Khe T. C. Tran

Complex vascular anatomy in live kidney donation: Imaging and consequences for clinical outcome

Background. Live donor kidneys with multiple arteries are associated with surgical complexity for removal and increased rate of recipient ureteral complications. We evaluated the outcome of vascular imaging and the clinical consequences of multiple arteries and veins. Methods. From 2001 to 2005 data of 288 live kidney donations and transplantations were prospectively collected. Vascular anatomy at operation was compared with vascular anatomy as imaged by magnetic resonance imaging (MRI) or subtraction angiography, and consequences of multiple vessels were investigated. Results. Simple renal anatomy with a solitary artery and vein was present in 208 (72%) kidneys. Sixty (21%) transplants had multiple arteries. Thirty (10%) transplants had multiple veins. Magnetic resonance imaging failed to predict arterial anatomy in 23 of 220 donors (10%) compared with 3 of 101 (3%) after angiography. The presence of multiple veins did not influence outcomes after nephrectomy in general. Multiple arteries did not affect clinical outcomes in open donor nephrectomy (n=103). In laparoscopic donor nephrectomy (n=185) multiple arteries were associated with longer operation times (245 vs. 221 min, P=0.023) and increased blood loss (225 vs. 220 mL, P=0.029). In general, neither multiple arteries nor vascular reconstructions influenced recipient creatinine clearance or ureteral complication rate. However, accessory arteries to the lower pole correlated with an increased rate of ureteral complications (47% vs. 14%, P=0.01). Conclusions. Multiple arteries may increase operation time. Accessory lower pole arteries are associated with a higher rate of recipient ureteral complications indicating the importance of arterial imaging. Currently, both magnetic resonance imaging and angiography provide suboptimal information on renal vascular anatomy.

Psychosocial and physical impairment after mini-incision open and laparoscopic donor nephrectomy: A prospective study.

Background. The aim of the present study was to prospectively investigate how mini-incision donor nephrectomy (MIDN) and laparoscopic donor nephrectomy (LDN) affected the donor’s quality of life and fatigue. Methods. Forty-five donors underwent MIDN and 55 donors underwent LDN. Quality of life and fatigue were recorded preoperatively and four times during one year follow-up on the Short-Form 36 (SF-36) and Multidimensional Fatigue Inventory-20 (MFI-20), respectively. Results. One-year response rates were 89% and 95% following MIDN and LDN, respectively. After MIDN, all dimensions of the SF-36 significantly declined. Most dimensions returned to preoperative values at three months except for “vitality” (six months) and “bodily pain” (12 months). After LDN, the scores of the SF-36 dimensions returned to preoperative values at three months, except for “vitality” and “role physical” (both six months). Between-groups analysis revealed significantly better scores of the SF-36 dimensions “physical function” (P=0.03) and “bodily pain” (P=0.04) following LDN at one month postoperatively. Fatigue scores did not significantly differ between the groups at any point in time. General and physical fatigue (MFI-20) remained affected up to one year after either type of surgery. After MIDN, 4% of the donors had returned to work at four weeks postoperatively versus 28% after LDN (P=0.04). Return to preoperative activity level was not significantly different between groups. Conclusions. Both procedures clearly impact quality of life and fatigue. The beneficial effect on the quality of life and the earlier return to work encourage us to advocate LDN as the surgical approach to be preferred.

Optimizing left-sided live kidney donation: Hand-assisted retroperitoneoscopic as alternative to standard laparoscopic donor nephrectomy

Laparoscopic donor nephrectomy (LDN) is less traumatic and painful than the open approach, with shorter convalescence time. Hand‐assisted retroperitoneoscopic (HARP) donor nephrectomy may have benefits, particularly in left‐sided nephrectomy, including shorter operation and warm‐ischemia time (WIT) and improved safety. We evaluated outcomes of HARP alongside LDN. From July 2006 to May 2008, 20 left‐sided HARP procedures and 40 left‐sided LDNs were performed. Intra and postoperative data were prospectively collected and analysis on outcome of both techniques was performed. More female patients underwent HARP compared to LDN (75% vs. 40%, P = 0.017). Other baseline characteristics were not significantly different. Median operation time and WIT were shorter in HARP (180 vs. 225 min, P = 0.002 and 3 vs. 5 min, P = 0.007 respectively). Blood loss did not differ (200 ml vs.150 ml, P = 0.39). Intra and postoperative complication rates for HARP and LDN (respectively 10% vs. 25%, P = 0.17 and 5% vs. 15%, P = 0.25) were not significantly different. During median follow‐up of 18 months estimated glomerular filtration rates in donors and recipients and graft‐ and recipient survival did not differ between groups. Hand‐assisted retroperitoneoscopic donor nephrectomy reduces operation and warm ischemia times, and provides at least equal safety. Hand‐assisted retroperitoneoscopic may be a valuable alternative for left‐sided LDN.

Mini-incision open donor nephrectomy as an alternative to classic lumbotomy: evolution of the open approach.

In Europe, the vast majority of transplant centres still performs open donor nephrectomy. This approach can therefore be considered the gold standard. At our institution, classic lumbotomy (CL) was replaced by a mini‐incision anterior flank incision (MIDN) thereby preserving the integrity of the muscles. Data of 60 donors who underwent MIDN were compared with 86 historical controls who underwent CL without rib resection. Median incision length measured 10.5 and 20 cm (MIDN versus CL, P < 0.001). Median operation time was 158 and 144 min (P = 0.02). Blood loss was significantly less after MIDN (median 210 vs. 300 ml, P = 0.01). Intra‐operatively, 4 (7%) and 1 (1%) bleeding episodes occurred. Postoperatively, complications occurred in 12% in both groups (P = 1.00). Hospital stay was 4 and 6 days (P < 0.001). In one (2%) and 11 (13%) donors (P = 0.02) late complications related to the incision occurred. After correction for baseline differences, recipient serum creatinine values were not significantly different during the first month following transplantation. In conclusion, MIDN is a safe approach, which reduces blood loss, hospital stay and the number of incision related complications when compared with CL with only a modest increase in operation time.

Laparoscopic donor nephrectomy in obese donors: easier to implement in overweight women?

Laparoscopic donor nephrectomy (LDN) has been proven feasible in overweight individuals, but remains technically challenging. As the perirenal fat distribution and consistency significantly differ between men and women, we investigated possible differences between the genders. Prospectively collected data of 37 female and 39 male donors with a body mass index (BMI) over 27 who underwent total LDN were compared. Ninety‐one donors with a BMI <25 served as controls. Clinically relevant differences were not observed between men and women of normal weight. In overweight donors, two (5%) procedures were converted to open in females and five (13%) in males. None of these conversions in females, but four conversions in males, appeared to be related to the donors perirenal fat (P = 0.05). Operation time (median 210 vs. 241 min, P = 0.01) and blood loss (median 100 vs. 200 ml, P = 0.04) were favorable in female donors. The number of complications did not significantly differ. Total LDN in overweight female donors does not lead to increased operation times, morbidity or technical complications. In contrast, the outcome in obese males seems to be less advantageous, indicating that total LDN in overweight women can be advocated as a routine procedure but in obese men reluctance seems justified.

Beneficial Effects of a New Fluid Regime on Kidney Function of Donor and Recipient during Laparoscopic v Open Donor Nephrectomy

BACKGROUND AND PURPOSE Laparoscopic donor nephrectomy (LDN) has been associated with delayed graft function compared with open donor nephrectomy (ODN). We have recently shown that the adverse effect of pneumoperitoneum (PP) on hemodynamics could be prevented by a new fluid regime. The aim of this study was to test the effect of this fluid regime on the kidney function of the donor and recipient after LDN and ODN. PATIENTS AND METHODS We prospectively collected data of 51 donors undergoing ODN and 59 donors undergoing LDN as well as data from the corresponding recipients. All donors and recipients were treated with a standardized anesthesia and fluid regime. This fluid regime consisted of preoperative overnight hydration together with a bolus of colloid administered before induction of anesthesia and before introduction of PP. Follow-up was 2 years. RESULTS Baseline characteristics of the two groups were comparable. Hemodynamics and urine output until nephrectomy were comparable between both groups. Donor kidney function did not differ after ODN and LDN. Estimated glomerular filtration rate, graft survival, and recipient survival did not differ between open and laparoscopically procured transplants. No adverse effects of the novel fluid regime (eg, pulmonary edema or additional oxygen supply) were observed in the donors. CONCLUSION In contrast to our earlier findings, the kidney function of the donor and recipient is comparable between ODN and LDN after introduction of a new fluid regime.

Ureteral length in live donor kidney transplantation; Does size matter?

The aim of this study was to evaluate the role of ureteral length on urological complications. Data were retrospective collected from the INEX‐trial database, a RCT to compare the intravesical to the extravesical ureteroneocystostomy. Ureteral length was measured in 198 recipients and used to divide recipients into three categories based on interquartile ranges: short (≤8.5 cm), medium (8.6–10.9 cm) and long ureters (≥11 cm). Urological complications were defined as the number of percutaneous nephrostomy placements (PCN). Fifty recipients fell into the short, 98 into the medium and 50 recipients into the long ureter category. Median follow‐up was 26 (range 2–45) months. There was no significant difference in number of PCN placements between the categories. There were 9 (18%) PCN placements in the short ureter category, 21 (20%) in medium ureter category and 10 (21%) in the long ureter category, P = 0.886. Risk factor analysis for gender, arterial multiplicity and type of ureteroneocystostomy showed no differences in PCN placements between the three ureteral length categories. We conclude that ureteral length alone does not seem to influence the number of urological complications.

Liver transplantation for non-exertional heat stroke-related acute liver failure

Heat stroke is a life-threatening condition characterised by hyperthermia leading to multiple organ dysfunction. Acute liver failure is a rare and potentially fatal consequence of heat stroke. Management of heat stroke is mainly supportive but liver transplantation can be considered as the treatment of acute liver failure in heat stroke. However, literature on liver transplantation as a treatment for acute liver failure in heat stroke is scarce. Until now, no cases of liver transplantation for acute liver failure in non-exertional heat stroke have been reported. Here, we present the first case report of a successful liver transplantation in a patient with acute liver failure caused by non-exertional heat stroke after a sauna visit.

OLDER LIVE KIDNEY DONORS: SAFETY ON LONG-TERM FOLLOW-UP: 252

Introduction: Renal transplantation is the optimal treatment for patients with end-stage renal disease. Questions have risen about the outcome of older kidney donors and especially the decline in glomerular filtration rate (GFR) after donation. The aim of the study was to evaluate long-term renal outcome after live kidney donation in older kidney donors. Methods: From 1994 to 2006 follow-up data of 539 consecutive live kidney donations were prospectively collected. Donors were categorized into three groups, based on age: <40 (n=162), 41-59 (n=260), >60 (n=117). Standard follow-up consisted of yearly serum creatinine, eGFR (MDRD-formula), blood pressure measurements. Results: Older donors had a lower eGFR pre-donation compared to middle-aged and young donors (80, 91, 102 ml/min respectively, p<0.001). During a median follow-up of 5.5 years, mean maximum decline in GFR was 38 ± 9%. There was no difference in percentage maximum decline in eGFR between the groups (Figure). At 5 years after donation, significantly more elderly had an eGFR < 60 ml/min compared to middle-aged and young donors (80% vs 47% vs 8% respectively, p<0.001). However, renal function stabilized during follow-up and no donor had an eGFR of less than 30 ml/min during follow-up. After donation 10% of older donors developed hypertension versus 9% of middle-aged donors. Conclusion: After kidney donation decline in eGFR is similar in young, middle-aged, and older donors. As kidney function does not progressively decline, live kidney donation by older donors is considered as safe.