Living Donor Nephrectomy Research Articles

Investigation of Systolic Blood Pressure, Diastolic Blood Pressure, and Pulse Pressure in Living Kidney Donors After Donor Nephrectomy

Kidney transplants from living donors have increased, but few studies have examined the long-term risks of live donor nephrectomy. This is the first study to report the blood pressure (BP) changes associated with cardiovascular disease and linked to chronic kidney disease (CKD) 1 year after live donor nephrectomy. This study examined a prospective cohort of patients who underwent donor nephrectomy between March 1, 2006, and December 31, 2016, at the Severance Hospital, Seoul, South Korea. CKD was defined as a glomerular filtration rate (GFR) of < 60 mL/min/1.73m2. Patients with a history of hypertension or CKD or an estimated GFR < 60 mL/min/1.73m2 were excluded; those examined after 1 year post-nephrectomy were included in the study population. Among 420 patients who underwent donor nephrectomy, 137 (32.6%) developed a first-time onset of a GFR < 60 mL/min/1.73m2 by the first year after surgery. After propensity score–matching the age, systolic BP (P < .001) and pulse pressure (P = .006) were significantly associated with the groups with newly developed CKD. Systolic BP and pulse pressure decreased significantly at 1 year after donor nephrectomy. These differences decreased after donor nephrectomy, possibly lowering the risk of cardiovascular disease.

Yearly Trends of Chronic Kidney Disease III Progressions in Living Kidney Donors

PurposeWe aim to see the rate of progression to chronic kidney disease stage III after living donor nephrectomy in a single institution annually. MethodsBetween May 2006 and July 2017, a total of 753 living kidney donors who were followed up more than 6 months were enrolled in the study. We divided normal function vs chronic kidney disease III at 6 months postoperatively. We compared the incidence rate of chronic kidney disease stage III annually. For analysis, the entire period was divided into Era 1 (2006–2008), Era 2 (2009–2011), Era 3 (2012–2014), and Era 4 (2015–2017). ResultsDuring the period, the incidence of chronic kidney disease stage III was 258 living donors (34.3%). The prevalence of chronic kidney disease stage III was 39.3%, 36.6%, 35.5%, and 29.3% in Era 1, Era 2, Era 3, and Era 4, respectively. The rate of chronic kidney disease stage III incidence serially decreased as the era passed (P = .046). There was no difference in age, smoking status, drinking status, body mass index, preoperative cholesterol, and uric acid among the eras. However, preoperative estimated glomerular filtration rate was 90.86 (SD, 4.12), 94.47 (SD, 16.62), 103.82 (SD, 0.68), and 105.66 (SD, 19.57) mL/min/1.73 m2 in Era 1, Era 2, Era 3, and Era 4, respectively (P = .001). ConclusionsThe incidence of chronic kidney disease stage III in living kidney donors for the last 3 years (Era 4) has decreased compared with the past (Era 1 and 2). The reason for this might be the effect of the change in the living donor guideline. Also, pre- and postoperative management method had an effect on renal function at 6 months.

Nefrectomía laparoscópica derecha de donante vivo: evaluación del resultado y asociación del IMC con la longitud de la vena renal derecha

AimsThe aim of this study was to describe outcomes of laparoscopic living donor right nephrectomy (LLDRN) and study factors affecting the length of right renal vein from the donors. Material and methodsThis study was conducted in 60 donors (48 males and 12 females) from January 2016 to December 2017. We performed a retrospective review of consecutive patients who underwent transperitoneal right laparoscopic living donor nephrectomy at our unit. ResultsLLDRN was successfully performed in all subjects by the same surgeons. Among 60 cases, 47 donors had single renal artery and vein, 2 cases had one artery and 2 veins, and 5 donors had 2 arteries and one vein, and the rest had 2-3 arteries with 1-3 veins. Operative time was 142.60±33.73min. Warm ischemic time was 2.64±0.76min. The mean hospital stay was 6.69±0.63 days. The median length of right renal vein was 1.92±0.41cm. All transplanted kidneys showed immediate function. No graft losses were recorded. Almost no gender differences were found in study variables except BMI and warm ischemic time, that was higher BMI but shorter warm ischemic time in female versus male donors. Further analysis showed a negative correlation between BMI and right renal vein (r=−0.282, P<0.05), but a positive correlation between operative time and estimate blood loss (r=0.37, P<0.01). ConclusionsLLDRN is a feasible safe procedure, less traumatic approach, and provides good outcomes kidney for recipients. Notably, in the study group the higher BMI was associated with resulting more difficult LLDRN and kidney transplantation.

Cost-effectiveness of four living-donor nephrectomy techniques from a hospital perspective.

In Europe, transplantation centres use different nephrectomy techniques: open surgery, and standard, hand-assisted and robot-assisted laparoscopies. Few studies have analysed the disparity in costs and clinical outcomes between techniques. Since donors are healthy patients expecting minimum pain and fast recovery, this study aimed to compare the cost-effectiveness of four nephrectomy techniques focusing on early surgical outcomes, an essential in the donation act. A micro-costing approach was used to estimate the cost of implementation from a hospital perspective. Estimates took into account sterilization costs for multiple-use equipment, costs for purchasing single-use equipment, staff and analgesics. The study recruited donors in 20 centres in France. Quality of life by EuroQol-5D was assessed preoperatively, and 4 and 90 days post-operatively. Two effectiveness indicators were built: quality-of-life recovery and post-operative pain days averted (PPDA). The study was registered at ClinicalTrials.gov NCT02830568, on 10 June 2010. A total of 264 donors were included; they underwent open surgery (n = 65), and standard (n = 65), hand-assisted (n = 65) and robot-assisted laparoscopies (n = 69). Use of the nephrectomy techniques differed greatly in cost of implementation and immediate post-operative outcomes but not in clinical outcomes at 90 days. At 4 days, hand-assisted laparoscopy provided the lowest cost per quality-of-life recovery unit of effectiveness (%) and PPDA (days) (€2056/40.1%/2.3 days, respectively). Robot-assisted laparoscopy was associated with the best post-operative outcomes but with the highest cost (€3430/59.1%/2.6 days). Hand-assisted, standard and robot-assisted laparoscopies are cost-effective techniques compared with open surgery. Hand-assisted surgery is the most cost-effective procedure. Robot-assisted surgery requires more healthcare resource use but enables the best clinical outcome.

Devenir à long terme de la fonction rénale et facteurs prédictifs d’insuffisance rénale chronique après don vivant

Living donor kidney transplants give the best results in term of renal function and are the principal solutions for the transplant shortage. However, donors selection and kidney function evaluation after surgery are essential. The objective of this study was to evaluate the prevalence and to identify the predictive factors of chronic renal failure for the donor, after living donor nephrectomy. It was a retrospective and monocentric study, including all the patients who underwent a living donor nephrectomy from 2007 to 2015 at the hospital of the Conception in Marseille. The primary study endpoint was renal function mesured by the glomerular filtration rate (GFR in mL/min) at 1 year and 5 years after surgery. The identification of moderate kidney failure predictive factors was achieved by an univariate and a multivariate analysis under Cox model. Ninety-one patients were included. There was 40,7% of men and media nage was 49 years (21; 70). Median pre-operative GFR was 94mL/min (67; 160). Median follow-up was 24 months (1; 120). Post operative GFR at 1 month, 1 year and 5 years was respectively 63mL/min (33; 90), 65mL/min (38; 107) and 67mL/min (56; 126) ans significantly lower than pre operative GFR (respectively P<0,001, P<0,001 et P=0,005). The prevalence of moderate kidney failure at 1 month, 1 year and 5 years was respectively 43,1%, 33,3% ans 25%. In univariate and multivariate analysis, the only parametre significantly associated with a 1 year GFR>60mL/min wasp re operative GFR>90mL/min OR 3,61 IC95% (1,27; 10,28) P=0,02. Living donor nephrectomy leads to an important medium to long term loss of renal function. Donors with pre operative GFR<90mL/min should benefit from a rigorous supervision and nephrological care. 3.

The true risk of living kidney donation.

The safety of living donor nephrectomy is essential to the continued success, growth, and sustainability of the clinical practice of living donor kidney transplantation. This review summarizes recent advances in our understanding of the perioperative and long-term risks faced by living kidney donors. Although adverse perioperative complications are extremely rare, donors particularly men, Black, or obese, frequently experience minor complications that result in delayed return to normal duties at home and work. Similarly, although long-term complications such as end-stage renal disease (ESRD) are rare, recent studies suggest a relative increase in risk of ESRD that is attributable to donation. Several risk calculators have been developed to help donors and their care providers quantify the baseline and postdonation risk of ESRD based on demographic and health characteristics. Thresholds of risk may help define what is an acceptable level of risk to the donor and the transplant center. Individualized risk calculators now allow care providers and potential donors to objectively and transparently participate in shared decision-making about the safety of living kidney donation.

Examining the effects of Hurricane Sandy among World Trade Center Health Registry (WTCHR) enrollees using a mixed methods approach

Laparoscopic donor nephrectomy (LDN) is considered the gold standard for live donor nephrectomies owing to lesser pain, shorter hospitalization, and earlier return to normal activities, yet it remains a technically challenging surgery. Repetition of a highly skilled task such as LDN should lead to improved performance reflected in shorter surgery times and a decrease in adverse events.The records of over 2524 LDNs from February 2004 to June 2019 were evaluated for duration of surgery (from incision time to clamping of the renal artery) and occurrence of complications.The mean duration of surgery ± SD from incision to clamp time for the first 100 cases at the inception of LDN was 166.13 ± 33.28 minutes whereas it was 124.59 ± 35.91 minutes for the best 100 consecutive cases in 2015 with a decrease of 41 minutes duration of surgery from incision to artery clamping. The adverse events were accessory renal artery injury (n = 10), splenic laceration (n = 2), bowel and mesocolon injuries (n = 12), venous or arterial clip slippage (n = 4), inferior vena cava tear (n = 2) pneumothorax (during stapler application, n = 1), missing gauze counts (n = 1), chylous ascites (n = 1), ureteric thermal injury (n = 2), and renal parenchyma injury (n = 3).LDN is a technically demanding surgery where surgeon experience appears to affect operative metrics such as operative time. The occurrence of intraoperative complications appears to be acceptably low, although serious complications are a possibility.

Robot-assisted laparoscopic donor nephrectomy: surgical feasibility and technique

BackgroundLaparoscopic donor nephrectomy (LDN) is currently accepted as the gold standard procedure for living donor nephrectomy. Robot-assisted LDN (RALDN), an evolving procedure, has recently shown potential to ultimately emerge as the preferred procedure. Here, we report our experience and the surgical technique followed for employing RALDN for living donation. MethodsThis retrospective study involved 56 consecutive patients who underwent RALDN between January 2015 and August 2018. Intraoperative and postoperative functional outcomes were analyzed and compared with the 45 patients who underwent hand-assisted LDN (HALDN) between May 2011 and December 2014. ResultsMean procedure time for RALDN was 150 (range 90–210) min, and mean overall intraoperative blood loss was <100 (range 50–200) mL. Mean warm ischemic time recorded was 2 (range 1–5) min. Intraoperative complications, including blood transfusion or open conversion, did not occur in any patient. ConclusionsThe procedural results of RALDN were comparable or superior to HALDN. Our RALDN approach is safe and feasible, and the procedure appears to be significantly easier for the surgeon. We suggest that our findings be externally validated to reassure reproducibility of the measurement in a prospective evaluation.

Patterns and predictors of fatigue following living donor nephrectomy: Findings from the KDOC Study.

This study sought to identify the prevalence, pattern, and predictors of clinical fatigue in 193 living kidney donors (LKDs) and 20 healthy controls (HCs) assessed at predonation and 1, 6, 12, and 24monthspostdonation. Relative to HCs, LKDs had significantly higher fatigue severity (P=.01), interference (P=.03), frequency (P=.002), and intensity (P=.01), and lower vitality (P<.001), at 1-month postdonation. Using published criteria, significantly more LKDs experienced clinical fatigue at 1 monthpostdonation, compared to HCs, on both the Fatigue Symptom Inventory (60% vs. 37%, P<.001) and SF-36 Vitality scale (67% vs. 16%, P<.001). No differences in fatigue scores or clinical prevalence were observed at other time points. Nearly half (47%) reported persistent clinical fatigue from 1 to 6months postdonation. Multivariable analyses demonstrated that LKDs presenting for evaluation with a history of affective disorder and low vitality, those with clinical mood disturbance and anxiety about future kidney failure after donation, and those with less physical activity engagement were at highest risk for persistent clinical fatigue 6monthspostdonation. Findings confirm inclusion of fatigue risk in existing OPTN informed consent requirements, have important clinical implications in the care of LKDs, and underscore the need for further scientific examination in this population.

MON-183 EXPERIENCE IN KIDNEY TRANSPLANTATION IN NEPHROLOGY & TRANSPLANT UNIT, TEACHING HOSPITAL, KANDY, SRI LANKA -A SINGLE CENTER EXPERIENCE

Kidney transplantation using organs from deceased or live donors, has been well established as the optimal management for patients with End Stage Renal Disease (ESRD). Along with the global data, Sri Lanka is also having a huge disparity between the need and the availability of kidneys. Nephrology & Transplant units in Sri Lanka, Teaching Hospital, Kandy commenced kidney transplantation on November, 2010 starting with live donor (LD) transplant. Deceased donor (DD) coordination programme was started in May, 2014. Retrospective data collection was done using registries from the theater and the deceased donor coordination center. Data with regard to the numbers of living and deceased donor transplants were collected from year 2001-2018. Sex and the age distribution of recipients and donors of 2017 and 2018 were analyzed. Year 2011 had the maximum number of LD transplants (n=93) while the numbers have decreased to 42 in 2018. Mean number of LD kidney transplant during the past decade is 78 per year. The DD transplants have increased from 8 in 2014 to 28 in 2018. The maximum number of total kidney transplants were done in 2016 (n=102) and it had dropped to 70 by 2018. The mean number of total kidney transplants done during the past decade is 92 per year. 2. Age and sex distribution of recipients Out of 168 recipients, 122 were males (72.61%) and the rest were females (n= 46, 27.38%). There were 59 (35.11%) DDs and 109 (64.88%) LDs. Among them there were only 5 of age <20 years (3.01%, 4 LD, 1 DD) , 56 in 20-40 years (33.73%, 45 LD, 11 DD), 103 in 40-60 years (62.04%, 58 LD, 45 DD) and only 4 with age >60 years(2.4%, 2 LD, 2 DD) . 3. Age and sex distribution of donors Out of 146 donors, 108 (73.97%) were LDs while the rest were DDs (n= 38, 26.02%). There were 78 (53.42%) males and 68 (46.57%) females. Three donors were of age <20 years (all male, DDs) and 43 were of age 20-39 years (29 LD, 14 DD) . Out of them 26 were males and the rest (n= 17) were females. Ninety one donors were within 40-59 years and consisted of 47 males and 44 females (73 LDs,18 DDs). Nine donors were of age >60 years (2 males, 7 females). Among them 6 were LDs and the rest (n=3) were DDs. Out of all there were 6 laparoscopic live donor nephrectomies done in 2018. Three DD kidneys were discarded due to unsuitability for transplantation following transfer. Liver retrieval started in 2018 and there were 12. Two liver transplants were done at our unit and the rest (n=10) were transferred to National Hospital, Sri Lanka. Although there is a dip in total annual kidney transplantations, the dialysis burden increases. The reasons are difficulty in finding a donor within a nuclear family, more stringent donor criteria, de motivation to find a LD due to availability of deceased donor programme etc. Two other major hospitals in the North Central province of Sri Lanka, at Anuradhapura and Polonnaruwa have also commenced kidney transplantations there by reducing our burden. However, it is very important to increase the supply of more kidneys. Education regarding organ donation, improvement of infrastructure for organ management, Donor card with consent for organ donation, consideration of expanded donor criteria, Laparoscopic donor nephrectomy, initiation of paired donor exchange programme needs attention.

Effect of Pneumoperitoneum on Renal Resistive Index and Renal Function in Patients Who Have Undergone Laparoscopic Living Donor Nephrectomy: A Pilot Study

IntroductionThe use of low-pressure pneumoperitoneum during laparoscopic living donor nephrectomy (LLDN) was assumed to cause less renal damage compared to high-pressure pneumoperitoneum. This study aims to evaluate the effect of low vs high-pressure pneumoperitoneum during LLDN on renal function and renal resistive index (RRI), which has never been done before. Materials and MethodsThe subjects were divided into 2 groups, low-pressure (8–10 mmHg) and high-pressure pneumoperitoneum (12–14 mmHg). The RRI, serum creatinine, and estimated glomerular filtration rate were measured during the perioperative period. ResultsA total of 45 samples were analyzed in this study: 17 subjects in the low-pressure pneumoperitoneum group and 28 subjects in the high-pressure group. RRI levels remained within the normal range (< .80) with no significant difference observed between the 2 groups (P > .05) before surgery, intraoperatively, or post-surgery. The preoperative and postoperative serum creatinine and glomerular filtration rate were similar in both groups. ConclusionsThe use of low-pressure pneumoperitoneum had no benefit compared to high-pressure pneumoperitoneum in preserving RRI and function in LLDN.

Living Donor Nephrectomy: Is It as Safe as It Can Be? Analysis of Living Donor Deaths in the United States.

The reported 90-day rate of death from living donor nephrectomy is 3 in 10,000 donations. Although this risk is low, the important question is how many deaths are preventable? To study this question, all living donor nephrectomy cases, 139,186 procedures, recorded in the Scientific Registry of Transplant Recipients database since its inception in 1987 were analyzed to determine the death rate and the number of deaths that were potentially preventable. Preventable deaths were defined as any death in the first 7 days except due to clearly unrelated events or death from hemorrhage, pulmonary embolism, infection, cardiovascular cause, or suicide in the first 90 days. The numbers of deaths at 7, 30, 90, and 365 days after donation were 16, 26, 38, and 86, which translated into 1.15, 1.87, 2.73, and 6.18 deaths per 10,000 donations, respectively. From 2000 onward, when coding was available for cause of death, 19 of the 30 deaths were deemed potentially preventable. The nonrisk-adjusted rate of death with laparoscopic donation was higher than open nephrectomy, but this difference did not reach statistical significance. Conversion from laparoscopic to open nephrectomy occurs in approximately 1 in 100 surgeries, and this rate has remained fairly steady since 2005. This analysis suggests that up to two thirds of deaths are potentially preventable. The transplant community should consider additional safety strategies such as simulation training of rare complications to lower donor risk.

Response to Letter to the Editor RE: Hirose et al., Safety and Efficacy of Retroperitoneoscopic Living Donor Nephrectomy: Comparison of Early Complication, Donor and Recipient Outcome with Hand-Assisted Laparoscopic Living Donor Nephrectomy by Hirose et al. (From: Goyal K, Singh AK, Kumar U, et al. J Endourol 2019;33:503; DOI: 10.1089/end.2019.0099).

Response to Letter to the Editor RE: Hirose et al., Safety and Efficacy of Retroperitoneoscopic Living Donor Nephrectomy: Comparison of Early Complication, Donor and Recipient Outcome with Hand-Assisted Laparoscopic Living Donor Nephrectomy by Hirose et al. (From: Goyal K, Singh AK, Kumar U, et al. J Endourol 2019;33:503; DOI: 10.1089/end.2019.0099).

Full Robot-Assisted Living Donor Nephrectomy and Kidney Transplantation in a Twin Dedicated Operating Room: Initial Experience From a High-Volume Robotic Center.

Purpose. To describe our initial experience with a full robot-assisted approach for living donor nephrectomy (RALDN) and kidney transplantation (RAKT) in a dedicated twin operating room. Methods. From January to December 2017, 5 cases of RALDN and RAKT were performed in a single high-volume robotic center. All patients underwent a standard left RALDN. The renal hilum was controlled with Hem-O-Lok clips (WECK) and the kidney extracted through a Pfannenstiel incision. RAKT was performed according to the Vattikuti Urology Institute-Medanta technique. Results. RALDN: median estimated blood loss was 182 mL (range = 80-450 mL), no postoperative blood transfusion was required. The median (range) warm ischemia time was 175 (90-220 seconds). No conversion was registered. Median console time was 143 minutes (range = 115-220 minutes). No major surgical intraoperative and postoperative early and late complications occurred. RAKT: all 5 patients successfully underwent RAKT. Median (range) console time was 230 (190-200) minutes, vascular suture time was 58.7 (48-73) minutes, cold ischemia time was 46.2 (30-88) minutes, and rewarming time was 61.2 (55-72) minutes. No conversion was required. No major surgical intraoperative and postoperative early and late complications occurred. Mean glomerular filtration rate at days 1, 3, and 7 postoperatively was 26, 42, and 57 (range = 6-90) mL/min/1.73 m2, respectively. No case of delayed graft function was observed. No anastomosis revision, urological complications, lymphocele, and surgical site infection occurred. Conclusions. In our experience, RALDN and RAKT are safe and effective. The intuitiveness of the robotic approach provided substantial benefits both for the living donor and recipient from the very beginning of our series. No intraoperative and postoperative complications occurred.

Donor and Recipient Outcomes following Robotic-Assisted Laparoscopic Living Donor Nephrectomy: A Systematic Review.

Aims We aimed to summarize available lines of evidence about intraoperative and postoperative donor outcomes following robotic-assisted laparoscopic donor nephrectomy (RALDN) as well as outcomes of graft and recipients. MethodsA systematic review of PubMed/Medline, ISI Web of Knowledge, and Scopus databases was performed in May 2018. The following search terms were combined: nephrectomy, robotic, and living donor. We included full papers that met the following criteria: original research; English language; human studies; enrolling patients undergoing RALDN. Results Eighteen studies involving 910 patients were included in the final analysis. Mean overall operative and warm ischemia times ranged from 139 to 306 minutes and from 1.5 to 5.8 minutes, respectively. Mean estimated blood loss varied from 30 to 146 mL and the incidence of intraoperative complications ranged from 0% to 6.7%. Conversion rate varied from 0% to 5%. The mean hospital length of stay varied from 1 to 5.8 days and incidence of early postoperative complications varied from 0% to 15.7%. No donor mortality was observed. The incidence of delayed graft function was reported in 7 cases. The one- and 10-year graft loss rates were 1% and 22%, respectively. ConclusionsBased on preliminary data, RALDN appears as a safe and effective procedure.

Diabetes in palliative and end-of-life care: scoping reviews as a systematic strategy for consideration of complementary medicine in clinical guidelines

Laparoscopic living donor nephrectomy (LLDN) has become the standard procedure for living kidney transplantation. Enhanced recovery after surgery (ERAS) is a multimodal perioperative management aimed at facilitating rapid patient recovery after major surgery by modifying the response to stress induced by exposure to surgery. This association can further reduce hospital stay, surgical stress, and perioperative morbidity of living kidney donors.In this retrospective analysis conducted at our institute, we compared the first 21 patients who underwent LLDN enrolled with the ERAS protocol with 55 patients who underwent LLDN with the fast-track protocol in the 5 years prior to ERAS protocol implementation.We evaluated 76 consecutive patients. After ERAS protocol implementation, elderly living donors had a shorter hospital stay and a faster return to normal life compared with the same age group of patients in the previous period. There were no major differences in median postoperative hospital stay and no meaningful differences in the percentage of complications after surgery and hospital readmissions.The introduction of the ERAS protocol for patients undergoing LLDN compared with the traditional protocol led to a reduction in postoperative hospitalization in elder donors, without determining a raise in the number of hospital complications and readmissions.

Chronic pain following laparoscopic living-donor nephrectomy: Prevalence and impact on quality of life.

Chronic postsurgical pain (CPSP) following laparoscopic donor nephrectomy (LDN) is a disregarded topic. In this cross‐sectional study, all consecutive patients who underwent an LDN at the Radboud University Medical Center (Radboudumc; 2003‐2016) were approached for participation. Five hundred twelve living kidney donors were included and asked to complete two questionnaires, including the McGill Pain Questionnaire and the RAND Short Form‐36 Health Status Inventory (RAND SF‐36) regarding their health‐related quality of life (HRQoL). The mean prevalence of CPSP following LDN was 5.7%, with a mean follow‐up time of 6 years. Possible predictors of CPSP following LDN are severe early postoperative pain, previous abdominal surgery, and preexisting backache. The RAND SF‐36 revealed an impaired HRQoL in patients with CPSP when compared to patients without CPSP. In conclusion, this study revealed that the prevalence of CPSP following LDN is substantial. Given the possible association between the presence of CPSP and impaired HRQoL scores, living kidney donors should be well informed in the preoperative phase about the risk of CPSP.

Letter to the Editor RE: Hirose et al., Safety and Efficacy of Retroperitoneoscopic Living Donor Nephrectomy: Comparison of Early Complication, Donor and Recipient Outcome with Hand-Assisted Laparoscopy Living Donor Nephrectomy (From: Hirose T, Hotta K, Iwami D, et al. J Endourol 2018;32:1120-1124; DOI: 10.1089/end.2018.0669).

Letter to the Editor RE: Hirose et al., Safety and Efficacy of Retroperitoneoscopic Living Donor Nephrectomy: Comparison of Early Complication, Donor and Recipient Outcome with Hand-Assisted Laparoscopy Living Donor Nephrectomy (From: Hirose T, Hotta K, Iwami D, et al. J Endourol 2018;32:1120-1124; DOI: 10.1089/end.2018.0669).

Bariatric surgery prior to living donor nephrectomy: a solution to expand the living donor kidney pool - a retrospective study.

Most transplant centers decline morbidly obese people for living kidney donation. Their inclusion in the living donor pool after weight loss and reversal of comorbidities by bariatric surgery could reverse the downward living donation trend. We investigated whether bariatric surgery in the morbidly obese altered their candidacy for donation, complicated their subsequent donor nephrectomy, and impacted their early postoperative outcomes in a series of 22 donors who had bariatric surgery 0.7-22 years prior to laparoscopic living donor nephrectomy. Eighteen would have been excluded from donation prior to bariatric surgery based on a body mass index (BMI) > 40. Seventeen reached a BMI < 35 after bariatric surgery. One had hypertension that resolved after bariatric surgery. Prior bariatric surgery did not influence port placement and laterality of donor nephrectomy. None required open conversion or blood transfusion. In an exploratory comparison with 37 donors with a BMI 35-40, length of stay and warm ischemic time were shorter, blood loss and postoperative complications were similar, and operative time was longer. We therefore advocate the consideration of bariatric surgery in preparation for donation in morbidly obese people since it positively alters their candidacy without major impact on the subsequent living donor nephrectomy and early outcomes.

Pure versus hand-assisted retroperitoneoscopic live donor nephrectomy: a retrospective cohort study of 1508 transplants from two centers.

Although minimally invasive procedures have been established as the standard for a donor nephrectomy, there are many different surgical techniques described in the literature. The aim of this study is to compare the outcomes of kidney transplant procedures using the pure retroperitoneoscopic donor nephrectomy (PRDN) and hand-assisted retroperitoneoscopic donor nephrectomy (HARDN) techniques. A retrospective study involving 1508 transplant procedures was conducted; 874 were PRDN procedures; and 634 were HARDN. We reviewed the outcomes of the PRDN and HARDN groups, which were performed at two different centers over an identical time period. Donors in the PRDN group had a longer operation time (P < 0.0001), reduced estimated blood loss (P < 0.0001), less open conversion (P = 0.0002), lower postoperative serum C-reactive protein levels (P < 0.0001), and a shorter postoperative hospital stay (P < 0.0001) than the HARDN group. Recipients in the PRDN group had lower serum creatinine levels at postoperative day 1-6 and the decreased incidence of slow graft function (P = 0.0017) than the HARDN group. The HARDN procedure was an independent risk factor for the incidence of acute rejection (P = 0.0211) and graft loss (P = 0.0193). Our study suggests that the PRDN procedure is less invasive for donors as it results in reduced blood loss, lower postoperative serum CRP levels, and a shorter postoperative stay than the HARDN procedure. Additionally, PRDN provides a better outcome for recipients as it lowers the incidence of acute rejection and improves graft survival compared to HARDN.