Kidney transplantation--a 46-year experience from the Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.

The limiting factor in organ transplantation is the availability of organs. Ongoing work to improve donation rates both at the public and the organizational level in donating hospitals is essential. We also think that encouragement of live donation is important, and the possibility of ABO incompatible transplantation has increased the number of LD transplantations. The one-year graft survival rate is excellent and focus has shifted towards achieving long-term results to reduce the attrition rate. There is also an increasing interest in studying and working to reduce comorbidities on a long-term basis and thus, improve survival rates and recipient quality of life.

Single or double arteries in the remnant kidney after donation: influence on the long-term outcome of the donor.

BACKGROUND: A kidney with a single artery is preferred for donation. We wondered how often the donor is left with double or triple arteries, and whether this has any implications for long-term kidney function. METHODS: The consecutive living donors from 1984 to 1988 were reevaluated for kidney function and outcome. RESULTS: In total, 154 donor nephrectomies were performed with an open anterior technique. Ninety-eight patients were left with a single artery to the remnant kidney and 56 (36%) with more than one. Six individuals were left with 3 arteries. The mean age at donation was 48 +/- 12 years and mean age at reevaluation was 68 +/- SD 12 years. In the group with a remnant single artery, the mean preoperative serum creatinine level was 87 +/- 11 micromol/L, at 6 months it was 127 +/- 20 micromol/L, and in 2007 it was 90 +/- SD 23 micromol/L. The estimated glomerular filtration rate (GFR) was 67 +/- 18 mL/min. Thirty-three percent of donors (19/58) had developed hypertension. Among the group with multiple remnant arteries, the mean preoperative serum creatinine level was 87 +/- SD 11 micromol/L, at 6 months it was 131 +/- 21 micromol/L, and in 2007 it was 100 +/- 45 micromol/L. Estimated GFR was 64 +/- 16) mL/min. Twenty-eight percent of the donors (10/36) had developed hypertension. CONCLUSIONS: One third of kidney donors were left with double or triple arteries to the remnant kidney. The 20-year follow-up showed no significant difference in the renal function between the 2 groups.

Living kidney donors developing end-stage renal disease.

The incidence of end-stage kidney failure (ESRF) was analyzed among the cohort of 1112 living kidney donors who underwent nephrectomy from 1965 through 2005. It was found that at least six persons had developed ESRF at 14 to 27 years (median = 20 years), following donation. Five of six were men. Five were parents and one, a sibling. The diagnoses were nephrosclerosis (n = 4), postrenal failure (n = 1), and renal carcinoma (n = 1). One donor, aged 45 years, underwent kidney transplantation.

Laparoscopic or open surgery for living donor nephrectomy.

BACKGROUND: The anterior extraperitoneal approach for living donor nephrectomy has been used in more than 700 living cases in the unit and proved to be safe for the donor. In 1998, laparoscopic nephrectomy was introduced as an option when technically feasible. We found it essential to investigate the consequences of the new technique. SUBJECTS AND METHODS: One hundred living donor kidney transplantations were performed from 1998 to June 2000, 45 with laparoscopic, 55 with open nephrectomy. The donors took part in a structured interview 4 weeks after the donation and their responses were categorized in three classes. RESULTS: In each group, one recipient had delayed initial function. The serum creatinine levels after 3 and 7 days or the GFR values after 6 months did not differ. One graft has been lost following laparoscopic nephrectomy and four after open surgery. For the laparoscopy donors, the median number of post-operative days in hospital was 5.0 days (range 2-9), vs 6.0 (4-8) after open surgery (NS). The requirement of opoid analgesics post-operatively was 5.0 doses (1-22) vs 6.0 (1-38) (P=0.02); and after 4 weeks, 23 of 45 laparoscopic donors were free of pain vs eight of 55 open nephrectomy donors (P=0.0004). Approximately one-third of all donors felt some restriction of physical activity and the majority complained of impaired physical energy. There were no differences between the groups. The duration of sick-leave after laparoscopic surgery was median 6 (2-19) weeks vs 7 (1-16) (NS). CONCLUSIONS: Laparoscopic nephrectomy is safe. Less post-operative pain is a definite advantage for the donor.

Low absolute glomerular filtration rate in the living kidney donor: a risk factor for graft loss.

BACKGROUND: There is no defined lower acceptable level of glomerular filtration rate (GFR) in potential living kidney donors. Considerations focus on the risk for the donor. We wanted to evaluate the outcome in the recipient in relation to the GFR of the living donor. METHODS: There were 344 living donated kidney transplantations performed January 1985 through February 1997 which were evaluated. Two thirds of the donors shared one haplotype with the recipient and 15% shared both. Of the donors 18% were above age 60. The median follow-up time (until graft loss) was 63 months. Before nephrectomy, the donors' GFR had been measured by isotope clearance. RESULTS: Twenty-six donors (7.6%) had an absolute GFR below 80 ml/min, i.e. not adjusted to 1.73 m2 body surface area (BSA). Cumulative graft survival, censored for graft loss because of death of the patient, was significantly reduced in recipients of grafts from donors with GFR <80 ml/min. A significant correlation between GFR and donor age was observed, but donor age per se was not identified as a risk factor for graft loss. In a Cox stepwise proportional hazards analysis, the relative risk for graft loss was 2.28 with a GFR below 80 ml/min (confidence interval 1.183-4.383, P=0.014) and with sharing one or both haplotypes 0.56 (0.313-0.988, P=0.046) and 0.36 (0.139-0.912, P=0.03), respectively. CONCLUSIONS: An absolute GFR below 80 ml/min in the living donor more than doubles the risk of graft loss. This fact should be considered when definitions of acceptable limits for donor GFR are discussed.