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Living donor kidney transplantation
KIDNEY DONATION AND OUTCOMES
Living Donor Kidney Transplantation: Standard Procedure G. Testa
K
IDNEY TRANSPLANTATION for the cure of endstage renal disease was first performed with a graft harvested from a living donor. The donor operation, an open nephrectomy, and the subsequent transplant were performed on December 1954 in Boston by Dr Harrison and Dr Murray.1 In the following almost 50 years, thousands of patients affected by end-stage renal failure have been freed of dialysis thanks to a living donor kidney transplantation. The nephrectomy performed in an open fashion has proven over the years to perfectly match the goals for which it had been designed: first to be a safe operation and second to provide a graft that can assure prompt function in the recipient. Safety for the donor it is not only directed to avoid potential surgical complications but primarily to a complete restoration of donor health and physical fitness. The goal should be to leave to the donor only one visible reminder of the operation she/he underwent: the scar of the skin incision. COMPLICATIONS AFTER DONOR NEPHRECTOMY
Several studies reviewing the mortality rate after open nephrectomy for kidney donation have shown that it has been kept over the years around 0.03%, or one death for 1600 procedures.2 This is lower then the predicted 0.8% mortality for class 1 patients, according to ASA. The number one cause of donor death has been pulmonary embolism. It means that a complete coagulation profile must be obtained and risk factors like obesity, smoking, and birth control pills must be taken into consideration when evaluating the donor. The early postoperative complication rate has been reported below 10% by several centers.3 The complications include wound infections, pneumothoraces, pneumonias, and urinary tract infec© 2003 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 35, 937–938 (2003)
tions in decreasing order. The late complications are related to the surgical approach utilized for the open nephrectomy and include incisional hernias, wound relaxations, and small bowel obstructions. The incidence of these late complications is hard to define. In fact they seem to account for sporadic events in any center with a large volume of living donor kidney transplantation. Nevertheless, late complications must be regarded as major since they imply a new admission and operation for the donor. It is difficult to define the “functional complications” intended as the potential hazard of decreasing function in the remaining kidney. Although some studies have shown increased proteinuria and blood pressure in some kidney donors, the clinical relevance of these findings seems to be minimal; the survival is not affected and the role of aging needs also to be considered.2 Even if not a surgical complication per se, depression after donation must be mentioned. It is most probably multifactorial in its pathogenesis, although connected to the personality profile of the donor and his or her reaction to the shifting of attention from the donor figure to the recipient after surgery is over. Its incidence stresses the importance of the psychosomatic evaluation of all donors and of a careful follow-up for some of them. OPEN DONOR NEPHRECTOMY
Open nephrectomy can be performed through a transperitoneal or an extraperitoneal approach. The transperitoneal approach is usually performed through a midline incision From the Division of Transplant Surgery, University of Illinois, Chicago, Illinois, USA. Address reprint requests to Giuliano Testa, MD, Division of Transplantation (MC 958), Department of Surgery, University of Illinois at Chicago, 840 S Wood Street, Chicago, IL 60612. 0041-1345/03/$–see front matter doi:10.1016/S0041-1345(03)00170-2 937
938
but also subcostal or pararectal incisions have been used. The promoters of these approaches claim the advantages of a more direct visualization of the vessels and decreased manipulation of the kidney. On the other hand, the incisions are more anteriorly located and consequently less cosmetic. Moreover, there is a potentially increased risk of bowel or spleen injury and with time of small bowel obstruction due to adhesions. The extraperitoneal approach can be performed through a flank incision, the most utilized one, a pararectal incision, or a subcostal incision. The flank incision especially can have a very good cosmetic result. It is the incision bearing the most postoperative pain and rarely can be complicated by muscle relaxation due to nerve injury. This last complication is difficult to repair surgically and may leave the patient handicapped. It seems that the postoperative complications and pain associated with the flank approach can be decreased by not taking the 12th rib and by avoiding the violation of the pleural cavity. Of note it has also being shown that donor size plays a role in the incidence of postoperative complications. In fact, donors, especially males, with a weight greater than 100 kg are more prone to develop postoperative complications. Besides incisional hernias, which may complicate all of the above incisions, one other long-term problem can be postoperative incisional pain. A study promoted by the University of Minnesota showed that up to 15% of the donors had at long-term moderate incisional pain and 1% severe incisional pain.4 LAPAROSCOPIC DONOR NEPHRECTOMY
The introduction of laparoscopic living donor nephrectomy by Ratner and colleagues5 has dramatically changed the standards of the operation. Many surgeons have accepted the laparoscopic approach and abandoned the open one. The results in terms of graft function are comparable between the two techniques. Nevertheless, the laparoscopic
TESTA
approach is associated with less postoperative pain and faster recovery, not to mention the fact that it is the public that asks for the laparoscopy nephrectomy. For this reason it seems foreseeable that in the next future fewer and fewer open nephrectomies will be performed. One consequence of the wide acceptance of the laparoscopic approach has been the development of mini-incisions for the open approach. These mini-incisions can be performed anteriorly on the abdominal wall or posteriorly through a transcostal approach. The operation is conducted in an extraperitoneal fashion.6,7 Although competing with the laparoscopic approach in terms of control of postoperative pain and speed of recovery, these incisions allow poor exposure of the vessels and require greater manipulation of the kidney. CONCLUSIONS
The open living donor nephrectomy has served thousand of donors and recipients. With the wider acceptance of the laparoscopic approach, open nephrectomy will be performed much less frequently. Nevertheless, it still has a role in patients with extensive previous abdominal surgery and in some cases of right nephrectomy and multiple vessels. In very lean donors the open approach can still be a valuable alternative to the laparoscopy, since the retrieval of the kidney can be performed through a very small incision and in little time. REFERENCES 1. Murray J: Surg Forum 6:432, 1955 2. Jones J: Transplant Rev 93:115, 1993 3. Johnson EM, Remucal MJ, Gillingham KJ, et al: Transplantation 64:1124, 1997 4. Johnson EM, Anderson JK, Jacobs C, et al: Transplantation 67:717, 1999 5. Ratner LE, Montgomery RA, Kavoussi LR: Nephrol Dial Transplant 14:2090, 1999 6. Shenoy S, Lowell JA, Ramachandran V, et al: J Am Coll Surg 194:240, 2002 7. Yang SL, Harkaway R, Badosa F, et al: Urology 59:673, 2002
Living Donor Kidney Transplantation: Standard Procedure G. Testa
K
IDNEY TRANSPLANTATION for the cure of endstage renal disease was first performed with a graft harvested from a living donor. The donor operation, an open nephrectomy, and the subsequent transplant were performed on December 1954 in Boston by Dr Harrison and Dr Murray.1 In the following almost 50 years, thousands of patients affected by end-stage renal failure have been freed of dialysis thanks to a living donor kidney transplantation. The nephrectomy performed in an open fashion has proven over the years to perfectly match the goals for which it had been designed: first to be a safe operation and second to provide a graft that can assure prompt function in the recipient. Safety for the donor it is not only directed to avoid potential surgical complications but primarily to a complete restoration of donor health and physical fitness. The goal should be to leave to the donor only one visible reminder of the operation she/he underwent: the scar of the skin incision. COMPLICATIONS AFTER DONOR NEPHRECTOMY
Several studies reviewing the mortality rate after open nephrectomy for kidney donation have shown that it has been kept over the years around 0.03%, or one death for 1600 procedures.2 This is lower then the predicted 0.8% mortality for class 1 patients, according to ASA. The number one cause of donor death has been pulmonary embolism. It means that a complete coagulation profile must be obtained and risk factors like obesity, smoking, and birth control pills must be taken into consideration when evaluating the donor. The early postoperative complication rate has been reported below 10% by several centers.3 The complications include wound infections, pneumothoraces, pneumonias, and urinary tract infec© 2003 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 35, 937–938 (2003)
tions in decreasing order. The late complications are related to the surgical approach utilized for the open nephrectomy and include incisional hernias, wound relaxations, and small bowel obstructions. The incidence of these late complications is hard to define. In fact they seem to account for sporadic events in any center with a large volume of living donor kidney transplantation. Nevertheless, late complications must be regarded as major since they imply a new admission and operation for the donor. It is difficult to define the “functional complications” intended as the potential hazard of decreasing function in the remaining kidney. Although some studies have shown increased proteinuria and blood pressure in some kidney donors, the clinical relevance of these findings seems to be minimal; the survival is not affected and the role of aging needs also to be considered.2 Even if not a surgical complication per se, depression after donation must be mentioned. It is most probably multifactorial in its pathogenesis, although connected to the personality profile of the donor and his or her reaction to the shifting of attention from the donor figure to the recipient after surgery is over. Its incidence stresses the importance of the psychosomatic evaluation of all donors and of a careful follow-up for some of them. OPEN DONOR NEPHRECTOMY
Open nephrectomy can be performed through a transperitoneal or an extraperitoneal approach. The transperitoneal approach is usually performed through a midline incision From the Division of Transplant Surgery, University of Illinois, Chicago, Illinois, USA. Address reprint requests to Giuliano Testa, MD, Division of Transplantation (MC 958), Department of Surgery, University of Illinois at Chicago, 840 S Wood Street, Chicago, IL 60612. 0041-1345/03/$–see front matter doi:10.1016/S0041-1345(03)00170-2 937
938
but also subcostal or pararectal incisions have been used. The promoters of these approaches claim the advantages of a more direct visualization of the vessels and decreased manipulation of the kidney. On the other hand, the incisions are more anteriorly located and consequently less cosmetic. Moreover, there is a potentially increased risk of bowel or spleen injury and with time of small bowel obstruction due to adhesions. The extraperitoneal approach can be performed through a flank incision, the most utilized one, a pararectal incision, or a subcostal incision. The flank incision especially can have a very good cosmetic result. It is the incision bearing the most postoperative pain and rarely can be complicated by muscle relaxation due to nerve injury. This last complication is difficult to repair surgically and may leave the patient handicapped. It seems that the postoperative complications and pain associated with the flank approach can be decreased by not taking the 12th rib and by avoiding the violation of the pleural cavity. Of note it has also being shown that donor size plays a role in the incidence of postoperative complications. In fact, donors, especially males, with a weight greater than 100 kg are more prone to develop postoperative complications. Besides incisional hernias, which may complicate all of the above incisions, one other long-term problem can be postoperative incisional pain. A study promoted by the University of Minnesota showed that up to 15% of the donors had at long-term moderate incisional pain and 1% severe incisional pain.4 LAPAROSCOPIC DONOR NEPHRECTOMY
The introduction of laparoscopic living donor nephrectomy by Ratner and colleagues5 has dramatically changed the standards of the operation. Many surgeons have accepted the laparoscopic approach and abandoned the open one. The results in terms of graft function are comparable between the two techniques. Nevertheless, the laparoscopic
TESTA
approach is associated with less postoperative pain and faster recovery, not to mention the fact that it is the public that asks for the laparoscopy nephrectomy. For this reason it seems foreseeable that in the next future fewer and fewer open nephrectomies will be performed. One consequence of the wide acceptance of the laparoscopic approach has been the development of mini-incisions for the open approach. These mini-incisions can be performed anteriorly on the abdominal wall or posteriorly through a transcostal approach. The operation is conducted in an extraperitoneal fashion.6,7 Although competing with the laparoscopic approach in terms of control of postoperative pain and speed of recovery, these incisions allow poor exposure of the vessels and require greater manipulation of the kidney. CONCLUSIONS
The open living donor nephrectomy has served thousand of donors and recipients. With the wider acceptance of the laparoscopic approach, open nephrectomy will be performed much less frequently. Nevertheless, it still has a role in patients with extensive previous abdominal surgery and in some cases of right nephrectomy and multiple vessels. In very lean donors the open approach can still be a valuable alternative to the laparoscopy, since the retrieval of the kidney can be performed through a very small incision and in little time. REFERENCES 1. Murray J: Surg Forum 6:432, 1955 2. Jones J: Transplant Rev 93:115, 1993 3. Johnson EM, Remucal MJ, Gillingham KJ, et al: Transplantation 64:1124, 1997 4. Johnson EM, Anderson JK, Jacobs C, et al: Transplantation 67:717, 1999 5. Ratner LE, Montgomery RA, Kavoussi LR: Nephrol Dial Transplant 14:2090, 1999 6. Shenoy S, Lowell JA, Ramachandran V, et al: J Am Coll Surg 194:240, 2002 7. Yang SL, Harkaway R, Badosa F, et al: Urology 59:673, 2002