N. R. Brook

Randomized clinical trial of laparoscopic versus open donor nephrectomy

This randomized controlled trial was designed to determine the safety and efficacy of laparoscopic donor nephrectomy (LDN) in comparison with short‐incision open donor nephrectomy (ODN).

Comparison of renal allograft fibrosis after transplantation from heart‐beating and non‐heart‐beating donors

Renal transplants from non‐heart‐beating donors (NHBDs) yield acceptable function and allograft survival rates in the medium term. However, the long‐term results are less certain and there is a paucity of information relating to the development of chronic allograft nephropathy. The aim of this study was to compare allograft fibrosis in kidneys transplanted from NHBDs and conventional heart‐beating donors (HBDs).

Randomized clinical trial of daclizumab induction and delayed introduction of tacrolimus for recipients of non‐heart‐beating kidney transplants

Kidneys from non‐heart‐beating donors (NHBDs) have high rates of delayed graft function (DGF). Use of calcineurin inhibitors is associated with a reduction in renal blood flow, which may delay graft recovery from ischaemic acute tubular necrosis.

Laparoscopic live donor nephrectomy

Renal transplant programmes continue to be restricted by a lack of suitable cadaveric organ donors and this has stimulated renewed interest in live donor kidney transplantation. Live donor kidneys yield the best patient and graft survival figures, but this must be balanced against the risks of donation, including the potential for donor death and serious postoperative complications. Many transplant surgeons in the UK continue to favour a considerable flank incision for donor nephrectomy1, and this may lead to a prolonged recovery period and a poor cosmetic result. Laparoscopic live donor nephrectomy was introduced into surgical practice in an attempt to remove some of the disincentives to donation. Retrospective reports suggest that it is associated with improved cosmesis, decreased severity and duration of postoperative pain, shorter inpatient stay, and a quicker return to work and normal activities, compared with conventional open donor nephrectomy2. Furthermore, the overall cost is lower and quality of life scores are higher than those associated with open operation3. These advantages appear to have been achieved without detriment to graft function or survival. Laparoscopic live donor nephrectomy now accounts for 31 per cent of live donor procedures in the USA, and 65 per cent of centres offer the procedure4. Despite encouraging UK figures indicating year-on-year increases in live donor activity, it seems that few centres have adopted the laparoscopic technique thus far. Although there is accumulating evidence that high-quality grafts can be safely procured from laparoscopic donors, randomized clinical trials comparing open and minimal access donor nephrectomy have not been forthcoming. A further difficulty in assessing results is the variety of approaches that have been employed for minimal access. The transperitoneal laparoscopic technique, introduced by Ratner and colleagues in 19952, is the most prevalent approach, but it presents particular technical problems. These include difficulty in obtaining sufficient length of renal vein, and in dealing with arterial and venous anomalies. The hand-assisted technique is learnt more quickly by surgeons with less laparoscopic experience, and both operating and renal warm ischaemic times5 are shorter. It utilizes an airtight sleeve for insertion of a hand into the peritoneal cavity while maintaining the pneumoperitoneum, thereby adding an element of control and dexterity. There is less experience of the retroperitoneal approach, but it may have a particular application in right donor nephrectomy. So far there is no clear evidence favouring any one of these techniques over another. In their comprehensive systematic review, presented in this issue of BJS, Handschin et al.6 examine the published evidence for key areas of contention and ambiguity associated with laparoscopic live donor nephrectomy. They concentrate on safety and efficacy, both for the donor and the engrafted organ, purported advantages of the laparoscopic procedure, and operative considerations such as conversion rate. For 175 laparoscopic procedures performed in the centre that introduced the technique there was an open conversion rate of 2 per cent7. Complications associated with ureteric ischaemia were more common after laparoscopic donor nephrectomy in some groups’ initial experience of the procedure8, but modifications in technique (ensuring that sufficient periureteral tissue is taken) have reduced this problem. Operating time is generally longer but this too has decreased with increasing experience in a number of centres8. In the authors’ institution two consultant surgeons perform the procedure together; there is evidence that this approach affords a faster operating time than that achieved with an inexperienced laparoscopic surgeon as the assistant9. The avoidance of mechanical, haemodynamic and ischaemic compromise of the graft is of paramount importance; this includes warm and cold ischaemic time. Warm times are short with all laparoscopic techniques, and cold times are kept to a minimum. Another concern has been that the positive pressure of the pneumoperitoneum may compromise renal blood flow. Although there is evidence of an increased plasma antidiuretic hormone level after laparoscopic compared with open operation, and an increased serum creatinine level up to 1 month after surgery with the former, there is no evidence that this has any impact on long-term graft function10. The common use of high volumes of intravenous fluid before and during the donor procedure in an attempt to keep the renal vein pressure high in the presence of a pneumoperitoneum may not be necessary. Two episodes of quite marked unilateral pulmonary oedema in the dependent lung have led the

Fibrosis-associated gene expression in renal transplant glomeruli after acute renal allograft rejection.

Acute allograft rejection is thought to be a risk factor for chronic allograft nephropathy, the cardinal features of which are vasculopathy, interstitial fibrosis and glomerulosclerosis. Fibrosis‐associated genes might act as ad interim surrogate markers for chronic allograft nephropathy. The aim of this study was to determine mRNA expression of fibrosis‐associated genes in glomeruli plucked from protocol renal transplant biopsies, in patients with or without a history of acute rejection.