Impact of fellowship training in initiating a laparoscopic donor nephrectomy program.

OBJECTIVES: Laparoscopic donor nephrectomy (LDN) is the current standard of care, but remains a challenging procedure. A urologist at our center performed 6 months of standard and hand-assisted laparoscopic nephrectomy (HALN) fellowship (46 cases, 30 as surgeon). He subsequently performed 30 HAL renal surgeries prior to initiating our hand-assisted laparoscopic donor nephrectomy (HALDN) program. METHODS: We reviewed the intra- and postoperative outcomes of the first 20 HALDNs performed at our center. We examined demographics, estimated blood loss (EBL), operative time, complications, change in hemoglobin and creatinine, length of hospital stay, warm ischemic time, and recipient outcome. RESULTS: Twenty (20) patients underwent HALDN between November 2003 and December 2005. The mean operative time was 277 minutes. EBL averaged 176 mL. An expected rise in creatinine of 0.1-0.8 mg/dL occurred in all patients. One (1) patient had a splenic abrasion and was transfused intraoperatively. Two (2) patients' courses were complicated by ileus. The remaining patients were discharged on postoperative days 2-6. There were no other complications. Warm ischemia time averaged 3.7 minutes. Two (2) recipients experienced acute or delayed rejection episodes, requiring increased immunosuppression. One (1) recipient had good renal function until he developed sepsis 3 months later and died. All recipients were discharged with functioning grafts, and there have been no ureteral strictures. CONCLUSIONS: Six (6) months of laparoscopic nephrectomy training plus a 30-case HAL/LRN surgical experience sufficiently prepares a surgeon to initiate a HALDN program. Even at a lower volume transplant center, positive operative results and long-term graft outcomes can be achieved.

Effect of changing the priority for HLA matching on the rates and outcomes of kidney transplantation in minority groups.

BACKGROUND: HLA typing and the time a patient has spent on the waiting list are the primary criteria used to allocate cadaveric kidneys for transplantation in the United States. Candidates with no HLA-A, B, and DR mismatches are given top priority, followed by candidates with the fewest mismatches at the HLA-B and DR loci; this policy contributes to a higher transplantation rate among whites than nonwhites. We hypothesized that changing this allocation policy would affect graft survival and the racial balance among transplant recipients. METHODS: We estimated the relative rates of kidney transplantation according to race resulting from the current allocation policy and racial differences in HLA antigen profiles, using a Cox model for the time from placement on the waiting list to transplantation. Another model, also adjusted for HLA-B and DR antigen profiles, estimated the relative rates of kidney transplantation that would result if the distribution of these antigen profiles were identical among the racial and ethnic groups. We also investigated the effect of HLA matching on the risk of graft failure, using a Cox model for the time from the first transplantation to graft failure. The results of the two analyses were used to estimate the change in the racial balance of transplantation and graft-failure rates that would result from the elimination of HLA-B matching or HLA-B and DR matching as a means of assigning priority. RESULTS: Eliminating the HLA-B matching as a priority while maintaining HLA-DR matching as a priority would decrease the number of transplantations among whites by 4.0 percent (166 fewer transplantations over a one-year period), whereas it would increase the number among nonwhites by 6.3 percent and increase the rate of graft loss by 2.0 percent. CONCLUSIONS: Removing HLA-B matching as a priority for the allocation of cadaveric kidneys could reduce the existing racial imbalance by increasing the number of transplantations among nonwhites, with only a small increase in the rate of graft loss.