Donor Nephrectomy Group Research Articles

#4776 RENAL RESERVE ASSESSMENT IN PATIENTS WHO UNDERWENT DONOR NEPHRECTOMY OVER A 15-YEAR FOLLOW-UP PERIOD AND COMPARISON WITH 2 OTHER PATIENTS

Abstract Background and Aims Since the beginning of living related/non-related transplantation programs, the long-term risks for kidney donors after donor nephrectomy have not been given enough significance. Initially, the emphasis was only on the good health of the living donor at the time of donation, but there was no monitoring of the donor's health and life quality post-op. In recent years, special attention has been given to kidney donors after living transplantation, as a result of a long-term follow-up and the fact that they are more susceptible to develop certain diseases, e.g. an increased risk of chronic kidney disease (CKD) and terminal renal failure (ESRD). Method The study was conducted as a retrospective case-control study. In our study, 243 patients, who were divided into three groups, were analysed. The case group consisted of patients who underwent donor nephrectomy (108 patients), the first control group consisted of patients who were being monitored because of simplex or parapelvic cysts with preserved renal function parameters (40 renal cyst patients with Bosniak classification ≤2) of similar age and sex, while the second control group consisted of patients who underwent a unilateral radical nephrectomy due to kidney cancer in T1bNoMo clinical stage (95 patients). Results The kidney donors from the case group were mainly females (60.2%) with the average age of 55.87 years at the time of transplantation. In comparison to the control groups, we observed a statistically significant difference in the radical nephrectomy group of patients, who were, on average, younger Caucasian males, with the average age of 46.84 years. The renal reserve recovery (GFR) was faster in the donor nephrectomy group (85%) than in the radical nephrectomy group, whose recovery was 76.67% of the initial values. Also, the values of serum creatinine (sCre) in the donor nephrectomy group after only one month were very similar to the values of sCre after ten years of follow-up (median was approximately 83 μmol/l). GFR according to the CKD EPI formula was initially the best in the group of patients with cysts, and this trend continued over the 15-year follow-up. After one year, eGFR CKD EPI corresponded to the second degree of renal impairment in both the donor and radical nephrectomy groups, bearing in mind the fact that in the group with radical nephrectomy it was lower than 65 ml/min/1.73m² after one year, and that the trend of declining kidney function was maintained even after 15 years of follow-up. On the other hand, in the donor nephrectomy group, after 10 years of follow-up, eGFR CKD EPI was above 65 ml/min/1.73m², i.e. above 60 ml/min/1.73m² after 15 years of follow-up. In contrast, in the group of patients with renal cysts, a reduced kidney function was verified only after 10 years of follow-up - less than 90 ml/min/1.73m², while it was maintained above 80 ml/min/1.73m² even after 15 years of follow-up. Conclusion Comparing these three groups, only in the donor nephrectomy group, one patient ended up on chronic hemodialysis treatment (0.92%), while in the other two groups there were no patients with terminal kidney failure. The values of serum creatinine - the median, were the same after 6 months and after 5 years post-op in the donor nephrectomy group (79 μmol/l). The aforementioned findings can help us predict the expected values of serum creatinine after donor nephrectomy in the future. In donors as well as in patients with renal cysts, the reason for higher mortality was not ESRD, but more often it was a sudden cardiac death or a cardiovascular disease. The well-being of the giver must be ensured both in the short and long term, but the potential harmful consequences for the recipient must be determined as well.

EVALUATION OF RESULTS OF LAPAROSCOPIC DONOR NEPHRECTOMY

Context: Chronic kidney disease is a major cause of mortality and morbidity in the world today. Diseases like diabetes mellitus, hypertension and glomerulonephritis more commonly lead to CKD, which in later stages (stage V CKD) may require renal replacement therapy through hemodialysis, peritoneal dialysis or renal transplant. Renal transplantation offers best form of renal replacement therapy. It can be performed by open or laparoscopic methods. Laparoscopic donor nephrectomy is associated with decrease post operative pain, lesser duration of hospitalization, etc. for donors, thus, leading to more number of people opting for kidney donation and augmenting the donor pool. To assess the impact of laparoscopic donor nephrectomy on graft func Aims: tion in recipient of kidney transplantation and to evaluate the advantages of laparoscopic surgery on donor. Settings and Design: A prospective observational study conducted at a tertiary care hospital of New Delhi. A total of 33 transpla Methods and Material: nt pairs were studied. Results of laparoscopic donor nephrectomies were assessed by graft function and donor well being. We studied operative time, warm ischemia time, length of hospitalization, post operative pain and return to work in donors and graft function along with time taken by serum creatinine to normalize in recipients. Statistical analysis used: Data entry was done on Microsoft Excel and was analysed over SPSS version 21.0. A short Results: duration of hospitalisation, low analgesics requirement, lesser post-operative pain, early oral intake, small scar, less chances of wound infection and better cosmesis were seen with laparoscopic donor nephrectomy. We observed that mean duration of donor nephrectomy was 365±73.09 mins with blood loss of 150ml and rst warm ischemia time of 6±0.92mins. Two patients had delayed graft function (DGF). Trend in serum urea and creatinine normalization and post-transplant urine outputs were similar to open donor nephrectomy group. Laparoscopic Conclusions: donor nephrectomy as a minimally invasive procedure is safe and effective. It leads to short hospitalisation, less post-operative pain, better cosmesis etc. for donor without affecting immediate or late graft function in recipient.

Renal Function after Nephrectomy: To Examine any Differences Between Kidney Cancer and Kidney Donation

Objective: To evaluate renal function after radical nephrectomy (RN) and donor nephrectomy (DN), and the differences in changes and identify factors that lead to chronic renal failure. Material and Methods: A retrospective review of patients diagnosed with renal cell carcinoma, who received RN and donors of living kidney transplantation. Kidney function in both groups was measured before and after surgery. We assessed the donors’ kidney functions using an estimated Glomerular filtration rate (eGFR), through a Modification of Diet in Renal Disease (MDRD) formula [GFR = 186 x serum creatine-1.154 age-0.203 x 0.742 (if the patient was female). Kidney function after surgery was evaluated at 1, 3, 6 and 12 months. Rates of renal function decline were analyzed compared with baseline.Results: A total of 249 patients were included in the study, 50 in the DN group and 199 in the RN group. The mean eGFRs before surgery were 68.6 ml/min/1.73m2 and 88.8 ml/min/1.73m2 in the RN and DN groups, respectively. During the first year postoperatively, renal function in the RN and DN groups decreased by approximately 25.6% and 27.2% from baseline, respectively.Conclusion: Renal function after surgery declined after both RN and DN, but the pattern of changes in renal function was different between the groups, possibly due to the patients in the DN group being younger and healthier. There were no differences in percentage of change in eGFR between the groups at the 1 year follow up.

Post nephrectomy renal function: Donor nephrectomy vs. radical nephrectomy

Background/Aim. Monitoring the renal function following donor nephrectomy (DN) or radical nephrectomy (RN) due to kidney tumors is considered essential. The aim of this study was to compare pre-operative and post-operative renal function in patients who underwent DN in relation to patients who underwent RN due to renal malignancy. Methods. A retrospective case-control study was performed, which included 199 patients divided into two groups: group 1 (105 patients) were patients who underwent DN due to living-related/unrelated kidney transplantation, while group 2 (94 patients) was a control group, and included patients who underwent RN due to clear cell renal cell carcinoma in the T1bNoM0 clinical stage, where this surgical procedure was the final form of treatment. Results. Preoperative estimated glomerular filtration rate (eGFR) according to the Chronic Kidney Disease?Epidemiology Collaboration (EPI) equation (eGFR EPI) in the DN group was 94.95 mL/min/1.73 m2, while in the RN group, it was 71.00 mL/min/1.73 m2. Patients who underwent RN tended to have eGFR EPI below 60 mL/min/1.73 m2 after ten years of follow-up compared with patients who underwent DN. In the DN group, the average eGFR EPI was 80.40 mL/min/1.73 m2, and in the RN group, it was 56.00 mL/min/1.73 m2. A higher incidence of diabetes mellitus (DM) and arterial hypertension (AH) was also observed in the DN group of patients compared to the RN group (AH: 44.3% vs. 21.3%; DM: 22.6% vs. 9.6%, respectively). Conclusion. Comparative monitoring of these two groups showed that in both groups, the recovery of the renal reserve was achieved one year after nephrectomy due to the known adaptive mechanisms. Even though the initial renal reserve in a kidney donor is reduced after living kidney transplantation (nephrectomy, permanent loss of renal mass), kidney donors recover kidney function within the first year after surgery due to the adaptive mechanisms.

Evaluation of Kidney Functions After Nephrectomy: Single Center Experience

Aim: In this study, it was aimed to investigate the kidney function, hypertension development and proteinuria in individuals with only one kidney . Patients and Methods: The study included 96 patients who had previously undergone nephrectomy with the causes of nephrolithiasis and chronic pyelonephritis-induced nonfunctional kidney, RCC (Renal Cell carcinoma), trauma, and donor nephrectomy among 17800 patients who applied to the Siirt State Hospital Nephrology and Urology outpatient clinics between January 2016 and December 2019. The data of the patients were obtained from patient files database retrospectiv ely. Results: A total of 96 patients, 45 female and 51 male, were included in the study. 23 (24%) of the patients had donor nephrectomy (DN), and 73 (76%) had nephrectomy (DE) due to nephrolithiasis, chronic pyelonephritis, trauma, and renal cell cancer (RCC). The patients were divided into two groups as those who underwent DN and DE due to other etiologies. Between DN and DE group, there was no statistically significant difference in terms of mean age, distribution of gender, presence of HT before nephrectomy, DM, presence of hematuria and new onset proteinuria (P> 0.05). Compared to the DN group, the frequency of new onset in CKD and HT development was significantly higher DE group. Conclusion: Nephrectomy is a risk factor for the development of CKD, proteinuria and hypertension. Therefore, preventive measures should be taken in a timely manner to reduce the prevalence of nephrectomies due to benign diseases.

Impact of the introduction of pure retroperitoneoscopic living‐donor nephrectomy on perioperative donor outcomes: A propensity score matching comparison with hand‐assisted laparoscopic living‐donor nephrectomy

We previously reported that the outcomes of pure retroperitoneoscopic donor nephrectomy are superior to those of hand-assisted retroperitoneoscopic donor nephrectomy. Consequently, we introduced pure retroperitoneoscopic donor nephrectomy in our hospital. Here, we compared perioperative outcomes between hand-assisted intra-abdominal laparoscopic donor nephrectomy and pure retroperitoneoscopic donor nephrectomy. We retrospectively reviewed data from 315 living-donor kidney transplantation procedures performed between October 2015 and December 2020 (213 involving hand-assisted intra-abdominal laparoscopic donor nephrectomy, October 2015 to June 2019; 102 involving pure retroperitoneoscopic donor nephrectomy, May 2019 to December 2020). After propensity score matching, 90 transplantations were included in each group (n=180 overall). Donors in the pure retroperitoneoscopic donor nephrectomy group had longer warm ischemia times (P< .001), lower serum C-reactive protein concentrations and white blood cell counts on postoperative day 1 (P< .001 and P< .001, respectively), and shorter postoperative stays (P< .001) than donors in the hand-assisted intra-abdominal laparoscopic donor nephrectomy group. Five (5.6%) modified Clavien-classifiable complications occurred in the hand-assisted intra-abdominal laparoscopic donor nephrectomy group; no complications occurred in the pure retroperitoneoscopic donor nephrectomy group (P= 0.008). One recipient in the hand-assisted intra-abdominal laparoscopic donor nephrectomy group had donor-related delayed graft function. There were no significant differences between groups in recipient estimated glomerular filtration on postoperative day 7. The introduction of pure retroperitoneoscopic donor nephrectomy was safe and effective. Moreover, it was less invasive and less harmful for donors, compared with hand-assisted intra-abdominal laparoscopic donor nephrectomy; recipient outcomes were equivalent.

Obese living kidney donors: a comparison of hand-assisted retroperitoneoscopic versus laparoscopic living donor nephrectomy

BackgroundThe aim of this study was to examine the difference in outcome between hand-assisted retroperitoneoscopic and laparoscopic living donor nephrectomy in obese donors, and the impact of donor body mass index on outcome.MethodsOut of 1108 living donors who underwent hand-assisted retroperitoneoscopic or laparoscopic donor nephrectomy between 2010 and 2018, 205 were identified having body mass index ≥ 30. These donors were included in this retrospective study, analyzing postoperative outcomes and remnant renal function.ResultsOut of 205 donors, 137 (66.8%) underwent hand-assisted retroperitoneoscopic donor nephrectomy and 68 donors (33.2%) underwent laparoscopic donor nephrectomy. Postoperative outcome did not show any significant differences between the hand-assisted retroperitoneoscopic donor nephrectomy group and the laparoscopic donor nephrectomy group in terms of major complications (2.2% vs. 1.5%, P = 0.72), postoperative pain scale (4 vs. 4, P = 0.67), and the length of stay (3 days vs. 3 days, P = 0.075). The results of kidney function in donors after nephrectomy demonstrated no significant differences between the groups. Additional analysis of 29 donors with body mass index ≥ 35 (14.1%) as compared with 176 donors with body mass index 30–35 (85.9%) revealed no significant differences between groups in postoperative outcomes as well as kidney function after donation.ConclusionOur results show that laparoscopic living donor nephrectomy for obese donors is safe and feasible with good postoperative outcomes. There were no significant differences regarding postoperative outcome between hand-assisted retroperitoneoscopic and laparoscopic donor nephrectomy. Furthermore, the outcome in donors with body mass index ≥ 35 was comparable to donors with body mass index 30–35.

Systemic immunologic and inflammatory response after transperitoneal versus retroperitoneal laparoscopic donor nephrectomy: A prospective observational study.

Laparoscopic donor nephrectomy (LDN) can be performed via either transperitoneal or retroperitoneal approach. Very few studies have been carried out till now, comparing immunologic and inflammatory responses in donors after these two approaches. This is a prospective observational study. Selection of approach was decided by the operating surgeon. All patients underwent peripheral venous blood sampling preoperatively and 24 h postoperatively for the measurement of C-reactive protein (CRP), interleukein-6 (IL-6), total leukocyte count (TLC), blood urea nitrogen (BUN), and serum creatinine (SCr). Operative time, warm ischemia time, hospital stay, requirement of analgesia, and complications were also recorded. From February 2013 to January 2015, we performed 54 LDNs (38 transperitoneal and 16 retroperitoneal). There were 49 females and five males. Mean operative time was not significantly different in these two approaches, but warm ischemia time was significantly less in the retroperitoneal laparoscopic donor nephrectomy (RLN) group. Postoperative inflammatory markers' (IL-6, CRP, and TLC) levels, BUN, and SCr rise in both of these approaches, but there was no significant difference observed between these two approaches. RLN is a safe and effective approach to preserve a longer right renal vein. It combines the benefit of both hand assistance and retroperitoneal approach. Warm ischemic time is significantly less in RLN group.

IJU this issue

This issue includes 12 Original Articles, two Review Articles, one Case Report and one Urological Note. In one of the Review Articles, Kageyama et al. (Shiga, Japan) traced the history of proteome research in urothelial cancers. In this review, they introduced one promising factor named C7orf24/GGCT as a good candidate target molecule for the therapy. Unfortunately, there are only a few molecules to date that are utilized in the clinical field. The other Review Article by Elsamra et al. (New York, USA) picked up a very practical topic on stenting for malignant ureteral obstruction. Taguchi et al. (Tokyo, Japan) retrospectively reviewed 200 cases of metastatic urothelial carcinoma in terms of neutrophil-to-lymphocyte ratio (NLR). They concluded that elevation of pretreatment neutrophil-to-lymphocyte ratio is a poor prognostic factor for metastatic urothelial cancers. In terms of urothelial cancer, Satake et al. (Tokyo, Japan) reported that preoperative pyuria is a good prognostic marker for non-muscle-invasive bladder cancer. They also concluded that the presence of preoperative pyuria is a useful predictor for recurrence after bacillus Calmette-Guérin therapy. These two articles suggest the important roles of the immune system in the treatment of urothelial cancer. Gershman et al. (Minnesota, USA) examined whether there is a difference in the risk of estimated glomerular filtration rate decline between continent and incontinent urinary diversion after radical cystectomy in patients with preoperative chronic kidney disease stage 2 or 3a. That study gave us very important information that there was no significant difference in long-term renal function between two types of urinary diversions. As Zapata et al. (North Carolina, USA) concluded from the Shared Equal Access Regional Cancer Hospital database, it is interesting that smoking is a predictor of extracapsular extension, positive surgical margin or larger tumor volume. They speculate that smoking might have an impact on the immunological response against prostate cancer. This issue contains two articles related to lymph node dissection. One on penile cancer, by da Costa et al. (Sao Paulo, Brazil), reported that lymphovascular invasion and lymph node ratio (the number of positive nodes/number of total resected nodes) were the independent prognostic factors. The authors successfully showed the impact of risk stratification using lymph node ratio, lymphovascular invasion and extranodal extension on the prognosis of node-positive penile cancer. In another article, Nakamura et al. (Kyoto, Japan) insisted on the importance of resecting both residual retroperitoneal lymph node mass and extraretroperitoneal masses because of the histopathological discordance. Recently, chronic kidney disease has become a serious concern in carrying out kidney surgery. Nephron-sparing surgery for small renal mass is required as much as possible in order to prevent chronic kidney disease after surgery. Lee et al. (Seoul, Korea) compared postoperative estimated glomerular filtration rate between kidney donors and radical nephrectomy patients. According to their propensity-matched study, definite estimated glomerular filtration rate recovery was observed in the donor nephrectomy group rather than the radical nephrectomy group, suggesting kidney cancer itself has an unfavorable nature. In terms of voiding dysfunction, a near-infrared spectroscopic study of interstitial cystitis patients by Matsumoto et al. (Chiba, Japan) is very unique. It sheds light on the neuromodulatory approach to interstitial cystitis. I appreciate you understanding that I cannot introduce all the issues because of the limited space. None declared.

Comparison of renal function after donor and radical nephrectomy

Glomerular filtration rate (GFR) is directly proportionate to nephron reserves. In this respect, it is known that the patients who underwent radical nephrectomy due to renal tumor are under high risk of chronic kidney disease (CKD) in the long term. In this study, it was aimed to compare post-operative renal functions of patients who underwent radical nephrectomy due to renal malignancy and who underwent donor nephrectomy as renal donors, to observe whether renal failure process develops or not, and to determine the factors that affect post-operative renal functions. 70 patients who underwent donor nephrectomy as renal donors and 130 patients who underwent radical nephrectomy due to renal tumor were studied. When we divided the groups as those with a GFR of below 60 mL/min/1.73 m2 and those with a GFR of above 60 mL/min/1.73 m2, we observed that GFR values of patients who underwent radical nephrectomy had a significantly stronger tendency to stay below 60 mL/min/1.73 m2 compared to patients who underwent donor nephrectomy (p < 0.001). When we divided the groups as those with a GFR of below 30 mL/min/1.73 m2 and those with a GFR of above 30 mL/min/1.73 m2, we observed that there were no patients in donor nephrectomy group whose GFR values dropped below 30 mL/min/1.73 m2 and there was not a statistically significant difference between the groups (p = 0.099). If possible, nephron sparing methods should be preferred for patients to undergo nephrectomy because of the tumor without ignoring oncologic results and it should be remembered that patient’s age and pre-operative renal functions may affect post-operative results in donor selection.

Protective response in renal transplantation: no clinical or molecular differences between open and laparoscopic donor nephrectomy

OBJECTIVE:Prolonged warm ischemia time and increased intra-abdominal pressure caused by pneumoperitoneum during a laparoscopic donor nephrectomy could enhance renal ischemia reperfusion injury. For this reason, laparoscopic donor nephrectomy may be associated with a slower graft function recovery. However, an adequate protective response may balance the ischemia reperfusion damage. This study investigated whether laparoscopic donor nephrectomy modified the protective response of renal tissue during kidney transplantation.METHODS:Patients undergoing live renal transplantation were prospectively analyzed and divided into two groups based on the donor nephrectomy approach used: 1) the control group, recipients of open donor nephrectomy (n = 29), and 2) the study group, recipients of laparoscopic donor nephrectomy (n = 26). Graft biopsies were obtained at two time points: T-1 = after warm ischemia time and T+1 = 45 minutes after kidney reperfusion. The samples were analyzed by immunohistochemistry for the Bcl-2 and HO-1 proteins and by real-time polymerase chain reaction for the mRNA expression of Bcl-2, HO-1 and vascular endothelial growth factor. RESULTS:The area under the curve for creatinine and delayed graft function were similar in both the laparoscopic and open groups. There was no difference in the protective gene expression between the laparoscopic donor nephrectomy and open donor nephrectomy groups. The protein expression of HO-1 and Bcl-2 were similar between the open and laparoscopic groups. Furthermore, the gene expression of B-cell lymphoma 2 correlated with the warm ischemia time in the open group (p = 0.047) and that of vascular endothelial growth factor with the area under the curve for creatinine in the laparoscopic group (p = 0.01).CONCLUSION:The postoperative renal function and protective factor expression were similar between laparoscopic donor nephrectomy and open donor nephrectomy. These findings ensure laparoscopic donor nephrectomy utilization in renal transplantation.

Long-Term Graft Function in a Randomized Clinical Trial Comparing Laparoscopic Versus Open Donor Nephrectomy

To evaluate and compare the long-term graft and survival rates in kidney transplant recipients who had undergone laparoscopic donor nephrectomy versus those who underwent open donor nephrectomy. Our study was done with 100 cases of laparoscopic donor nephrectomy and 100 cases of open donor nephrectomy, performed between July 2001 and September 2003. Mean follow-up of recipients in this study was 6.6 ± 2.4 years (range, 1-9.3 y). This study has a longer follow-up than previous randomized clinical trials. We compared patient and graft survival in recipients of laparoscopic donor nephrectomy versus those who had open donor nephrectomy. Mean duration of kidney warm ischemia time was 8.7 ± 2.7 minutes for laparoscopic donor nephrectomy and 1.8 ± 0.92 minutes for open donor nephrectomy. There were no significant differences in 5-year graft survival between the laparoscopic donor nephrectomy and open donor nephrectomy groups (89.5% vs 84.3%; P = .96). There were no differences in delayed graft function between the laparoscopic donor nephrectomy and open donor nephrectomy groups (8 and 11 patients; P = .135). There was a significant difference in 5-year graft survival between recipients with a history of delayed graft function and those without delayed graft function (63.2% vs 89.7%; P = .04). Despite a longer warm ischemia time in laparoscopic donor nephrectomy group (8.69 vs 1.87 min; P = .0001), warm ischemia time had no effect on graft outcome in long-term follow-up. Although earlier experiences with laparoscopic donor nephrectomies were associated with concerns about long-term effects of laparoscopic donation on the graft function in the recipient, our long-term results confirm that laparoscopic donor nephrectomy provides similar graft outcome to open donor nephrectomy.

Cytokine elevation and transaminitis after laparoscopic donor nephrectomy

Acute kidney injury frequently occurs in the critically ill and often progresses into multiorgan dysfunction syndrome, resulting in high mortality. We previously showed that nephrectomized mice had increased interleukin (IL)-6 and tumor necrosis factor (TNF)-α that directly contributed to systemic inflammation and hepatic injury. In this study, we examined whether patients undergoing laparoscopic donor nephrectomy have increased postoperative cytokine levels with injury to the liver and whether the remaining kidney sustains injury. Serial serum and urine samples were collected from 32 patients undergoing laparoscopic donor nephrectomy and 17 patients undergoing nonrenal laparoscopic surgery. Serum IL-6, IL-18, TNF-α and monocyte chemotactic protein-1 (MCP-1) (markers of systemic inflammation) and urinary neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), MCP-1, and IL-18 (markers of acute kidney injury) were quantified by enzyme-linked immunosorbent assay. We also analyzed serum creatinine, aspartate transaminase (AST), and alanine transaminase to assess liver injury. Patients who underwent donor nephrectomy not only demonstrated increased serum creatinine but also had significant increases in serum IL-6, MCP-1, and AST. Serum TNF-α also trended upward in donor nephrectomy patients. Finally, the donor nephrectomy group showed increased urinary NGAL but not KIM-1 at 24 h. Taken together, our findings of increased serum IL-6, MCP-1, and AST after donor nephrectomy suggest that an acute reduction of kidney function induces systemic inflammation and may have distant effects on the liver. Further studies are needed to correlate increased urinary NGAL after donor nephrectomy both as a potential marker for renal tubular stress and/or hypertrophy in the contralateral kidney.

Comparison of Complications of Laparoscopic Versus Laparoendoscopic Single Site Donor Nephrectomy Using the Modified Clavien Grading System

We compared postoperative complications of laparoendoscopic single site and standard laparoscopic living donor nephrectomy using a standardized complication reporting system. We retrospectively analyzed the records of consecutive patients who underwent a total of 663 laparoscopic living donor nephrectomies and 101 laparoendoscopic single site donor nephrectomies. All data were recorded retrospectively. The 30-day complication rate was compiled and graded using the modified Clavien complication scale. Multivariate binary logistic regression was used to determine independent predictors of complications. Baseline demographics were comparable between the groups. Compared to those with laparoscopic living donor nephrectomy patients who underwent laparoendoscopic single site donor nephrectomy had a shorter hospital stay and less estimated blood loss but longer operative time (p <0.05) as well as higher oral but lower intravenous in hospital analgesic requirements (p <0.05). Mean warm ischemia time was marginally lower in the laparoendoscopic single site donor nephrectomy group (3.9 vs 4 minutes, p = 0.03). At 30 days there was no difference in the overall complication rate between the laparoscopic living and laparoendoscopic single site donor nephrectomy groups (7.1% vs 7.9%, p >0.05). There were 8 major complications (grade 3 to 5) in the laparoscopic living donor nephrectomy group but only 1 in the laparoendoscopic single site group. Multivariate binary logistic regression analysis revealed that estimated blood loss was a predictor of fewer complications at 30 days. With appropriate patient selection and operative experience laparoendoscopic single site donor nephrectomy may be a safe procedure associated with postoperative outcomes similar to those of laparoscopic living donor nephrectomy as well as low morbidity. Using a standardized complication system can aid in counseling potential donors in the future.

Comparison between laparoscopic and subcostal mini-incision for live donor nephrectomy.

The aim of this study was to compare the results of laparoscopic donor nephrectomy with open donor nephrectomy. A non-randomized prospective analysis was conducted of living donor kidney transplantations (118 open donor nephrectomies; 57 laparoscopic donor nephrectomies) between January 2005 and December 2007 in the Kidney Transplantation Unit of Hospital das Clínicas of Faculdade de Medicina of the Universidade de São Paulo. Mean donor operative time, mean donor hospital stay, mean postoperative creatinine values, and rates of complications and graft survival were similar for both groups. A significant statistical difference in warm ischemia time was observed between the open donor nephrectomy and laparoscopic donor nephrectomy groups (p < 0.001). There was only one conversion in the laparoscopic donor nephrectomy group. Laparoscopic donor nephrectomy is a safe procedure for a donor nephrectomy, comparable to an open procedure with similar results despite a longer warm ischemia time.

Factors affecting changes in the glomerular filtration rate after unilateral nephrectomy in living kidney donors and patients with renal disease.

We evaluated the factors affecting changes in the postoperative glomerular filtration rate (GFR) after unilateral nephrectomy in living kidney donors and patients with renal disease. We studied 141 subjects who underwent living donor nephrectomy for renal transplantation (n = 75) or unilateral nephrectomy for renal diseases (n = 66). The GFR of the individual kidney was determined by Tc-99m DTPA scintigraphy before and after nephrectomy. By performing multiple linear regression analysis, we evaluated the factors that are thought to affect changes in GFR, such as age, sex, body mass index (BMI), preoperative GFR, preoperative creatinine level, operated side, presence of diabetes mellitus (DM), presence of hypertension (HTN), and duration of follow-up. In both the donor nephrectomy and the disease nephrectomy groups, GFR increased significantly after nephrectomy (46.9 ± 8.4 to 58.1 ± 12.5 vs. 43.0 ± 9.6 to 48.6 ± 12.8ml/min, p < 0.05). In the donor nephrectomy group, age was significantly associated with change in GFR (β = -0.3, p < 0.005). In the disease nephrectomy group, HTN, preoperative creatinine level, and age were significantly associated with change in GFR (β = -6.2, p < 0.005; β = -10.9, p < 0.01; β = -0.2, p < 0.01, respectively). This compensatory change in GFR was not significantly related to sex, duration of follow-up, or operated side in either group. The compensatory change in the GFR of the remaining kidney declined with increasing age in both living kidney donors and patients with renal disease.

Right laparoscopic donor nephrectomy: The Washington Hospital Center experience

Objectives To review 167 consecutive laparoscopic living donor nephrectomies performed at the Washington Hospital Center to determine whether the side of extraction, right versus left, affects the operative outcomes. Methods From January 2003 to June 2005, 167 consecutive patients (127 left and 40 right) underwent laparoscopic living donor nephrectomy. The right-sided and left-sided procedures were compared in the following categories: operative time, warm ischemia time, length of stay, and complications. Results The mean operative time for a right donor nephrectomy was 220 minutes versus 228 minutes for a left. The mean estimated blood loss was 115 mL for right donor nephrectomy versus 106 mL for the left. The corresponding mean warm ischemia times were 5.32 minutes and 4.91 minutes. The median length of stay was 3 days in both groups. Five minor and three major complications occurred, including 2 patients with recognized bowel injuries and 1 patient who required reoperation for a bladder injury. Conclusions Historically, laparoscopic living donor nephrectomy has been performed solely on the left side because of the increased length of the left renal vein. However, in our experience, the operative parameters and postoperative results were equivalent in the right and left laparoscopic donor nephrectomy groups. Therefore, we recommend removal of the more appropriate kidney, regardless of side.

Antidiuretic Hormone Release During Laparoscopic Donor Nephrectomy--Invited Critique

Background: During laparoscopic procedures, increased intra-abdominal pressure may cause transient renal dysfunction due to impaired renal blood flow and induction of neurohormones. However, the relationship between antidiuretic hormone (ADH) secretion and increased intra-abdominal pressure is poorly understood. Hypothesis: Laparoscopic donor nephrectomy (LDN) is associated with an increase in plasma ADH concentration, which influences renal function in both the donor and transplanted graft. Objectives: To evaluate plasma ADH levels during LDN and to correlate ADH levels with graft function. Design and Interventions: In 30 patients who underwent LDN, plasma ADH levels were collected before insufflation, during surgery, after desufflation, and 24 hours after the procedure. In 6 patients who had open donor nephrectomy, blood samples were obtained as controls. Furthermore, graft function, operative characteristics, and clinical outcome were compared. Setting: University hospital. Results: In the LDN group, mean ADH levels during pneumoperitoneum and 30 minutes postinsufflation were significantly higher compared with preinsufflation values (P<.001). Twenty-four hours after LDN, mean ADH levels had returned to normal values. There were no significant differences in ADH levels in the open donor nephrectomy group. No significant differences in either intraoperative diuresis, blood pressure readings, or postoperative graft function were documented among the 2 groups. Conclusions: In this study, LDN was associated with an increase in plasma ADH that appeared to be related to increased intra-abdominal pressure. We conclude that the increased ADH concentrations during LDN are not associated with clinically significant changes in either the kidney donor or the transplanted graft.

Antidiuretic hormone release during laparoscopic donor nephrectomy.

During laparoscopic procedures, increased intra-abdominal pressure may cause transient renal dysfunction due to impaired renal blood flow and induction of neurohormones. However, the relationship between antidiuretic hormone (ADH) secretion and increased intra-abdominal pressure is poorly understood. Laparoscopic donor nephrectomy (LDN) is associated with an increase in plasma ADH concentration, which influences renal function in both the donor and transplanted graft. To evaluate plasma ADH levels during LDN and to correlate ADH levels with graft function. In 30 patients who underwent LDN, plasma ADH levels were collected before insufflation, during surgery, after desufflation, and 24 hours after the procedure. In 6 patients who had open donor nephrectomy, blood samples were obtained as controls. Furthermore, graft function, operative characteristics, and clinical outcome were compared. University hospital. In the LDN group, mean ADH levels during pneumoperitoneum and 30 minutes postinsufflation were significantly higher compared with preinsufflation values (P<.001). Twenty-four hours after LDN, mean ADH levels had returned to normal values. There were no significant differences in ADH levels in the open donor nephrectomy group. No significant differences in either intraoperative diuresis, blood pressure readings, or postoperative graft function were documented among the 2 groups. In this study, LDN was associated with an increase in plasma ADH that appeared to be related to increased intra-abdominal pressure. We conclude that the increased ADH concentrations during LDN are not associated with clinically significant changes in either the kidney donor or the transplanted graft.