Long-term prognosis after kidney donation: a propensity score matched comparison of living donors and non-donors from two population cohorts.

BACKGROUND: Live donor nephrectomy is a safe procedure. However, long-term donor prognosis is debated, necessitating high-quality studies. METHODS: A follow-up study of 761 living kidney donors was conducted, who visited the outpatient clinic and were propensity score matched and compared to 1522 non-donors from population-based cohort studies. Primary outcome was kidney function. Secondary outcomes were BMI (kg/m2), incidences of hypertension, diabetes, cardiovascular events, cardiovascular and overall mortality, and quality of life. RESULTS: Median follow-up after donation was 8.0 years. Donors had an increase in serum creatinine of 26 µmol/l (95% CI 24-28), a decrease in eGFR of 27 ml/min/1.73 m2 (95% CI - 29 to - 26), and an eGFR decline of 32% (95% CI 30-33) as compared to non-donors. There was no difference in outcomes between the groups for ESRD, microalbuminuria, BMI, incidence of diabetes or cardiovascular events, and mortality. A lower risk of new-onset hypertension (OR 0.45, 95% CI 0.33-0.62) was found among donors. The EQ-5D health-related scores were higher among donors, whereas the SF-12 physical and mental component scores were lower. CONCLUSION: Loss of kidney mass after live donation does not translate into negative long-term outcomes in terms of morbidity and mortality compared to non-donors. TRIAL REGISTRATION: Dutch Trial Register NTR3795.

LOng-term follow-up after liVE kidney donation (LOVE) study: a longitudinal comparison study protocol.

BACKGROUND: The benefits of live donor kidney transplantation must be balanced against the potential harm to the donor. Well-designed prospective studies are needed to study the long-term consequences of kidney donation. METHODS: The "LOng-term follow-up after liVE kidney donation" (LOVE) study is a single center longitudinal cohort study on long-term consequences after living kidney donation. We will study individuals who have donated a kidney from 1981 through 2010 in the Erasmus University Medical Center in Rotterdam, The Netherlands. In this time period, 1092 individuals donated a kidney and contact information is available for all individuals. Each participating donor will be matched (1:4) to non-donors derived from the population-based cohort studies of the Rotterdam Study and the Study of Health in Pomerania. Matching will be based on baseline age, gender, BMI, ethnicity, kidney function, blood pressure, pre-existing co-morbidity, smoking, the use of alcohol and highest education degree. Follow-up data is collected on kidney function, kidney-related comorbidity, mortality, quality of life and psychological outcomes in all participants. DISCUSSION: This study will provide evidence on the long-term consequences of live kidney donation for the donor compared to matched non-donors and evaluate the current donor eligibility criteria. TRIAL REGISTRATION: Dutch Trial Register NTR3795 .

More than a decade after live donor nephrectomy: a prospective cohort study.

Previously reported short-term results after live kidney donation show no negative consequences for the donor. The incidence of new-onset morbidity takes years to emerge, making it highly likely that this will be missed during short-term follow-up. Therefore, evidence on long-term outcome is essential. A 10-year follow-up on renal function, hypertension, quality of life (QOL), fatigue, and survival was performed of a prospective cohort of 100 donors. After a median follow-up time of 10 years, clinical data were available for 97 donors and QOL data for 74 donors. Nine donors died during follow-up of unrelated causes to donation, and one donor was lost to follow-up. There was a significant decrease in kidney function of 12.9 ml/min (P < 0.001) at follow-up. QOL showed significant clinically relevant decreases of 10-year follow-up scores in SF-36 dimensions of physical function (P < 0.001), bodily pain (P = 0.001), and general health (P < 0.001). MFI-20 scores were significantly higher for general fatigue (P < 0.001), physical fatigue (P < 0.001), reduced activity (P = 0.019), and reduced motivation (P = 0.030). New-onset hypertension was present in 25.6% of the donors. Donor outcomes are excellent 10 years post-donation. Kidney function appears stable, and hypertension does not seem to occur more frequently compared to the general population.

Can right-sided hand-assisted retroperitoneoscopic donor nephrectomy be advocated above standard laparoscopic donor nephrectomy: a randomized pilot study.

Endoscopic techniques have contributed to early recovery and increased quality of life (QOL) of live kidney donors. However, laparoscopic donor nephrectomy (LDN) may have its limitations, and hand-assisted retroperitoneoscopic donor nephrectomy (HARP) has been introduced, mainly as a potentially safer alternative. In a randomized fashion, we explored the feasibility and potential benefits of HARP for right-sided donor nephrectomy in a referral center with longstanding expertise on the standard laparoscopic approach. Forty donors were randomly assigned to either LDN or HARP. Primary outcome was operating time, and secondary outcomes included QOL, complications, pain, morphine requirement, blood loss, warm ischemia time, and hospital stay. Follow-up time was 1 year. Skin-to-skin time did not significantly differ between both groups (162 vs. 158 min, P = 0.98). As compared to LDN, HARP resulted in a shorter warm ischemia time (2.8 vs. 3.9 min, P < 0.001) and increased blood loss (187 vs. 50 ml, P < 0.001). QOL, complication rate, pain, or hospital stay was not significantly different between the groups. Right-sided HARP is feasible but does not confer clear benefits over standard right-sided LDN yet. Further studies should explore the value of HARP in difficult cases such as the obese donor and the value of HARP for transplantation centers starting a live kidney donation program (Dutch Trial Register number: NTR3096). Nevertheless, HARP is a valuable addition to the surgical armamentarium in live donor surgery.

Incision-related outcome after live donor nephrectomy: a single-center experience.

BACKGROUND: Live donor nephrectomy is routinely performed. However, little is known regarding the incision-related outcome. The aim of the present study was to evaluate the prevalence of incisional hernias (IH) and to assess body image and cosmesis scores after donation. METHODS: Questionnaires on IH, body image, and cosmesis were sent to all donors who underwent laparoscopic donor nephrectomy or mini-incision donor nephrectomy between January 2000 and December 2009. RESULTS: In total, 444 replies were received (75 %). Seven donors (1.5 %) had undergone a surgical correction of an IH. Surgical site infection and steroid use appeared to be independent risk factors for the development of an IH (p = 0.001 and 0.021, respectively). Body image and cosmesis scores were excellent. Elderly donors had significantly higher cosmesis scores when compared with young donors (p < 0.001). Donor age of 60 years or higher, correction of an IH, and survival of the recipient appeared to be independent factors associated with a higher score on the cosmesis scale in multivariate analysis. CONCLUSIONS: This is the largest study describing the prevalence of IH and cosmetic outcome after donor nephrectomy. The prevalence of IH after live donor nephrectomy is very low, and body image and cosmesis scores are excellent. Consequently, incision-related outcomes pose no barrier to live donor nephrectomy.

Unspecified live kidney donation by urological patients.

BACKGROUND: Individuals with benign kidney disorders undergoing nephrectomy have three possibilities: Autotransplantation, with a certain risk of complications, but without a clear benefit; discarding the kidney; or living kidney donation. AIM: To investigate whether patients with benign kidney disorders and a medical indication for nephrectomy are suitable as unspecified live kidney donors. METHODS: We searched all clinical data from 1994-2019 for unspecified donors and their transplant recipients (n = 160). Nine of these 160 donors had pre-existing kidney disorders necessitating nephrectomy and had decided to donate their kidney anonymously after discussing the possibility of kidney donation. We studied the clinical course of these nine donating patients and their transplant recipients. RESULTS: Seven of nine donating patients indicated unbearable loin pain as the main complaint, one donating patient refused ureterocutaneostomy and one had two aneurysms of the renal artery. Postoperatively, seven donating patients described absence of pain and one a significant reduction after the nephrectomy. The average 1-year creatinine level in the donating patients was 88 µmol/L and after a median of 6.9 years the average creatinine level was 86.6 µmol/L. In the transplant recipients, one major complication occurred which led to death and in one transplant recipient graft function failed to normalize at first but has been stable for nine years now. Currently, all transplant recipients are off dialysis. CONCLUSION: Our data show that patients undergoing nephrectomy as part of treatment in selected kidney disorders can function as live kidney donors.

3D Endoscopic Donor Nephrectomy Versus Robot-assisted Donor Nephrectomy: A Detailed Comparison of 2 Prospective Cohorts.

BACKGROUND: There are 2 endoscopic surgical techniques that implement 3-dimensional (3D) vision to overcome visual misperception: 3D endoscopy and the da Vinci surgical system. 3D endoscopy has several advantages, such as the presence of tactile feedback and easy implementation, at lower costs. We aimed to assess whether 3D endoscopy could be an alternative to the robot during living donor nephrectomy. METHODS: Between April 2015 and April 2016, we prospectively collected data on 40 patients undergoing 3D endoscopic living donor nephrectomies in 1 center, performed by a da Vinci-certified surgeon. Data on donors' perioperative results and recipient and graft survival were collected. These data were compared to 40 robot-assisted donor nephrectomies performed in the same center (between January 2012 and May 2014). RESULTS: Baseline characteristics for both groups were comparable. Intraoperative results showed a significantly shorter median skin-to-skin time of 138.5 minutes (125.8-163.8) versus 169.0 (141.5-209.8) minutes in favor of the 3D group (P = 0.001). Warm ischemia time (P = 0.003) and hilar phase for both single (1 artery and vein) and multiple anatomies (≥1 artery and/or vein [P = 0.002 and P = 0.010, respectively]) were also significantly reduced in favor of the 3D group, with a flat learning curve. Follow-up demonstrated no readmissions nor significant differences for donors, recipients, and graft survival. CONCLUSIONS: 3D endoscopy may be a good alternative to robot-assisted donor nephrectomy because morbidity, graft, and recipient survival were comparable, with a significantly shorter median skin-to-skin time, warm ischemia time, and hilar dissection phase. Furthermore, implementation was easy and at lower costs, whereas tactile feedback was preserved.

Randomized controlled trial comparing hand-assisted retroperitoneoscopic versus standard laparoscopic donor nephrectomy.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) has become the gold standard for live-donor nephrectomy, as it results in a short convalescence time and increased quality of life. However, intraoperative safety has been debated, as severe complications occur incidentally. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP) is an alternative approach, combining the safety of hand-guided surgery with the benefits of endoscopic techniques and retroperitoneal access. We assessed the best approach to optimize donors' quality of life and safety. METHODS: In two tertiary referral centers, donors undergoing left-sided nephrectomy were randomly assigned to HARP or LDN. Primary endpoint was physical function, one of the dimensions of the Short Form-36 questionnaire on quality of life, at 1 month postoperatively. Secondary endpoints included intraoperative events and operation times. Follow-up was 1 year. RESULTS: In total, 190 donors were randomized. Physical function at 1 month follow-up did not significantly differ between groups (estimated difference, 1.79; 95% confidence interval, -4.1 to 7.68; P=0.55). HARP resulted in significantly shorter skin-to-skin time (mean, 159 vs. 188 min; P<0.001), shorter warm ischemia time (2 vs. 5 min; P<0.001) and a lower intraoperative event rate (5% vs. 11%, P=0.117). Length of stay (both 3 days; P=0.135) and postoperative complication rate (8% vs. 8%; P=1.00) were not significantly different. Potential graft-related complications did not significantly differ (6% vs. 13%; P=0.137). CONCLUSIONS: Compared with LDN, left-sided HARP leads to similar quality of life, shorter operating time, and warm ischemia time. Therefore, we recommend HARP as a valuable alternative to the laparoscopic approach for left-sided donor nephrectomy.

Quality of life of elderly live kidney donors.

BACKGROUND: Expanding the use of elderly live donors may help meet the demand for kidney transplants. The aim of this study was to quantify the effect of the surgical procedure on the quality of life (QOL) of elderly donors compared with younger donors. METHODS: Alongside three prospective studies (two randomized) running between May 2001 and October 2010, we asked 501 live donors to fill out the Short Form-36 questionnaire preoperatively and at 1, 3, 6, and 12 months postoperatively. We defined live donors 60 years or older as elderly. Between-group analyses regarding QOL were adjusted for baseline values and gender. RESULTS: One hundred thirty-five donors were older and 366 donors were younger than 60 years. The response rate was high, with 87% at 12 months postoperatively. Elderly donors less often scored as American Society of Anaesthesiology classification 1 (60% vs. 81%; P<0.001) indicating a higher rate of minor comorbidity. At 1 month postoperatively, between-group analysis showed a significant advantage in QOL in favor of the elderly group regarding the dimensions "bodily pain" (7 points; P=0.001), "role physical" (18 points; P<0.001), and "vitality" (5 points; P=0.008). At 3 months, "bodily pain" (3 points, P=0.04) and "role physical" (8 points, P=0.02) were still in favor of the older group. At 6 and 12 months, "physical function" was in favor of the younger group (3 and 5 points, respectively; P=0.04 and P<0.001). CONCLUSIONS: This study demonstrates that elderly donors recover relatively fast. The perspective of excellent postoperative QOL may help convince elderly individuals to donate.

Cost-effectiveness of hand-assisted retroperitoneoscopic versus standard laparoscopic donor nephrectomy: a randomized study.

BACKGROUND: Live kidney donation has a clear economical benefit over dialysis and deceased-donor transplantation. Compared with mini-incision open donor nephrectomy, laparoscopic donor nephrectomy (LDN) is considered cost-effective. However, little is known on the cost-effectiveness of hand-assisted retroperitoneoscopic donor nephrectomy (HARP). This study evaluated the cost-effectiveness of HARP versus LDN. METHODS: Alongside a randomized controlled trial, the cost-effectiveness of HARP versus LDN was assessed. Eighty-six donors were included in the LDN group and 82 in the HARP group. All in-hospital costs were recorded. During follow-up, return-to-work and other societal costs were documented up to 1 year. The EuroQol-5D questionnaire was administered up to 1 year postoperatively to calculate quality-adjusted life years (QALYs). RESULTS: Mean total costs from a healthcare perspective were $8935 for HARP and $8650 for LDN (P = 0.25). Mean total costs from a societal perspective were $16,357 for HARP and $16,286 for LDN (P = 0.79). On average, donors completely resumed their daytime jobs on day 54 in the HARP group and on day 52 in the LDN group (P = 0.65). LDN resulted in a gain of 0.005 QALYs. CONCLUSIONS: Absolute costs of both procedures are very low and the differences in costs and QALYs between LDN and HARP are very small. Other arguments, such as donor safety and pain, should determine the choice between HARP and LDN.

[A young man with parasites during surgery]. / Een man met peroperatief vrijkomende parasieten.

An 18-year-old man came to the Emergency Room at the Academic Hospital Paramaribo (Suriname) with a solitary supra-umbilical gunshot-wound. The patient was hypovolemic, with dropping blood pressure and rising pulse, surgery was indicated. After incision of the abdominal midline 1.5 l of blood drained, immediately followed by the appearance of 2 long thin worms. During inspection of the abdominal cavity a perforation of the duodenum and sigmoid and a mesenterial bleeding was seen and treated. Inspection of the small intestine showed presence of Ascaris lumbricoides (roundworm).

Intravesical versus extravesical ureteroneocystostomy in kidney transplantation: a systematic review and meta-analysis.

Urological complications are still a major problem postoperatively with a reported incidence of up to 30%, associated with significant morbidity, mortality, prolonged hospital stay and high medical costs. To date, there is no evidence favouring either an extravesical or an intravesical approach. The purpose of this systematic review and meta-analysis is to determine if an intravesical or extravesical anastomosis in kidney transplantation is to be preferred. Comprehensive searches were conducted in PubMed, Embase and the Cochrane Library. Reference lists were searched manually. The methodology was in accordance with the PRISMA statement. Two randomized controlled trials and seventeen cohort studies were identified. Based on the meta-analysis, outcome was in favour of the extravesical anastomosis. A relative risk (RR) for stenosis of 0.67 (confidence interval (CI), 0.48-0.93; p = 0.02), for leakage 0.55 (CI 0.39-0.80; p = 0.001) for the total number of urological complications 0.56 (CI 0.41-0.76; p < 0.001) and for haematuria of 0.41 (CI 0.22-0.76; p = 0.005) was demonstrated. Based on our results, we conclude that there is evidence in favour of the extravesical ureteroneocystostomy for having a smaller amount of urological complications in kidney transplantation.

Attitudes among surgeons towards live-donor nephrectomy: a European update.

BACKGROUND: The increasing number of living kidney donors in the last decade has led to the development of novel surgical techniques for live-donor nephrectomy. The aim of the present study was to evaluate the current status of the surgical approach in Europe. METHODS: A survey was sent to 119 transplant centers in 12 European countries. Questions included the number of donors, the technique used, and the acceptance of donors with comorbidities. RESULTS: Ninety-six centers (81%) replied. The number of living donors per center ranged from 0 to 124. Thirty-one institutions (32%) harvested kidneys using open techniques only. Six centers (6%) applied both endoscopic and open techniques; 59 centers (61%) performed endoscopic donor nephrectomy only. Lack of evidence that endoscopic techniques provide superior results was the main reason for still performing open donor nephrectomy. In seven centers, a lumbotomy is still performed. Seventy-two centers (75%) accept donors with a body mass index of more than 30 kg/m, the median upper limit in these centers was 35 kg/m (range, 31-40). Donors with an American Society of Anesthesiologists classification higher than 1 were accepted in 55% of the centers. CONCLUSIONS: Live kidney donation in general and minimally invasive donor nephrectomy in particular are more commonly applied in Northern and Western Europe. However, a classic lumbotomy is still performed in a minority of centers. Because minimally invasive techniques have been proven superior, more attention should be given to educational programs in this field to let many kidney donors benefit.