Leonienke F. C. Dols

Live donor nephrectomy: a review of evidence for surgical techniques

Live kidney donation is an important alternative for patients with end‐stage renal disease. To date, the health of live kidney donors at long‐term follow‐up is good, and the procedure is considered to be safe. Surgical practice has evolved from the open lumbotomy, through mini‐incision muscle‐splitting open donor nephrectomy, to minimally invasive laparoscopic techniques. There are different minimally invasive techniques, including standard laparoscopic, hand‐assisted laparoscopic, hand‐assisted retroperitoneoscopic, pure retroperitoneoscopic, and robotic‐assisted live donor nephrectomy. At present, these minimally invasive techniques are subjected to clinical trials focusing on surgical outcome, quality of life, costs, long‐term follow‐up, and also morbidity of donor, recipient, and graft. In practice, many centers only perform donor nephrectomy on young healthy donors with normal weight. There is increasing evidence that donor nephrectomy with multiple arteries, right kidney and obese patients can be done with precaution. In this review, we address the surgical part of live kidney donation and the best level of evidence for all surgical techniques and issues surrounding the technique.

Living kidney donors: Impact of age on long-term safety

The safety of older live kidney donors, especially the decline in glomerular filtration rate (GFR) after donation, has been debated. In this study we evaluated long‐term renal outcome in older live kidney donors. From 1994 to 2006 follow‐up data of 539 consecutive live kidney donations were prospectively collected, during yearly visits to the outpatient clinic. Donors were categorized into two groups, based on age: <60 (n = 422) and ≥60 (n = 117). Elderly had lower GFR predonation (80 vs. 96 mL/min respectively, p < 0.001). During median follow‐up of 5.5 years, maximum decline in eGFR was 38%± 9% and the percentage maximum decline was not different in both groups. On long‐term follow‐up, significantly more elderly had an eGFR <60 mL/min (131 (80%) vs. 94 (31%), p < 0.001). However, renal function was stable and no eGFR of less than 30 mL/min was seen. In multivariate analysis higher body mass index (HR 1.09, 95%CI 1.03–1.14) and more HLA mismatches (HR 1.17, 95%CI 1.03–1.34) were significantly correlated with worse graft survival. Donor age did not influence graft survival. After kidney donation decline in eGFR is similar in younger and older donors. As kidney function does not progressively decline, live kidney donation by elderly is considered safe.

Laparoscopic donor nephrectomy: a plea for the right-sided approach.

Background. Laparoscopic donor nephrectomy (LDN) has become the preferred procedure for live donor nephrectomy. Most transplant surgeons are reluctant toward right-sided LDN (R-LDN) fearing short vessels and renal vein thrombosis. Methods. In our institution, selection of the appropriate kidney for donation was based on the same criteria that traditionally governed open donor nephrectomy. All intraoperative and postoperative data were prospectively recorded. Results. One hundred fifty-nine R-LDNs (56%) and 124 left-sided LDNs (L-LDN, 44%) were performed. Demographics did not significantly differ. Complications occurred in 10 (6%) vs. 23 (19%) procedures (R-LDN vs. L-LDN, P=0.002), resulting in 2 and 11 conversions, respectively. Right-sided kidney donation was the only independent preventative factor for complications in multivariate analysis (P=0.008, Odds ratio 0.33). R-LDN was associated with shorter operation time (mean 202 vs. 247 min, P<0.001) and less blood loss (139 vs. 294 mL, P<0.001). Hospital stay was 3 days in both groups. With regard to the recipients, the second warm ischemia time was similar (29 vs. 28 min, P=0.699). Conclusions. R-LDN is faster and safer than L-LDN and does not adversely affect graft function. R-LDN may be advocated to allow donors to benefit from the advantages of laparoscopic surgery.

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.

Long‐Term Follow‐up of a Randomized Trial Comparing Laparoscopic and Mini‐Incision Open Live Donor Nephrectomy

Long‐term physical and psychosocial effects of laparoscopic and open kidney donation are ill defined. We performed long‐term follow‐up of 100 live kidney donors, who had been randomly assigned to mini‐incision open donor nephrectomy (MIDN) or laparoscopic donor nephrectomy (LDN). Data included blood pressure, glomerular filtration rate, quality of life (SF‐36), fatigue (MFI‐20) and graft survival. After median follow‐up of 6 years clinical and laboratory data were available for 47 donors (94%) in both groups; quality of life data for 35 donors (70%) in the MIDN group, and 37 donors (74%) in the LDN group. After 6 years, mean estimated glomerular filtration rates did not significantly differ between MIDN (75 mL/min) and LDN (76 mL/min, p = 0.39). Most dimensions of the SF‐36 and MFI‐20 did not significantly differ between groups at long‐term follow‐up, and most scores had returned to baseline. Twelve percent of the donors reported persistent complaints, but no major complications requiring surgical intervention. Five‐year death‐censored graft survival was 90% for LDN, and 85% for MIDN (p = 0.50). Long‐term outcome of live kidney donation is excellent from the perspective of both the donor and the recipient.

Randomized controlled trial comparing hand-assisted retroperitoneoscopic versus standard laparoscopic donor nephrectomy

Background Laparoscopic donor nephrectomy (LDN) has become the gold standard for live-donor nephrectomy, as it results in a short convalescence time and increased quality of life. However, intraoperative safety has been debated, as severe complications occur incidentally. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP) is an alternative approach, combining the safety of hand-guided surgery with the benefits of endoscopic techniques and retroperitoneal access. We assessed the best approach to optimize donors’ quality of life and safety. Methods In two tertiary referral centers, donors undergoing left-sided nephrectomy were randomly assigned to HARP or LDN. Primary endpoint was physical function, one of the dimensions of the Short Form-36 questionnaire on quality of life, at 1 month postoperatively. Secondary endpoints included intraoperative events and operation times. Follow-up was 1 year. Results In total, 190 donors were randomized. Physical function at 1 month follow-up did not significantly differ between groups (estimated difference, 1.79; 95% confidence interval, −4.1 to 7.68; P=0.55). HARP resulted in significantly shorter skin-to-skin time (mean, 159 vs. 188 min; P<0.001), shorter warm ischemia time (2 vs. 5 min; P<0.001) and a lower intraoperative event rate (5% vs. 11%, P=0.117). Length of stay (both 3 days; P=0.135) and postoperative complication rate (8% vs. 8%; P=1.00) were not significantly different. Potential graft-related complications did not significantly differ (6% vs. 13%; P=0.137). Conclusions Compared with LDN, left-sided HARP leads to similar quality of life, shorter operating time, and warm ischemia time. Therefore, we recommend HARP as a valuable alternative to the laparoscopic approach for left-sided donor nephrectomy.

Attitudes among surgeons towards live-donor nephrectomy: a European update.

Background The increasing number of living kidney donors in the last decade has led to the development of novel surgical techniques for live-donor nephrectomy. The aim of the present study was to evaluate the current status of the surgical approach in Europe. Methods A survey was sent to 119 transplant centers in 12 European countries. Questions included the number of donors, the technique used, and the acceptance of donors with comorbidities. Results Ninety-six centers (81%) replied. The number of living donors per center ranged from 0 to 124. Thirty-one institutions (32%) harvested kidneys using open techniques only. Six centers (6%) applied both endoscopic and open techniques; 59 centers (61%) performed endoscopic donor nephrectomy only. Lack of evidence that endoscopic techniques provide superior results was the main reason for still performing open donor nephrectomy. In seven centers, a lumbotomy is still performed. Seventy-two centers (75%) accept donors with a body mass index of more than 30 kg/m2, the median upper limit in these centers was 35 kg/m2 (range, 31–40). Donors with an American Society of Anesthesiologists classification higher than 1 were accepted in 55% of the centers. Conclusions Live kidney donation in general and minimally invasive donor nephrectomy in particular are more commonly applied in Northern and Western Europe. However, a classic lumbotomy is still performed in a minority of centers. Because minimally invasive techniques have been proven superior, more attention should be given to educational programs in this field to let many kidney donors benefit.

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.

Hand-assisted retroperitoneoscopic versus standard laparoscopic donor nephrectomy: HARP-trial

BackgroundTransplantation is the only treatment offering long-term benefit to patients with chronic kidney failure. Live donor nephrectomy is performed on healthy individuals who do not receive direct therapeutic benefit of the procedure themselves. In order to guarantee the donors safety, it is important to optimise the surgical approach. Recently we demonstrated the benefit of laparoscopic nephrectomy experienced by the donor. However, this method is characterised by higher in hospital costs, longer operating times and it requires a well-trained surgeon. The hand-assisted retroperitoneoscopic technique may be an alternative to a complete laparoscopic, transperitoneal approach. The peritoneum remains intact and the risk of visceral injuries is reduced. Hand-assistance results in a faster procedure and a significantly reduced operating time. The feasibility of this method has been demonstrated recently, but as to date there are no data available advocating the use of one technique above the other.Methods/designThe HARP-trial is a multi-centre randomised controlled, single-blind trial. The study compares the hand-assisted retroperitoneoscopic approach with standard laparoscopic donor nephrectomy. The objective is to determine the best approach for live donor nephrectomy to optimise donors safety and comfort while reducing donation related costs.DiscussionThis study will contribute to the evidence on any benefits of hand-assisted retroperitoneoscopic versus standard laparoscopic donor nephrectomy.Trial RegistrationDutch Trial Register NTR1433

Quality of life of elderly live kidney donors.

Background Expanding the use of elderly live donors may help meet the demand for kidney transplants. The aim of this study was to quantify the effect of the surgical procedure on the quality of life (QOL) of elderly donors compared with younger donors. Methods Alongside three prospective studies (two randomized) running between May 2001 and October 2010, we asked 501 live donors to fill out the Short Form-36 questionnaire preoperatively and at 1, 3, 6, and 12 months postoperatively. We defined live donors 60 years or older as elderly. Between-group analyses regarding QOL were adjusted for baseline values and gender. Results One hundred thirty-five donors were older and 366 donors were younger than 60 years. The response rate was high, with 87% at 12 months postoperatively. Elderly donors less often scored as American Society of Anaesthesiology classification 1 (60% vs. 81%; P<0.001) indicating a higher rate of minor comorbidity. At 1 month postoperatively, between-group analysis showed a significant advantage in QOL in favor of the elderly group regarding the dimensions “bodily pain” (7 points; P=0.001), “role physical” (18 points; P<0.001), and “vitality” (5 points; P=0.008). At 3 months, “bodily pain” (3 points, P=0.04) and “role physical” (8 points, P=0.02) were still in favor of the older group. At 6 and 12 months, “physical function” was in favor of the younger group (3 and 5 points, respectively; P=0.04 and P<0.001). Conclusions This study demonstrates that elderly donors recover relatively fast. The perspective of excellent postoperative QOL may help convince elderly individuals to donate.