Older living donors provide excellent quality kidneys: a single center experience (older living donors)

BACKGROUND: The role of advanced age live donors remains controversial because of decline in glomerular filtration rate and perceived increased risks of perioperative complications. METHODS: A retrospective review of all live donor transplants performed from January 2000 to December 2003. RESULTS: Seventy-eight live donor transplants were performed during the period of review, 47 (60.3%) female and 31 (39.7%) male. Twenty-two (28.2%) of the donors were >50 yr old, 15 (68%) female and seven (32%) male. Living related donation was performed in 56 (74.4%) and unrelated in 20 (35.6%). Laparoscopic nephrectomy was performed in 29 (37.2%) and open nephrectomy in 49 (62.8%). More donors >50 underwent laparoscopic nephrectomy, 13 of 22 (59.1%) vs. 16 of 56 (28.6%). Overall patient and graft survival at 1 yr are 97 and 97%. One-year patient and graft survival is 100% vs. 96% and 100% vs. 96% in the older vs. young donors. Rejection occurred in nine of 78 (11.5%), but was not different between groups. Older donors had a reduced creatinine clearance 107.5 +/- 3.4 vs. 124.2 +/- 3.1 mL/min (p = 0.002) and a reduced clearance normalized for body surface area 60.6 +/- 3.6 mL/(min m2) vs. 70.2 +/- 2.6 mL/(min m2) (p = 0.045). Recipient serum creatinine was higher on postoperative day 1 in the older donor group 5.4 mg/dL vs. 4.4 mg/dL (p = 0.009). There was no difference in recipient serum creatinine at postoperative day 7, 30, 90, 180, 365 and 730. Donor serum creatinine was not different between groups on postoperative days 1, 7 and 30 but was higher in group 1 vs. group 2 on postoperative day 365, 1.26 +/- 0.26 mg/dL vs. 1.01 +/- 0.18 mg/dL (p = 0.020). CONCLUSIONS: Despite a reduced initial creatinine clearance, renal function is comparable in recipients of both young and old donor kidneys. Older donors had a slightly reduced serum creatinine 1 yr post-donation that warrants additional follow-up to determine if the observations continue. The introduction of laparoscopic nephrectomy may provide additional incentive for older donors to present for live donor nephrectomy.     

Similar long-term outcomes for laparoscopic versus open live-donor nephrectomy kidney grafts: an OPTN database analysis of 5532 adult recipients

Prior studies that included both adult and pediatric recipients suggested slower early graft function for laparoscopically (vs. openly) procured live donor kidney grafts (LD-Ktxs). Any potential long-term impact, however, remains unknown. We compared long-term outcomes of 2685 (49%) laparoscopic vs. 2847 (51%) open LD-Ktxs reported to the Organ Procurement and Transplantation Network performed in adult (> or =18 yrs) recipients between November 1999 and December 2000, with follow-up to February 2006. Acute and chronic rejection accounted for 152 laparoscopic (51%) vs. 148 (46%) open graft losses (P=NS). At discharge and at 5 years, graft function was similar for both groups; graft survival at 5 years was 79% (laparoscopic) vs. 80% (open) (P=NS). We conclude that despite prior reports of slower early laparoscopic LD-Ktx function, both laparoscopic and open nephrectomy are equally effective for procurement of kidneys for adult recipients with regard to short- and long-term (>5 years) function and survival. Future studies must investigate whether these findings apply also to pediatric LD-Ktx recipients.     

Laparoscopic Live Donor Nephrectomy: A Risk Factor for Delayed Function and Rejection in Pediatric Kidney Recipients? A UNOS Analysis

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

Learning laparoscopic donor nephrectomy safely: a report on 100 cases

HYPOTHESIS: There is concern that learning laparoscopic live donor nephrectomy (LLDN) is associated with increased morbidity. We propose that with a team approach LLDN can be learned safely, without increased donor morbidity or graft failure, even during the early portion of a learning curve. DESIGN: Case series with cohort comparison. SETTING: Tertiary referral center. PATIENTS: The laparoscopic group consisted of 100 donors and 100 recipients; the open group, 50 donors and 50 recipients. INTERVENTIONS: A team approach that combines laparoscopic and urologic expertise was used to perform 100 cases of LLDN. MAIN OUTCOME MEASURES: Donor morbidity and graft function in the laparoscopic group were compared with those in the open group. RESULTS: Laparoscopic live donor nephrectomy was completed in 99 patients. One patient required conversion to open donor nephrectomy because of intraoperative hemorrhage. Minor complications occurred in 6 laparoscopic group donors (6%) and 3 open group donors (6%). Laparoscopic and open group donors were of similar age. Operative times were longer for laparoscopic group donors (231 vs 209 minutes). Mean hospital stay was shorter for laparoscopic group donors (3.3 vs 4.7 days). Graft function was comparable between the laparoscopic and open groups, with equivalent postoperative creatinine levels. Graft survival was comparable. Recipient ureteral complications occurred with less frequency (2% vs 6%) in the laparoscopic group. CONCLUSIONS: By forming an operative team that combines expertise in laparoscopy with expertise in live donor nephrectomy, surgeons can learn LLDN safely. Adoption of the techniques developed by those who pioneered the procedure can further minimize the morbidity associated with a learning curve.     

Early and late recipient graft function and donor outcome after laparoscopic vs open adult live donor nephrectomy for pediatric renal transplantation

BACKGROUND: Laparoscopically procured live donor kidney grafts are increasingly transplanted into pediatric recipients. The safety and efficacy of this changed surgical practice are unknown. HYPOTHESIS: Outcomes of laparoscopic vs open donor grafts in recipients 18 years and younger are equivalent. DESIGN AND SETTING: Retrospective review at an academic tertiary care referral center. PATIENTS: Eleven consecutive pediatric recipients of laparoscopically procured kidneys between April 1, 1997, and December 31, 2001, were pair matched for age with 11 recipients of openly procured kidneys between December 1, 1991, and March 31, 1997; the 22 adult donors were also studied. MAIN OUTCOME MEASURES: Recipients: surgical complications, graft function and survival. Donors: perioperative morbidity and length of hospital stay. RESULTS: Twenty (91%) of 22 kidneys were donated by a parent of the recipient. In recipients of laparoscopically procured grafts, we observed significantly lower creatinine clearances and higher creatinine levels on days 1, 4, and 6, but by 1 month, graft function was similar in both groups. No significant differences in surgical complications, delayed function, acute and chronic rejection, and graft survival rates were found. No laparoscopic or open donor required blood transfusion, reoperation, or hospital readmission. One laparoscopic donor (9%) was converted to open nephrectomy. For laparoscopic vs open donors, median operative time was longer (difference, 67 min; P =.08), but median postoperative length of stay was significantly shorter (3 vs 5 days; P =.02). CONCLUSIONS: Laparoscopic live donor nephrectomy has no adverse impact on pediatric recipient outcomes. For donors, the laparoscopic operation is safe and the hospital stay is shortened. These results support the continued use of laparoscopically procured live donor kidneys in pediatric renal transplantation.     

Increased transplantation of kidneys with multiple renal arteries in the laparoscopic live donor nephrectomy era: surgical technique and surgical and nonsurgical donor and recipient outcomes

BACKGROUND: For anatomical and technical reasons, many transplant centers restrict laparoscopic live donor nephrectomy (in contrast with open live donor nephrectomy) to left kidneys. HYPOTHESIS: This change in surgical practice increases procurement and transplantation rates of live donor kidneys with multiple renal arteries (RAs), without affecting donor and recipient outcomes. DESIGN AND SETTING: Retrospective review at an academic tertiary care referral center comparing laparoscopically procured single vs multiple-RA kidney grafts (April 1997 to October 2000). PATIENTS: Seventy-nine consecutive left laparoscopic live kidney donors and 78 transplant recipients. MAIN OUTCOME MEASURES: Donor and recipient complications and postoperative length of stay; cold and warm ischemia time; operating time; short-term and long-term graft function; and survival. RESULTS: We noted multiple RAs in 21 (27%) of all kidneys. The proportion of donors with 1 or more perioperative complications was 19% in the single-RA group vs 10% in the multiple-RA group (P was not significant). For the recipients, we noted no significant differences between groups with respect to surgical complications, quality of early and late graft function, rejection rates, graft losses (all immunologic), and graft survival. Cold and warm ischemia time and length of stay were similar for donors and recipients in both groups. Median operating times were significantly longer for the multiple-RA vs single-RA group (difference, 41 minutes for donors and 45 minutes for recipients; P<.02). CONCLUSIONS: While the introduction of laparoscopic live donor nephrectomy has significantly increased the number of grafts with multiple RAs (compared with historical open controls), this change in practice is safe for both donors and recipients from a patient outcome-based perspective. However, from an economic perspective, the longer operating time associated with multiple-RA grafts provides strong added rationale for optimization of surgical instruments and techniques to make right-sided laparoscopic nephrectomy a routine intervention.     

Laparoscopic donor nephrectomy: effects of learning curve on surgical outcomes

Our objective was to determine the effect of an experienced laparoscopic surgeon's learning curve with laparoscopic donor nephrectomy (LDN) on patient outcome and graft function. MATERIALS AND METHODS: Retrospective review of the medical records of the initial 73 consecutive LDN patients and corresponding transplant recipients was performed. All of the LDN were performed by a single, experienced laparoscopic surgeon (C.P.S.). The method of LDN was slightly different between the groups. RESULTS: Patients were divided into early and late groups with 37 and 36 patients, respectively. There was no statistically significant difference in mean estimated blood loss (245 +/- 671.2 vs 84.7 +/- 63.9 mL), warm ischemia time (159.7 +/- 66.3 vs 150.8 +/- 63.0 seconds), postoperative creatinine levels (1.34 +/- 0.24 vs 1.29 +/- 0.26 mg/dL,), recipient mean creatinine level at 1 month (1.57 +/- .98 vs 1.53 +/- 0.46 mg/dL), and hospital stay (2.49 +/- 0.87 vs 2.47 +/- 0.56 days) between the early and late groups. However, the difference in mean operative time between early and late groups was statistically significant (255.2 +/- 42.4 vs. 209.1 +/- 30.8 minutes, P < .05). In addition, there were 8 (21.6%) vs 4 (11.1%) instances of slow graft function and 3 (8.1%) vs 0 instances of delayed graft function among the recipients in early group versus the late group. There were four (10.8%) vs two (5.6%) minor complications among donors of the early and late groups, respectively. CONCLUSION: There is a significant decrease in operating time and incidence of delayed graft function following the first 37 patients who underwent LDN by an experienced laparoscopist. Improvement in operative technique decreased operative time and improved perioperative graft function as evidenced by decreased slow graft function and delayed graft function in the late group.     

Hand-Assisted Laparoscopic Living-Donor Nephrectomy as an Alternative to Traditional Laparoscopic Living-Donor Nephrectomy

The benefits of laparoscopic living-donor nephrectomy (LDN) are well described, while similar data on hand-assisted laparoscopic living-donor nephrectomy (HALDN) are lacking. We compare hand-assisted laparoscopic living-donor nephrectomy with open donor nephrectomy. One hundred consecutive hand-assisted laparoscopic living-donor nephrectomy (10/98-8/01) donor/recipient pairs were compared to 50 open donor nephrectomy pairs (8/97-1/00). Mean donor weights were similar (179.6 +/- 40.8 vs. 167.4 +/- 30.3 lb; p = NS), while donor age was greater among hand-assisted laparoscopic living-donor nephrectomy (38.2 +/- 9.5 vs. 31.2 +/- 7.8 year; p < 0.01). Right nephrectomies was fewer in hand-assisted laparoscopic living-donor nephrectomy [17/100 (17%) vs. 22/50 (44%); p < 0.05]. Operative time for hand-assisted laparoscopic living-donor nephrectomy (3.9 +/- 0.7 vs. 2.9 +/- 0.5 h; p < 0.01) was longer; however, return to diet (6.9 +/- 2.8 vs. 25.6 +/- 6.1 h; p < 0.01), narcotics requirement (17.9 +/- 6.3 vs. 56.3 +/- 6.4h; p < 0.01) and length of stay (51.7 +/- 22.2 vs. 129.6 +/- 65.7 h; p < 0.01) were less than open donor nephrectomy. Costs were similar ($11072 vs. 10840). Graft function and 1-week Cr of 1.4 +/- 0.9 vs. 1.6 +/- 1.1 g/dL (p = NS) were similar. With the introduction of HALDN, our laparoscopic living-donor nephrectomy program has increased by 20%. Thus, similar to traditional laparoscopic donor nephrectomy, hand-assisted laparoscopic living-donor nephrectomy provides advantages over open donor nephrectomy without increasing costs.     

Comparison of laparoscopic and open donor nephrectomy: UK experience

A comparison of laparoscopic and open donor nephrectomy is presented by authors from the UK. They found that the laparoscopic approach could safely be offered to patients treated in experienced units and after adequate training fo the surgeon, with no increase in complications or decrease in efficacy. OBJECTIVE: To compare our early experience of laparoscopic donor nephrectomy (LDN) with a contemporary cohort of conventional open donor nephrectomy (ODN). PATIENTS AND METHODS: Transperitoneal left-sided LDN was offered to carefully selected potential live kidney donors on the basis of vascular anatomy. The first 20 donors who underwent LDN were compared with a control group of 20 patients who had ODN. Donors and recipients were compared for demographics, intraoperative variables, postoperative complications and allograft function. RESULTS: There was no peri-operative mortality in either group. No laparoscopic procedure required open conversion. The operating time was comparable (165 vs 153 min); LDN was associated with significantly less intraoperative blood loss (200 vs 350 mL; Mann-Whitney U, P = 0.01) and hospital stay (3 vs 5 days; P < 0.001). The graft warm ischaemic time was significantly longer for LDN (5 vs 2 min; P < 0.001) but this did not appear to affect either the delayed graft function rate (5% vs 10%, not significant) or serum creatinine level at discharge (125 vs 126 micromol/L). CONCLUSIONS: UK centres with experience of advanced laparoscopy and ODN can safely offer LDN to potential live donors.     

Comparison of graft survival in live donor nephrectomy: hand-assisted laparoscopic v open procedures

PURPOSE: Laparoscopic donor nephrectomy is associated with decreased morbidity while maintaining similar graft function in short-term follow-up compared with open surgery. We investigated hand-assisted laparoscopic donor nephrectomy (HALDN) in comparison with standard open donor nephrectomy (ODN) in living donors. PATIENTS AND METHODS: Two hundred patients who received a living-donor kidney and were followed up for more than 1 year were enrolled. The procedure was performed exclusively on the left kidney through either HALDN or ODN from January 2001 to July 2004. The probability of graft survival was determined using the Kaplan-Meier method. Multivariate analysis using a Cox regression hazard model was performed to identify the predictors of graft survival. RESULTS: The mean operative time, estimated blood loss, warm ischemic time, and operation-related complications were compared. There was no difference in graft function. The cumulative graft survival at 1 and 3 years was similar in the two groups: 98% and 97%. Episodes of acute rejection were an independent predictor of graft survival. CONCLUSIONS: Hand-assisted laparoscopic nephrectomy in living donors is safe and effective with results similar to those of open nephrectomy with regard to graft function.     

Superior Long-Term Results of Simultaneous Pancreas–Kidney Transplantation from Pediatric Donors

The shortage of cadaveric donors for simultaneous pancreas-kidney transplantation has prompted the use of cadaveric organs from pediatric donors. The long-term outcome and its impact on overall long-term survival are unknown. A total of 680 recipients receiving cadaver Simultaneous pancreas-kidney (SPK) transplantation from pediatric and adult donors between July 1986 and September 2001 were analyzed and compared. Ten-year kidney and pancreas graft survival for SPK transplantation from donors aged <18 years (n = 142) were 80% and 72%, respectively, compared to 61% pancreas and kidney graft survival from donors > or =18 years of age (n = 538; p = 0.03 and 0.05, respectively). Five years post-transplant, blood glucose, HbA1c and creatinine clearance were significantly better in recipients from pediatric donors (85.3 +/- 13 mg/dL, 5.5 +/- 3.5% and 65.6 +/- 16 mL/min, respectively), compared to recipients from adult donors (95.1 +/- 29 mg/dL, 5.9 +/- 3.5% and 58.3 +/- 17 mL/min; p = 0.001, 0.01 and 0.002, respectively). Causes of graft failure for kidney and pancreas transplants were similar between the two groups. No statistically significant difference was observed in patient survival between recipients from pediatric donors compared to adult donors (85% vs. 76%, p = 0.29). When recipients of SPK from pediatric donors were stratified according to age (3-11 years and 12-17 years) and compared, no difference in kidney or pancreas graft survival was observed (kidney 76.4% vs. 81.3%, p = 0.15; pancreas 75% vs. 76%, p = 0.10, respectively). Pediatric donors represent a valuable source of organs, providing excellent short- and long-term outcomes. Wide utilization of pediatric organs will substantially increase the donor pool.     

Outcome of Kidney Transplantation With Transumbilical Laparoendoscopic Single-Site Donor Nephrectomy: A Single-Center Experience

AimThe aim of this study is to present the outcome of kidney transplantation after laparoendoscopic single-site donor nephrectomy (LESS DN) compared with conventional laparoscopic donor nephrectomy (LDN) in a single-center experience.MethodsThis retrospective study compares data from the initial experience with 110 consecutive LESS DN donors and their recipients (group A) with 205 consecutive conventional LDN donors and their recipients (group B).ResultsThis study compared 110 LESS DNs completed in an 18-month period with 205 LDNs completed in the immediately preceding 42-month period. All procedures were performed by the same surgeon. In groups A and B, respectively, the incidence of immediate graft function was 90% vs 91.2%, slow graft function was 9% vs 5.3%, delayed graft function was 0.9% vs 2.9%, graft loss was 0.9% vs 2.9%, and death with a functioning graft was 0.9% vs 1.5%. The mean serum creatinine levels were 1.3 ± 0.93 mg/dL vs 1.4 ± 1.2 mg/dL (P = .447), 1.1 ± 0.33 mg/dL vs 1.2 ± 0.75 mg/dL (P = .184), and 1.05 ± 0.25 mg/dL vs 1.1 ± 0.39 mg/dL (P = .224) at 7, 30, and 365 days after transplantation. The estimated glomerular filtration rate at 1 year was 88 ± 18.2 vs 83 ± 12.2 mL/min/1.73 m² (P = .004). The mean donor operative times in groups A and B were 175.9 ± 24.9 minutes vs 199.88 ± 37.06 minutes (P = .0001), respectively, and the mean warm ischemia time was 5.2 ± 1.02 minutes vs 3.64 ± 1.38 minutes, respectively (P = .0001). The mean body mass index, the incidence of complex vascular anatomy, and the rate of complications were the same in the 2 donor groups.ConclusionsThe outcome of kidney transplantation after LESS DN is comparable to conventional LDN. LESS DN can be employed as the primary approach for kidney donation with low donor risk and without compromising recipient outcomes.     

The Detrimental Effect of Poor Early Graft Function After Laparoscopic Live Donor Nephrectomy on Graft Outcomes

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

Hand-assisted laparoscopic donor nephrectomy is safe and results in increased kidney donation

The impact of hand-assisted laparoscopic donor nephrectomy on kidney allograft function, perioperative complications, and organ supply was evaluated by retrospective analysis of 41 hand-assisted laparoscopic donor nephrectomy patients and their recipients between January and October 2003. Serum creatinine at discharge, length of stay, estimated blood loss, operative time, and perioperative complications were analyzed. The mean values for laparoscopic donors and their recipients were 1.2 +/- 0.3 and 1.3 +/- 0.8 mg/dL for creatinine, 3.3 +/- 0.8 and 6.7 +/- 3 days for length of stay, and 110.4 +/- 76.9 and 111.6 +/- 56 mL for estimated blood loss, respectively. No major complications occurred in the laparoscopic donors. The number of living kidney donors increased by 94% compared to the mean of the previous 4 years following implementation of the laparoscopic program. Hand-assisted laparoscopic donor nephrectomy is safe, results in excellent allograft function, and significantly increases donation.     

Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry

PURPOSE: A review of the existing literature showed that the subject of live donor nephrectomy is a seat of underreporting and underestimation of complications. We provide a systematic comparison between laparoscopic and open live donor nephrectomy with special emphasis on the safety of donors and grafts. MATERIALS AND METHODS: The PubMed literature database was searched from inception to October 2006. A comparison was made between laparoscopic and open live donor nephrectomy regarding donor safety and graft efficacy. RESULTS: The review included 69 studies. There were 7 randomized controlled trials, 5 prospective nonrandomized studies, 22 retrospective controlled studies, 26 large (greater than 100 donors), retrospective, noncontrolled studies, 8 case reports and 1 experimental study. Most investigators concluded that, compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure. On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. In terms of donor safety at least 8 perioperative deaths were recorded after laparoscopic live donor nephrectomy. These perioperative deaths were not documented in recent review articles. Ten perioperative deaths were reported with open live donor nephrectomy by 1991. No perioperative mortalities have been recorded following open live donor nephrectomy since 1991. Regarding graft safety, at least 15 graft losses directly related to the surgical technique of laparoscopic live donor nephrectomy were found but none was emphasized in recent review articles. The incidence of graft loss due to technical reasons in the early reports of open live donor nephrectomy was not properly documented in the literature. CONCLUSIONS: We are in need of a live organ donor registry to determine the combined experience of complications and long-term outcomes, rather than short-term reports from single institutions. Like all other new techniques, laparoscopic live donor nephrectomy should be developed and improved at a few centers of excellence to avoid the loss of a donor or a graft.     

Comparison of Open and Retroperitonoscopic Donor Nephrectomy in Terms of Lipid and Protein Peroxidation Responses

Background

This study was designed to compare donors who underwent open (ODN) versus retroperitonoscopic nephrectomy (RDN) in terms of intra-operative oxidative stress and recipients graft function in the early postoperative period.

Methods

Among 40 patients who underwent donor nephrectomy, 23 were operated via an open method and 17 via retroperitonoscopic method. To analyze oxidative stress, we measured plasma levels of malondialdehyde (MDA), protein carbonyl, and protein sulfhydryl moieties in donor venous blood before induction of anesthesia and postoperatively at 0, 6, and 24 hours. The influence of oxidative stress on graft function was evaluated by means of the postoperative 5th day recipient creatinine and estimated glomerular filtration rate (eGFR) Modification of Diet in Renal Disease Formula (MDRD) to evaluate delayed graft function (DGF) status.

Results

ODN patients showed significantly higher 24-hour mean levels of MDA, (6,139 ± 1,854 vs 4,813 ± 1,771 nmol/L; P = .01), protein carbonyl (366 ± 64 vs 311 ± 62 μmol/L; P = .01) and protein sulfhydryl (468 ± 110 vs 386 ± 75 μmol/L; P = .01) moieties compared with those RDN patients. However, ODN and RDN recipients were similar in terms of 5th day mean creatinine and eGFR (1.1 ± 0.3 vs 1.4 ± 0.8 mg/dL and 69.15 ± 12.24 vs 56.31 ± 25.2, respectively) and DGF status (4.4% [1/23] vs 5.9% [1/17], respectively).

Conclusions

Although ODN donors were more prone to intra-operative oxidative stress than RDN donors, based on significantly higher levels of oxidative stress markers, this difference seems to not significantly influence recipients early graft function.     

Outcomes After Transplantation of Deceased-Donor Kidneys with Rising Serum Creatinine

The increasing number of candidates for kidney transplantation and relatively unchanged deceased-donor pool has led to expansion in the criteria for donor acceptability. Outcomes of kidneys from donors with progressively rising creatinine values have not been reported. Patients transplanted between September 2003 and August 2006 with kidneys from donors with peak creatinine levels >2.0 mg/dL were stratified into two groups based on the terminal creatinine and evaluated for outcome: (1) falling creatinine (FC)(n= 27), terminal creatinine at least 0.2mg/dL less than peak, and (2) rising creatinine (RC)(n=24), terminal creatinine = peak. The mean terminal creatinine was significantly higher in the RC group (3.2 +/- 1.3 mg/dL) compared to the FC group (1.9 +/- 0.9 mg/dL)(p<0.0001). Peak creatinine values were similar (RC, 3.2 +/- 1.3; FC, 3.1 +/- 1.3; p=0.6521) between the two groups. Rates of delayed graft function (RC, 24%; FC 32%; p=0.7881) and mean creatinine at follow-up (RC, 1.6 +/- 0.6, FC 1.6 +/- 0.4; p=0.3533) were not significantly different. With a mean follow-up of 287 +/- 274 days, allograft survival was 92% in the RC recipients and 89% in the FC recipients. Under certain conditions, kidneys from donors with rising serum creatinine can be used safely with reasonable early outcomes.     

Laparoscopic Versus Open Renal Procurement for Pediatric Recipients of Living Donor Renal Transplantation

Despite reports demonstrating the safety of laparoscopic donor nephrectomy (LDN) for pediatric recipients of renal transplants, recent evidence has challenged using LDN for recipients 5 years of age or younger. We retrospectively reviewed the records of all pediatric recipients of living donor renal transplants from September 2000 through August 2004. We compared those who received allografts recovered by LDN (n = 34) with those recovered by open donor nephrectomy (ODN, n = 26). Outcomes of interest included operative complications, postoperative renal function, the incidence of delayed graft function or episodes of acute rejection and long-term graft function. Donor and recipient demographic data were similar for the LDN and ODN groups. Serum creatinine and calculated creatinine clearance were not significantly different between groups both in the early postoperative period and at long-term follow-up (p > 0.142). Rates of delayed graft function and acute rejection did not differ between groups. Among recipients aged 5 years old or younger stratified by donor technique (9 LDN, 5 ODN recipients), no difference was noted in graft outcomes both early and long-term (p > 0.079). At our center, pediatric LDN recipients have graft outcomes comparable to those of ODN recipients. At experienced centers, we recommend continued use of LDN for pediatric recipients of all ages.     

Deceased donor kidney transplantation in autosomal dominant polycystic kidney disease: a single-center experience

Renal transplantation (RTx) has become the treatment of choice for end-stage renal disease (ESRD) in autosomal dominant polycystic kidney disease (ADPKD), the most common genetic kidney disease. Because of the inheritable nature of this disease, live related donors might be avoided due to the fear of future appearance of polycystic disease. This retrospective singlecenter study was undertaken to evaluate patient/graft survival function vis-a-vis serum creatinine (SCr), rejection episodes and mortality in ADPKD vs matched control patients. Between 2000 and 2009, 18 (7.4%) deceased donor renal transplant (DDRTx) were performed for ESRD due to ADPKD. Diagnosis of ADPKD was established by family history and ultrasound. An individualized approach was applied for the need of pre-transplant nephrectomy. All recipients received rabbit-anti-thymocyte globulin induction and maintenance triple immunosuppression. Delayed graft function was observed in 33% patients, and 16% had biopsy-proven acute rejection. Over mean follow-up of 4.67 ± 2.2 years, patient and graft survival rates were 72.22% and 83.33%, with mean SCr (mg/dL) of 1.44 ± 0.54, 1.78 ± 0.42 and 2.2 ± 0.6 at 1, 5 and 10 years. Overall, 44.4% (n-8) underwent pre-transplant nephrectomy. Infection and cardio/cerebrovascular events were the main causes of death. Patient, graft survival and acute rejection were similar between ADPKD and control group. DDRTx in ADPKD has acceptable patient and graft survival. Because of the inheritable nature of the disease, and unavailability of genetic linkage analysis as a routine, DDRTx is a viable option to avoid using unrelated donors.     

Hand-assisted laparoscopic nephrectomy in living donors

Hand-assisted laparoscopic nephrectomy (HLN) in living donors is a minimally invasive surgical modality that uses classic laparoscopic techniques either combined or not with the use of the surgeon's hand as a support tool during renal dissection maneuvers. The purpose of this study was to describe the initial experience with HLN technique in renal donors. Among 58 hand-assisted laparoscopic nephrectomies, the left kidney was removed in 39 donors (67%) and the right in 19 (33%). Surgery time ranged from 55 to 270 minutes (mean 156.9 +/- 49.5). Warm ischemia time ranged from 2 to 11 minutes (mean 4.38 +/- 2.31 min), with an estimated mean blood loss during the intraoperative period of 268 mL. Conversion to open surgery was required for four (6.8%) patients due to a vascular lesion. Upon graft evaluation, we observed immediate diuresis in 56 (96.3%) cases, with a mean serum creatinine on postoperative day 7 of 1.74 +/- 1.61 mg/dL. Renal vein thrombosis requiring graft removal occurred in one (1.7%) patient. Lymphocele was observed in three recipients (5.1%), and urinary leakage due to ureteral necrosis in three cases (5.1%). HLN for living donors is a safe procedure and an effective alternative to open nephrectomy. In this series, the procedure displayed low morbidity after surgery, providing a good morphological and functional quality of the graft for the recipient.