Living donor transplant: Right vs left kidney

Khan et al’ single-centre, retrospective study on the use of right or left kidneys in living-donor renal transplantation, offers the opportunity to further discuss a complex and debated topic in clinical transplantation. In brief, the authors confirm that, despite the historical preference for left kidneys, attributed to their anatomical advantages during donor nephrectomy and recipient transplantation, right kidneys can provide excellent outcomes when donors and recipients are carefully selected, and a meticulous surgical technique is applied in every step of the process. Usefully, the article includes some practical tips to help less experienced surgeons address the technical challenges of right kidney transplantation, such as extended renal vein dissection or full mobilization of the iliac vein of the recipient to minimize tension during anastomosis. Although limited by the selective use of minimally invasive (MI) nephrectomy for left kidneys, this work underscores the importance of expanding the living-donor pool, challenging the traditional taboos, and facilitating access to transplantation for a wider population of patients around the globe. Properly designed studies with larger sample size, comparable MI surgical techniques, prospective data collection, and long-term donor and recipient outcomes are warranted.

Comparative study of living donor kidney transplants: Right vs left

BACKGROUND

Transplant teams often hesitate to use the right kidney (RK) in living donor (LD) transplants due to the complexities of anastomosing the short, thin-walled right renal veins, which can potentially lead to graft loss or graft dysfunction. Nevertheless, circumstances may arise where selecting the RK over the left kidney (LK) is unavoidable. Consequently, it is crucial to thoroughly examine the implications of such a choice on the overall transplant outcome.

AIM

To compare transplant outcomes between recipients of RK and LK while examining the factors that influence these outcomes.

METHODS

We retrospectively analyzed data from adult patients who received LD kidney transplants involving meticulous patient selection and surgical techniques at our center from January 2020 to December 2023. We included all kidney donors who were over 18, fit to donate, and had undergone diethylenetriamine pentaacetic acid split function and/or computed tomography based volumetry. The variables examined comprised donor and recipient demographics, and outcome measures included technical graft loss (TGL), delayed or slow graft function (SGF), and post-transplant serum creatinine (SC) trends. We used a logistic regression model to assess the likelihood of adverse outcomes considering the donor kidney side.

RESULTS

Of the 250 transplants performed during the period, 56 (22%) were RKs. The recipient demographics and transplant factors were comparable for the right and LKs, except that the donor warm and cold ischemia time were shorter for RKs. TGL and SGF each occurred in 2% (n = 1) of RKs and 0.5% (n = 1) of LKs, the difference being insignificant. These complications, however, were not related to the venous anastomosis. One RK (2%) developed delayed graft function after 48 hours, which was attributable to postoperative hypoxia rather than the surgical technique. The post-transplant SC trend and mean SC at the last follow-up were similar across both kidney sides.

CONCLUSION

The donor kidney side has little impact on post-transplant adverse events and graft function in LD transplants, provided that careful patient selection and precise surgical techniques are employed.

Right and left living donor nephrectomy and operative approach: A systematic review and meta-analysis of donor and recipient outcomes

INTRODUCTION

The left kidney is preferable in living donor nephrectomy (LDN). We aimed to investigate the safety and efficacy of right versus left LDN in both donor and recipients. A subgroup analysis of outcomes based on operative approach was also performed.

METHODS

A systematic review and meta-analysis was performed as per PRISMA guidelines. Outcomes of interest were extracted from included studies and analysed.

RESULTS

There were 31 studies included with 79,912 transplants. Left LDN was performed in 84.1 % of cases and right LDN in 15.9 %. Right LDN was associated with reduced EBL (P = 0.010), intra-operative complications (P = 0.030) and operative time (P = 0.006), but higher rates of conversion to open surgery (1.4 % vs 0.9 %). However, right living donor renal transplantation (LDRT) had higher rates of delayed graft function (5.4 % vs 4.2 %, P < 0.0001) and graft loss (2.6 % vs 1.1 %, P < 0.0001). Graft survival was reduced in right LDRT at 3 years (92.0 % vs 94.2 %, P = 0.001) but comparable to left LDRT at 1- and 5-years. Otherwise, donor and recipient peri-operative outcomes and serum creatinine levels were comparable in both groups. Hand-assisted LDN was associated with shorter warm ischaemia time (P < 0.0001) but longer length of stay (LOS) than laparoscopic LDN and robotic-assisted LDN (P < 0.0001). RA-LDN was associated with less EBL and shorter LOS (both P < 0.0001) while patients who underwent L-LDN had a lower mean serum creatinine (SCr) level on discharge (P < 0.0001).

CONCLUSION

Right LDRT has higher rates of delayed graft function and graft loss compared to left LDRT. Minimally-invasive surgical approaches potentially offer improved outcomes but further large-scale randomised controlled trials studies are required to confirm this finding.

Vascular Reconstruction of Multiple Renal Arteries-A Risk Factor for Transplant Renal Artery Stenosis: Insight From a Matched Case-Control Study

Transplant Renal Artery Stenosis (TRAS) is the leading vascular complication following kidney transplantation (KT), causing premature allograft loss and increased post-KT mortality. While risk factors for TRAS, such as prolonged cold ischemia time and delayed graft function, are well-documented in deceased donor-KT, the risk factors remain less clearly defined in living donor-KT. This matched case-control study, conducted at a leading national transplant center predominantly performing living donor-KT, evaluated risk factors and long-term outcomes of clinical TRAS (cTRAS). cTRAS cases diagnosed from January 2009 to December 2022 were matched with four control kidney transplant recipients (KTRs) in a study powered to assess whether ex-vivo arterial vascular reconstruction of multiple renal arteries (VR-MRA) increases the risk of cTRAS. Among 2,454 KTs, 28 KTRs (1.14%) were diagnosed with cTRAS around 3.62 ± 1.04 months post-KT, with renal allograft dysfunction (92.86%) as the most common presenting feature. Notably, 27 cTRAS cases were successfully treated with endovascular intervention, yielding favorable outcomes over a 6-180 months follow-up period. The study identified ex-vivo VR-MRA as an independent risk factor for cTRAS (P < 0.001). cTRAS cases receiving timely treatment exhibited long-term outcomes in graft and patient survival similar to control KTRs. Early screening and timely intervention for cTRAS post-KT may improve graft and patient outcomes.

Laterality of live-donor nephrectomy: does it have a urologic impact on post-donation pregnancy?

BACKGROUND

Our center policy is to promote right nephrectomy for pre-menopausal live donor donors. This is based on the traditional belief that ureteral obstruction and subsequent urinary tract infections (UTIs) of post-donation pregnancies would be more frequent among female donors with a solitary right (compared to left) kidney. Studies that support or dismiss our policy are lacking. Therefore, we conducted this study.

METHODS

100 donors who had post-donation pregnancy were included. They underwent an updated clinical, laboratory and ultrasound assessment. They were classified into two groups: right and left nephrectomy groups. Both groups were compared relative to pre- and post-donation data, urinary troubles during or after post-donation pregnancies as well as their current kidney function.

RESULTS

Right nephrectomy was carried-out in 60 donors (60%). Post-donation acute pyelonephritis was not reported in either group. Unexpectedly, right nephrectomy group had a slightly higher (yet insignificant) lower UTIs during post-donation pregnancy. Furthermore, obstructive uropathy {two donors) and end stage renal disease (one donor) were only reported among right nephrectomy group. Both groups were comparable in terms of their current kidney function.

CONCLUSION

Despite that the endeavor to retrieve the right rather than the left kidney among premenopausal women could give them the benefit of doubt in regard to possible obstructive uropathy and UTIs during their subsequent pregnancies, this policy is likely an overdoing practice. Larger-scale studies are needed.

Laparoscopic Living Donor Nephrectomy in a Donor With Situs Inversus Totalis: It is Not a Contraindication to Kidney Transplant

Situs inversus totalis (SIT) is a rare anatomic anomaly representing 180° inversion of all internal organs. We report a case of laparoscopic living donor nephrectomy in a donor with SIT. A 55-year-old man volunteered to provide a living kidney source for his son. The donor was in good physical condition, with no clinical history of obesity, hypertension, diabetes, and other abnormalities. Preoperative X-ray thoracic and abdominal scans showed that the donor had a total organ transposition inversus. Computed tomographic renal vascular three-dimensional reconstruction scan showed that the patient had 2 left renal arteries and 1 right renal artery. All data collected comply with the Helsinki Congress and the Declaration of Istanbul. We chose to perform a transabdominal route laparoscopic living donor nephrectomy of the right kidney. The donor did not experience operation-related complications and was discharged on the fourth postoperative day. The recipient did not have a rejection reaction, and the recipient recovered successfully. This case illustrates that laparoscopic living donor nephrectomy is fully feasible in this population.

Transplanting a left or right donor kidney into the left or right iliac fossa: importance of laterality and site of venous anastomosis

Data on the impact of donor-to-recipient laterality on kidney transplantation are lacking. This study evaluated the impact of donor-to-iliac fossa laterality and the site of venous anastomosis on operating time and surgical outcome. This retrospective single-center study analyzed 1262 deceased donor adult kidney transplants into pristine iliac fossa. Multivariable linear and logistic regression analyses were used to identify variables with an impact on operating time and surgical complications. Operating time was shorter by 11 min in median for transplantations into the right iliac fossa compared to the left iliac fossa (p < 0.001). Operating time in left-to-right donor-to-recipient combination was shorter by 17 min in median if venous anastomoses were performed on the caval vein or common iliac vein as compared to anastomoses to the external iliac vein (p < 0.001). Overall, the shortest operating times (median 112.5 min) were achieved in left-to-right donor-to-recipient combinations with venous anastomosis to the caval or common iliac vein, without an increase in surgical complications. Kidney transplantation into the right iliac fossa with anastomosis to the caval vein or the common iliac vein saves operating time and reduces thrombotic complications. Acceptance of a left donor kidney is likely to further reduce operating time.

Association Between Side of Living Kidney Donation and Post-Transplant Outcomes

Background: Right-sided living donor kidneys have longer renal arteries and shorter veins that make vascular anastomosis more challenging. We sought to determine whether recipients of right-sided living donor kidneys have worse outcomes than left-sided kidney recipients.

Methods: An observational analysis of the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) was undertaken. We used adjusted logistic regression to determine the association between side and delayed graft function (DGF) and time-stratified adjusted cox regression models for graft and patient survivals.

Results: Between 2004 and 2018, 4,050 living donor kidney transplants were conducted with 696 (17.2%) using right kidneys. With reference to left kidneys, the adjusted OR (95% CI) for DGF was 2.01 (1.31–3.09) for recipients with right kidneys. Within 30 days, 46 allografts (1.4%) were lost, with major causes of overall graft loss being technical, primary non-function and death. Recipients of right donor kidneys experienced a greater risk of early graft loss (aHR 2.02 [95% CI 1.06–3.86], p = 0.03), but not beyond 30 days (aHR 0.97 [95% CI 0.80–1.19], p = 0.8]).

Conclusion: Technical challenge is the most common cause of early graft loss. The risk of early graft loss among recipients who received right kidneys is doubled compared to those who received left living donor kidneys.

Robotic versus hand-assisted laparoscopic living donor nephrectomy: comparison of two minimally invasive techniques in kidney transplantation

Robot-assisted donor nephrectomy (RDN) is increasingly used due to its advantages such as its precision and reduced learning curve when compared to laparoscopic techniques. Concerns remain among surgeons regarding possible longer warm ischemia time. This study aimed to compare patients undergoing robotic living donor nephrectomy to the more frequently used hand-assisted laparoscopic nephrectomy (HLDN) technique, focusing on warm ischemia time, total operative time, learning curve, hospital length of stay, donor renal function and post-operative complications. Retrospective study comparing RDN to HLDN in a collaborative transplant network. 176 patients were included, 72 in RDN and 104 in HLDN. Left-sided nephrectomy was favored in RDN (82% vs 52%, p < 0.01). Operative time was longer in RDN (287 vs 160 min; p < 0.01), while warm ischemia time was similar (221 vs 213 secs, p = 0.446). The hospital stay was shorter in RDN (3.9 vs 5.7 days, p < 0.01).Concerning renal function, a slightpersistent increase of 7% of the creatinine ratio was observed in the RDN compared to the HLDN group (1.56 vs 1.44 at 1-month checkup, p < 0.01). The results show that RDN appears safe and efficient in comparison to the gold-standard HLDN technique. Warm ischemia time was similar for both techniques, whereas RDN operative time was longer. Patients undergoing RDN had a shorter hospital stay, this being possibly mitigated by differences in center release criteria. Donor renal function needs to be assessed on a longer-term basis for both techniques.

Comparing outcomes in right versus left kidney transplantation: A systematic review and meta-analysis

INTRODUCTION

Transplantation of right kidneys can pose technical challenges due to the short right renal vein. Whether this results in inferior outcomes remains controversial.

METHOD

Healthcare Database Advanced Search (HDAS) was used to identify relevant studies. Two authors independently reviewed each study. Statistical analyses were performed using random effects models and results expressed as HR or relative risk (RR) with 95% confidence intervals. Subgroup analyses were performed in kidneys from deceased donors (DD) and living donors (LD).

RESULTS

A total of 35 studies (257,429 participants) were identified. Both deceased and living donor right kidneys were at increased risk of delayed graft function (DGF; RR = 1.12[1.06-1.18] and RR = 1.33[1.21-1.46] respectively; both p < .0001). In absolute terms, for each 100 kidney pairs of DD kidneys transplanted there are 2.72 (1.67-3.78, p < .00001) excess episodes of DGF in right kidneys. Graft thromboses and graft loss due to technical failure was also significantly more likely in right kidneys, in both DD and LD settings. There was no evidence that laterality alters long term graft survival in LD or DD.

CONCLUSION

Right kidneys have inferior early outcomes, with higher rates of DGF, technical failure and graft thrombosis. However, these differences are small in absolute terms, and long-term graft survival is equivalent.

Midline Rotation of the Right Renal Hilum During Hand-Assisted Laparoscopic Living Donor Nephrectomy

BACKGROUND/OBJECTIVES

Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney.

METHODS

Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 - 36. Graft vein and arterial anastomosis data were also reported.

RESULTS

Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 - 60) and 53 (3 - 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications.

CONCLUSIONS

The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery.

Hand-assisted retroperitoneoscopic donor nephrectomy offers more liberal use of right kidneys: lessons learned from 565 cases - a retrospective single-center study

The introduction of laparoscopic donor nephrectomy caused a shift toward' left donor nephrectomy. Some centers report a significantly low rate of endoscopic right donor nephrectomy. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP-DN) was introduced as a novel surgical technique, which aims to avoid intra-abdominal complications. It was also reported to provide technical advantages for right-sided DN. In this retrospective single-center study, we evaluated the impact of HARP-DN technique on utilization of right-sided DNs. After the implementation of HARP-DN on February 2009, a total of 565 DNs were performed until December 2015. The introduction of HARP-DN technique resulted in an immediate increase in the utilization of right kidneys from 6.1% to an average of 19.6% annually. The donors 'outcome was similar to the left-sided and right-sided DN groups, excluding the increased incidence of incisional hernias in left kidney donors. None of the donors developed intra-abdominal complications. In conclusion, the implementation of HARP technique significantly increased the use of right-sided DNs, which enables a more liberal use of donors in LDKT.

[The first 50 robot-assisted donor nephrectomies : Lessons learned]

Hintergrund

Die minimal-invasive Donornephrektomie (DN) ist inzwischen operativer Standard, bezüglich der Rolle von roboterassistierten Verfahren gibt es bisher keinen Konsens.

Fragestellung

Die ersten 50 transperitonealen roboterassistierten Donornephrektomien (RDN) einer urologischen Universitätsklinik in Deutschland wurden retrospektiv ausgewertet.

Material und Methoden

Patientencharakteristika, intra- und postoperative Parameter wurden erfasst und die Nierenfunktion in einem 5‑jährigen Follow-up ausgewertet. Signifikante Prädiktoren für die Nierenfunktion bei Entlassung und ein Jahr postoperativ wurden in einem multivariablen Regressionsmodell bestimmt.

Ergebnisse

Die RDN hat exzellente Ergebnisse mit niedriger Komplikationsrate, kurzer warmer (WIZ) und kalter Ischämiezeit (KIZ) sowie geringem Blutverlust und kurzer Patientenverweildauer. Die Seite der Nierenentnahme hat hierauf keine Auswirkungen. Nach RDN sind etwa 50 % der Spender formal niereninsuffizient, was aber zumeist ohne Relevanz ist, weil sich die Nierenfunktion der Spender im Follow-up nicht weiter verschlechtert. Die postoperative Nierenfunktion lässt sich bei der RDN mithilfe der präoperativen eGFR (errechnete glomeruläre Filtrationsrate) und dem Spenderalter sehr gut vorhersagen.

Schlussfolgerungen

Die robotische DN stellt eine sehr gute Alternative zu anderen minimal-invasiven Operationsverfahren dar, die von Beginn an exzellente operative Ergebnisse ermöglicht.

Right Kidney Mini-Invasive Living Donor Nephrectomy: A Safe and Efficient Alternative

INTRODUCTION

Right kidney living donor transplantation is considered more difficult and associated with more complications. The objective was to evaluate donor safety and graft function of right hand-assisted laparoscopic donor nephrectomy (HALDN).

METHODS

A total of 270 consecutive HALDN procedures have been performed in our institution up to April 2017. We retrospectively compared the outcomes of right-sided nephrectomy (R-HALDN) to left-sided nephrectomy (L-HALDN) to evaluate donor safety and graft function of R-HALDN.

RESULTS

Sixty-seven right kidneys were removed for functional asymmetry in favour of left kidney (35/67) or left kidney multiple arteries (28/67). Among the donors, neither conversion to open surgery nor preoperative blood transfusion was necessary. There was no significant difference in operative time, compared to L-HALDN group (170 ± 37 min vs. 171 ± 32 min; p value = 0.182). Warm ischaemia time was significantly longer for R-HALDN (4.0 ± 1.6 min vs. 3.0 ± 1.7 min; p < 0.001). There was no significant difference in terms of post-operative complications and serum Cr levels. Among the recipients, there were no graft venous thrombosis. There was no significant difference in delayed graft function (3 for R-HALDN group and 8 for L-HALDN group; p value = 0.847), serum Cr levels, and graft survival.

CONCLUSION

R-HALDN is a safe procedure for kidney donors, with excellent graft function for the recipients, compared to L-HALDN.

Inferior Long-Term Graft Survival of Suboptimal Kidneys After Living Donor Kidney Transplantation

BACKGROUND

In living donors, if both kidneys are considered to be of equal quality, the side with favorable anatomy for transplant is usually selected. A "suboptimal kidney" is a kidney that has a significant abnormality and is chosen to maintain the principle of leaving the better kidney with the donor. We hypothesized that the long-term outcome of suboptimal kidney is inferior to that of the normal kidney.

METHODS

In a retrospective analysis of 1744 living donor kidney transplantations performed between 1999 and 2015 at our institution, 172 allografts were considered as a suboptimal kidney (9.9%). Median length of follow-up after living donor kidney transplantation was 59.5 months (interquartile range 26.3-100.8). This study strictly complied with the Helsinki Congress and the Istanbul Declaration regarding donor source.

RESULTS

The reasons for suboptimal kidneys were cysts or tumors (46.5%), arterial abnormalities (22.7%), inferior size or function (19.8%), and anatomic abnormalities (11.0%). Suboptimal kidneys showed worse long-term overall graft survival regardless of the reasons (5-year: control vs suboptimal kidney; 88.9% vs 79.3%, P = .001 and 10-year: 73.6% vs 63.5%, P = .004). Suboptimal kidneys showed a 1.6-fold higher adjusted hazard ratio (aHR) of all-cause graft loss (95% confidence interval [CI]: 1.1-2.5, P = .025) and had the same impact as older donor age (≥ 54 years old, aHR: 1.6, 95% CI: 1.1-2.4, P = .008).

CONCLUSIONS

The impact of suboptimal kidney should be factored into the donor selection process.

Outcomes From Right Versus Left Deceased-Donor Kidney Transplants: A US National Cohort Study

RATIONALE & OBJECTIVE

There may be important transplant-related differences between right and left kidneys, including logistical/surgical considerations about vessel length for the right compared to the left kidney from the same donor. Because US centers choose between the right and left kidney when their recipient is ranked higher on a "match-run," we sought to determine whether deceased-donor right kidneys have had worse posttransplantation outcomes than left kidneys.

STUDY DESIGN

Paired Organ Procurement and Transplantation Network analysis.

SETTING & PARTICIPANTS

Deceased-donor kidney pairs transplanted during 1990 to 2016.

EXPOSURE

Right versus left kidney controlling for other significant factors.

OUTCOMES

Delayed graft function (DGF), all-cause and death-censored graft failure, and mortality.

ANALYTICAL APPROACH

Multivariable conditional logistic regression for DGF; proportional hazards models (conditional on same donor) for failure/mortality with right kidneys (operationalized as 6-month time-varying coefficients) adjusting for DGF and other confounders.

RESULTS

87,112 recipient pairs shared the following donor characteristics: mean age of 41 ± 14 years, 60% males, and 11% with cardiac death. Recipient characteristics were numerically similar by donor kidney side but with some statistical differences given the sample size. Right kidneys had slightly longer cold ischemia time. DGF occurred more often for right kidneys (28% vs 25.8%; P < 0.001; adjusted OR, 1.15 [95% CI, 1.12-1.17]). The adjusted hazard ratio (aHR) for all-cause graft failure with right kidneys within 6 months was 1.07 (95% CI, 1.03-1.11), and was 0.99 (95% CI, 0.97-1.01) thereafter. The aHRs for death-censored graft failure with right kidneys before and after 6 months were 1.11 (95% CI, 1.06-1.16) and 0.96 (95% CI, 0.93-0.99), respectively; the corresonding aHRs for mortality were 0.99 (95% CI, 0.93-1.04) and 1.00 (95% CI, 0.98-1.03), respectively.

LIMITATIONS

Registry data, different transplant eras, reasons for kidney side unavailable.

CONCLUSIONS

There is modest association for transplantation of right kidneys with DGF and graft loss within the first 6 months, which is lost beyond this time point. These findings do not support the use of laterality of deceased-donor kidneys as an important factor in organ acceptance decisions.

Hand-assisted laparoscopic nephrectomy in a high risk overweight donor with left-sided IVC, and previous abdominal surgery

•

Surgical planning based on preoperative CTA is necessary in patients with vascular anomalies in order to avoid complications.

•

Intrabdominal adhesions are common in patients with previous abdominal surgery and can affect the surgical approach for donor nephrectomy.

•

Considering the extension of the donor eligibility criteria, it is expected to see cases with congenital vascular anomalies.

Introduction

The extension of donor eligibility criteria represents one of the possible ways to increase the organ shortage, thus decreasing the waiting time for kidney transplantation. Expectedly, this strategy is associated with a growing number of more technically demanding living donor nephrectomy procedures requiring careful assessment, and sound surgical experience in order to avoid intraoperative complications.

Case presentation

After a thorough evaluation through preoperative imaging, we performed a hand-assisted left laparoscopic living donor nephrectomy in a 56 year-old overweight patient with history of prior abdominal surgery, harboring a left-sided inferior vena cava (IVC).

Discussion/conclusion

This case describes our comprehensive approach in this complex surgical scenario to preserve donor safety and provide an optimal kidney graft.

Predicting urine output after kidney transplantation: development and internal validation of a nomogram for clinical use

Purpose:

To analyze pre-transplantation and early postoperative factors affecting post-transplantation urine output and develop a predictive nomogram.

Patients and Methods:

Retrospective analysis of non-preemptive first transplanted adult patients between 2001-2016. The outcomes were hourly diuresis in mL/Kg in the 1^st (UO₁) and 8^th (UO₈) postoperative days (POD). Predictors for both UO₁ and UO₈ were cold ischemia time (CIT), patient and donor age and sex, HLA I and II compatibility, pre-transplantation duration of renal replacement therapy (RRT), cause of ESRD (ESRD) and immunosuppressive regimen. UO₈ predictors also included UO₁, 1^st/0^th POD plasma creatinine concentration ratio (Cr_1/0), and occurrence of acute cellular rejection (AR). Multivariable linear regression was employed to produce nomograms for UO₁ and UO₈.

Results:

Four hundred and seventy-three patients were included, mostly deceased donor kidneys’ recipients (361, 70.4%). CIT inversely correlated with UO₁ and UO₈ (Spearman's p=-0.43 and −0.37). CR_1/0 inversely correlated with UO₈ (p=-0.47). On multivariable analysis UO₁ was mainly influenced by CIT, with additional influences of donor age and sex, HLA II matching and ESRD. UO₁ was the strongest predictor of UO₈, with significant influences of AR and ESRD.

Conclusions:

The predominant influence of CIT on UO₁ rapidly wanes and is replaced by indicators of functional recovery (mainly UO₁) and allograft's immunologic acceptance (AR absence). Mean absolute errors for nomograms were 0.08 mL/Kg h (UO₁) and 0.05 mL/Kg h (UO₈).

Mini-incision Living Donor Nephrectomy and Trans-peritoneal Laparoscopic Nephrectomy: Will There Be a Place for New Evidence?

OBJECTIVES

To compare mini-incision donor nephrectomy (MDN) with laparoscopic donor nephrectomy (LDN) performed by the same surgical team, regarding short- and long-term outcomes.

METHODS

Three hundred and five patients, who underwent donor nephrectomy in our institution, through an MDN (n = 141) between January 1998-November 2011 and LDN (n = 164) since June 2010-December 2017, were compared.

RESULTS

The mean operative time for MDN (120 ± 29 minutes) was not significantly different when compared to LDN (113 ± 34 minutes), but when comparing the first 50 LDN and the 50 most recent, we found a reduction in the duration of the procedure. Laparoscopic donors had a shorter warm ischemia time (229 seconds vs 310 seconds, P = .01), particularly the 50 most recent, hospital stay (4.3 days vs 5.9 days, P < .001), and postoperative complications (P = .03). The incidence of graft acute tubular necrosis (ATN) was superior in the MDN (89% vs 25%, P < .001), although there was no significant difference regarding first-year serum creatinine (SCr) and glomerular filtration rate (GFR) (SCr 1.38 mg/dL vs SCr 1.33 mg/dL and GFR 63.7 mL/min vs 63.1 mL/min) comparing the 2 groups. Long-term graft survival did not significantly differ between groups. There was also no relationship between postoperative ATN events and long-term graft function.

CONCLUSIONS

With the growing experience of the high-volume centers and with specialized teams, LDN could be considered the most suitable technique for living donor nephrectomy with better results in short-term results (warm ischemia time, hospital stay, and postoperative complications), without difference in long-term outcomes.

Correlation and Prediction of Living-Donor Remaining Function by Using Predonation Computed Tomography-Based Volumetric Measurements: Role of Remaining Kidney Volume

OBJECTIVES

Kidney volume in healthy living donors may serve as a surrogate marker of renal function. Here, we evaluated whether preserved kidney volume correlated with and could predict donor renal function at 2 years postdonation using the CKD-EPI estimated glomerular filtration rate equation.

MATERIALS AND METHODS

Healthy living donors (n = 208) with computed tomography volume measurements were evaluated for renal function before and after donation. Preserved kidney volume was adjusted to body surface area. Demographic characteristics (including race/ethnicity and sex) and renal function variables of donors were analyzed for postdonation renal function.

RESULTS

Donor mean age was 39.4 ± 10.7 years (36.2% males, 91.9% white). Median adjusted preserved kidney volume was 180.6 mL. At 2 years postdonation, median estimated glomerular filtration rate was 62.4 mL/min (interquartile range, 54.8-73.2 mL/min). Predonation estimated glomerular filtration rate, age, and adjusted preserved kidney volume were found to be inde-pendent predictors of 2-year estimated glomerular filtration rate (P < .001). We further analyzed data by stratifying preserved kidney volumes into tertiles. Mean 2-year estimated glomerular filtration rates were 57.9 ± 12, 65 ± 16, and 73 ± 17 mL/min for lowest to highest tertile groups, respectively (P < .05). The odds ratio of having a 2-year postdonation estimated glomerular filtration rate of < 60 mL/min for donors in the lowest tertile group was 3.51 (95% confidence interval, 1.9-6.4; P < .001), whereas the risk for donors in the highest tertile group was 0.23 (95% confidence interval, 0.12-0.44; P< .001). Sensitivity analysis result was 0.764 (95% confidence interval, 0.69-0.82; P = .005) for adjusted preserved kidney volume and estimated glomerular filtration rate of < 60 mL/min.

CONCLUSIONS

Remaining kidney volume before donation correlated with and predicted estimated glomerular filtration rate after donation. Remaining kidney volume should be assessed when selecting kidneys from healthy donors.

Which One Is the Best for Living Donation: A Multiple-Artery Left Kidney Nephrectomy or a Right Kidney Nephrectomy?

INTRODUCTION

The current approach in living-donor kidney transplant is to preserve the best kidney for the donor and harvest the contralateral one. Due to a shorter renal vein and a greater incidence of venous thrombosis, left kidneys are more frequently elected. Notwithstanding, arterial anatomy may be complex and thus render the transplantation procedure more difficult and prone to complications.

OBJECTIVES

To analyze the outcomes after multiple-artery left kidney nephrectomy (MALKN) and right kidney nephrectomy (RKN).

RESULTS

Seventy-three cases were performed from 1999 to 2017 in our institution: 34 MALKN and 39 RKN. The mean operative time was significantly longer in MALKN. Warm ischemia time, donor and receptor hospital stay, and postoperative complications did not differ between groups. There was a positive correlation between renal arteries' ostia distance in MALKN and the duration of warm ischemia period. There was no significant difference in the incidence of acute tubular necrosis, first-year variations in serum creatinine, and glomerular filtration rate between groups. Long-term graft survival did not significantly differ between groups. Three cases of vein thrombosis after RKN were reported with graft loss.

CONCLUSION

The safety and efficacy of MALKN does not differ from RKN, although there appears to be a higher incidence of vein thrombosis after right kidney transplantation. Despite being technically more demanding, particularly in cases with distant artery ostia, MALKN could be a better option than RKN for living donation, expanding the available donor pool, although more studies are needed to affirm this conclusion.

Silvinato A, Bernardo WM, Santos LS. Living donor nephrectomy

OBJECTIVE

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors.

CONCLUSIONS

The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Open Management of the Renal Vein Is a Safe Modification in Right-Sided Laparoscopic Living Donor Nephrectomy to Maximize Graft Vein Length

BACKGROUND

The primary objective in living donor kidney transplantation is donor safety. In laparoscopic living donor nephrectomy, most centers prefer the left kidney for donation given the shorter renal vein, higher rate of thromboses, and more difficult surgical procedure for right kidney retrieval. The goal of this study was to demonstrate the feasibility of a hybrid technique using a Satinsky clamp in right-sided living donor nephrectomy to obtain maximal renal vein and to compare the outcome with standard left-sided laparoscopic donor nephrectomies.

MATERIAL AND METHODS

Between 2005 and 2013, 77 patients underwent a left (group L) and 54 a right (group R) living donor nephrectomy. In group R, after laparoscopic dissection and mobilization of the right kidney, two 12-mm trocar incisions in the right upper quadrant were connected in a 5-7 cm subcostal incision. The caval vein was partially clamped under direct vision prior to dissection of the renal vein. The venotomy was then closed with a running 4-0 Prolene suture. The two groups were compared with regard to surgical complications, graft function, and graft survival.

RESULTS

Using this technique, no significant difference with regard to complications or graft function was observed. Serum creatinine at discharge in donor group L was 1.23 (±0.43) mg/dL and in donor group R 1.21 (±0.37) mg/dL (P = .71). Graft survival at one year was 100% in both groups.

CONCLUSION

Open management of the renal vein is a safe alternative in laparoscopic right-sided donor nephrectomy and ensures maximal length of the vein.

Implantation of Right Kidneys: Is the Risk of Technical Graft Loss Real?

BACKGROUND

The left kidney (LK) is preferred by transplant surgeons, because its vein is always of good length and has a thick wall that enables safe suturing. On the other hand, the right renal vein is generally shorter and thinner walled, and well known for its technical difficulty during venous anastomosis, and can result in graft loss. We examined our living (LD) and deceased donor (DD) recipient data and compared the incidence of technical graft loss and early graft function in right and left kidneys.

METHODS

A cohort of 58 adult and pediatric recipients received an LD or DD kidney between January 2015 and December 2016. The donor and recipient data were retrieved and retrospectively analyzed. Technical graft loss was defined as graft thrombosis within the 7 days after transplant.

RESULTS

Right kidneys (RKs) were not a risk factor for technical graft loss, and no graft was lost for technical reasons in either LD or DD transplants. Early graft function in LK and RKs was also comparable in the LD cohort, and there were no LKs in the DD cohort.

CONCLUSION

Based on our data, the use of RKs was not a risk factor for technical graft loss and early graft function was comparable to LKs.

KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.

Prediction, prevention, and management of delayed graft function: where are we now?

Delayed graft function (DGF) remains a major barrier to improved outcomes after kidney transplantation. High-risk transplant recipients can be identified, but no definitive prediction model exists. Novel biomarkers to predict DGF in the first hours post-transplant, such as neutrophil gelatinase-associated lipocalin (NGAL), are under investigation. Donor management to minimize the profound physiological consequences of brain death is highly complex. A hormonal resuscitation package to manage the catecholamine "storm" that follows brain death is recommended. Donor pretreatment with dopamine prior to procurement lowers the rate of DGF. Hypothermic machine perfusion may offer a significant reduction in the rate of DGF vs simple cold storage, but costs need to be evaluated. Surgically, reducing warm ischemia time may be advantageous. Research into recipient preconditioning options has so far not generated clinically helpful interventions. Diagnostic criteria for DGF vary, but requirement for dialysis and/or persistent high serum creatinine is likely to remain key to diagnosis until current work on early biomarkers has progressed further. Management centers on close monitoring of graft (non)function and physiological parameters. With so many unanswered questions, substantial reductions in the toll of DGF in the near future seem unlikely but concentrated research on many levels offers long-term promise.