Renal outcome 25 years after donor nephrectomy. J Urol. 2001;166:2043-2047. [PMID: 11696703 DOI: 10.1016/s0022-5347(05)65502-4]

Medical risk analysis of renal transplant donors

AIM

The aim of this study was to evaluate the long-term medical risks of living-related donors in our center.

PATIENTS AND METHODS

185 living-related donors participated in the study. The factors assessed were creatinine clearance rate (CrCl), serum creatinine (SCr), BUN, hematocrit levels, proteinuria, microalbuminuria and hypertension rates, and renal parenchyma thickness and kidney dimensions predonation as well as at the last follow-up. In addition, we examined postoperative complications. A lombotomy incision was the choice for donor nephrectomy procedure routinely.

RESULTS

The mean length of hospital stay after donor nephrectomy was 3.2 +/- 0.6 days (range, 2-5 days). Seven donors readmitted during the first month after operation with surgical site infection were treated successfully. Four donors were reoperated for incisional hernia repairs and discharged without complication. The mean follow-up period was 61.6 +/- 50.4 months (range, 2-180 months). Mean ages of the donors at operation and at the last follow-up were 50.9 +/- 12.7 years (range, 20-81 years) and 56.5 +/- 11.9 years (range, 29-77 years), respectively. The male-to-female ratio was 0.69. Mean SCr levels and CrCl rates predonation and at the last follow-up were 0.83 +/- 0.22 mg/dL versus 1.1 +/- 0.2 mg/dL (P < .001), and 103.9 +/- 28.8 mL/min versus 88.3 +/- 25.9 mL/min (P = .03), respectively. SCr levels were within normal limits in all donors at predonation and at the last follow-up. At the last follow-up, CrCl was also within expected normal limits in all donors. Hypertension was detected in 13 donors. Mean predonation and at the last follow-up renal parenchymal thickness, BUN, and hematocrit levels were similar. Kidney dimensions were significantly different at the last follow-up after donation (P = .001). Eleven donors displayed proteinuria and 19 had microalbuminuria at the last follow-up, which had been negative for all donors predonation. There were seven surgical site infections and 4 incisional herniae.

CONCLUSION

Donor nephrectomy was performed with low surgical morbidity and comparable results of clinical and laboratory data to the age-matched general population.

Arteriosclerosis in kidneys from healthy live donors: comparison of wedge and needle core perioperative biopsies

CONTEXT

Although risks associated with live kidney donation are low, there are few pathologic studies of kidneys from live donors, and possible risk factors for development of hypertension or renal insufficiency remain unknown. There are many studies of histopathologic changes in deceased donor kidneys and how these changes affect subsequent graft function; most are based on wedge rather than needle core biopsies.

OBJECTIVE

To examine the frequency and severity of arterial fibrointimal thickening and other pathologic lesions in kidneys from healthy live donors and compare wedge and needle core biopsies as methods for evaluating these changes.

DESIGN

For 36 of 332 live donor renal transplantations performed from January 2004 through November 2006, a wedge biopsy of the transplanted kidney was done prior to and/or after implantation, and a needle core biopsy was done postimplantation or during the ensuing 7 days. For these 36 allografts, we compared pathologic features of the wedge and core perioperative biopsies.

RESULTS

Findings on core and wedge biopsies were similar, except for arterial fibrointimal thickening. Moderate thickening (Banff cv2) was present on 13 core biopsies, and mild thickening (cv1) was present on another 10; by contrast, no wedge biopsies showed cv2 lesions, and only 8 showed cv1. Arterial thickening on core but not wedge biopsies correlated significantly with increasing patient age.

CONCLUSIONS

The findings indicate that needle core biopsies are superior to wedge biopsies for evaluating vascular changes in donor kidneys, and they suggest a need for studies correlating such changes with long-term outcomes of live donors, particularly older donors.

Rosiglitazone treatment attenuates expression of inflammatory hallmarks in the remaining kidney following contralateral nephrectomy

BACKGROUND/AIMS

Following kidney donation, living kidney donors have been reported to develop anemia and pronounced inflammation. Therapeutic strategies for ameliorating unilateral nephrectomy-induced inflammation would be beneficiary for the living donors. We applied rosiglitazone to attenuate inflammatory processes ongoing within the remaining kidney following contralateral nephrectomy.

METHODS

20 Sprague-Dawley rats were subjected to left unilateral nephrectomy and 20 others to sham operation. Half of each group was treated for 2 weeks with rosiglitazone (5 mg/kg body weight). After sacrifice, intrarenal transforming growth factor (TGF)-beta, angiotensin-II (A-II), interleukin (IL)-6, IL-10, IL-4 and nitric oxide (NO) were assessed, and histologic sections stained to assess the inflammatory cell infiltration. Renal function was evaluated by creatinine, urea, cystatin C measurements.

RESULTS

Intrarenal IL-6, A-II and TGF-beta were significantly augmented, while NO was significantly decreased in kidneys remaining after contralateral nephrectomy. Rosiglitazone treatment abrogated augmented IL-6, A-II and TGF-beta synthesis and restored intrarenal NO availability in the remaining kidneys. Rosiglitazone also augmented anti-inflammatory IL-4 cytokine synthesis, while IL-10 production, leukocyte infiltration and renal function parameters remained unchanged.

CONCLUSIONS

Rosiglitazone treatment attenuates the proinflammatory responses, represented by augmented IL-6, A-II and TGF-beta production, developing in the remaining kidney following contralateral nephrectomy. In addition, by stimulating IL-4 synthesis and restoring NO availability, rosiglitazone treatment initiates counteractive anti-inflammatory responses in the remaining kidney.

Open partial nephrectomy: an essential operation with an expanding role

PURPOSE OF REVIEW

To describe the rationale for expanding the role of partial nephrectomy in the treatment of renal cortical tumors.

RECENT FINDINGS

Renal tumors are a family of neoplasms ranging from the benign oncocytoma, to the indolent papillary and chromophobe carcinomas, to the more potentially malignant clear cell carcinomas that account for 54% of the lesions resected, but 90% of those that metastasize. Due to a contemporary stage migration, 70% of the tumors are detected incidentally with a median tumor size of below 4.0 cm. Partial nephrectomy for tumors of 7 cm or less provides equivalent oncological tumor control to radical nephrectomy with maximum preservation of long-term renal function. Twenty-six percent of patients prior to operation already have stage 3 chronic kidney disease with an estimated glomerular filtration rate of less than 60 ml/min/1.73 m. Chronic kidney disease is an independent risk factor for the development of cardiovascular disease, hospitalization and death. The likelihood of freedom from a glomerular filtration rate of less than 45 was 95% after partial nephrectomy, but only 64% following radical nephrectomy.

SUMMARY

Partial nephrectomy is an essential surgical approach to the small kidney tumor and provides equivalent local tumor control while preventing the new onset or worsening of chronic kidney disease.

Donor factors influencing graft outcomes in live donor kidney transplantation

Living donor renal allograft survival is superior to that achieved from deceased donors, although graft outcome is suboptimal in some of these patients. In an effort to identify the subset of patients at high risk for poor outcomes we studied donor risk factors in 248 living kidney donor-recipient pairs. Unadjusted donor (125)I-iothalamate GFR (iGFR), donor age more than 45 years, donor total cholesterol level less than 200 mg/dL, and donor systolic blood pressure (SBP) less than 120 mm Hg were correlated with allograft estimated glomerular filtration rate (eGFR), and incidence of acute rejection (AR), delayed graft function and/or graft loss at 2 years posttransplantation. Donor iGFR less than 110 mL/min (slope=-7.40, P<0.01), donors more than 45 years (slope=-8.76, P<0.01), donor total cholesterol levels more than 200 mg/dL (slope=-10.03, P<0.01), and SBP more than 120 mm Hg (slope=-5.60, P=0.03) were associated with lower eGFR. By multivariable linear regression analysis these variables remained independently associated with lower eGFR, and poorer outcomes. The increasing number of donor factors (age, iGFR, cholesterol, and blood pressure) was directly associated with worse posttransplant eGFR (P<0.01). In conclusion, our data suggest that routine assessment of living donor parameters could supplement the consideration of recipient characteristics in predicting posttransplant risk of graft injury/dysfunction.

Living donor kidney transplantation

Living donor kidney transplantation is the optimum treatment for the uremic patient. Successful kidney transplantations started in 1953 in Boston and in Sweden in 1964. This article showed data on the selection of the donor, surgical techniques for the removal of the kidney, and follow-up of short-term complications. The long-term results included the number of donors who developed hypertension and the few donors who developed end-stage renal failure (ESRF) and the reasons for this. Finally, new groups of donors such as blood group-incompatible donors and anonymous donors have been accepted, each of whom have their own programs. This article also discussed our responsibilities as renal specialists or transplant surgeons for kidney donors at surgery and postsurgery.

Nutrient restriction impairs nephrogenesis in a gender-specific manner in the ovine fetus

Inadequate nutrition compromises fetal development and poses long-term health risks for the offspring, even without decreased birth weight. The present study sought to 1) establish the ontogeny of fetal renal glomerulus number (GN) in sheep and 2) evaluate the effects of 50% global nutrient restriction (NR) during early to midgestation on GN and the renin-angiotensin system in the fetal kidney. GN increased from 78 dG (68,560 +/- 3802) to 135 dG (586,118 +/- 25,792). NR increased combined kidney weight (29 +/- 0.6 g versus 23 +/- 1.1 g), whereas decreased GN relative to right kidney weight approached significance in males (26,000 +/- 5300 versus 39,000 +/- 2800 GN/g) compared with control (C) males and females. NR decreased immunoreactive angiotensin II (Ang II) type 1 receptor (AT1) in the NR kidneys at 78 dG and increased renin at 135 dG. Immunoreactive renin decreased from 78 to 135 dG. Female fetuses had more immunoreactive Ang II type 2 receptor (AT2) than male fetuses at 78 dG and males had more AT1 at 135 dG. The present study demonstrates gender-specific differences in fetal growth and development and in fetal kidney development in pregnancies affected by NR.

Imputing variance estimates do not alter the conclusions of a meta-analysis with continuous outcomes: a case study of changes in renal function after living kidney donation

OBJECTIVE

To assess how different imputation methods used to account for missing variance data in primary studies influence tests of heterogeneity and pooled results from a meta-analysis with continuous outcomes.

STUDY DESIGN AND SETTING

Point and variance estimates for changes in serum creatinine, glomerular filtration rate, systolic blood pressure, and diastolic blood pressure were variably reported among 48 primary longitudinal studies of living kidney donors (71%-78% of point estimates were reported, 8%-13% of variance data were reported). We compared the results of meta-analysis, which either were restricted to available data or used four methods to impute missing variance data. These methods used reported P-values, reported nonparametric summaries, results from other similar studies using multiple imputation, or results from estimated correlation coefficients.

RESULTS

Significant heterogeneity was present in all four outcomes regardless of the imputation methods applied. The random effects point estimates and 95% confidence intervals varied little across imputation methods, and the differences were not clinically significant.

CONCLUSIONS

Different methods to impute the variance data in the primary studies did not alter the conclusions from this meta-analysis of continuous outcomes. Such reproducibility increases confidence in the results. However, as with most meta-analyses, there was no gold standard of truth, and results must be interpreted judiciously. The generalization of these findings to other meta-analyses, which differ in outcomes, missing data, or between-study heterogeneity, requires further consideration.

Racial disparities in living kidney donation: is there a lack of willing donors or an excess of medically unsuitable candidates?

BACKGROUND

Live kidney donation is safe for healthy donors and an effective treatment for patients with end-stage renal disease. Many potential donors are referred for live kidney donation, but only a small percentage donate. This study aims to determine reasons for nondonation and establish if racial differences exist.

METHODS

A retrospective database and chart review of all patients that were referred for potential live kidney donation from January 1, 2000 to December 31, 2004 was conducted.

RESULTS

In all, 30.3% of referred potential live kidney donors were lost to follow-up. Primary reasons for nondonation (n=1,050) included unsuitable donor health (43.1%) and recipient-based causes (41.3%). Immunologic incompatibility accounted for 9.7% of all nondonations. Racial differences indicated more African Americans had incompatible blood types (P=0.01) or ineligible recipients (26.7% vs. 14.4%, P<0.01). More non-African Americans donated (13.2% vs. 4.6%, P<0.01) or were halted because the potential recipient received another organ (living/cadaveric) (20.0% versus 7.9%, P<0.01). Nondonation due to overall donor health (including diabetes and hypertension) did not differ between races, but subanalysis indicated more African American nondonation was due to high body mass index (P=0.01).

CONCLUSIONS

Determining the reason behind nondonation is a first step towards understanding low rates of live kidney donation. More African American donor referrals are lost to follow-up while rates of other reasons were similar among races. This may indicate that African Americans are not more frequently medically unsuitable, but that the divergence in rates of live kidney donation is caused by a disparity in willingness to donate among African Americans.

Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study

BACKGROUND

Chronic kidney disease is a graded and independent risk factor for substantial comorbidity and death. We aimed to examine new onset of chronic kidney disease in patients with small, renal cortical tumours undergoing radical or partial nephrectomy.

METHODS

We did a retrospective cohort study of 662 patients with a normal concentration of serum creatinine and two healthy kidneys undergoing elective partial or radical nephrectomy for a solitary, renal cortical tumour (</=4 cm) between 1989 and 2005 at a referral cancer centre. Glomerular filtration rate (GFR) was estimated with the abbreviated Modification in Diet and Renal Disease Study equation. Separate analysis was undertaken, with chronic kidney disease defined as GFR lower than 60 mL/min per 1.73 m(2) and GFR lower than 45 mL/min per 1.73 m(2).

FINDINGS

171 (26%) patients had pre-existing chronic kidney disease before surgery. After surgery, the 3-year probability of freedom from new onset of GFR lower than 60 mL/min per 1.73 m(2) was 80% (95% CI 73-85) after partial nephrectomy and 35% (28-43; p<0.0001) after radical nephrectomy; corresponding values for GFRs lower than 45 mL/min per 1.73 m(2) were 95% (91-98) and 64% (56-70; p<0.0001), respectively. Multivariable analysis showed that radical nephrectomy remained an independent risk factor for patients developing new onset of GFR lower than 60 mL/min per 1.73 m(2) (hazard ratio 3.82 [95% CI 2.75-5.32]) and 45 mL/min per 1.73 m(2) (11.8 [6.24-22.4]; both p<0.0001).

INTERPRETATION

Because the baseline kidney function of patients with renal cortical tumours is lower than previously thought, accurate assessment of kidney function is essential before surgery. Radical nephrectomy is a significant risk factor for the development of chronic kidney disease and might no longer be regarded as the gold standard treatment for small, renal cortical tumours.

Proteinuria and reduced kidney function in living kidney donors: A systematic review, meta-analysis, and meta-regression

We reviewed any study where 10 or more healthy adults donated a kidney, and proteinuria, or glomerular filtration rate (GFR) was assessed at least 1 year later. Bibliographic databases were searched until November 2005. 31 primary authors provided additional information. Forty-eight studies from 27 countries followed a total of 5048 donors. An average of 7 years after donation (range 1-25 years), the average 24 h urine protein was 154 mg/day and the average GFR was 86 ml/min. In eight studies which reported GFR in categories, 12% of donors developed a GFR between 30 and 59 ml/min (range 0-28%), and 0.2% a GFR less than 30 ml/min (range 0-2.2%). In controlled studies urinary protein was higher in donors and became more pronounced with time (three studies totaling 59 controls and 129 donors; controls 83 mg/day, donors 147 mg/day, weighted mean difference 66 mg/day, 95% confidence interval (CI) 24-108). An initial decrement in GFR after donation was not accompanied by accelerated losses over that anticipated with normal aging (six studies totaling 189 controls and 239 donors; controls 96 ml/min, donors 84 ml/min, weighted mean difference 10 ml/min, 95% CI 6-15; difference not associated with time after donation (P=0.2)). Kidney donation results in small increases in urinary protein. An initial decrement in GFR is not followed by accelerated losses over a subsequent 15 years. Future studies will provide better estimates, and identify those donors at least risk of long-term morbidity.

Risk of renal insufficiency in African-Americans after radical nephrectomy for kidney cancer

PURPOSE

We conducted a retrospective review to evaluate the change in serum creatinine in an African-American population undergoing radical nephrectomy.

MATERIALS AND METHODS

Race, and preoperative and follow-up creatinine data were extracted from the medical records of all patients who underwent radical nephrectomy performed by a single surgeon. Patients were classified as African-American or black and non-African-American. The non-African-American group included Caucasian, Asian, and Hispanic patients.

RESULTS

A total of 22 African-American and 19 non-African-American patients were studied. Mean preoperative creatinine was 1.3 mg/dL in African-American patients and 1.1 in non-African-American patients (P = 0.07). Average follow-up creatinine was 1.7 in the African-Americans, with a mean change in creatinine of 0.4, compared to the non-African-Americans, in which mean follow-up creatinine was 1.3 (P = 0.004) with a mean change of 0.2 (P = 0.048). Average follow-up creatinine was higher in African-American hypertensive (2.0 mg/dl) compared with non-African-American hypertensive patients (1.4 mg/dl; P = 0.002). Average change in creatinine was also higher in African-American hypertensive versus non-African-American hypertensive patients (0.6 vs. 0.2 mg/dl, P = 0.048). There were no racial differences seen in normotensive cases. Average follow-up was 9.7 months for African-American and 11.6 months for non-African-American patients.

CONCLUSIONS

Our data indicate that race may be a significant risk factor for renal deterioration after radical nephrectomy.

Prognostic nomogram for renal insufficiency after radical or partial nephrectomy

PURPOSE

We analyzed prognostic factors to predict renal insufficiency after partial or radical nephrectomy. We developed and performed internal validations of a postoperative nomogram for this purpose. We used a prospectively updated renal tumor database of more than 1,500 patients.

MATERIALS AND METHODS

From July 1989 to October 2003, 161 partial nephrectomies and 857 radical nephrectomies performed at Memorial Sloan-Kettering Cancer Center for renal cortical tumors were analyzed. Computerized tomography images were reviewed by a single radiologist. Kidney volume was calculated using the ellipsoid formula, V = L1 x L2 x L3 x pi/6, where V represents volume and L represents length. Renal insufficiency was defined by 2 serum creatinine values greater than 2.0 mg/dl at least 1 month postoperatively. Tumor histology was not an exclusion criterion and yet we excluded cases of bilateral synchronous disease. Prognostic variables were preoperative serum creatinine, American Society of Anesthesiologists score, percent change in kidney volume after surgery, and patient age and sex.

RESULTS

Renal insufficiency was noted in 105 of the 857 patients with radical nephrectomy (12.3%) and in 6 of the 161 with partial nephrectomy (3.7%) studied. Patients had a median followup of 21.2 months (maximum 157.9). The 7-year probability of freedom from renal insufficiency in the cohort was 79.1% (95% CI 74.6 to 83.6). The nomogram was designed based on a Cox proportional hazards regression model. Following internal statistical validation nomogram predictions appeared accurate and discriminating with a concordance index of 0.835.

CONCLUSIONS

A nomogram was developed that can predict the 7-year probability of renal insufficiency in patients undergoing radical or partial nephrectomy.

Living-donor kidney transplantation: the Freiburg experience

BACKGROUND AND AIM

The objective of this study was to determine outcome after living-donor kidney transplantation in a single-center institution in Germany.

MATERIALS AND METHODS

From 1976 to May 2005, a total of 298 living-donor kidney transplants were performed at the University of Freiburg. Most recipients (78.8%) were placed on cyclosporine, mycophenolate mofetil, and corticosteroids maintenance immunosuppression. Cox proportional hazard model was applied to analyze predictors for patient and graft survival. Mean follow-up was 5.3 years.

RESULTS

According to Kaplan-Meier calculation, 1-, 5-, and 10-year patient survival was 98.6, 92.7, and 86.8%, respectively. Kidney function rate was 95.5, 82.8, and 67.9%, respectively. A 5-year graft function rate continued to increase from 79.5% in patients transplanted before 1996 to 83.6% in patients transplanted thereafter. In a Cox regression model recipient age above 50 years, duration of dialysis above 2 years and preexisting type 1 diabetes mellitus were associated with a decreased patient survival. Graft survival was mostly influenced by the type of immunosuppression and preexisting hypertension of the recipient.

CONCLUSIONS

Our results demonstrate that living-donor kidney transplantation is a highly effective therapy for patients with end stage renal failure. Updates in immunosuppression, recipient selection, and operative technique may have contributed to the improved graft survival over the past three decades.

Postoperative outcome of open donor nephrectomy under epidural analgesia: a descriptive analysis

PURPOSE

Patients subjected to open donor nephrectomy with epidural analgesia were analyzed to determine whether there was a relation between catheter placement site and the appearance of complications and satisfactory analgesia and to determine whether this factor had an impact upon recovery and return to preoperative life.

METHODS

A cohort of 36 open donor nephrectomies were performed with postoperative epidural analgesia. Two groups were analyzed: thoracic (22 patients) and lumbar catheters (14 patients). There was a 72-hour evaluation followed by phone contact. Besides detecting related complications pain was evaluated using a visual analog scale (VAS 0 to 10) in the postanesthesia care unit and at 6, 24, 48 and 72 hours postoperatively. Satisfactory analgesia was defined as a VAS of 3 or less.

RESULTS

In all cases the analgesic solution was composed of bupivacaine 0.125% with an opioid in 97%. Patients showed complications in 72% (26/36); the only significant association was motor blockade in the lumbar group (21% vs 0% in the thoracic, P = .023). Patients had a mean VAS of 2.83 +/- 1.77. There was a larger proportion of pain-free patients (VAS 0) in the thoracic group; in addition, there was no VAS of 10 in this group. Ambulation was resumed in less than 24 hours in 57% of patients, having a mean VAS of 2.1 +/- 1.5 compared with 3.2 +/- 1.6 among those who ambulated after 24 hours (P = .04). There was no association between perioperative pain control and the interval to normal activities.

CONCLUSIONS

Without a control group, we can hardly evaluate the impact of epidural analgesia on perioperative outcome. Notwithstanding, the obtained pain control may justify its use in these patients. An important issue is to maintain a low VAS (<3), especially in the first 24 hours, which may make a clinically important difference for early ambulation.

Organization of a High-Volume Kidney Transplant Program???The ???Assembly Line??? Approach

This report describes the organization of a high-volume Brazilian kidney transplant program. With use of an "assembly line" approach, 2,461 kidney transplantations were performed between 1999 and 2004, fulfilling government expectations without compromising the care of the patients. The annual number of kidney transplants increased from 428 to 656 per year. In our Organ Procurement Organization (with 7 million inhabitants), brain death notifications increased from 196 to 461, but less than 25% became actual donors. There are 3,200 patients on the waiting list and recipient selection is based of human leukocyte antigen matching (25 new listings per week). More than 700 first appointments for living donation occur every year. A significant number of recipients are of black race and have been receiving dialysis for long periods of time. The majority of patients are followed locally (100-120 appointments per day). Transplant outcomes among living-donor recipients are comparable to those of large registries, but inferior outcomes have been observed among recipients of deceased-donor organs. However, consistent improvement has been seen in more recent years. The present report also discusses issues related to local regulations and solutions to improve efficiency and outcomes.

Medical Risks in Living Kidney Donors: Absence of Proof Is Not Proof of Absence

Living-kidney donation has become increasingly widespread, yet there has been little critical analysis of existing studies of long-term medical outcomes in living donors. This review analyzes issues in study design that affect the quality of the evidence and summarizes possible risk factors in living donors. Virtually all studies of long-term outcomes in donors are retrospective, many with large losses to follow-up, and therefore are subject to selection bias. Most studies have small sample sizes and are underpowered to detect clinically meaningful differences between donors and comparison groups. Many studies compare donors with the general population, but donors are screened to be healthier than the general population and this may not be a valid comparison group. Difficulties in measurement of BP and renal function may underestimate the impact of donation on these outcomes. Several studies have identified possible risk factors for development of hypertension, proteinuria, and ESRD, but potential vulnerability factors in donors have not been well explored and there is a paucity of data on cardiovascular risk factors in donors. Prospective registration of living kidney donors and prospective studies of diverse populations of donors are essential to protect living donors and preserve living-kidney donation.

Assessment of serum cystatin C in children with congenital solitary kidney

The aim of the study was to assess serum cystatin C level in children with a congenital solitary kidney, depending on their age and compensatory overgrowth of the kidney. The study group (I) consisted of 36 children, 3-21 years of age (median 10.8 years), with a congenital solitary kidney and no other urinary defects. The control group (C) contained 36 healthy children, 5-21 years old (median 10.9 years). Nephelometric methods were used to determine serum cystatin C level, the Jaffe method to assess creatinine concentration and the Schwartz formula to estimate glomerular filtration rate. Kidney length was measured with the patient in a supine position, and overgrowth was estimated (O%) in comparison with the respective kidney in the control group. Serum cystatin C level in group I was higher than that in the control group (P<0.05). Increased values, above 0.95 mg/l, were found in 16/36 (44%) children aged 12-21 years. Glomerular filtration rate (GFR, estimated by the Schwartz formula) and creatinine level in group I were similar to those of the control group (P>0.05). Increased kidney length was found (median 18.2%). Cystatin C concentration was positively correlated with O% (r=0.406, P<0.01) and kidney length to child height ratio (L/H) (r=0.376, P<0.05). We conclude that Increased serum cystatin C concentration in patients with a unilateral congenital solitary kidney occurs after 12 years of age and correlates with compensatory overgrowth of the kidney.

The impact of accepting living kidney donors with mild hypertension or proteinuria on transplantation rates

BACKGROUND

As waiting times for kidney transplantation increase, individuals with hypertension or proteinuria may be considered as eligible living donors. We set out to determine how frequently donors are excluded because of hypertension or proteinuria and to what extent accepting such donors would increase transplantation rates.

METHODS

Wait lists from 4 Canadian transplantation centers were examined for causes of living kidney donor exclusion. Donors with hypertension (clinic blood pressure >140/90 mm Hg or requiring antihypertensive medication) or proteinuria historically have been excluded at these centers. We define potentially acceptable hypertension as a clinic blood pressure less than 150/100 mm Hg or less than 140/90 mm Hg if administered a single antihypertensive medication and define acceptable proteinuria as protein of 0.15 to 0.3 g/d.

RESULTS

Only 35% (124 of 352 patients) of wait-listed patients had a living donor evaluated (n = 180 potential donors). Primary reasons for donor exclusion were immunologic: a positive cross-match (32%; n = 59) or blood group type incompatibility (22%; n = 40). Hypertension or proteinuria were less common (17%; n = 31). Of 31 donors excluded for hypertension or proteinuria, only 13 had results in the acceptable range. Acceptance of these donors would have resulted in transplantation of 3% (12 of 352 patients) of the wait-list population.

CONCLUSION

Accepting living donors with mild hypertension and proteinuria will lead to a slight increase in transplantation rates. Efforts to improve living donor awareness and overcome immunologic barriers to transplantation may have a greater impact.

Dyslipidemia and weight gain secondary to lifestyle changes in living renal transplant donors

We evaluated renal function, lipid profile, body weight, and physical activity of living donors in long-term follow-up after nephrectomy. A total of 121 living donors were compared with 81 healthy subjects with normal renal function and no history of any surgery or disease. Before and after donor nephrectomies, we recorded age, body weight, systolic and diastolic blood pressures, serum creatinine, creatinine clearance, lipids, and serum glucose levels of the donors. Preoperative (baseline) and postoperative (last visit) physical activities of donors and controls were evaluated through the Modified Baecke Questionnaire (occupational activities, sports activities, leisure-time activities). There were no differences between donors and controls for age (P = .772), gender (P = .927), and follow-up period (P = .564). According to baseline levels, blood pressure and serum creatinine were increased and creatinine clearance was decreased (P < .001 for all). The mean increases in body weight (P = .012), LDL (P = .004), and triglyceride (P < .001) were higher in donors than in controls. But the mean decrease in HDL was not different between controls and donors (P = .057). Indices of sports and total activities were lower in donors than in controls on the last visit (P < .001). Indices of occupational and leisure-time activities were similar on the last visit in donors and in controls (P = .126, P = .083). The alterations in total cholesterol and total activity showed significant negative correlations in donors (r = -.581, P < .001). Also, the alterations in total cholesterol and body weight showed a significant correlation (r = .25, P = .02). We followed donors together with serum lipid levels, body weight, and total physical activities as well as blood pressure and renal function tests.

One Living Donor and Two Donations: Sequential Kidney and Liver Donation With 20-Years Interval

The shortage of cadaveric donor organs remains the critical factor limiting the use of organ transplantation. In this environment of organ shortage, living donor transplantation has emerged as a reasonable therapeutic alternative. Simultaneous kidney-liver transplantation from the same donor has been described. We report a case of right liver lobe transplant from a living donor who had donated his kidney to the same recipient 20 years prior.

[Assessment of long-term renal function after nephrectomy. Study of 53 patients]

BACKGROUND AND OBJECTIVE

Patients with unilateral nephrectomy maintain the remaining kidney function over time, as it has been described in healthy kidney donors.

PATIENTS AND METHOD

We performed a cross-sectional study of 53 patients who were followed 5 or more years after nephrectomy. Serum creatinine, BUN, Glomerular Filtration Rate (GFR) (24 hours urine collection and Cockcroft formula), microalbuminuria, proteinuria, Body Mass Index and the annual loss rate of renal function were measured or calculated over the follow-up period. We retrospectively considered the presence of risk factors like diabetes, hypertension, microalbuminuria, dyslipemia, smoking habit, obesity and ACE inhibitors or angiotensin-receptor antagonists treatment. We divided our patients into two groups: group I (normal or mild renal failure: GFR > 50 cc/min and or serum creatinine < 1.4 mg/dL) and group II (moderate or severe renal failure).

RESULTS

The main cause of nephrectomy was renal tuberculosis, followed by lithiasis and pyonephrosis. In addition, 7.5% of patients were kidney donors. At the time of study, 22.7% had diabetes, 60.4% hypertension and 39.6% were obese. The mean age was 60 years (37 years at the moment of nephrectomy). The GFR final mean was 53.6 cc/min (58.8 cc/min by Cockcroft formula). The mean renal function loss rate was 1 cc/min/year. 35% of the patients had moderate or severe kidney failure and were included in group II; 32% had proteinuria and 56.6% had abnormal microalbuminuria. The univariate risk factors analysis for the development of renal failure showed inter-group statistical significative differences in current age, nephrectomy age, microalbuminuria, proteinuria, and hypertension prevalence (p = 0.008). With regard to the progression rate, we found a significant correlation with final microalbuminuria (r = 0.358, p = 0.03). Current age and final proteinuria were found to be significant risk factors in the multivariate analysis.

CONCLUSIONS

A high prevalence of renal insufficiency was found among patients with unilateral nephrectomy, which is mainly related to age and proteinuria. The renal function loss rate is slow and is influenced by microalbuminuria.

The Effect of Laparoscopic and Open Donor Nephrectomy on the Long-Term Renal Function in Donor and Recipient: A Retrospective Study

Pneumoperitoneum, as used in laparoscopic donor nephrectomy (LDN), may result in negative effects on renal function in donor and recipient. This study compares long-term serum creatinine in donor and recipient after laparoscopic and open donor nephrectomy (ODN). A retrospective analysis of 120 LDN and 100 ODN donors and their recipients was performed. Serum creatinine of donor and recipient was recorded and analyzed. The follow-up period posttransplantation was 3 years. Serum creatinine in the recipients was significantly higher in the LDN groups the first week after transplantation. Serum creatinine in the donor was significantly higher in the LDN group at 1 day, 3 months, and 1 year posttransplant. Finally, creatinine levels remained 40% higher compared to preoperative values in both donor groups. LDN results in higher short-term serum creatinine levels in donor and recipient. Long-term serum creatinine levels were comparable after LDN or ODN in donor and recipient.

Living kidney donor follow-up in a dedicated clinic

BACKGROUND

Long-term effects of uninephrectomy for kidney donation are of particular interest in the currently increasing practice of living-donor transplantation. We have retrospectively analyzed the general health status and renal and cardiovascular consequences of living-related kidney donation.

METHODS

Data of living-related kidney donors who were regularly followed up in a dedicated clinic at the Sindh Institute of Urology and Transplantation between July 2000 and January 2004 was retrieved. They had donated their kidneys from 1986 onward. Data on weight, blood pressure, creatinine clearance, level of proteinuria, and new onset diabetes mellitus were analyzed.

RESULTS

Seven hundred and thirty-six donors with a mean age of 36+/-10.9 years (M:F 1.1:1) were evaluated. With a mean postnephrectomy duration of 3+/-3.2 years (range 6 months-18 years), the creatinine clearance fell to 87% of prenephrectomy values, and 49 (6.7%) had a creatinine clearance of less than 60 mL/ min. Hypertension developed in 76 (10.3%) donors, and 179 (24.3%) had proteinuria exceeding 150 mg/24 hr. Overweight (27.8%) and obese subjects (11.5%) had a higher prevalence of hypertension and new onset diabetes mellitus. One donor developed end-stage renal failure.

CONCLUSION

Donor nephrectomy has minimal adverse effects on overall health status. Regular donor follow-up identifies at-risk populations and potentially modifiable factors.

Hypothesis: Uric acid, nephron number, and the pathogenesis of essential hypertension

BACKGROUND

Essential hypertension affects more than 25% of the world's population. Genetic, physiologic, and epidemiologic studies provide clues to its origins, but a clear understanding has been elusive. Recent experimental and clinical studies have implicated uric acid in the onset of essential hypertension.

METHODS

In a retrospective chart review, we identified 95 children with confirmed, new onset hypertension, and evaluated the cause of hypertension and parental history of hypertension, birth weight, and serum uric acid. In an open-label, cross-over trial we treated 5 children with confirmed essential hypertension with allopurinol as single treatment agent, and screened for change in blood pressure by casual and ambulatory methods. In tissue culture experiments, we evaluated the effect of uric acid on glomerular endothelial cell function.

RESULTS

Elevation of serum uric acid is related to the onset of essential hypertension in children, reduced birth weight, and endothelial dysfunction. Normalization of uric acid appears to ameliorate new onset essential hypertension.

CONCLUSION

These findings, combined with animal model data, support the hypothesis that uric acid has a key role in the pathogenesis of early onset essential hypertension, and may unify some of the disparate theories of the origins of essential hypertension.

Quality of life of living kidney donors in Germany: a survey with the Validated Short Form-36 and Giessen Subjective Complaints List-24 questionnaires

BACKGROUND

Most studies evaluating the impact of kidney donation on donors' quality of life (QOL) have limitations such as small cohort size, unmatched references, use of nonstandardized and nonvalidated questionnaires, or low response rates.

METHODS

We performed a study on donors' QOL that was designed to avoid these limitations. All available living renal donors in our department in the last 18 years were included in the study. QOL was assessed with two validated, standardized questionnaires (Short Form-36, Giessen Subjective Complaints List [Giessener Beschwerdebogen]-24) and compared with gender- and age-matched references. In addition, specific questions relating to kidney donation were asked.

RESULTS

The response rate (89.8%) is one of the highest reported for studies on QOL of living kidney donors. Most donors had an equal or better QOL than the healthy population. Donors' willingness to donate again (93.4%) or recommend living-donor kidney transplantation (92.4%) was high, irrespective of complications. A small number of donors experienced financial drawbacks or occupational disadvantages. Donors aged 31 to 40 years were found to be at risk of QOL deterioration after organ donation. Donor and recipient complications had a significant impact on donors' QOL. One third of the donors found that the psychologic care preceding and after kidney donation was insufficient.

CONCLUSIONS

Our findings support the practice of living-donor kidney transplantation as a good means to meet the persisting organ shortage. Further effort must be put into minimizing donor and recipient complications. The specific demands of younger donors should be further elucidated. In addition to medical follow-up, living kidney donors should also be offered lifelong psychologic counseling.

Blood Pressure and Renal Function after Kidney Donation from Hypertensive Living Donors

BACKGROUND

Rising numbers of patients reaching end-stage kidney disease intensify the demand for expansion of the living-kidney-donor pool. On the basis of low risk in white donors with essential hypertension, our transplant center undertook a structured program of accepting hypertensive donors if kidney function and urine protein were normal. This study reports outcomes of hypertensive donors 1 year after kidney donation.

METHODS

We studied detailed measurements of blood pressure (oscillometric, hypertensive therapy nurse [RN], and ambulatory blood pressure monitoring [ABPM]), clinical, and renal characteristics (iothalamate glomerular filtration rate [GFR], urine protein, and microalbumin) in 148 living kidney donors before and 6 to 12 months after nephrectomy. Twenty-four were hypertensive (awake ABPM>135/85 mm Hg and clinic/RN BP>140/90 mm Hg) before donation.

RESULTS

After 282 days, normotensive donors had no change in awake ABPM pressure (pre 121 +/- 1/75 +/- 2 vs. post 120 +/- 1/ 5 +/- 1 mm Hg), whereas BP in hypertensive donors fell with both nonpharmacologic and drug therapy (pre 142 +/- 3/85 +/- 2 to post 132 +/- 2/80 +/- 1 mm Hg, P<.01). Hypertensive donors were older (53.4 vs. 41.4 years, P<.001) and had lower GFR after kidney donation (61 +/- 2 vs. 68 +/- 1 mL/min/1.73m, P<.01). After correction for age, no independent BP effect was evident for predicting GFR either before or after nephrectomy. Urine protein and microalbumin did not change in either group after donor nephrectomy.

CONCLUSIONS

Our results indicate that white subjects with moderate, essential hypertension and normal kidney function have no adverse effects regarding blood pressure, GFR, or urinary protein excretion during the first year after living kidney donation. Although further studies are essential to confirm long-term safety, these data suggest that selected hypertensive patients may be accepted for living kidney donation.

The Prediction of Renal Function 6 Years After Unilateral Nephrectomy Using Preoperative Risk Factors

PURPOSE

Since middle-aged and elderly patients seem to have risk factors affecting renal function, it is important to predict postoperative renal function prior to unilateral nephrectomy (UNx). We evaluated preoperative factors for predicting postoperative renal function in middle-aged and elderly patients with renal cell carcinoma (RCC) treated with radical nephrectomy (RNx).

MATERIALS AND METHODS

In 201 patients who underwent RNx preoperative records and postoperative serum creatinine (SCR) 6 years after nephrectomy were available. Postoperative renal insufficiency was defined as serum creatinine 1.4 mg/dl or greater. The relationship of each preoperative and postoperative factor was analyzed. Logistic regression analysis was performed to evaluate preoperative factors for predicting postoperative SCR 1.4 mg/dl or greater after 6 years.

RESULTS

There was a significant difference in postoperative SCR between female and male patients, and between those with and without hypertension, diabetes and proteinuria (p <0.05). Age, hemoglobin, preoperative SCR, blood urea nitrogen, uric acid and K significantly correlated with postoperative SCR (p <0.05). The increase in SCR during 6 years after UNx was significantly higher in patients with hypertension, diabetes and proteinuria than in their respective counterparts (p <0.05). Multivariate stepwise logistic regression analysis demonstrated that preoperative serum creatinine, hypertension and proteinuria were significant independent factors predicting postoperative renal function 6 years after UNx in patients with RCC (p <0.05).

CONCLUSIONS

Preoperative SCR, hypertension and proteinuria are useful factors for predicting postoperative renal function after RNx in patients with RCC.

The Heroism of Women and Men

Heroism consists of actions undertaken to help others, despite the possibility that they may result in the helper's death or injury. The authors examine heroism by women and men in 2 extremely dangerous settings: the emergency situations in which Carnegie medalists rescued others and the holocaust in which some non-Jews risked their lives to rescue Jews. The authors also consider 3 risky but less dangerous prosocial actions: living kidney donations, volunteering for the Peace Corps, and volunteering for Doctors of the World. Although the Carnegie medalists were disproportionately men, the other actions yielded representations of women that were at least equal to and in most cases higher than those of men. These findings have important implications for the psychology of heroism and of gender.

Causes and consequences of kidney loss in patients with nephrolithiasis

BACKGROUND

It is unknown whether stone formers may safely donate a kidney. Nephrectomy could accelerate stone formation, or loss of filtration with age. We contrast, here, the course of stone patients with two versus one kidney.

METHODS

One hundred fifteen patients with a single functioning kidney were compared with 3151 patients with two kidneys. Cause of kidney loss was determined, along with stone types, rates of stone formation, urine stone risk factors, and creatinine clearance.

RESULTS

Women were 49.6% of the patients with kidney loss, compared to 33.6% of ordinary stone formers. Obstruction, stone burden, and infection were the most common reasons for kidney loss. We found an increased number of struvite and calcium phosphate stones among single kidney patients. Before and during treatment, single kidney patients had fewer stones than ordinary stone formers. Creatinine clearance was lower in the single kidney patients; rate of loss of kidney function with age was higher among single kidney males versus two kidney males if all patients are considered. Among males >age 45 years, the difference disappears. Females with one and two kidneys lost function with age at equivalent rates. Compared with nonstone formers, male stone formers lose kidney function with age at an accelerated rate.

CONCLUSION

Nephrectomy does not worsen stone disease. It may increase loss of renal function among younger males. The pattern of renal function loss with age differs between stone formers and nonstone formers.

Risks and complications in 160 living kidney donors who underwent nephroureterectomy

BACKGROUND

The rate of living donor renal transplantations has increased. However, in view of the possible complications, the question as to whether the condition of the recipient justifies operation of the donor still remains unanswered. The present retrospective study evaluates the perioperative and post-operative risks and complications for the donor at a single major transplantation centre.

METHODS

From 1994 to 2001, 160 live donor nephroureterectomies were performed. The median age of living donors was 51 years (range 21-77 years); 19 patients were older than 61 years. After confirming blood group compatibility and negative cross-match, donors underwent an extensive medical and psychological examination. Comorbidities and anatomical features of the donor were evaluated and the impact they may have on the outcome was determined. The nephroureterectomies were performed transperitoneally, with the right kidney being preferred. Pre-operative, intraoperative and post-operative complications were documented. Serum creatinine levels as well as new-onset proteinuria or hypertension were used as criteria for assessing long-term renal function.

RESULTS

Complications were observed in 41 donors: 35 were minor and six were major (splenectomy; revisions due to liver bleeding, incarcerated umbilical hernia or infected pancreatic pseudocyst; pneumothorax; and acute renal failure). No patient died. Multiple arteries (14 patients), significant renal artery stenosis (two patients) and additional risk factors (e.g. increased age and previous operations) did not affect the complication rate. In the post-operative follow-up period of 0.5-62 months (mean: 38 months), renal function remained stable in all donors.

CONCLUSIONS

Living donor nephrectomy appears to be a safe intervention in specialized centres, where it entails a low morbidity for the donor. Even in high-risk donors, long-term complications were not observed.

Serial determination of glomerular filtration rate in conscious mice using FITC-inulin clearance

Two nonradioactive methods for determining glomerular filtration rate (GFR) in conscious mice using FITC-labeled inulin (FITC-inulin) were evaluated. The first method measured GFR using clearance kinetics of plasma FITC-inulin after a single bolus injection. Based on a two-compartment model, estimated GFR was 236.69 +/- 16.55 and 140.20 +/- 22.27 microl/min in male and female C57BL/6J mice, respectively. Total or (5/6) nephrectomy reduced inulin clearance to 0 or 32.80 +/- 9.32 microl/min, respectively. Conversely, diabetes mellitus induced by streptozotocin was associated with increased GFR. The other approach measured urinary inulin clearance using intraperitoneal microosmotic pumps to deliver FITC-inulin and metabolic cages to collect timed urine samples. This approach yielded similar GFR values of 211.11 +/- 26.56 and 157.36 +/- 20.02 microl/min in male and female mice, respectively. These studies demonstrate the feasibility of repeated nonisotopic measurement of inulin clearance in conscious mice.