliability of a complication classification system for orthopaedic surgery

BACKGROUND

Quality of health care and safety have been emphasized by various professional and governmental groups. However, no standardized method exists for grading and reporting complications in orthopaedic surgery. Conclusions regarding outcomes are incomplete without a standardized, objective complication grading scheme applied concurrently. The general surgery literature has the Clavien-Dindo classification that meets the above criteria.

QUESTIONS/PURPOSES

We asked whether a previously reported classification would show high intraobserver and interobserver reliabilities when modified for orthopaedic surgery specifically looking at hip preservation surgery. We therefore determined the interreader and intrareader reliabilities of the adapted classification scheme as applied to hip preservation surgery.

METHODS

We adapted the validated Clavien-Dindo complication classification system and tested its reliability for orthopaedic surgery, specifically hip preservation surgery. There are five grades based on the treatment required to manage the complication and the potential for long-term morbidity. Forty-four complication scenarios were created from a prospective multicenter database of hip preservation procedures and from the literature. Ten readers who perform hip surgery at eight centers in three countries graded the scenarios at two different times. Fleiss' and Cohen's κ statistics were performed for interobserver and intraobserver reliabilities, respectively.

RESULTS

The overall Fleiss' κ value for interobserver reliability was 0.887 (95% CI, 0.855-0.891). The weighted κ was 0.925 (95% CI, 0.894-0.956) for Grade I, 0.838 (95% CI, 0.807-0.869) for Grade II, 0.87 (95% CI, 0.835-0.866) for Grade III, and 0.898 (95% CI, 0.866-0.929) for Grade IV. The Cohen's κ value for intraobserver reliability was 0.891 (95% CI, 0.857-0.925).

CONCLUSIONS

The adapted classification system shows high interobserver and intraobserver reliabilities for grading of complications when applied to orthopaedic surgery looking at complications of hip preservation surgery. This grading scheme may facilitate standardization of complication reporting and make outcome studies more comparable.

Risks and outcomes of living donation

Living donors supply approximately 40% of renal allografts in the United States. Based on current data, perioperative mortality after donor nephrectomy is approximately 3 per 10,000 cases, and major and minor perioperative complications affect approximately 3% to 6% and 22% of donors, respectively. Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it appear to increase ESRD risk among white donors. Within the donor population, the likelihood of postdonation chronic renal failure and medical comorbidities such as hypertension and diabetes appears to be relatively higher among some donor subgroups, such as African Americans and obese donors, but the impact of uninephrectomy on the lifetime risks of adverse events expected without nephrectomy in these subgroups has not yet been defined. As national follow-up of living donors in the United States is limited in scope, duration, and completeness, additional methods for quantifying risk among diverse living donors are needed. In addition to improved national collection of follow-up data, possible sources of information on donor outcomes may include focused studies with carefully defined control groups, and database integration projects that link national donor registration records to other data sources. Given the growth and evolving characteristics of the living donor population, as well as changes in surgical techniques, tracking of short- and long-term risks after living kidney donation is vital to support truly informed consent and to maintain public trust in living donation. The transplant community must persist in their efforts to accurately assess risk across demographically diverse living kidney donors.

Expanding the donor pool: living donor nephrectomy in the elderly and the overweight

BACKGROUND

Increasing demand for donor kidneys, in parallel with trends toward more elderly and obese populations, make it important to continuously review donor pool inclusion criteria. Acceptance of elderly and obese living donors remains controversial, with a higher incidence of comorbidity and the greater risk of postoperative complications sighted as reasons for caution. Drawing on our center's experience, we aim to determine whether older age and obesity are in fact associated with greater perioperative risk, and longer term complications in donors undergoing nephrectomy.

METHODS

Three hundred eighty-three living donor nephrectomies conducted at one of the United Kingdom's largest transplant units over the last 5 years were stratified into groups according to age and body mass index. Perioperative endpoints and postdonation follow-up data collected at 6-to-12-monthly intervals were analyzed and compared.

RESULTS

No significant differences in operative parameters, including operative time and estimated blood loss, were reported between groups. Rates of early postoperative complications were not significantly different, although subgroup analysis showed a higher incidence of respiratory complications at the extremes of obesity (body mass index ≥ 40 kg/m²). On follow-up, renal function parameters showed significant change postnephrectomy, but between-group variation was not significant. Mortality and major complication rates were comparably low in all groups of study.

CONCLUSIONS

In our unit's experience, nephrectomy in selected donors who may otherwise have been precluded from participation on account of their age or weight, is feasible and associated with perioperative and longer term outcomes comparable with their younger nonobese counterparts. It provides a basis for informed consent of "extended criteria" donors.

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.

The living kidney donor evaluation: focus on renal issues

Living kidney donor evaluations and follow-up have previously been addressed mostly by transplant physicians and surgeons. However, this area is significantly informed by basic principles of renal physiology and is of increasing clinical interest to general nephrologists. The general nephrology community is increasingly involved in evaluating the suitability of potential donors and in following them after donation when questions are raised about low GFR, hypertension, and other renal concerns. This article focuses on some of the most central and common issues that arise in evaluating potential donors and attempts to provide guidance on the basis of our review of the living donor literature, extrapolations from the general nephrology literature, and our own clinical experience.

Long-term outcomes of kidney donors

As the demand for kidney transplantation, particularly from living donors, continues to rise, there is increasing and much needed interest in accurately quantifying the long-term risks of kidney donation. We review the outcomes of kidney donors in the domains of survival, perioperative mortality, risk of end-stage renal disease, quality of life, course of diabetes mellitus in donors, pregnancy after donation, obesity, and prevalence of other health conditions.

Minimally invasive living donor nephrectomy - introduction of hand-assistance

Conventional open living donor nephrectomy (LDN) technique is perceived as a barrier for expanding living donor programmes. Thus, minimal invasive surgery techniques have been advocated to overcome this hurdle. The aim of this study was to evaluate our experience on minimally invasive LDN. During the last decade we have gradually expanded the use of minimally invasive LDN with various techniques; strictly laparoscopic versus hand-assisted, and laparoscopic versus retroperitoneoscopic. This study is based on 305 consecutive minimally invasive LDN's, from 1998 to 2009. By multiple regression analysis, minimally invasive hand-assisted technique was shown to be associated with a significantly lower risk of major complications and intraoperative incidents, as well as reduced warm ischemia and operative time. In our opinion, the introduction of hand-assisted technique is probably the most significant single factor for improved results, although accumulated experience and developments in equipment will contribute. Our experience indicates that learning curves are facilitated by the use of hand-assisted technique. Improvements in surgical outcomes following donor nephrectomy may enhance living donor programmes.

Application of artificial neural networks in renal transplantation: classification of nephrotoxicity and acute cellular rejection episodes

Complications associated with kidney transplantation and immunosuppression can be prevented or treated effectively if diagnosed in the early stages by posttransplant monitoring. One of the major problems is diseases that occur during the first year after kidney transplantation. For this purpose, we used different classifiers to predict events of nephrotoxicity versus acute cellular rejection episodes. The classifiers were evaluated according to values of sensitivity, specificity and area under ROC curves (RCA). The classifier with better accuracy rate for nephrotoxicity achieved the value of 75.68% and RCA classifier reached the accuracy of 80.89%. These results are encouraging, with rates of accuracy and error consistent with work purpose.

Morbidity and mortality in 1022 consecutive living donor nephrectomies: benefits of a living donor registry

BACKGROUND

We assessed postoperative complication rates in living donor nephrectomies (LDN) during the last decade (1997-2008).

METHODS

Postoperative complications were classified by the Clavien grading system. We defined Clavien grade more than or equal to 3 as major complications. A total of 1022 LDNs performed during the period 1997-2008 were included.

RESULTS

Median age at donation was 47.7 years (range 18.4-78.9), and mean body mass index was 25.4 (SD 3.2). There was no peri- or postoperative mortality. Laparoscopic nephrectomy was performed in 244 (23.9%) donors. Three of these needed surgical conversion. A total of 30 major (2.9%) and 184 (18%) minor complications were registered. There was a higher frequency of major complications in the laparoscopic group (4.1% vs. 2.6%), but the difference was not statistically significant. Twenty-three donors underwent early re-operations. Wound infection developed in 3.7% of donors. Increased risk was associated with body mass index more than 25 (OR 4.03; 95% CI 1.80, 9.04) and smoking (OR 4.38; 95% CI 2.30, 9.96). Significant perioperative bleeding occurred in 1.6%. There were seven cases of renal artery laceration. Increased risk for a combined endpoint of intraoperative incidents, major complications and significant bleeding were seen in relation to laparoscopic surgery (OR 2.63; 95% CI 1.33, 5.19).

CONCLUSION

The risk of major complications related to LDN is low, but do represent a potential hazard to the donor. The special nature of LDN and the constantly evolving operative technique requires vigilant surveillance, by the use of national or supranational registries/databases.