Complications of donor nephrectomy

[Renal transplantation with living donors. A critical analysis of surgical procedures based on 40 years of experience]

INTRODUCTION

Absolute priority in an LDKT programme are donnor safety and kidney optimal anatomical and functional preservation. Reduced donnor morbidities, both at short and long term, are important objectives. Excellent technical grafting is a must as are the strategies employed for facilitatig it. We revised the incidences of our whole LDKT programme (40 years 243 donors) to confirm if these exigences have been acomplished or a change to new surgical procedures is recommended.

MATERIAL AND METHODS

Between 1968-2008 243 nephrectomies and grafting has been performed, a reduced number per year (A cadaver programme has been running simultaneously since 1964). For the nephrectomies a Turner-Warrick apprach was inititialy used and since 1973 a miniincisional, anterior, extraperitoneal approach of approximately 10 cm in length. The right kidney was removed in 75% of the cases and the right iliac area for the implant in 85% In adjacent opperating rooms, one team performs the nephrectomy while the other prepares and dissects free the grafting vessels. Most of the time the same senior surgeon performed both operatios: the nephrectomy and the implant. Peroperative and postoperative complications were evaluated by urologists and nephrologists in charge.

RESULTS

No donors dead, organs lost or major complications in the donors have been documented. Minor complications such as intestinal paresia, wound infection, persistent incisional pain were common. Miniincisional abdominal approach reduced postoperative pain and hospital stay (4 days). At long term no incisional hernia or abdominal paresia have been documented. Simultaneous work reduces ischemia time (30-45 s warm: 30-45 min cold) and opperatig room occupation(patient preparation plus anesthesia plus operation) estimated in 90-120 min for the nephrectomy and 120-160 for the grafting. The responsibility of the senior surgeon in both procedures facilitates vessel selection for the grafting.

CONCLUSIONS

No reasons have been found to reconvert our current nephrectomy procedure to laparoscopic or modify current surgical strategy. Superior safety of open surgery for donors and organs is confirmed. Pain and recovery time are reduced in laparoscopic surgery but not as much when compared with miniincisional approach. Open surgery permits optimal anatomical and functional organ extration facilitatig the quality of the implant. As numbers matter in laparoscopic surgery open nephrectomy is recommended for reduced LDKT programmes.

Open versus laparoscopic live donor nephrectomy: a focus on the safety of donors and the need for a donor registry

PURPOSE

A review of the existing literature showed that the subject of live donor nephrectomy is a seat of underreporting and underestimation of complications. We provide a systematic comparison between laparoscopic and open live donor nephrectomy with special emphasis on the safety of donors and grafts.

MATERIALS AND METHODS

The PubMed literature database was searched from inception to October 2006. A comparison was made between laparoscopic and open live donor nephrectomy regarding donor safety and graft efficacy.

RESULTS

The review included 69 studies. There were 7 randomized controlled trials, 5 prospective nonrandomized studies, 22 retrospective controlled studies, 26 large (greater than 100 donors), retrospective, noncontrolled studies, 8 case reports and 1 experimental study. Most investigators concluded that, compared to open live donor nephrectomy, laparoscopic live donor nephrectomy provides equal graft function, an equal rejection rate, equal urological complications, and equal patient and graft survival. Analgesic requirements, pain data, hospital stay and time to return to work are significantly in favor of the laparoscopic procedure. On the other hand, laparoscopic live donor nephrectomy has the disadvantages of increased operative time, increased warm ischemia time and increased major complications requiring reoperation. In terms of donor safety at least 8 perioperative deaths were recorded after laparoscopic live donor nephrectomy. These perioperative deaths were not documented in recent review articles. Ten perioperative deaths were reported with open live donor nephrectomy by 1991. No perioperative mortalities have been recorded following open live donor nephrectomy since 1991. Regarding graft safety, at least 15 graft losses directly related to the surgical technique of laparoscopic live donor nephrectomy were found but none was emphasized in recent review articles. The incidence of graft loss due to technical reasons in the early reports of open live donor nephrectomy was not properly documented in the literature.

CONCLUSIONS

We are in need of a live organ donor registry to determine the combined experience of complications and long-term outcomes, rather than short-term reports from single institutions. Like all other new techniques, laparoscopic live donor nephrectomy should be developed and improved at a few centers of excellence to avoid the loss of a donor or a graft.

Mini-incisions by lombotomy or subcostal access in living kidney donors: a randomized trial comparing pain, safety, and quality of life

OBJECTIVES

The aim of this study was to compare two mini-incision techniques and judge the impact on the quality of life, pain, and safety of living kidney donors.

PATIENTS AND METHODS

From March through September 2003, a prospective randomized study with 60 donors had nephrectomy performed - 30 through a lombotomy and another 30 patients underwent subcostal mini-incisions. The same anesthetic procedure was used for both groups. All patients were evaluated from baseline (T0) to day 90 after surgery. Pain evaluation included visual analog scale (VAS) and drug usage. To assess quality of life (QOL), the questionnaire SF-36 was used and surgical outcomes were also checked.

RESULTS

Sixty patients (41.6 +/- 8.9 yr old) were included in the protocol. Regarding incision length and blood loss, no statistical difference was observed. However, irrespective to the site of the mini-incision, patients with body mass index (BMI) higher than 25 kg/m(2) had significantly longer incision length as well as higher blood loss. There were no complications. No significant difference in tramadol or in pain perception was observed between groups. QOL was also not different between groups, however, there was a significant loss with subsequent return to baseline levels.

CONCLUSION

The position of the mini-incision (lombotomy or subcostal) has no significant impact on surgical outcomes, pain perception, and QOL of living kidney donors. Mini-incision techniques represent fast and safe approaches to perform nephrectomy in the healthy population. Special care must be taken in obese patients in order to minimize surgical complications.

THORACIC COMPLICATIONS DURING UROLOGICAL LAPAROSCOPY

PURPOSE

We documented thoracic related complications during urological laparoscopic surgery.

MATERIALS AND METHODS

A total of 1129 patients underwent major urological laparoscopic procedures in a 5-year period. Operative reports and postoperative radiographic reports were retrospectively reviewed to identify patients with thoracic related medical and surgical sequelae. Of the patients 619 (55%) underwent at least 1 chest x-ray in the immediate or early postoperative period. In the remaining 510 patients (45%) there was no clinical indication to perform chest x-ray.

RESULTS

Of 619 patients undergoing chest x-ray 438 (71%) were completely normal. Medical pulmonary complications, surgical thoracic complications and subclinical, incidentally detected gas collections in the chest were identified in 12.6%, 0.5% and 5.5% of patients, respectively. Medical complications in 12.6% of cases included pulmonary infiltrate/atelectasis in 9.7%, pleural effusion in 4.8% and pulmonary embolus in 0.3%. Surgical complications included symptomatic pneumothorax in 4 patients (0.35%), hemothorax in 1 (0.08%) and chylothorax in 1 (0.08%). Subclinical abnormal thoracic gas collections were radiographically noted in 34 of the 619 patients (5.5%) on chest x-ray, including pneumomediastinum in 19 (3.1%), pneumothorax in 10 (1.6%) and pneumopericardium in 5 (0.8%). Overall 36 of 40 (90%) thoracic surgical complications (3) and subclinical, incidentally detected gas collections (33) occurred during retroperitoneal laparoscopy. Re-intervention was necessary in 6 patients (0.5%), namely pulmonary embolus requiring vena caval filter placement in 3 (0.3%), pneumothorax requiring a chest tube in 2 (0.17%) and hemothorax requiring emergency open thoracotomy in 1 (0.08%). No patient underwent open conversion to complete the initial proposed operation.

CONCLUSIONS

Due to its high solubility the expectant management of incidental CO2 pneumothorax, pneumopericardium and pneumomediastinum is recommended initially in the clinically stable patient. Inadvertent diaphragmatic entry can be satisfactorily repaired laparoscopically without open conversion. Although it is rare, surgical thoracic complications are potentially life threatening, requiring prompt identification and management.

Complications and risks of living donor nephrectomy

BACKGROUND

Short- and long-term patient and graft survival rates are better for living donor (vs. cadaver) kidney transplant recipients. However, donor nephrectomy is associated with at least some morbidity and mortality. We have previously estimated the mortality of living donor nephrectomy to be 0.03%. In our present study, to determine associated perioperative morbidity, we reviewed donor nephrectomies performed at our institution from January 1, 1985, to December 31, 1995.

METHODS

The records of 871 donors were complete and available for review. Of these donors, 380 (44%) were male and 491 (56%) were female. The mean age at the time of donation was 38 years (range: 17-74 years), and mean postoperative stay was 4.9 days (range: 2-14 days).

RESULTS

We noted two (0.2%) major complications: femoral nerve compression with resulting weakness, and a retained sponge that required reexploration. We noted 86 minor complications in 69 (8%) donors: 22 (2.4%) suspected wound infections (only 1 wound was opened), 13 (1.5%) pneumothoraces (6 required intervention, 7 resolved spontaneously), 11 (1.3%) unexplained fevers, 8 (0.9%) instances of operative blood loss > or = 750 ml (not associated with other complications), 8 (0.9%) pneumonias (all of which resolved quickly with antibiotics alone), 5 (0.6%) wound hematomas or seromas (none were opened), 4 (0.5%) phlebitic intravenous sites, 3 (0.3%) urinary tract infections, 3 (0.3%) readmissions (2 for pain control and 1 for mild confusion that resolved with discontinuation of narcotics), 3 (0.3%) cases of atelectasis, 2 (0.2%) corneal abrasions, 1 (0.1%) subacute epididymitis, 1 (0.1%) Clostridium difficile colitis, 1 (0.1%) urethral trauma from catheter placement, and 1 (0.1%) enterotomy. At our institution, no donor died or required ventilation or intensive care. We noted no myocardial infarctions, deep wound infections, or reexplorations for bleeding. Analysis, by logistic regression, identified these significant risk factors for perioperative complications: male gender (vs. female, P<0.001), pleural entry (vs. no pleural entry, P<0.004), and weight > or = 100 kg (vs. < 100 kg, P<0.02). Similar analysis identified these significant risk factors for postoperative stay > 5 days: operative duration > or = 4 hr (vs. < 4 hr, P<0.001) and age > or = 50 years (vs. < 50 years, P<0.001).

CONCLUSIONS

Living donor nephrectomy can be done with little major morbidity. The risks of nephrectomy must be balanced against the better outcome for recipients of living donor transplants.

Living donor nephrectomy: a 20-year experience

OBJECTIVES

To review the selection criteria and perioperative morbidity in patients undergoing living-related donor nephrectomy.

METHODS

Retrospective chart review.

RESULTS

Six hundred eighty-one patients underwent living donor nephrectomy during a 20-year period without any mortality. The postoperative morbidity included pneumothorax requiring a chest tube in 7%, urinary tract infection in 5%, wound infection in 4%, and need for blood replacement in 0.3% of patients. Two patients had clinically apparent pulmonary emboli.

CONCLUSIONS

Living donor nephrectomy remains a valuable source of kidneys for transplantation but is not without risk. By using care in donor selection and surgical management, operative complications can be kept low.

[Advantages and risks of kidney transplantation from related donors]

Living related kidney transplantation must offer the recipient distinct advantages over cadaveric grafting in order to justify the health risk undertaken by the donor. At Steglitz Medical Center in Berlin from 1970 to 1987 30 such transplantations were performed (5% of all kidney transplantations) where the donor was a relative of the recipient. In cases of haploidentity and positive mixed lymphocyte culture, the recipients were pretreated with donor-specific transfusions. The posttransplantation graft function rate was higher in the group where the donated kidney came from a relative than where it did not (after 2 years under cyclosporin: 92% vs 73%, P = 0.04), and corticosteroid treatment could be terminated more frequently under cyclosporin (95% vs 51%, P = 0.001). Transplantations from living related donors were performed more often in foreigners (43% vs 20%, P = 0.01) and children (19% vs 4%, P = 0.0001). Perioperative complications in the donor nephrectomy occurred in 63% of the cases, severe ones in 13% (bleeding, pneumonia, and late abscess). Late sequelae were not observed. The short waiting time, the high graft function rate, and the low steroid requirement justify kidney transplantation from living related donors providing strict indicational criteria are observed.

Lymphorrhea as postoperative complication of living donor nephrectomy: a case report

We report a case of lymphorrhea after living donor nephrectomy. Clinically the donor presented with an increased flow of a liquid characteristic of lymph, which was treated successfully with iodinated povidone. The possible pathogenic mechanisms implicated in the development of lymphocele following renal transplantation are discussed.

Living related kidney donors. A 14-year experience

Living related donor (LRD) nephrectomies are controversial due to the risks to the donor and improved cadaveric graft survival using cyclosporine A. Between December 22, 1970, and December 31, 1984, 1096 renal transplants were performed at a single institution, 314 (28.6%) from LRD. The average age was 34.3 years (range: 18-67); none had preoperative hypertension. All nephrectomies were performed transabdominally. Major perioperative complications occurred in 22 (7.0%). These include wound infections (3.5%), pancreatitis (1.0%), injuries to spleen (1.0%) or adrenal gland (0.3%) requiring removal, pneumonitis (0.6%), ulnar nerve palsy (0.6%), femoral artery thrombosis after arteriogram (0.3%), pulmonary embolus (0.3%), and upper pole infarct of contralateral kidney (0.3%). There are six known deaths in this series, none of which were related to the operation. Major late complications were seen in 50 (20.0%) of 250 patients followed for 6 to 175 months (mean 53.1 months). These included definite hypertension (5.6%), suture granuloma (4.4%), incisional hernia (3.6%), proteinuria (2.4%), bowel obstruction (2.0%), nephrolithiasis (1.2%), wound infection (0.4%), scrotal hydrocele (0.4%), and chronic pancreatitis (0.4%). While the risk of hypertension appears to increase as the interval from donation increases, no cases of renal failure after donation have been noted, and negligible proteinuria among those followed long-term has been seen in this series. It is felt that living related kidney donation is justified when the relative is sincerely motivated and well informed prior to donation.

Urinary albumin excretion after donor nephrectomy

Surgical ablation of renal tissue in animals leads to compensatory hyperfiltration, hypertension, and focal glomerular sclerosis in remnant nephrons, in association with albuminuria; the detection of slightly elevated urinary albumin (microalbuminuria) has been shown to predict later, more severe renal disease in diabetics. To determine whether unilateral nephrectomy in humans initiates a similar pathogenetic sequence, we measured urinary albumin excretion (UalbV), total protein excretion (UprotV), creatinine clearance (Ccreat) and blood pressure in 22 transplant donors before and at intervals up to 3 years after donor nephrectomy. Urinary albumin was determined using a sensitive enzyme immunoassay (ELISA). Mean Ccreat fell on average to 68% of prenephrectomy values at all times after nephrectomy, indicating a rise of 33% in average single nephron filtration rate. Mean absolute and fractional albumin excretion rates and UprotV values were transiently elevated one week postnephrectomy, but returned thereafter to values not significantly different from prenephrectomy values. Blood pressure rose slightly, but significantly, with time after nephrectomy. Average increases of 10 mm and 5 mm in systolic and diastolic pressures, respectively, were noted by 2 years after surgery. In this study, there was no evidence of glomerular injury from hyperfiltration in the 3 years following donor nephrectomy.

Hypertension and proteinuria: long-term sequelae of uninephrectomy in humans

Renal function and blood pressure were assessed in 52 renal allograft donors 10 years or more following uninephrectomy, and their current function compared to their pre-uninephrectomy function as well as to age- and sex-matched control subjects consisting of inpatient potential renal donors and a normal "outpatient" population. The results show no significant deterioration in renal function as determined by serum creatinine or creatinine clearance, as a function of years post-uninephrectomy or age at the time of donation. A higher incidence of proteinuria and hypertension was found in male donors as compared to their pre-uninephrectomy values and to age- and sex-matched, inpatient and outpatient control subjects. Female donors had increased proteinuria when compared to pre-uninephrectomy and to age-matched, inpatient potential donors. However, the extent of proteinuria and hypertension was not significantly different from outpatient age-matched females with two kidneys. In our population, uninephrectomy is associated with mild proteinuria and hypertension.

Anterior extraperitoneal donor nephrectomy

The anterior extraperitoneal approach was compared to the flank approach for living donor nephrectomy in a series of 36 familial donors. The former procedure (23 cases) not only afforded superior visualization of renal vessels but also was probably at least as safe as the latter (13 cases) for donors with risk factors of obesity, age more than 45 years and pulmonary disease. Anterior extraperitoneal nephrectomy appears to be indicated for donors with multiple renal arteries and skeletal deformities, including thoracolumbar arthritis.

Experience with live donor nephrectomy

We studied 100 patients undergoing nephrectomy for living related renal transplantation. after completion of tissue typing preoperative studies included urinalysis and culture, creatinine clearance determination, excretory urography and renal arteriography. Patient characteristics, preoperative test, surgical approach, complications, long-term followup and cost factors were reviewed. There was no mortality and morbidity was minimal except for wound complications. Renal function generally remained normal. Donor nephrectomy is a worthwhile and safe procedure with an acceptably low incidence of postoperative complications.

Minimal mortality of renal surgery

Eight hundred fourteen renal operative procedures were reviewed to determine overall mortality and to identify patients at risk. The over-all mortality was 1.35%, but as high as 30% in patients with uremia and spesis. Carcinomatosis contributed to higher mortality in other groups. In the absence of these three factors renal surgery was associated with very low or no postoperative (thirty day) mortality.

Children as renal donors

With the exception of identical twins, preadolescent children have been excluded as renal donors. The justification for this policy appears to be based on a notion that renal donation is an altruistic act, primarily for the benefit of another, and that stringent standards of informed consent must be followed. This paper challenges the present policy on two grounds: consent from adults who donate kidneys is generally not informed, and therefore it is inconsistent to use the consent requirement as a justification for excluding children; and renal donation by adults can be seen as a procedure done for the benefit of the donor (as well as the recipient), and the appropriate rules for using children as donors should therefore be those pertaining to beneficial intrusions on nonconsenting subjects.

Mixed leukocyte culture incompatibility index for donor-recipient selection in kidney transplantation

The mixed leukocyte culture test has been applied to selection of histocompatibility non-identical donor-recipient pairs for renal transplantation. The clinical course of transplant recipients who have histocompatibility mismatches but low mixed leukocyte culture stimulation is similar to that of mixed leukocyte culture and histocompatibility identical recipients. Living donor-recipient pairs with high mixed leukocyte culture stimulation had no better graft survival than cadaver recipients. An incompatibility index derived from mixed leukocyte culture may aid in the selection of satisfactory non-identical living related donors and may help avoid use of immunologically unsatisfactory living donors.

Live donor nephrectomy

Donor nephrectomy was performed on 39 living related renal donors. The preoperative evaluation, surgical technique, and postoperative follow-up are presented. Major or minor complications developed in 23 per cent of the patients and included acute myocardial infarction, brachial plexus injury, acute glomerulonephritis, ileus, pneumonia, and urinary tract infection. All complications had resolved by six months postoperatively.