The influence of periarterial papaverine application on intraoperative renal function and blood flow during laparoscopic donor nephrectomy in a pig model

Background: The transplantation of live donor kidneys harvested laparoscopically is associated with a higher incidence of delayed graft function than the transplantation of grafts harvested via the open technique. The delay is believed to be due to a decrease in renal blood flow during laparoscopic donor nephrectomy (LDN). The aim of this study was to evaluate whether renal function and blood perfusion can be enhanced by the periarterial application of papaverine during LDN. Methods: Renal function and blood flow were studied in a porcine model that included a total of 24 pigs (20–30 kg). In 12 of the pigs, urine output and creatinine clearance were determined as measures of renal function. In the other 12 pigs, renal blood flow was determined using fluorescent-labeled microspheres. In each group, the pigs were randomized into two subgroups, one with and one without a perivascular injection of 50 mg papaverine. Results: As compared to the controls, the animals receiving papaverine had a significantly higher urine output (3.1 ± 1.6 vs 0.9 ± 0.45 ml/h/kg; p = 0.02), superior creatinine clearance (2.22 ± 0.5 vs 0.95 ± 0.1 ml/min/kg; p = 0.038), and enhanced renal blood flow (4.9 ± 2.2 vs 2.1 ± 0.8 ml/min/g; p = 0.008). Conclusions: When applied to the tissue surrounding the renal artery, papaverine substantially improves renal function and blood flow during laparoscopic live kidney donation. Whether graft optimization during kidney procurement also translates into improved posttransplantation function remains to be established. Presented at the 8th World Congress of Endoscopic Surgery, Society of American Gastrointestinal Endoscopic Surgeons (SAGES) meeting, New York, NY, USA, 13–16 March     

Periarterial application of papaverine during laparoscopic donor nephrectomy improves early graft function after kidney transplantation in pigs

Background: Laparoscopic donor nephrectomy (LDN) increases incentives to donation by subjects who might refuse an open operation. However, the incidence of delayed graft function is higher after LDN than after open operation. This may be caused by the reduction of renal perfusion as a result of the raised intraabdominal pressure and mechanically induced renal angiospasm during the operation. We conducted experiments to find out whether the application of papaverine around the renal artery during LDN could improve early graft function after transplantation. Methods: Renal function was studied in 10 male pigs (weight ~25 kg). The left kidney was harvested laparoscopically (intraabdominal pressure 8 mmHg). Five animals were randomly selected to have perivascular application of 50 mg papaverine (treatment group) before preparation of the vessels. In controls no papaverine was used. After LDN and open right nephrectomy the left kidney was autotransplanted. The main outcome measures were volume of urine produced and creatinine clearance during the first 20 h after the transplant. Results: The groups were comparable in respect of body weight, hemodynamic values, amount of infusions, warm and cold ischemia time, and duration of anastomosis. Urine output and creatinine clearance were significantly higher in pigs treated with papaverine than in controls. Conclusions: Papaverine substantially improved early graft function in pigs when applied around the renal artery during LDN. Whether this is applicable to procurement of human kidneys remains to be evaluated. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and IPEG, Los Angeles, CA, USA, 10–15 March 2003     

Living-unrelated kidney donation: a single-center experience

For 140 consecutive renal transplants performed from January 1995 to October 1997, 25 (18%) were from living-unrelated donors (15 women, 10 men, aged 25–63, mean 43 yr). All donors had pre-transplant imaging evaluation of renal anatomy following renal function assessment (minimal creatinine clearance 75 cm³/min). Admission to the hospital on the day of donation preceded nephrectomy under general anesthesia using an anterior flank, extra-retroperitoneal approach (no rib resection). Post-operative epidural pain control was used for all but 1 donor. The 25 kidney donors were hospitalized for 2 (n=1), 3 (n=12), 4 (n=7), or 5–8 d (n=5) (average 3.9 d) and had a mean hospitalization charge of $15 501 (range $10 808–$29 579). One intra-operative hemorrhage required transfusion; 1 late neural-related pain syndrome required outpatient wound exploration. Two kidneys were lost: a husband recipient from repetitive acute rejections at 3 months; a friend recipient from chronic rejection at 2.5 yr; both await cadaver transplant. The other 23 kidneys are functioning with a mean serum creatinine of 1.8 (range 1.0–3.3) at 3–36 months (patient survival 100%; graft survival 92%). While most donors were spouses (8 husbands and 10 wives), friends, distant cousins, in-laws, and adoptive relatives did well as donors and recipients. Transplantation may increase by 20% or more at centers which encourage broad application of living donor nephrectomy.     

Laparoscopic live donor right nephrectomy: a new technique to maximize the length of the renal vein using a modified Endo GIA stapler

OBJECTIVES: To report the utilization of a modified Endo GIA vascular stapler to obtain the full length of the renal vein during transperitoneal laparoscopic live donor right nephrectomy. METHODS: We used a modified Endo GIA stapler, in which the triple staggered rows of staples were removed from the kidney donor side to obtain the full length of the right renal vein. This technique has currently been used in nine consecutive transperitoneal laparoscopic right donor nephrectomies. RESULTS: With this technique, the entire right renal vein length was harvested in all cases, without vascular complications. Mean renal warm ischemia time from clamping of the renal vessels to cold perfusion was 135s, and mean receptor postoperative glomerular filtration rate after 30 d was 67.3 ml/min. There were no graft losses. CONCLUSIONS: A novel technique for laparoscopic live donor right nephrectomy is described. It allows harvesting the full length of the right renal vein in a safe and feasible way without compromising warm ischemia time.     

Living donor renal transplantation with incidental renal cell carcinoma from donor allograft

To report our series of cases with living donor kidney transplant by laparoscopic nephrectomy with incidental renal cell carcinomas (RCC) at the time of transplant. We performed a search of cases of renal allografts from living donors with incidental tumors which were confirmed as RCC in final pathology. The graft nephrectomy was performed via hand‐assisted laparoscopic procedure. All cases underwent partial nephrectomy of the tumor during the back‐table preparation of the graft and sent for pathological analysis. We performed 435 living donor kidney transplants at our Institution and identified four cases consistent with the diagnosis of RCC. Two of them were clear cell type, one papillary and one multilocular RCC. All the tumors presented at stage I of TNM classification. After a median follow‐up of 36 months, three patients remain free of dialysis with good allograft function. One noncompliant patient presented with a glomerular filtration rate (GFr) below 15 ml/min after a BK viral infection. At the end of follow‐up period, all patients had remained free of tumor. Donors with suspicious renal masses might be accepted for living donation. Partial nephrectomy before transplantation could offer a cure for the disease without risks for the recipient with therapeutic benefit for the donor.     

Right laparoscopic live donor nephrectomy: a single institution experience

BACKGROUND: Laparoscopic live donor nephrectomy (LLDN) is increasingly used by transplantation centers worldwide. As in open live donor nephrectomy, the left kidney is preferred for LLDN; however, not all potential donors have anatomy conducive to left nephrectomy. The purpose of our study, therefore, was to report on a large, single-institution experience with right LLDN performed using a hand-assisted, transperitoneal approach. METHODS: We performed a retrospective review of 40 consecutive patients who underwent transperitoneal right hand-assisted LLDN at our institution. Information on donor age, relation to recipient, and indication for right-sided donation was collected. Surgical demographics included operative time, warm ischemia time, and estimated blood loss. Recipients were followed for graft loss and for long-term renal allograft function. RESULTS: The indications for right-sided donor nephrectomy were a difference in split renal function of greater than 10%, multiple left renal vessels, and right renal cysts. The mean surgical time in our series was 115.8 min, with a mean estimated blood loss of 85.7 mL and a warm ischemia time of 116.0 seconds. Surgical and postoperative complications were limited. Mean serum creatinine levels in the recipients were 1.6 mg/dL on day 7, 1.4 mg/dL on day 30, and 1.4 mg/dL at 1 year after transplantation. CONCLUSIONS: Right LLDN using a hand-assisted, transperitoneal technique was performed with minimal morbidity and favorable graft function. We believe that offering hand-assisted LLDN to patients with an indication for right-sided donation can safely and effectively increase the pool of donor organs available to patients with end-stage renal disease.     

Estimated and Measured Donor Creatinine Clearance are Poor Predictors of Long-Term Renal Graft Function and Survival

The objective of this study was to evaluate estimated and measured donor renal function in predicting graft function long-term and to identify donor criteria associated with nonacceptable graft prognosis. In 200 consecutive cadaver donors creatinine clearance was measured at explantation and estimated using the Cockcroft formula on admission serum creatinine. Graft function was evaluated in recipients (n = 387) by 24-h creatinine clearance regularly during 3 years after transplantation. Measured creatinine clearance correlated to some extent with long-term graft function, while Cockcroft estimation was slightly superior and similar to using donor age only. Kidneys from donors with intra-operative creatinine clearance < or = 55 mL/min (median 50 mL/min) produced acceptable recipient graft function of 48 mL/min at 3 years and 76% 3-year graft survival. Donor age > or =60 years resulted in clearance at 3 years of 29 mL/min and 78% 3-year graft survival; adding the criteria of admission Cockcroft < or =60 mL/min, graft function at 3 years (28 mL/min) and 3-year graft survival (76%) were similar. In conclusion, creatinine-based estimates of the functional capacity of the donor kidney, calculated or intra-operatively measured, do little to improve the ability of donor age alone to predict long-term allograft function after renal transplantation, and nonacceptable donors are not discriminated.     

Laparoscopic nephrectomy: prediction of outcome in relation to the preoperative risk factors in two approaches

PURPOSE: The data on laparoscopic nephrectomy in Mansoura Urology & Nephrology Center were reviewed to identify the preoperative findings that may predict the need for conversion to open surgery. PATIENTS AND METHODS: One hundred sixty-three patients were subjected to transperitoneal laparoscopic nephrectomy, while 82 underwent retroperitoneal laparoscopic nephrectomy for benign renal diseases. The preoperative demographic data and laboratory and radiologic findings of these patients were correlated with failure rate of the laparoscopic procedure. RESULTS: The overall failure rate was 10.4% and 11% for the transperitoneal and retroperitoneal approach, respectively. Positive urine culture, renographic clearance of the removed kidney (>10 ml/min), and learning curve were independently associated with a greater risk of failure in patients undergoing transperitoneal nephrectomy. For the retroperitoneal approach, a positive urine culture, renographic clearance (> or =10 ml/min), and large kidney showed statistical significance. CONCLUSION: Preoperative data could be used as a predictor of laparoscopic nephrectomy outcome in patients with benign renal diseases. A more experienced surgeon should be selected for risky cases, bearing in mind the greater potential for early conversion to open surgery.     

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.     

Age, gender, and body mass index are associated with renal function after kidney donation

Renal function is thoroughly evaluated before live kidney donation. However, some donors experience impaired recovery of renal function after donation. Our aim was to assess estimated glomerular filtration rate (eGFR) and mean relative (%) increase in creatinine one yr after donor nephrectomy. The study was based on retrospective data from kidney donors during the period 1997-2009. Pre-operative and one-yr follow-up data were available for 721 of 1067 donors. Mean relative increase in creatinine and eGFR were stratified by gender, body mass index (BMI), and age at donation. At one yr post-donation, overweight (BMI > 5 kg/m(2) ) women 50 yr or older experienced the lowest eGFR of 49.6 ± 8.8 mL/min/1.73 m(2) . Men younger than 50 yr with normal weight (BMI < 25 kg/m(2) ) had the highest eGFR of 66.6 ± 10.4 mL/min/1.73 m(2) . Overweight men 50 yr or older had the highest relative increase in creatinine of 49.4% compared to pre-donation. Men under 50 yr with normal weight had the smallest increase in creatinine of 35.2%. In multivariate analysis, older age (p < 0.001), male gender (p < 0.001), and overweight (p = 0.01) were associated with relative increase in creatinine after donation. Potential donors should be offered counseling regarding overweight, as this is a modifiable risk factor.     

Are concerns over right laparoscopic donor nephrectomy unwarranted?

OBJECTIVE: To examine the ability of several large, experienced transplantation centers to perform right-sided laparoscopic donor nephrectomy safely with equivalent long-term renal allograft function. SUMMARY BACKGROUND DATA: Early reports noted a higher incidence of renal vein thrombosis and eventual graft loss. However, exclusion of right-sided donors would deprive a significant proportion of donors a laparoscopically harvested graft. METHODS: A retrospective review was performed among 97 patients from seven centers performing right-sided laparoscopic donor nephrectomy. Surgical and postoperative demographic factors were evaluated. Complications were identified and long-term renal allograft function was compared with historical left-sided laparoscopic donor nephrectomy cohorts. RESULTS: Right laparoscopic donor nephrectomy was performed for varying reasons, including multiple left renal arteries or veins, smaller right kidney, or cystic right renal mass. Mean surgical time was 235.0 +/- 66.7 minutes, with a mean blood loss of 139 +/- 165.8 mL. Conversion was required in three patients secondary to bleeding or anatomical anomalies. Mean warm ischemic time was limited at 238 +/- 112 seconds. Return to diet was achieved on average after 7.5 +/- 2.3 hours, with mean discharge at 54.6 +/- 22.8 hours. Two grafts were lost during the early experience of these centers to renal vein thrombosis. Both surgical and postoperative complications were limited, with few long-term adverse effects. Mean serum creatinine levels were higher than open and left laparoscopic donor nephrectomy on postoperative day 1, but at all remaining intervals the right laparoscopic donors had equivalent creatinine values. CONCLUSIONS: These results confirm that right laparoscopic donor nephrectomy provides similar patient benefits, including early return to diet and discharge. Long-term creatinine values were no higher than in traditional open donor or left laparoscopic donor cohorts. These results establish that early concerns about high thrombosis rates are not supported by a multiinstitutional review of laparoscopic right donor nephrectomies.     

Detrimental effects of controlled reperfusion on renal function after porcine autotransplantation are fully compensated by the use of Carolina rinse solution

Despite extensive efforts in the fields of donor selection and management, standardisation of organ retrieval procedures, storage solutions, and novel immunosuppressive protocols, the rates of delayed graft function (DGF) after renal transplantation have been stagnating between 30% and 50%. As DGF exerts negative influences on acute rejection episodes and long-term organ function, the early phase of transplantation immediately following reperfusion deserves special interest. Several studies on machine-controlled reperfusion showed promising results in various organs, in experimental and clinical settings. Moreover, the flushing of organs with Carolina rinse solution (CR) immediately prior to reperfusion has been proven beneficial and is being clinically applied in human liver transplantation in recognised departments. In our study, we set up an autogenic porcine kidney transplantation model and assessed the normal values (control group) for creatinine clearance (ClCr) and urine output per hour (U/h) after "standard" reperfusion similar to clinical transplantation. Subsequently, kidneys of the experimental group 1 were reperfused at a blood pressure (RR) under the systemic level by means of a roller pump. Group 2 kidneys were rinsed with CR before controlled reperfusion, analogous to group 1. Both groups were compared with each other and with the assessed normal values. Our findings for Group 1 are that pressure-reduced reperfusion negatively affected immediate graft function. ClCr was reduced from 9.9 (control group) to 3.4 ml/min, U/h from 233 to 132 ml ( P<0.05). Group 2 showed that rinsing the kidneys with CR before reperfusion improved functional parameters highly significantly, compared with group 1 (ClCr: 13.5 vs 3.4 ml/min, U/h: 384 vs 132 ml; P<0.05) and even showed a positive trend compared with the control group (ClCr: 13.5 vs 9.9 ml/min, U/h: 384 vs 233 ml; P=0.0546). We can conclude that in a model of porcine renal autotransplantation, pressure-reduced reperfusion via a roller pump is detrimental to early kidney graft function. The flushing of organs with CR prior to controlled reperfusion significantly improves ClCr as well as urine output.     

Regional versus general anesthesia for donor nephrectomy: effects on graft function

Various general and regional anesthesia methods are used successfully in living-donor kidney transplantation. This study compared kidney graft function after general versus combined spinal-epidural anesthesia for donor nephrectomy. The study groups included recipients who received grafts from donors who had undergone nephrectomy under general anesthesia (GA group; n=10), and recipients who received grafts from donors who had combined spinal-epidural anesthesia (CSE group, n=10). Standard continuous epidural anesthesia was administered during all transplantations. Graft function was assessed using scintigraphy and Doppler ultrasonography on days 3 and 7. Urine levels of microalbumin, creatinine, and creatinine clearance rate were measured/calculated in 24-hour urine samples collected on postoperative days 3 and 7. There were no differences on either day 3 or day 7 with respect to glomerular filtration rate, microalbuminuria, or creatinine clearance rate (P >.05 for all). There were also no differences between the groups with respect to other scintigraphic findings on day 3 or day 7 (P >.05 for all). Ultrasonography on day 7 showed significantly higher mean peak systolic flow in the main renal artery in the CSE group than in the GA group (P=.035). The results suggest that GA and CSE for donor nephrectomy have similar effects on kidney graft function in recipients.     

Effect of intravascular volume expansion on renal function during prolonged CO2 pneumoperitoneum

OBJECTIVE: To evaluate whether intravascular volume expansion would improve renal blood flow and function during prolonged CO2 pneumoperitoneum. SUMMARY BACKGROUND DATA: Although laparoscopic living donor nephrectomies have a considerably reduced risk of complications for the donors, significant concerns exist regarding procurement of a kidney in the altered physiologic environment of CO2 pneumoperitoneum. Recent studies have documented adverse effects of CO2 pneumoperitoneum on renal hemodynamics. METHODS: Renal and systemic hemodynamics and renal histology were studied in a porcine CO2 pneumoperitoneum model. After placement of a pulmonary artery catheter, carotid arterial line, Foley catheter, and renal artery ultrasonic flow probe, CO2 pneumoperitoneum (15 mmHg) was maintained for 4 hours. Pigs were randomized into three intravascular fluid protocol groups: euvolemic (3 mLkg/hour isotonic crystalloid), hypervolemic (15 mL/kg/hour isotonic crystalloid), or hypertonic (3 mL/kg/hour isotonic crystalloid plus 1.2 mL/kg/hour 7.5% NaCl). RESULTS: In the euvolemic group, prolonged CO2 pneumoperitoneum caused decreased renal blood flow, oliguria, and impaired creatinine clearance. Both isotonic and hypertonic volume expansions reversed the changes in renal blood flow and urine output, but impaired creatinine clearance persisted. CONCLUSIONS: Intravascular volume expansion alleviates the effects of CO2 pneumoperitoneum on renal hemodynamics in a porcine model. Hypertonic saline (7.5% NaCl) solution may maximize renal blood flow in prolonged pneumoperitoneum, but it does not completely prevent renal dysfunction in this setting. This study suggests that routine intraoperative volume expansion is important during laparoscopic live donor nephrectomy.     

Comparative analysis about hemodynamic and renal blood flow effects during open versus laparoscopic nephrectomy. An experimental study

BackgroundThe increase of intraabdominal pressure to 10 mmHg provokes a decrease of renal blood flow (RBF). Pneumoperitoneum during laparoscopic techniques with intra-abdominal pressure (IAP) to 15 mmHg, results in a decrease in RBF, urine output and glomerular filtration rate (GFR).PurposeAnalyze the changes in RBF, urine output an GFR in a porcine experimental model during open vs laparoscopic nephrectomy.Materials and methods30 pigs (medium weigh= 22.6+3.2 Kg) were divided into two groups: Laparoscopic nephrectomy was performed using 15 pigs and open nephrectomy in 15 pigs, following a living donor nephrectomy autotransplantation model. Study parameters were urine volume and GFR baseline values, 30 and 60 minutes during nephrectomy. RBF was measured using an electromagnetic flow catheter around the main renal artery during the initial 60 minutes of nephrectomy.ResultsThe laparoscopic technique was associated with a significant reduction of RBF (80+2.7 vs 262+3 ml/min) (p < 0.005), diuresis (42%) and GFR (38%), vs the open group.ConclusionsLaparoscopic nephrectomy involves a significant reduction of RBF, GFR and diuresis, which is potentially transcendent in living donor nephrectomy and kidney transplantation.     

Why we consistently use the left donor kidney in living related transplantation: initial experience of right laparoscopic donor nephrectomy and comparison with left nephrectomy

OBJECTIVES: Laparoscopic donor nephrectomy has become the method of choice for removal of living donor kidneys. However, the majority of laparoscopic donor nephrectomy cases have been limited to the left side owing to technical difficulties and renal vessel length. This study described the technique and compared donor outcomes and graft function of right and left laparoscopic donor nephrectomy. MATERIALS AND METHODS: Among 25 patients, 6 consecutive donors underwent right laparoscopic donor nephrectomy from March 2002 to January 2005. They were compared to 19 patients with left laparoscopic donor nephrectomy. We compared operative times, warm ischemia times, serial creatinines, creatinine clearances, complications, and graft function. RESULTS: There was no significant difference in any metric. The operative times (303 min. vs 274 min., P > .05) and warm ischemia times (133 s vs 186 s, P > .05) were similar between right and left laparoscopic donor nephrectomy procedures. In left laparoscopic donor nephrectomy, 3 patients had transient brachial plexus neuropathies. No major complication occurred among patients undergoing right laparoscopic donor nephrectomy. This study demonstrated that both donor and recipient outcomes are similar for right and left laparoscopic donor nephrectomy. CONCLUSIONS: Consistent use of the left kidney has not affected clinical outcomes. With hand-assisted laparoscopy, the right laparoscopic donor nephrectomy is safe, providing excellent graft function.     

Laparoscopic adult donor nephrectomy for pediatric renal transplantation

To evaluate retrospectively our laparoscopic adult donor nephrectomy experience for pediatric transplantation. Since February 1995, 7 adult donors have undergone laparoscopic donor nephrectomy for pediatric renal transplantation (recipients younger than 18 years and weighing less than 30 kg). The outcomes of these donors and pediatric recipients were evaluated. The 7 laparoscopic renal donors had a median operative time of 306 minutes, median allograft warm ischemia time of 275 seconds, median blood loss of 200 mL, median hospital stay of 3 days, and 14.2% overall complication rate. No graft loss or patient mortality occurred. The pediatric recipients of the laparoscopic live-donor allografts had a median creatinine clearance level of 52.1, 52.1, 44, and 41.1 mL/min at 3, 6, 12, and 18 months, respectively. The overall complication rate was 14.2%. The 1 and 2-year graft survival rates were 100%. No mortality occurred in the pediatric recipients. Laparoscopic donor nephrectomy is well tolerated by the adult donors and appears to provide acceptable recipient and allograft outcomes in the pediatric population.     

Living kidney donor follow-up in a dedicated clinic

BACKGROUND: Long-term effects of uninephrectomy for kidney donation are of particular interest in the currently increasing practice of living-donor transplantation. We have retrospectively analyzed the general health status and renal and cardiovascular consequences of living-related kidney donation. METHODS: Data of living-related kidney donors who were regularly followed up in a dedicated clinic at the Sindh Institute of Urology and Transplantation between July 2000 and January 2004 was retrieved. They had donated their kidneys from 1986 onward. Data on weight, blood pressure, creatinine clearance, level of proteinuria, and new onset diabetes mellitus were analyzed. RESULTS: Seven hundred and thirty-six donors with a mean age of 36+/-10.9 years (M:F 1.1:1) were evaluated. With a mean postnephrectomy duration of 3+/-3.2 years (range 6 months-18 years), the creatinine clearance fell to 87% of prenephrectomy values, and 49 (6.7%) had a creatinine clearance of less than 60 mL/ min. Hypertension developed in 76 (10.3%) donors, and 179 (24.3%) had proteinuria exceeding 150 mg/24 hr. Overweight (27.8%) and obese subjects (11.5%) had a higher prevalence of hypertension and new onset diabetes mellitus. One donor developed end-stage renal failure. CONCLUSION: Donor nephrectomy has minimal adverse effects on overall health status. Regular donor follow-up identifies at-risk populations and potentially modifiable factors.     

Beagle犬腹腔镜活体供肾-移植模型的建立

目的 探讨Beagle犬腹腔镜活体供肾-移植模型建立的安全性和可行性。方法 8条beagle犬随机分为两组,实验组行腹腔镜左肾供肾切取术,对照组行开放左肾供肾切取术,两组分别行组内同种异体肾移植术并置于左侧髂窝,同时切除白体右肾。统计两组取肾手术时间、术中失血量、热缺血时间、切口长度,肾移植手术时间、术中失血量、供肾动静脉吻合时间等手术指标及术后实验犬肌酐、尿素氮变化情况。结果 实验组腹腔镜供肾切取术均成功完成,无一例中转开腹,其中供肾切取手术时间(61.5±11.0)min,术中失血量(13.9±6.8) ml,供肾热缺血时间(81.4±9.3)s;对照组开放供肾切取术,无一例失败,其中供肾切取手术时间(66.1 ±13.5) min,术中失血量(32.7±4.8) ml,供肾热缺血时间(28.5±5.6)s;8例次同种异体肾移植术,全部成功,受体移植手术时间(87.3±13.9) min,术中失血量(13.5±5.2) ml,动脉吻合时间(19.8±6.7) min,静脉吻合时间(22.8±3.5) min,术后1个月观察期间内,无漏尿、出血、感染等并发症发生,术后第3天实验犬肌酐、尿素氮指标恢复正常。结论 Beagle犬腹腔镜活体供肾-移植模型的建立操作相对简便、容易掌握,成活率高,安全、可靠。     

The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy

Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage. OBJECTIVE: To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function. PATIENTS AND METHODS: Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN. RESULTS: In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age > or = 70 years and a serum creatinine level after LPN of > or = 1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN. CONCLUSIONS: The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of approximately 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min.