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

Hypertension and Kidney Function After Living Kidney Donation

Importance

Recent guidelines call for better evidence on health outcomes after living kidney donation.

Objective

To determine the risk of hypertension in normotensive adults who donated a kidney compared with nondonors of similar baseline health. Their rates of estimated glomerular filtration rate (eGFR) decline and risk of albuminuria were also compared.

Design, Setting, and Participants

Prospective cohort study of 924 standard-criteria living kidney donors enrolled before surgery and a concurrent sample of 396 nondonors. Recruitment occurred from 2004 to 2014 from 17 transplant centers (12 in Canada and 5 in Australia); follow-up occurred until November 2021. Donors and nondonors had the same annual schedule of follow-up assessments. Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics.

Exposure

Living kidney donation.

Main Outcomes and Measures

Hypertension (systolic blood pressure [SBP] ≥140 mm Hg, diastolic blood pressure [DBP] ≥90 mm Hg, or antihypertensive medication), annualized change in eGFR (starting 12 months after donation/simulated donation date in nondonors), and albuminuria (albumin to creatinine ratio ≥3 mg/mmol [≥30 mg/g]).

Results

Among the 924 donors, 66% were female; they had a mean age of 47 years and a mean eGFR of 100 mL/min/1.73 m2. Donors were more likely than nondonors to have a family history of kidney failure (464/922 [50%] vs 89/394 [23%], respectively). After statistical weighting, the sample of nondonors increased to 928 and baseline characteristics were similar between the 2 groups. During a median follow-up of 7.3 years (IQR, 6.0-9.0), in weighted analysis, hypertension occurred in 161 of 924 donors (17%) and 158 of 928 nondonors (17%) (weighted hazard ratio, 1.11 [95% CI, 0.75-1.66]). The longitudinal change in mean blood pressure was similar in donors and nondonors. After the initial drop in donors' eGFR after nephrectomy (mean, 32 mL/min/1.73 m2), donors had a 1.4-mL/min/1.73 m2 (95% CI, 1.2-1.5) per year lesser decline in eGFR than nondonors. However, more donors than nondonors had an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up (438/924 [47%] vs 49/928 [5%]). Albuminuria occurred in 132 of 905 donors (15%) and 95 of 904 nondonors (11%) (weighted hazard ratio, 1.46 [95% CI, 0.97-2.21]); the weighted between-group difference in the albumin to creatinine ratio was 1.02 (95% CI, 0.88-1.19).

Conclusions and Relevance

In this cohort study of living kidney donors and nondonors with the same follow-up schedule, the risks of hypertension and albuminuria were not significantly different. After the initial drop in eGFR from nephrectomy, donors had a slower mean rate of eGFR decline than nondonors but were more likely to have an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up.

Trial Registration

ClinicalTrials.gov Identifier: NCT00936078.

Analysis of sexual dysfunction development among male and female living kidney donors

INTRODUCTION

Living kidney donations (LKDs) face a persistent demand for patients with end-stage renal disease, emphasizing the importance of LKDs' growth and success. Although living kidney donors generally exhibit excellent survival rates, little research has explored the development of long-term sexual dysfunction following LKD.

OBJECTIVES

This study aimed to analyze differences in 5-year sexual dysfunction outcomes between male and female living kidney donors, utilizing the TriNetX database, a federated network of electronic medical records from multiple U.S. healthcare organizations.

METHODS

A propensity score-matched cohort study compared 45-year sexual dysfunction outcomes in adult male and female living kidney donors from December 2013 to December 2022. Cohorts were matched on age; sex; race and ethnicity; diabetes, cardiovascular, genitourinary, and psychiatric comorbidities; lifestyle-related factors; and medications that may impact normal sexual functioning. Primary outcomes included hazard ratio (HR) for decreased libido, sexual dysfunction (composite of male erectile dysfunction, ejaculatory disorders, vaginismus/dyspareunia, infertility, orgasmic disorders, arousal/desire disorders), and sexually transmitted diseases. Secondary outcomes assessed sex counseling and interpersonal relationship issues with spouses or partners.

RESULTS

The matched cohorts included 2315 patients each (male, female), and the mean age was 42.3 ± 12.5 years. At 5 years, male donors had a significantly higher HR for sexual dysfunction (HR, 3.768; 95% confidence interval, 1.929-7.358). Erectile dysfunction occurred in 1% of male patients, while vaginismus/dyspareunia affected <1% of female patients. Other sexual disorders, decreased libido, sexually transmitted diseases, and incidences of sexual and interspousal counseling were not significantly different.

CONCLUSION

Male living kidney donors faced a higher risk of developing sexual dysfunction 5 years after donation. While LKD remains a safe and viable alternative, clinicians and donors should be mindful of the potential association with sexual dysfunction postdonation. Further research may enhance support for the well-being of living kidney donors.

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.

A fair exchange: why living kidney donors in England should be financially compensated

Every year, hundreds of patients in England die whilst waiting for a kidney transplant, and this is evidence that the current system of altruistic-based donation is not sufficient to address the shortage of kidneys available for transplant. To address this problem, we propose a monopsony system whereby kidney donors can opt-in to receive financial compensation, whilst still preserving the right of individuals to donate without receiving any compensation. A monopsony system describes a market structure where there is only one 'buyer'-in this case the National Health Service. By doing so, several hundred lives could be saved each year in England, wait times for a kidney transplant could be significantly reduced, and it would lessen the burden on dialysis services. Furthermore, compensation would help alleviate the common disincentives to living kidney donation, such as its potential associated health and psychological costs, and it would also help to increase awareness of living kidney donation. The proposed system would also result in significant cost savings that could then be redirected towards preventing kidney disease and reducing health disparities. While concerns about exploitation, coercion, and the 'crowding out' of altruistic donors exist, we believe that careful implementation can mitigate these issues. Therefore, we recommend piloting financial compensation for living kidney donors at a transplant centre in England.

Study of the predictive factors affecting outcomes of patients undergoing transperitoneal laparoscopic donor nephrectomy

PURPOSE

We aim to study the preoperative and intraoperative factors and compare against specific outcomes in patients undergoing transperitoneal laparoscopic donor nephrectomy and see if we could find what were the predictive factors for these outcomes.

METHODS

This is a prospective cohort study done in a single high-volume transplant center. 153 kidney donors were evaluated over a period of 1 year. The preoperative factors such as age, gender, smoking status, obesity, visceral obesity, perinephric fat thickness, number of vessels, anatomic abnormalities, comorbidities, and side of kidney and intraoperative factors such as lay of colon on the kidney, height of splenic or hepatic flexure of colon, loaded or unloaded colon, and sticky mesenteric fat were compared against specific outcomes such as duration of surgery, duration of hospital stay, postoperative paralytic ileus, and postoperative wound complications.

RESULTS

Multivariate logistic regression models were used to study the variables of interest against the various outcomes. There were three positive risk factors for increased hospital stay, which were perinephric fat thickness and height of splenic or hepatic flexure of colon and smoking history. There was one positive risk factor for postoperative paralytic ileus which is lay of colon with relation to kidney and there was one positive risk factor for postoperative wound complication which was visceral fat area.

CONCLUSION

The predictive factors for adverse postoperative outcomes after transperitoneal laparoscopic donor nephrectomy were perinephric fat thickness, height of splenic or hepatic flexure, smoking status, lay or redundancy of colon with relation to kidney and visceral fat area.

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.

Complications After Hand-Assisted Laparoscopic Living Donor Nephrectomy

OBJECTIVE

To study the complications of hand-assisted laparoscopic living donor nephrectomy (HALLDN) with an emphasis on complications occurring early after hospital discharge up to 120 days after surgery.

PATIENTS AND METHODS

We retrospectively categorized complications using the Clavien-Dindo classification in 3002 HALLDNs performed at 1 center from January 1, 2000, through December 31, 2019. In addition to overall summaries, modeling was used to identify correlates of complications before and after living donation.

RESULTS

Of these donors, 87% were White, 59% were female, the mean age was 45 years (range, 18-77 years), 30.3% had a body mass index of at least 30, and 36.3% had previous abdominopelvic surgery. There were no deaths related to the surgery. The incidence of major complications (intraoperative complications plus Clavien-Dindo grade ≥III postoperatively) was 2.5% (n=74). The overall complication rate was 12.4% (n=371), including 15 intraoperative, 76 postoperative before discharge, and 280 after discharge to 120 days. Reoperation was required in 1.8% of patients (n=54), and all but 1 of these were incision-related problems. Seventy-six percent of all complications occurred after discharge, including 85% of the reoperations. For major complications, no risk factor was found. Risk factors for any complication included paramedian incision (hazard ratio [HR], 2.54; 95% CI, 1.49 to 4.34; P<.001); a history of abdominopelvic surgery (HR, 1.37; 95% CI, 1.07 to 1.76; P=.01), male sex (HR, 1.37; 95% CI, 1.07 to 1.76; P=.01), non-White race (HR, 1.40; 95% CI, 1.05 to 1.88; P=.02), and early era of the experience.

CONCLUSION

Most major complications of HALLDN occur after discharge, suggesting that close follow-up is warranted and that the current literature may underestimate the true incidence.

Safety and Intraoperative Results in Live Kidney Donors with Vascular Multiplicity After Hand-Assisted Laparoscopy Living Donor Nephrectomy

Background and Purpose

Vascular multiplicity is the most frequent anatomic variation in kidney donors. Despite concerns about risks, these allografts are increasingly used to overcome the shortage of kidney donors. The safety and clinical outcomes in living kidney donors were evaluated with vascular multiplicity after hand-assisted laparoscopic living donor nephrectomy (HALDN).

Patients and Methods

Data from all living kidney donors who underwent HALDN from 2008 to 2021 was retrospectively reviewed. Patients were divided into two groups as single (SRV) and multiple renal vessels (MRV), and a comparative analysis was done. The primary outcomes include operating room time (ORT), days of hospital stay, estimated blood loss, complications, conversion, and re-operations.

Results

MRV were present in 166 out of 612 donors (27.1%). Among those, 10 (1.6%) donors had simultaneous multiple arteries and veins. Additionally, the prevalence of artery and vein multiplicity was 21.8% (n = 134) and 3.5% (n = 22), respectively. Warm ischemia time was significantly different among the two groups but not clinically important. The number of conversions to open technique, the mean ORT, the median blood loss, and days of hospital stay were similar between the SRV and MRV groups, without significant differences. According to the modified Clavien-classification system, no differences were found in the complication rates between the two groups (p = 0.29). Complication rates were 3.3% and 3.6% for the SRV and MRV groups, respectively.

Conclusion

HALDN is a procedure with safe intraoperative results, even with vascular multiplicity. The presence of multiple renal arteries or veins has no negative impact on the outcome of the donor after living donor nephrectomy.

Impact of Perioperative Complications on Living Kidney Donor Health-Related Quality of Life and Mental Health: Results From a Prospective Cohort Study

Background:

Although living kidney donation is safe, some donors experience perioperative complications.

Objective:

This study explored how perioperative complications affected donor-reported health-related quality of life, depression, and anxiety.

Design:

This research was a conducted as a prospective cohort study.

Setting:

Twelve transplant centers across Canada.

Patients:

A total of 912 living kidney donors were included in this study.

Measurements:

Short Form 36 health survey, Beck Depression Inventory and Beck Anxiety Inventory.

Methods:

Living kidney donors were prospectively enrolled predonation between 2009 to 2014. Donor perioperative complications were graded using the Clavien-Dindo classification system. Mental and physical health-related quality of life was assessed with the 3 measurements; measurements were taken predonation and at 3- and 12-months postdonation.

Results:

Seventy-four donors (8%) experienced a perioperative complication; most were minor (n = 67 [91%]), and all minor complications resolved before hospital discharge. The presence (versus absence) of a perioperative complication was associated with lower mental health-related quality of life and higher depression symptoms 3-month postdonation; neither of these differences persisted at 12-month. Perioperative complications were not associated with any changes in physical health-related quality of life or anxiety 3-month postdonation.

Limitations:

Minor complications may have been missed and information on complications postdischarge were not collected. No minimal clinically significant change has been defined for kidney donors across the 3 measurements.

Conclusions:

These findings highlight a potential opportunity to better support the psychosocial needs of donors who experience perioperative complications in the months following donation.

Trial registration:

NCT00319579 and NCT00936078.

Experiencing one's own body and body image in living kidney donors-A sociological and psychological study

BACKGROUND

The aim of the study was to perform an in-depth exploratory analysis of the experience and image of one's body among living kidney donors.

METHOD

The research was carried out using mixed methodology. The study on experiencing one's own body was carried out using the sociological methodology of the grounded theory (qualitative research). This method was supplemented with psychometric measurement-the Body Esteem Scale (quantitative research). The basic research method was the in-depth interview. Using this method, a group of 25 living kidney donors who had not experienced any serious health or psychological problems after donation was examined. The participants of the study came from three transplant centers in Poland.

RESULTS

The data from the sociological interviews indicate that the donors: 1. do not experience radical changes in the functioning of their body; 2. maintain full control over it and do not feel the absence of a kidney in the body; 3. consciously and reflectively take care of their body after donation. In addition, the sociological research indicates that caring for one's own body also includes the transferred organ. The kidney donors experience a kind of bodily identity extension, including the recipient's body. However, the personal and social identity of the studied kidney donors is not disturbed in any way. The psychometric data correspond to the sociological results and indicate: 1. a lack of extreme emotional assessments about one's body; 2. awareness of one's own body and consistency of its image; 3. reduced emotional assessment of body zones directly related to the surgery; 4. differences in body image between the sexes.

CONCLUSIONS

The research results presented in the text indicate not only the possibility, but also the need for triangulation of research methods in the study of the experience and image of one's own body in living kidney donors. The proposed research approach employing mixed methodology within the fields of sociology and psychology for researching the phenomenon of living kidney donation is not very common.

The Evolution of Living Donor Nephrectomy Program at A Hellenic Transplant Center. Laparoscopic vs. Open Donor Nephrectomy: Single-Center Experience

Since its introduction in 1995, laparoscopic nephrectomy has emerged as the preferred surgical approach for living donor nephrectomy. Given the ubiquity of the surgical procedure and the need for favorable outcomes, as it is an elective operation on otherwise healthy individuals, it is imperative to ensure appropriate preoperative risk stratification and anticipate intraoperative challenges. The aim of the present study was to compare peri-and postoperative outcomes of living kidney donors (LD), who had undergone laparoscopic nephrectomy (LDN), with a control group of those who had undergone open nephrectomy (ODN). Health-related quality of life (QoL) was also assessed using the validated SF-36 questionnaire. Data from 252 LD from a single transplant center from March 2015 to December 2020 were analyzed retrospectively. In total, 117 donors in the LDN and 135 in the ODN groups were assessed. Demographics, type of transplantation, BMI, duration of surgery, length of hospital stay, peri- and postoperative complications, renal function at discharge and QoL were recorded and compared between the two groups using Stata 13.0 software. There was no difference in baseline characteristics, nor in the prevalence of peri-and postoperative complications, with a total complication rate of 16% (mostly minor, Clavien–Dindo grade II) in both groups, while a different pattern of surgical complications was noticed between them. Duration of surgery was significantly longer in the ODN group (median 240 min vs. 160 min in LDN, p < 0.01), warm ischemia time was longer in the LDN group (median 6 min vs.2 min in ODN, p < 0.01) and length of hospital stay shorter in the LDN group (median 3 days vs. 7 days in ODN). Conversion rate from laparoscopic to open surgery was 2.5%. There was a drop in estimated glomerular filtration rate (eGFR) at discharge of 36 mL/min in the LDN and 32 mL/min in the ODN groups, respectively (p = 0.03). No death, readmission or reoperation were recorded. There was a significant difference in favor of LDN group for each one of the eight items of the questionnaire (SF1–SF8). As for the two summary scores, while the total physical component summary (PCS) score was comparable between the two groups (57.87 in the LDN group and 57.07 in the ODN group), the mental component summary (MCS) score was significantly higher (62.14 vs. 45.22, p < 0.001) in the LDN group. This study provides evidence that minimally invasive surgery can be performed safely, with very good short-term outcomes, providing several benefits for the living kidney donor, thereby contributing to expanding the living donor pool, which is essential, especially in countries with deceased-donor organ shortage.