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

Long-term end-stage renal disease risks after living kidney donation: a systematic review and meta-analysis

BACKGROUND

Recent studies have shown that donor nephrectomy can induce renal function impairment. However, few meta-analysis studies about this have proceeded. Therefore, the objective of this systematic review and meta-analysis including all data of recent research studies was to determine whether living donor nephrectomy (LDN) could induce renal function impairment.

METHODS

By November 2020, comprehensive literature searches were performed on PubMed, Embase, and Cochrane databases. Inclusion criteria were: (1) observational studies with data about overall end-stage renal disease (ESRD) or chronic kidney disease (CKD) of living kidney donors, (2) control group consisted of people without donor nephrectomy, and (3) outcomes of studies included long-term end-stage renal disease risks after living kidney donation. Risk of Bias in Non-randomized Studies of interventions (ROBINS-I) assessment tool was used to evaluate our methodological quality.

RESULTS

The qualitative review included 11 studies and the meta-analysis included 5 studies. In the meta-analysis, the integrated overall ESRD risk was 5.57 (95% CI: 2.03-15.30). Regarding the overall risk of bias using ROBINS-I assessment tool, 0 studies was rated as "Low", 7 studies were rated as "moderate", 2 studies were rated as "Serious", and two studies were rated as "Critical".

CONCLUSIONS

Our study showed that LDN increased ESRD risk in LDN patients. However, in our meta-analysis, variables in included studies were not uniform and the number of included studies was small. To have a definite conclusion, meta-analyses of well-planned and detailed studies need to be conducted in the future.

The Minnesota attributable risk of kidney donation (MARKD) study: a retrospective cohort study of long-term (> 50 year) outcomes after kidney donation compared to well-matched healthy controls

BACKGROUND

There is uncertainty about the long-term risks of living kidney donation. Well-designed studies with controls well-matched on risk factors for kidney disease are needed to understand the attributable risks of kidney donation.

METHODS

The goal of the Minnesota Attributable Risk of Kidney Donation (MARKD) study is to compare the long-term (> 50 years) outcomes of living donors (LDs) to contemporary and geographically similar controls that are well-matched on health status. University of Minnesota (n = 4022; 1st transplant: 1963) and Mayo Clinic LDs (n = 3035; 1st transplant: 1963) will be matched to Rochester Epidemiology Project (REP) controls (approximately 4 controls to 1 donor) on the basis of age, sex, and race/ethnicity. The REP controls are a well-defined population, with detailed medical record data linked between all providers in Olmsted and surrounding counties, that come from the same geographic region and era (early 1960s to present) as the donors. Controls will be carefully selected to have health status acceptable for donation on the index date (date their matched donor donated). Further refinement of the control group will include confirmed kidney health (e.g., normal serum creatinine and/or no proteinuria) and matching (on index date) of body mass index, smoking history, family history of chronic kidney disease, and blood pressure. Outcomes will be ascertained from national registries (National Death Index and United States Renal Data System) and a new survey administered to both donors and controls; the data will be supplemented by prior surveys and medical record review of donors and REP controls. The outcomes to be compared are all-cause mortality, end-stage kidney disease, cardiovascular disease and mortality, estimated glomerular filtration rate (eGFR) trajectory and chronic kidney disease, pregnancy risks, and development of diseases that frequently lead to chronic kidney disease (e.g. hypertension, diabetes, and obesity). We will additionally evaluate whether the risk of donation differs based on baseline characteristics.

DISCUSSION

Our study will provide a comprehensive assessment of long-term living donor risk to inform candidate living donors, and to inform the follow-up and care of current living donors.

Association of Pre- and Post-Donation Renal Function with Midterm Estimated Glomerular Filtration Rate in Living Kidney Donors: A Retrospective Study

PURPOSE

The estimated glomerular filtration rate (eGFR) at 6 months after donation (eGFR_6m) is strongly associated with the risk of end-stage renal disease in living kidney donors. This study aimed to investigate the incidence of eGFR_6m <60 mL/min/1.73 m² (eGFR_6m <60) and identify the risk factors that can predict the occurrence of eGFR_6m <60 in living kidney donors.

MATERIALS AND METHODS

Living kidney donors who underwent nephrectomy at Severance Hospital between January 2009 and December 2019 were identified. We excluded 94 of 1233 donors whose creatinine values at 6 months after donation were missing. The risk factors for eGFR_6m <60 were assessed using multivariate regression analysis. The optimal cutoff points for candidate risk factors for predicting eGFR_6m <60 occurrence were determined using the Youden index.

RESULTS

The eGFR_6m <60 occurred in 17.3% of the participants. Older age (≥44 years), history of hypertension, lower preoperative eGFR (<101 mL/min/1.73 m²), and degree of increase in creatinine levels on postoperative day 2 compared to those before surgery (ΔCr2_pre) (≥0.39 mg/dL) increased the risk of eGFR_6m <60. The addition of ΔCr2_pre to preoperative eGFR yielded a higher predictive accuracy for predicting eGFR_6m <60 than that with preoperative eGFR alone {area under the receiver operating characteristic curve=0.886 [95% confidence interval (CI), 0.863-0.908] vs. 0.862 (95% CI, 0.838-0.887), p<0.001}.

CONCLUSION

The incidence of eGFR_6m <60 was 17.3%. Older age, lower preoperative eGFR, history of hypertension, and greater ΔCr2_pre were associated with the occurrence of eGFR_6m <60 after living donor nephrectomy. The combination of preoperative eGFR and ΔCr2_pre showed the highest predictive power for eGFR_6m <60.

Whole and cortical kidney volume predict 5-year post-nephrectomy eGFR in Indian living kidney donors

AIM

To study the additional utility of pre-nephrectomy whole and cortical kidney volumes (WKV, CKV) in predicting long-term post-nephrectomy kidney function in Indian living kidney donors (LKDs).

METHODS

This retrospective cohort study included all LKDs who underwent nephrectomy between 1 January 2006 and 31 December 2015 at our centre, had pre-nephrectomy height, weight and computed tomography (CT) angiography with arterial and nephrographic phase documented, and 5-year post-nephrectomy creatinine values measured. Correlation between body surface area (BSA) adjusted pre-nephrectomy total CKV, WKV and pre-nephrectomy CKD EPI eGFR; BSA-adjusted remnant pre-nephrectomy CKV (rCKV), WKV (rWKV) and 5-year post-nephrectomy CKD EPI creatinine eGFR (5yeGFRCr ); predictors of 5yeGFRCr  < 70% of pre-nephrectomy CKD EPI creatinine eGFR (pre-eGFRCr ), and an equation to predict 5yeGFRCr from pre-nephrectomy variables were calculated.

RESULTS

A total of 196 LKDs (74% female, mean age 41.7 ± 11.0 years) were included in the study. Total WKV showed higher correlation with pre-nephrectomy eGFR than CKV, the highest with CKD EPI cystatin eGFR. Remnant WKV showed higher correlation than rCKV with post-nephrectomy eGFRCr and this increased over time. Older age, lower rWKV or rCKV, higher BSA, and higher pre-eGFRCr identified LKDs with 5yeGFRCr  < 70% of pre-eGFRCr , with rCKV identifying a higher proportion (4.5%) of such LKDs. A model including rWKV or rCKV predicted 5yeGFRCr better than one including age, gender, BSA and pre-eGFRCr alone.

CONCLUSION

Inclusion of pre-nephrectomy remnant CKV and WKV into models for 5yeGFRCr and sub-optimal post-nephrectomy adaptation in Indian LKDs improves their accuracy. CKD EPI cystatin eGFR correlates better with functional renal mass.

Galectin-3-A New Player of Kidney Damage or an Innocent Bystander in Children with a Single Kidney?

The aim of this study was to evaluate the galectin-3 (Gal-3) level in children with a congenital solitary functioning kidney (cSFK) and determine its association with common renal function parameters. The study consisted of 68 children (49 males) with cSFK. We demonstrated that children with cSFK had a lower level of galectin-3 than that of healthy subjects (p < 0.001). No significant differences in serum cystatin C (Cys C) levels between the cSFK children and the reference group were found. The subjects with cSFK and reduced estimated glomerular filtration rate (eGFR) had significantly higher levels of Gal-3 and Cys C compared to those with normal eGFR (p < 0.05). Children with eGFR <60 mL/min/1.73 m² showed significant statistical differences between the values of area under ROC curve (AUC) for Gal-3 (AUC 0.91) and Cys C (AUC 0.96) compared to that for creatinine level (AUC 0.76). Similar analyses carried out among cSFK children with eGFR <90 mL/min/1.73 m² revealed an AUC value of 0.69 for Gal-3, 0.74 for Cys C, and 0.64 for creatinine; however, no significant superiority was shown for any of them. The receiver operating characteristic (ROC) analyses for identifying the SFK children among all participants based on the serum levels of Gal-3 and Cys C did not show any diagnostic profile (AUCs for Gal-3 and Cys C were 0.22 and 0.59, respectively). A positive correlation between the Gal-3 and Cys C concentrations was found (r = 0.39, p = 0.001). We demonstrated for the first time that Gal-3 might play an important role in the subtle kidney damage in children with cSFK. However, further prospective studies are required to confirm the potential applicability of Gal-3 as an early biomarker for kidney injury and possible progression to CKD.

Tumor Necrosis Factor-Like Weak Inducer of Apoptosis and Selected Cytokines-Potential Biomarkers in Children with Solitary Functioning Kidney

This study was performed to explore serum tumor necrosis factor-like weak inducer of apoptosis (TWEAK) and its dependent cytokines urinary excretion: monocyte chemoattractant protein-1 (MCP-1) and regulated on activation, normal T cell expressed and secreted chemokine (RANTES) with their relation to the kidney function parameters in children with solitary functioning kidney (SFK). The study included 80 children and adolescents (median age 9.75 year) with congenital and acquired (after surgical removal) SFK. Serum TWEAK and urinary MCP-1 and RANTES levels were significantly higher in SFK patients (p < 0.05). The serum TWEAK was positively related to serum creatinine (r = 0.356; p < 0.001). Moreover, in SFK the receiver operating characteristic analyses revealed good diagnostic profile for serum TWEAK with AUC (Area Under The Curve)—0.853, uRANTES—0.757, and for RANTES/cr.: AUC—0.816. Analysis carried out to identify children with impaired renal function (albuminuria and/or decreased estimated glomerular filtration rate < 90 mL/min/1.73 m² and/or hypertension) showed good profile for TWEAK (AUC—0.79) and quite good profile for uRANTES and RANTES/cr. (AUC 0.66 and 0.631, respectively). This is the first study investigating serum TWEAK and urinary excretion of MCP-1 and RANTES together in children with SFK. Obtained results indicate that TWEAK and RANTES may serve as potential markers of renal impairment.

Impact of Accessory Renal Artery Coverage on Renal Function during Endovascular Aortic Aneurysm Repair

BACKGROUND

Long-term outcomes of accessory renal artery (ARA) coverage after endovascular aneurysm repair (EVAR) are unknown. We analyzed the impact of ARA coverage on renal function long-term.

METHODS

This retrospective, monocentric study included patients treated by EVAR between 2008 and 2016. Patients with at least one ARA covered with EVAR (ARA group) were compared with patients with no covered ARA (control group). Renal function was determined by estimating the glomerular filtration rate (eGFR) and graded according to chronic kidney disease (CKD) classification stages.

RESULTS

A total of 184 patients were included (ARA group, n = 25; control group, n = 159). Renal risk factors were similar in the 2 groups. Mean (±standard deviation) duration of follow-up was 41.6 ± 25.8 months. Preoperative eGFR (mL/min/1.73 m²) was 68.9 ± 17.8 in the ARA group and 72.5 ± 17.4 in the control group (P = 0.33), with a similar decline in the 2 groups during follow-up (-6.52 ± 11.6 ARA group vs. -6.43 ± 13.8 control group; P = 0.97). At the end of the study, 8 ARA patients and 56 controls had deteriorated by one CKD stage (32% vs. 35.2%, respectively; P = 0.75). Rate of renal infarction was significantly higher in the ARA group (96% vs. 1.9%; P < 0.0001). In multivariate analysis, suprarenal fixation was identified as a risk factor for a decline in renal function (odds ratio = 2.01 [95% confidence interval: 1.05-3.84]; P = 0.04).

CONCLUSIONS

ARA coverage after EVAR does not appear to affect renal function long-term. Suprarenal fixation led to a greater decline in renal function.

Long-term compensation of renal function after donor nephrectomy

Background

Living donors are the major source of kidneys in countries with a shortage of deceased donors. Kidney donation after careful donor selection is generally accepted as a safe procedure, but the physiologic consequences after donor nephrectomy are not fully verified. In this study we retrospectively reviewed the renal function of the residual kidney in living donors.

Methods

Post-nephrectomy laboratory data of 1,175 living donors (60.7%) from 1,933 living donors who received uninephrectomy from January 1999 to December 2017 at Yonsei University, Severance Hospital, Korea were retrospectively collected. Post-nephrectomy renal function was monitored by the relative ratio of estimated glomerular filtration rate (e-GFR; pre-nephrectomy e-GFR ratio vs. post-nephrectomy e-GFR) that was calculated by the Modification of Diet in Renal Disease formula.

Results

During 36.3±37.6 months of mean follow-up, two cases (0.17%, 2/1,175) of renal failure developed. The mean e-GFR decreased to 64.3±14.2 mL/min/1.73 m² immediately after nephrectomy from 99.2±19.9 mL/min/1.73 m² of the pre-nephrectomy e-GFR. Early decrement of e-GFR was prominent in male and obese donors (body mass index >25 kg/m², P<0.05). The e-GFR ratio increased according to post-nephrectomy duration, and the mean increment degree of e-GFR ratio after nephrectomy calculated by linear regression analysis was 1.94% per year. Unlike the early decrement of e-GFR ratio after nephrectomy, donor factors such as degree of obesity and donor sex did not affect the late increment of e-GFR ratio after nephrectomy (P>0.05).

Conclusions

Our data showed that long-term compensation of the renal function after nephrectomy occurs independently of preoperative donor characteristics.

Long-term outcome of kidney transplant by using restored kidney grafts after tumour ex vivo excision - a prospective study

The aim of this study is to report long-term outcomes of kidney transplantation by using the kidney graft after a small tumour ex vivo excision. A structured programme was established to use the restored kidney graft from urological referral after radical nephrectomy. The criteria were defined as tumour size ≤3 cm, margin clear on frozen section and recipients aged ≥60 years or those on the urgent list for transplantation as a result of imminent lack of dialysis access. The recipients were followed up regularly for surveillance of tumour recurrence. Between February 2007 and February 2018, 28 recipients had kidney transplantation by using the restored kidney grafts. The tumour size was 2.6 ± 0.7 cm. The follow-up was median 7 years without evidence of tumour recurrence. The patient and graft survival was satisfactory. Kidney transplantation by using restored kidneys after a small tumour excision is a novel source for selected recipients. The long-term patient and graft survival is satisfactory. Although there is a risk of tumour recurrence, it is rare event. Together with literature review, we would support use of kidney graft after a small tumour excision for selected recipients.

Should minors and young adults qualify as potential live kidney donors? The views of international transplant professionals

Although live kidney donation (LD) has become an increasingly common procedure, European and US transplant centres disagree as to whether minors and young adults should qualify as donor candidates. Therefore, we aimed to better understand the attitudes and viewpoints of transplant professionals. We conducted fourteen in-depth interviews with a purposive sample of international transplant professionals from various professional backgrounds. Data analysis was guided by QUAGOL, a systematic approach based on the constant-comparative method. Professionals expressed a cautionary view, worrying about the uncertain long-term medical and psychosocial consequences of LD at a young age. They also worried that young individuals' decisions are more likely to be influenced by their psychosocial developmental stage or family pressure. As these concerns were more significant for minors as compared to young adults, minors were deemed ineligible for LD except for in highly exceptional circumstances. Professionals' attitudes were also influenced by the expected benefits for the recipient and the availability of therapeutic alternatives, as well as the strength of the donor-recipient relationship. More prospective research on the long-term medical and psychological outcomes in young adult donors is likely to shed more light on the acceptability of LD by adolescents and young adults.

Prevalence and risk factors of hypertension following nephrectomy in living kidney donors

Living donor kidney transplantation is the treatment of choice for the patients with end-stage renal disease, especially where deceased donor programs are limited. There are limited data on the outcomes of living kidney donors (LKD) from developing countries, especially from North Africa. The aim of this study is to evaluate the prevalence of hypertension (HTN) in LKD and to analyze its risk factors. This is a longitudinal monocentric study, and the donors who underwent nephrectomy for donation between 2006 and 2015 were included. Ninety-two donors were assessed. The mean age at the time of nephrectomy was 42.8 ± 10 years (21-68 years). The sex ratio was 0.6. At the time of donation, the median systolic blood pressure was 120 mm Hg and the median diastolic blood pressure was 70 mm Hg. HTN was noted in 4% of donors. The median follow-up duration was 26 months. Two years after donation, the prevalence of HTN was 28% in the study group (8% male and 20% female). The mean time to development of HTN was 16 months. Associations between HTN after donation and the cardiovascular family history, age >40 years, HTN, obesity, android obesity, glomerular filtration rate GFR <90 mL/min/1.73 m², perioperative HTN, and dyslipidemia were noted. The multivariate analysis showed that obesity at the time of donation was a risk factor for HTN (odds ratio = 4.8; P = 0.04). Obese donor [body mass index (BMI) ≥30)] has higher risk of HTN after nephrectomy than nonobese donor.

Low Birth Weight, Blood Pressure and Renal Susceptibility

PURPOSE OF THE REVIEW

The purpose of this review is to highlight the clinical significance of increased renal risk that has its origins in fetal life. This review will also discuss the critical need to identify therapeutic interventions for use in a pregnancy complicated by placental dysfunction and intrauterine growth restriction that can mitigate the developmental origins of kidney disease without inflicting additional harm on the developing fetus.

RECENT FINDINGS

A reduction in nephron number is a contributory factor in the pathogenesis of hypertension and kidney disease in low birth weight individuals. Reduced nephron number may heighten susceptibility to a secondary renal insult, and recent studies suggest that perinatal history including birth weight should be considered in the assessment of renal risk in kidney donors. This review highlights current findings related to placental dysfunction, intrauterine growth restriction, increased risk for renal injury and disease, and potential therapeutic interventions.

Solitary kidney and risk of chronic kidney disease

The renal outcome of solitary kidney remains controversial. We examined the longitudinal association of congenital or acquired solitary kidney with the development of chronic kidney disease (CKD). A cohort study was performed involving 271,171 Korean men and women free of CKD at baseline who underwent a health screening program and who were followed annually or biennially for an average of 5.4 years. Solitary kidney was determined based on ultrasonographic findings. CKD was defined as an estimated glomerular filtration rate of < 60 ml/min/1.73 m² and/or the presence of proteinuria in two or more consecutive visits. During 1,472,519.6 person-years of follow-up, 2989 participants developed CKD (incidence rate: 2.0 per 1000 person-years). After adjustment for potential confounders, the aHR (95% CIs) for incident CKD comparing solitary kidney to the control was 3.26 (1.63-6.54). In analyses of cause-specific solitary kidney, aHR (95% CIs) for CKD comparing unilateral nephrectomy and congenital solitary kidney to the control were 6.18 (2.31-16.49) and 2.22 (0.83-5.92), respectively. The association between solitary kidney and CKD was stronger in men. Having a solitary kidney was independently associated with an increased risk of CKD development. Therefore, preventive strategies for reducing the risk of CKD are required in individuals with a solitary kidney.

Comparing Long-Term Outcomes Following Radical and Partial Nephrectomy for cT1 Renal Cell Carcinoma in Young and Healthy Individuals

Background

Despite randomized data demonstrating better overall survival favoring radical nephrectomy, partial nephrectomy continues to be the treatment of choice for low-stage renal cell carcinoma.

Methods

We utilized the National Cancer Database to identify patients younger than 50 years diagnosed with low-stage renal cell carcinoma (cT1) treated with radical nephrectomy or partial nephrectomy (2004-2007). Inverse probability of treatment weighting adjustment was performed for all preoperative factors to account for confounding factors. Kaplan-Meier curves and Cox proportional hazards regression analyses were used to compare overall survival of patients in the two treatment arms. Sensitivity analysis was performed to explore the interaction of type of surgery and clinical stage on overall survival.

Results

Among the 3009 patients (median age = 44 years [interquartile range (IQR) = 40-47 years]), 2454 patients (81.6%) were treated with radical nephrectomy and 555 patients (18.4%) with partial nephrectomy. The median follow-up was 108.6 months (IQR = 80.2-124.3 months) during which 297 patients (12.1%) in the radical nephrectomy arm and 58 patients (10.5%) in the partial nephrectomy arm died. Following inverse probability of treatment weighting adjustment, there was no difference in overall survival between patients treated with partial nephrectomy and radical nephrectomy (hazard ratio = 0.83, 95% confidence interval = 0.63 to 1.10, P = .196). There were no statistically significant interactions between type of surgery and clinical stage on treatment outcome.

Conclusions

There was no difference in long-term overall survival between radical and partial nephrectomy in young and healthy patients. This patient cohort may have sufficient renal reserve over their lifetime, and preserving nephrons by partial nephrectomy may be unnecessary.

Retrospective study to identify risk factors for chronic kidney disease in children with congenital solitary functioning kidney detected by neonatal renal ultrasound screening

To evaluate the prognostic significance of factors frequently associated with a reduction in renal mass, such as prematurity, low birth weight, and congenital anomalies of kidney and urinary tract (CAKUT), in patients with solitary functioning kidney (SFK) and investigate signs of early renal injury due to glomerular hyperfiltration damage or dysplasia in the remaining kidney.Retrospective observational study of congenital SFK diagnosed and followed at a tertiary care hospital over a period of 10 years in which 32,900 newborns underwent routine neonatal abdominal ultrasound screening. We analyzed age at diagnosis, sex, gestational age, anthropometric measurements at birth and prenatal and neonatal ultrasound findings, in addition to follow-up data corresponding to imaging findings (ultrasound, micturating cystourethrography, dimercaptosuccinic acid renal, and scintigraphy), ipsilateral CAKUT, compensatory hypertrophy, and renal injury in the form of albuminuria, blood pressure, and estimated glomerular filtration rate (eGFR).In total, 128 congenital SFK cases were detected (1 per 257 live births). Of these, 117 (91.4%) were diagnosed by neonatal ultrasound screening and 44.5% of these had been previously identified by prenatal ultrasound. Neonatal ultrasound had a specificity of 100% and a sensitivity of 92.1%. Forty-five patients (35.2%) had ipsilateral CAKUT and the most common type was urinary collecting system anomalies (75.5%). Over a median follow-up of 6.3 years (1-10 years), compensatory renal hypertrophy was observed in 81 patients (63.7%), most of whom had ipsilateral CAKUT (76.1% vs 56.6% of patients without ipsilateral CAKUT). Albuminuria and hypertension were observed in 3.12% and 5% of patients, respectively, and both were associated with ipsilateral CAKUT (P < .05). In addition, 75% of albuminuria cases (P = .031), 83.3% of hypertension cases (P = .004), and 100% of decreased eGFRcases (P = .031) were significantly associated with CAKUT (renal parenchymal anomaly category), being the strongest predictor of GFR the presence or absence of CAKUT.Neonatal ultrasound screening is useful for the early diagnosis of SFK. The presence of ipsilateral CAKUT should be evaluated in all patients with SFK as congenital anomalies of the renal parenchyma are associated with a poorer prognosis. Because morbidity from CAKUTs may not develop until adulthood, patients should be closely followed throughout life.

Single-Center Long-Term Follow-Up of Kidney Donors in Argentina (Hospital Italiano de Buenos Aires)

INTRODUCTION

Living kidney donor (LKD) transplantation is increasing due to organ shortage. Clinical studies have shown that the risk of developing end-stage renal disease (ESRD) in donors is similar to that in the general population. Our goal was to evaluate postdonation renal outcomes assessed by glomerular filtration rate (GFR), proteinuria, and blood pressure.

METHODS

A total of 210 LKD transplants were performed at Hospital Italiano de Buenos Aires between 2000 and 2014. Postdonation outcomes were analyzed in 109 donors. GFR was assessed by 24-hour creatinine clearance (as 24-hour ClCr) and estimated using the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Additionally, we correlated the predonation renal functional reserve (RFR) with postdonation GFR. Donor results were compared to the expected GFR (adjusted to age and single kidney). Other renal outcome indicators measured were albuminuria and blood pressure, and they were compared (predonation and postdonation) using univariate analysis.

RESULTS

A total of 109 patients were followed up for 47 ± 34 months (range, 12-168): 70% were female, age at donation was 48.58 years (range, 25-70), and predonation serum creatinine was 0.85 ± 0.17 mg/dL. Postnephrectomy GFR (24-hour ClCr) was significantly lower compared to predonation GFR (105.38 ± 21.78 mL/min/1.73 m² vs 90.14 ± 17.78 mL/min/1.73 m²). However, postdonation GFR was not significantly different compared to the expected GFR. No differences were found for blood pressure or albuminuria. Age >50 and an RFR (<20%) was associated with a lower GFR.

CONCLUSIONS

In this population of LKD, renal outcome (24-hour CrCl, albuminuria, and blood pressure) was within the expected outcome for healthy individuals after uninephrectomy.

The National Landscape of Living Kidney Donor Follow-Up in the United States

In 2013, the Organ Procurement and Transplantation Network (OPTN)/ United Network for Organ Sharing (UNOS) mandated that transplant centers collect data on living kidney donors (LKDs) at 6 months, 1 year, and 2 years postdonation, with policy-defined thresholds for the proportion of complete living donor follow-up (LDF) data submitted in a timely manner (60 days before or after the expected visit date). While mandated, it was unclear how centers across the country would perform in meeting thresholds, given potential donor and center-level challenges of LDF. To better understand the impact of this policy, we studied Scientific Registry of Transplant Recipients data for 31,615 LKDs between January 2010 and June 2015, comparing proportions of complete and timely LDF form submissions before and after policy implementation. We also used multilevel logistic regression to assess donor- and center-level characteristics associated with complete and timely LDF submissions. Complete and timely 2-year LDF increased from 33% prepolicy (January 2010 through January 2013) to 54% postpolicy (February 2013 through June 2015) (p < 0.001). In an adjusted model, the odds of 2-year LDF increased by 22% per year prepolicy (p < 0.001) and 23% per year postpolicy (p < 0.001). Despite these annual increases in LDF, only 43% (87/202) of centers met the OPTN/UNOS-required 6-month, 1-year, and 2-year LDF thresholds for LKDs who donated in 2013. These findings motivate further evaluation of LDF barriers and the optimal approaches to capturing outcomes after living donation.

Assessment of long-term cardiovascular effects of unilateral nephrectomy

PURPOSE

There is conflicting evidence regarding long-term effects of unilateral nephrectomy such as cardiovascular diseases. Excessive increase in blood pressure (BP) during exercise called "hypertensive response to exercise" may be a sign of unborn hypertension and increased cardiovascular risk. Decrease in glomerular filtration rate (GFR) in patients with unilateral nephrectomy may be associated with disturbance of circadian BP changes without affecting the absolute levels of BP. We aimed to investigate the circadian BP changes and hypertensive response to exercise in normotensive patients with preserved renal functions who had undergone unilateral nephrectomy for other causes rather than organ donation.

METHODS

This study enrolled 32 patients (mean age 43.4 ± 9.9 years, male 15) with unilateral nephrectomy and 40 healthy controls (mean age 47 ± 6.1 years, male 17). All patients were undergone both office and ambulatory BP measurements and treadmill stress test.

RESULTS

The median time since nephrectomy was 12 (9-22) years in the patient group. The median GFR of the patient group was lower than that of the controls without significance [85.1 (76.0-97.9) vs. 93.2 (84.5-104.9), respectively; p = 0.14]. There was no significant difference between groups in terms of office BP measurements, night time diastolic and systolic BP, mean arterial pressure (MAP), night/day time ratio of MAP in ambulatory BP measurements. The results of treadmill stress tests and hypertensive response to exercise ratios were also similar between the groups.

CONCLUSION

This study revealed that there was no increase in long-term cardiovascular risks one decade after unilateral nephrectomy based on circadian BP changes and hypertensive response to exercise in normotensive patients.

Perioperative morbidity and long-term outcome of unilateral nephrectomy in feline kidney donors: 141 cases (1998-2013)

OBJECTIVE To evaluate the outcome associated with unilateral nephrectomy in feline kidney donors. DESIGN Retrospective case series. ANIMALS 141 cats. PROCEDURES Medical records of cats that underwent nephrectomy for renal donation were reviewed for information on signalment, date of renal donation, results of blood and urine analyses, infectious disease history, anesthetic protocols, intra- and postoperative complications, and postoperative analgesic protocols. Long-term follow-up data were obtained via client telephone interview and review of referring veterinarian medical records. RESULTS All donors were healthy young adult cats with a median age of 1.5 years (range, 0.8 to 2 years). No cats died or were euthanized during the perioperative period. Intraoperative complications occurred in 2 cats, and postoperative complications occurred in 17. Median time from nephrectomy to hospital discharge was 3.6 days (range, 2 to 8 days). Long-term follow-up information was available for 99 cats, with a median interval between nephrectomy and follow-up of 10 years (range, 0.25 to 15 years). Six cats had a history of urinary tract disease including stable chronic kidney disease (n = 3), acute kidney injury (2), and cystitis (1). Nine cats were dead at follow-up; death was attributed to chronic renal failure in 2 and acute ureteral obstruction in 4. CONCLUSIONS AND CLINICAL RELEVANCE Feline donor nephrectomy had an acceptably low perioperative morbidity in this series. Most cats (84%) for which follow-up information was available had no associated long-term effects. However, a small subset (7%) developed renal insufficiency or died of urinary tract disease.

Should living kidney donors with hypertension be considered for organ donation?

PURPOSE OF REVIEW

The large number of end-stage kidney disease patients waiting for a kidney transplant often means years of delay before a suitable organ becomes available. Living kidney donors are one way to circumvent such long waiting times, and the desire to increase the pool of living kidney donors has allowed the selection of donors with hypertension.

RECENT FINDINGS

Hypertensive kidney donors, despite having larger glomeruli, and fewer glomeruli, particularly when over the age of 50 years, do well in follow-up. The data are mainly in white living kidney donors whose preexisting hypertension has been well controlled [blood pressure (BP) <140/90 mmHg] on one or two antihypertensive medications. Those selected for donation do as well as nonhypertensive donors as long they are older (age >50 years), nonobese (BMI 26-30 kg/m), and have no evidence of end-organ damage prior to donation.

SUMMARY

Although the data supporting long-term safety of nephrectomy in hypertensive donors are modest, small studies with short-term follow-up suggest no increase in the incidence of kidney disease or worsening of the control of hypertension in donors with a history of high BP.

Racial Differences in the Living Kidney Donation Experience and Implications for Education

Context

Much has been written about the barriers to deceased organ donation in the African American community. However, relatively little research has been conducted on barriers to living donation among African Americans. A shortage of suitable deceased donor kidneys among African Americans has encouraged donation from living donors.

Objective

As a follow-up to several focus groups with health professionals about barriers to living donation and suggestions for educational interventions, we sought to determine kidney donors' thoughts and feelings about their donation.

Design

Telephone interviews with past donors.

Participants

Nine African Americans and 9 whites were selected from a database of laparoscopic donor nephrectomies from 1993 to 2003.

Outcome Measures

Transcribed phone interviews were reviewed by 3 researchers to determine recurring themes and categorize responses.

Results

Responses were categorized into 8 areas of concern: health, financial, life with 1 kidney, procreation, psychosocial matters, surgery related, success of the transplant, and concerns about the future. Whites (n =9) tended to volunteer more for laparoscopic kidney donation than did African Americans (n = 2). African American concerns focused on future health and living with only 1 kidney, whereas whites had concerns about the surgery and the medical system.

Conclusions

Findings indicated that education is the best way to reach living donors and dispell fears. Promoting general health of African Americans may increase their willingness to be a living donor. Altruistic motives are the main motivation for donation, and intervention programs should target groups on a personal level to help individuals see that they can make a difference in improving or saving lives.

Ethical Issues Surrounding High-Risk Kidney Recipients: Implications for the Living Donor

Evaulating patients for living kidney donor transplantation involving a recipient with significant medical issues can create an ethical debate about whether to proceed with surgery. Donors must be informed of the surgical risk to proceed with donating a kidney and their decision must be a voluntary one. A detailed informed consent should be obtained from high-risk living kidney donor transplant recipients as well as donors and family members after the high perioperative risk potential has been explained to them. In addition, family members need to be informed of and acknowledge that a living kidney donor transplant recipient with pretransplant extrarenal morbidity has a higher risk of a serious adverse outcome event such as graft failure or recipient death. We review 2 cases involving living kidney donor transplant recipients with significant comorbidity and discuss ethical considerations, donor risk, and the need for an extended informed consent.

Long-term safety in living kidney donors for paediatric transplantation. Single-centre prospective study

INTRODUCTION

There is enough evidence concerning the short-term safety of living donors after kidney transplantation. However, long-term complications continue to be studied, with a particular interest in young donors. Previous studies have been conducted in older donors for adult renal patients. We present a study of long-term complications in kidney donors for our paediatric population.

METHODS

We carried out a long-term donor study for the 54 living kidney-donor transplantations performed at our department from 1979 to June 2014. We monitored the glomerular filtration rate (GFR) on the basis of 24-hour urine creatinine clearance, 24-hour proteinuria and the development of arterial hypertension in the 48 donors who were followed up for more than one year. Only the 39 patients who were exclusively followed up by our department have been included in the results analysis.

RESULTS

GFR through creatinine clearance was stable after an initial decrease. No proteinuria was observed in any of the cases. One patient developed chronic kidney disease (CKD), which resulted in a cumulative incidence of 2%. GFR below 60mL/min/1.73 m² was not reported in any other patients. Arterial hypertension was diagnosed in 25% of donors, 90% of which were treated with antihypertensives.

CONCLUSIONS

Risk of CKD and hypertension in living kidney donors for paediatric recipients, who are carefully monitored throughout their evolution, is similar to that of the general population. Therefore, this technique appears to be safe in both the short and long term.

Investigating kidney donation as a risk factor for hypertension and microalbuminuria: findings from the Swiss prospective follow-up of living kidney donors

OBJECTIVES

To assess the role of nephrectomy as a risk factor for the development of hypertension and microalbuminuria.

DESIGN

Prospective, long-term follow-up study.

SETTING

Swiss Organ Living-Donor Health Registry.

PARTICIPANTS

All living kidney donors in Switzerland between 1993 and 2009.

INTERVENTIONS

Data on health status and renal function before 1 year and biennially after donation were collected.

PRIMARY AND SECONDARY OUTCOME MEASURES

Comparison of 1-year and 5-year occurrences of hypertension among normotensive donors with 1-year and 5-year estimates from the Framingham hypertension risk score. Multivariate random intercept models were used to investigate changes of albumin excretion after donation, correcting for repeated measurements and cofactors such as age, male gender and body mass index.

RESULTS

A total of 1214 donors contributed 3918 data entries with a completed biennial follow-up rate of 74% during a 10-year period. Mean (SD) follow-up of donors was 31.6 months (34.4). Median age at donation was 50.5 years (IQR 42.2-58.8); 806 donors (66.4%) were women. Donation increased the risk of hypertension after 1 year by 3.64 (95% CI 3.52 to 3.76; p<0.001). Those participants remaining normotensive 1 year after donation return to a risk similar to that of the healthy Framingham population. Microalbuminuria before donation was dependent on donor age but not on the presence of hypertension. After nephrectomy, hypertension became the main driver for changes in albumin excretion (OR 1.19; 95% CI 0.13 to 2.25; p=0.03) and donor age had no effect.

CONCLUSIONS

Nephrectomy propagates hypertension and increases susceptibility for the development of hypertension-induced microalbuminuria.

Upper tract urothelial carcinoma: Paradigm shift towards nephron sparing management

Upper tract urothelial carcinoma (UTUC) is relatively rare compared to urothelial carcinoma of the lower tract, comprising only 5%-10% of all urothelial cancers. Although both entities share histologic properties, UTUC tends to be more invasive at diagnosis and portend a worse prognosis, with a 5 year overall mortality of 23%. To date, the gold standard management of UTUC has been radical nephroureterectomy (RNU), with nephron sparing techniques reserved for solitary kidneys or cases where the patient could not tolerate radical surgery. Limited data from these series, as well as select series where nephron-sparing endoscopic management has been offered to a broader patient base, suggest that minimally invasive, nephron sparing techniques can offer comparable oncologic and survival outcomes to RNU in appropriately selected patients. We review the current literature on the topic and discuss long term outcomes and sequelae of the gold standard treatment, RNU. We also discuss the oncologic outcomes of minimally invasive, endoscopic management of UTUC. Our goal is to provide the reader a comprehensive overview of the current state of the field in order to inform and guide their treatment decisions.

Renal cell carcinoma: risks and benefits of nephron-sparing surgery for T1 tumors

Renal cell carcinoma is the most common cancer of the kidneys that is primarily treated with surgery, including removal of part or all the involved kidney depending on size and tumor, complexity, and patient characteristics. Partial nephrectomy historically was restricted to cases of solitary kidney or bilateral tumors. It was then started for masses smaller than 4 cm and currently is even studied and justified in tumors smaller than 7 cm if surgically feasible. Although partial nephrectomy preserves kidney tissue and, therefore, delays or prevents the new onset of CKD and ESRD, radical nephrectomy is still overused even for the small tumors. Studies have shown that although this practice is driven by an easier complete removal of the kidney especially in the era of minimally invasive surgery, partial nephrectomy is successful in curing cancer and achieving excellent cancer-specific survival in addition to its benefits on cardiovascular health. Nowadays interest in preserving healthy kidney tissue is increasing to the level of studying the impact of larger volume removed around the kidney and the histopathology of that non-neoplastic tissue to predict kidney function behavior postoperatively.

Comparison of postoperative estimated glomerular filtration rate between kidney donors and radical nephrectomy patients, and risk factors for postoperative chronic kidney disease

OBJECTIVES

To compare post-nephrectomy renal function between kidney donors and renal cell carcinoma patients, to evaluate trends in recovery, and to identify factors relevant to renal failure.

METHODS

Patients who had radical or donor nephrectomy from four different institutions between 2003 and 2012 were reviewed. Propensity score matching was carried out and 79 patients were selected for each group. The estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula preoperatively and postoperatively at 1, 3, 6, 12, 24 and 36 months. Mean estimated glomerular filtration rate was compared, and the difference between preoperative values and each preceding date was calculated. A multivariate logistic regression was used to determine independent factors for a decrease in estimated glomerular filtration rate to <60 mL/min/1.73 m(2) .

RESULTS

The donor nephrectomy group showed a trend of improved estimated glomerular filtration rate recovery at 24 months and 36 months compared with the radical nephrectomy group, which was statistically significant (P = 0.028, P = 0.012). Multivariate logistic regression showed that renal cell carcinoma (odds ratio 4.605, 95% confidence interval 1.626-13.040, P = 0.004), a baseline estimated glomerular filtration rate lower than 110 (odds ratio 4.477, 95% confidence interval 1.360-14.742, P = 0.014) and age older than 40 years (odds ratio 21.616, 95% confidence interval 2.761-169.222, P = 0.003) were predictive factors for a decrease in renal function.

CONCLUSIONS

Renal cell carcinoma is an independent risk factor for chronic kidney disease after nephrectomy. In addition, age older than 40 years and a baseline estimated glomerular filtration rate of 110 mL/min/1.73 m(2) or less seem to represent risk factors associated with chronic kidney disease after nephrectomy.

Fetal programming and cardiovascular pathology

Low birth weight serves as a crude proxy for impaired growth during fetal life and indicates a failure for the fetus to achieve its full growth potential. Low birth weight can occur in response to numerous etiologies that include complications during pregnancy, poor prenatal care, parental smoking, maternal alcohol consumption, or stress. Numerous epidemiological and experimental studies demonstrate that birth weight is inversely associated with blood pressure and coronary heart disease. Sex and age impact the developmental programming of hypertension. In addition, impaired growth during fetal life also programs enhanced vulnerability to a secondary insult. Macrosomia, which occurs in response to maternal obesity, diabetes, and excessive weight gain during gestation, is also associated with increased cardiovascular risk. Yet, the exact mechanisms that permanently change the structure, physiology, and endocrine health of an individual across their lifespan following altered growth during fetal life are not entirely clear. Transmission of increased risk from one generation to the next in the absence of an additional prenatal insult indicates an important role for epigenetic processes. Experimental studies also indicate that the sympathetic nervous system, the renin angiotensin system, increased production of oxidative stress, and increased endothelin play an important role in the developmental programming of blood pressure in later life. Thus, this review will highlight how adverse influences during fetal life and early development program an increased risk for cardiovascular disease including high blood pressure and provide an overview of the underlying mechanisms that contribute to the fetal origins of cardiovascular pathology.

Open mini-flank partial nephrectomy: an essential contemporary operation

Secondary to the widespread use of the modern imaging techniques of computed tomography, magnetic resonance imaging, and ultrasound, 70% of renal tumors today are detected incidentally with a median tumor size of less than 4 cm. Twenty years ago, all renal tumors, regardless of size were treated with radical nephrectomy (RN). Elective partial nephrectomy (PN) has emerged as the treatment of choice for small renal tumors. The basis of this paradigm shift is three major factors: (1) cancer specific survival is equivalent for T1 tumors (7 cm or less) whether treated by PN or RN; (2) approximately 45% of renal tumors have indolent or benign pathology; and (3) PN prevents or delays the onset of chronic kidney disease, a condition associated with increased cardiovascular morbidity and mortality. Although PN can be technically demanding and associated with potential complications of bleeding, infection, and urinary fistula, the patient derived benefits of this operation far outweigh the risks. We have developed a "mini-flank" open surgical approach that is highly effective and, coupled with rapid recovery postoperative care pathways associated with a 2-day length of hospital stay.

Experiences obtaining insurance after live kidney donation

The impact of kidney donation on the ability to change or initiate health or life insurance following donation is unknown. To quantify this risk, we surveyed 1046 individuals who donated a kidney at our center between 1970 and 2011. Participants were asked whether they changed or initiated health or life insurance after donation, and if they had any difficulty doing so. Among 395 donors who changed or initiated health insurance after donation, 27 (7%) reported difficulty; among those who reported difficulty, 15 were denied altogether, 12 were charged a higher premium and 8 were told they had a preexisting condition because they were kidney donors. Among 186 donors who changed or initiated life insurance after donation, 46 (25%) reported difficulty; among those who reported difficulty, 23 were denied altogether, 27 were charged a higher premium and 17 were told they had a preexisting condition because they were kidney donors. In this single-center study, a high proportion of kidney donors reported difficulty changing or initiating insurance, particularly life insurance. These practices by insurers create unnecessary burden and stress for those choosing to donate and could negatively impact the likelihood of live kidney donation among those considering donation.

Single-centre long-term follow-up of live kidney donors demonstrates preserved kidney function but the necessity of a structured lifelong follow-up

BACKGROUND

The increase of live kidney donation (LKD) demands that we scrutinize its long-term consequences. Socialized medicine in Sweden has allowed us to survey long-term consequences of LKD with a high response rate.

METHODS

Between 1974 and 2008, 455 LKDs were performed; 28 donors were deceased and 14 had moved abroad at the time of the survey. Of the remaining 413, 96% agreed to participate in a retrospective study with laboratory testing and answering a questionnaire.

RESULTS

Mean age at donation was 49 ± 10 years, and the mean time since nephrectomy was 11 ± 7 years (range 1-33). No death was of renal cause. S-creatinine at follow-up was 93 ± 18 μmol/L, 28% had treated hypertension, of whom only 52% had BP <140/90. Eleven per cent had spot microalbuminuria, and 1% were diagnosed with diabetes mellitus. Seventy-one per cent had check-ups at least every second year, but 14% had no check-ups. Eighty per cent would be willing to donate again if it were possible, and only 3% regretted the donation.

CONCLUSION

Renal function is well preserved in the long term after donation, no case of end-stage renal disease was identified, and a large majority of our donors would donate again if it were possible. Although rates of microalbuminuria and hypertension were at expected levels, a significant number of donors demonstrated elevated blood pressure levels and inadequate antihypertensive treatment. A relatively large number of donors did not receive regular check-ups. Both of these issues demonstrate the need for a better-structured lifelong follow-up.

The Outcomes of Living Kidney Donation from Medically Complex Donors: Implications for the Donor and the Recipient

Living kidney donation is an important option for patients with end-stage renal disease (ESRD), and has improved life expectancy and quality for patients otherwise requiring maintenance dialysis or deceased-donor transplantation. Given the favorable outcomes of live donation and the shortage of organs to transplant, individuals with potentially unfavorable demographic and clinical characteristics are increasingly being permitted to donate kidneys. While this trend has successfully expanded the live donor pool, it has raised concerns as to which acceptance criteria are safe. This review aims to summarize the existing literature on the outcomes of transplantation from medically complex, living kidney donors, including both donor and recipient outcomes when available.

Partial nephrectomy achieves local tumor control and prevents chronic kidney disease

Over the last 10 years, a rapidly changing clinical landscape has created an optimal environment to expand the use of partial nephrectomy for the treatment of renal cortical tumors. The main factors responsible for the increasing use of partial nephrectomy relate to the appreciation of the diversity of renal cortical tumor histology, the tumor stage and size migration associated with their incidental detection, and the oncological efficacy of partial nephrectomy for tumors of 7 cm or smaller. Evidence has now emerged that radical nephrectomy performed during the treatment of a small renal mass may further reduce an already impaired baseline renal function and place the patient in the realm of chronic kidney disease. Important new information concerning chronic kidney disease, a condition far more prevalent in the aging US population than previously appreciated, and its associated cardiovascular morbidity and mortality, now places maximal renal functional preservation on a par with local tumor control as surgical plans are formulated for the resection of a small renal cortical tumor.

Nutrient-restricted fetus and the cardio–renal connection in hypertensive offspring

A suboptimal intrauterine environment has a number of deleterious effects on fetal development and postpartum health outcomes. Epidemiological studies on several human populations have linked socioeconomic status and low birth weight to an increased incidence of diseases such as hypertension, diabetes, obesity and cardiovascular disease. A growing number of experimental studies in a variety of animal models demonstrate that maternal stressors, such as nutrition and reduced uterine perfusion, affect the intrauterine milieu and result in increased blood pressure in offspring. Several mechanisms appear to contribute to hypertension, including vascular dysfunction and increased peripheral resistance, altered cardio-renal structure and alterations in cardio-renal function. Although many studies have characterized models of developmentally generated hypertension, few have begun to seek therapeutic modalities to ameliorate its incidence. This review discusses recent work that refines hypotheses linking a suboptimal intrauterine environment to cardiovascular and renal phenotypes that have increased susceptibility to cardiovascular disease and hypertension.

Renal function following curative surgery for renal cell carcinoma: who is at risk for renal insufficiency?

Purpose

To investigate the incidence and predictive factors associated with the development of chronic kidney disease (CKD) in patients undergoing curative surgery for renal cell carcinoma.

Materials and Methods

From 2003 to 2010, we retrospectively investigated 108 patients undergoing partial nephrectomy or radical nephrectomy (RN) for renal tumors with a preoperative glomerular filtration rate (GFR)≥60. The GFR was calculated by use of the four-variable modification of diet in renal disease (MDRD) formula. CKD was defined as an estimated GFR (eGFR) less than 60 mL/min per 1.73 m². Demographic and clinicopathologic parameters were evaluated by using the chi-square and Student t-tests and multivariate regression analysis to determine the variables independently associated with the development of postoperative CKD.

Results

Of the 108 patients without preoperative CKD, CKD developed in 43 patients (39.8%). In the analysis of clinical factors between patients with and those without CKD development, gender, body mass index, diabetes mellitus, hypertension, and tumor size were not significant clinical factors. Statistical significance for CKD development was found for age of 60 years or greater (p=0.013), decreased preoperative eGFR (p<0.001), and RN group (p<0.001). In the multivariate analysis, decreased preoperative eGFR (p=0.001) and RN group (p=0.002) were significant independent predictors.

Conclusions

The results of our study show that decreased preoperative renal function and RN were significant independent predictors of postoperative CKD. In patients who had a relatively decreased preoperative eGFR, especially when estimated by use of the MDRD formula, nephron-sparing surgery should be considered for the treatment of small renal tumors.

Change in renal parenchymal volume in living kidney transplant donors

PURPOSE

Uninephrectomy would induce compensatory hypertrophy in the remaining kidney. We investigated the relationship between changes in renal parenchymal volume (RPV) and renal function after nephrectomy in living kidney donors.

METHODS

From July 2011 and January 2012, 45 kidney donors were enrolled in this study. Magnetic resonance scanning was performed before surgery, 3 and 7 days postoperatively, and RPV was calculated through disc summarize methods. Participants were followed up for 1 year.

RESULTS

The RPV of the remaining kidney was 118.06 ± 23.51 cm(3) and then increased by 21.23 % to 143.13 ± 25.52 cm(3) at 3 days and by 24.17 % to 146.60 ± 25.86 cm(3) at 7 days. Multivariate regression analysis showed that preoperative RPV is positively related to its initial function (p = 0.037); the RPV at 7 days is directly related to its initial, preoperative size (p < 0.001). With respect to change in postoperative RPV, there is bigger gain in size in smaller kidneys (p = 0.005). The kidneys that has ≥20 % increase RPV after 7 days are more likely to show further increase in GFR at 1 year (p = 0.024).

CONCLUSIONS

Uninephrectomy induced immediately increment in RPV of the remaining kidney. Donors with RPV increase of ≥20 % at 1 week have a more favourable renal function adaptation at 1 year.

Oncological and renal medical importance of kidney-sparing surgery

In the past decade, the medical and oncological rationale for kidney-sparing surgical approaches for small renal masses has been clarified. Although radical nephrectomy is still necessary for many patients diagnosed with large renal tumours, accumulating evidence indicates that partial nephrectomy provides equivalent oncological outcomes while also preserving renal function and preventing the adverse cardiovascular effects of chronic kidney disease. Furthermore, approximately 45% of resected small renal tumours are benign or indolent, with limited--if any--metastatic potential. Patients who develop kidney cancer often have medical comorbidities that can affect kidney function, such as diabetes and hypertension, and histological examination of the non-tumour-bearing elements of the kidney demonstrate significant pathological changes in the vast majority of patients. For elderly patients or patients with comorbidities, active surveillance provides an alternative kidney-sparing approach, and is associated with extremely low rates of clinical disease progression and metastases. Despite these important advances in understanding, which support the use of partial nephrectomy for the treatment of small renal masses, the technique remains underused.

Demographic, metabolic, and blood pressure characteristics of living kidney donors spanning five decades

While cautious criteria for selection of living kidney donors are credited for favorable outcomes, recent practice changes may include acceptance of less than ideal donors. To characterize trends in donor acceptance, the Renal and Lung Living Donors Evaluation (RELIVE) Study evaluated 8,951 kidney donors who donated between 1963 and 2007 at three major U.S. transplant centers. Over the study interval, there was an increase in the percentage of donors >40 years old from 38% to 51%; donors >60 years varied between 1% and 4%. The proportion of donors with obesity increased from 8% to 26% and with glucose intolerance from 9% to 25%. The percentage of hypertensive donors was consistent (5-8%). Accepted donors ≥60 years old were more likely to have obesity, glucose intolerance, and/or hypertension compared to younger donors (p<0.0001). Our results demonstrate important trends in acceptance of older and more obese donors. The fraction of older donors accepted with glucose intolerance or hypertension remains small and for the majority includes mild elevations in glucose or blood pressure that were previously classified as within normal limits.

Living donor nephrectomy--quantifying the risk for the donor

Living kidney donation is on the rise, either due to cultural or ethical reasons or due to a lack of deceased donor kidneys. For adequately counseling of a potential living kidney donor, medical professionals must know not only the immediate risks of kidney donation but also possible long-term effects of kidney donation on the donor's physical and psychological well-being. This also includes a range of aspects such as quality of life, insurance issues, and family planning following kidney donation. This review article is based on a Medline and PubMed search and elucidates the risks living kidney donors face with regard to all aspects just mentioned. Living kidney donation does not end with the operative procedure--long-term cost-free physical and psychological follow-up should be offered to each donor for the gift he or she is willing to give to the recipient.

Death or Dialysis? the Risk of Dialysis-Dependent Chronic Renal Failure after Trauma Nephrectomy

Although renal trauma is increasingly managed nonoperatively, severe renovascular injuries occasionally require nephrectomy. Long-term outcomes after trauma nephrectomy are unknown. We hypothesized that the risk of end-stage renal disease (ESRD) is minimal after trauma nephrectomy. We conducted a retrospective review of the following: 1) our university-based, urban trauma center database; 2) the National Trauma Data Bank (NTDB); 3) the National Inpatient Sample (NIS); and 4) the U.S. Renal Data System (USRDS). Data were compiled to estimate the risk of ESRD after trauma nephrectomy in the United States. Of the 232 patients who sustained traumatic renal injuries at our institution from 1998 to 2007, 36 (16%) underwent a nephrectomy an average of approximately four nephrectomies per year. The NTDB reported 1780 trauma nephrectomies from 2002 to 2006, an average of 356 per year. The 2005 NIS data estimated that in the United States, over 20,000 nephrectomies are performed annually for renal cell carcinoma. The USRDS annual incidence of ESRD requiring hemodialysis is over 90,000, of which 0.1 per cent (100 per year) of renal failure is the result of traumatic or surgical loss of a kidney. Considering the large number of nephrectomies performed for cancer, we estimated the risk of trauma nephrectomy causing renal failure that requires dialysis to be 0.5 per cent. National data regarding the etiology of renal failure among patients with ESRD reveal a very low incidence of trauma nephrectomy (0.5%) as a cause; therefore, nephrectomy for trauma can be performed with little concern for long-term dialysis dependence.

Do living kidney donors have CKD?

Living kidney donor transplantation is an increasingly used treatment for end-stage renal disease because it both confers excellent outcomes to transplant recipients, and is considered a safe procedure for prospective donors. The short- and long-term safety of prospective donors is paramount to the continued success of living donation. Although the initial experience with living kidney donors mostly included the healthiest donors, increasing need for organs and secular trends in the general population have subtly reshaped prevailing suitability criteria for donation. As the practice of living donation evolved over time, our understanding of kidney disease has also changed as we embraced the framework of the K-DOQI guidelines. It is not uncommon for donors to fit into some of the K-DOQI guidelines paradigms of risk and disease; however, whether there is a true biological consequence or whether it is a merely semantic conundrum remains unclear. Regardless, this is an important issue, and therefore future efforts should aim at addressing this matter.

Are calcineurin inhibitors-free regimens ready for prime time?

The goal of research in transplant therapeutics is to achieve safe and effective immunosuppression strategies that allow durable engraftment free of toxicities. The calcineurin inhibitors (CNIs) regimens, because of their inherent toxicities (including nephrotoxicity), have been unable to meet these promises. Over the past decade acute cellular rejection decreased dramatically with a concomitant robust increase in 1-year graft survival; however, long-term graft outcome showed only modest improvement. This is due in part to the toxicities of the immunosuppressive drugs. The quest for a toxicity-free-CNI-free regimen has been both intense and frustrating. A turning point in CNIs-free therapy may have occurred with the recent approval of belatacept, which represents a new paradigm in immunosuppression: biological therapy for chronic immunosuppression devoid of the usual toxicities associated with the CNIs. Belatacept, a fusion receptor protein, blocks costimulation signals necessary for the activation of T cells. Although costimulation blockade has not been shown to induce tolerance, it can provide safe and effective immunosuppression without renal or cardiovascular toxicities. The approval of belatacept in both the United States and Europe for use in renal transplantation will finally push CNI-free regimens into prime time. Novel biologics such as ASKP1240 (a human anti-CD40 monoclonal antibody) and one small molecule, tofacitinib, may advance further the use of CNI-free regimens in organ transplantation.