Chylous ascites secondary to laparoscopic donor nephrectomy.

Live donor renal transplantation offers many significant advantages over cadaveric donor transplantation. Yet living donation continues to be underused, accounting for less than 30% of all donor renal transplants. In an attempt to remove the disincentives to live donation, Ratner et al. developed laparoscopic donor nephrectomy (LDN). LDN is gaining acceptance in the transplant community. The overriding concern must always be the safety and welfare of the donor. To this end, potential complications of LDN must be identified and discussed. We present a patient who developed the complication of chylous ascites from LDN. To improve the laparoscopic technique further, a discussion of its successes and complications needs to be encouraged. To this end, we present chylous ascites as a potential complication after LDN. We also offer suggestions to minimize the likelihood of this complication.

Laparoscopic donor nephrectomy: impact on an established renal transplant program.

The current disparity of viable organs and patients in need of a transplant has been an impetus for innovative measures. Live donor renal transplantation offers significant advantages compared with cadaveric donor transplantation: increased graft and patient survival, diminution in incidence of delayed graft function, acute tubular necrosis (ATN), and reduction in waiting time. Notwithstanding these gains live donors continue to be underutilized and account for only approximately one quarter of all renal transplants performed in the United States. It has been felt that inherent disincentives to live donation have slowed its growth. These include degree and duration of postoperative pain and convalescence, child care concerns, cosmetic concerns, and time until return to full activities and employment. In an attempt to curtail the disincentives to live donation, laparoscopic live donation (laparoscopic donor nephrectomy; LDN) was developed. The purpose of this study was to compare the results of our first 25 laparoscopic nephrectomies (performed over a 10-month period from September 1998 through July 1999) with the previous 25 standard open donor nephrectomies (ODNs) completed over the past 3 years. We conducted a retrospective review of all donor nephrectomies and recipient pairs performed over the past 3 years. End points included sex, operative time, length of stay, immediate and long-term renal function, and willingness to donate. There were no differences in demographics of the ODN versus the LDN group. The average length of stay was 2.48+/-0.72 days for the LDN versus 4.08+/-0.28 days for the ODN. ODN and LDN have comparable short- and long-term function with no delayed graft function and no complications. Growth of living donor transplant has increased from 16 per cent of all kidney transplants performed in 1995 to 23 per cent in 1999. We conclude that LDN is a viable alternative to the standard donor operation. LDN has had a positive impact on the donor pool by minimizing disincentives to live donation. With the initiation of our laparoscopic program the number of LDNs has increased. Presently the live donor pool is the most viable alternative to significantly increase the number of kidneys for transplantation.

Failure of dialysis access: revise or replace?

Providing adequate long-term dialysis access has become increasingly difficult. In order to evaluate the operative factors associated with early failure of dialysis access, 2337 operations performed in 1124 patients over an 8-year period were retrospectively reviewed. Evaluation of 1306 procedures that eventually failed and required operative revision or repair provided the basis for this study. Access failure occurred in 459 (41%) of the 1124 patients. An average of 2.8 episodes of failure (range 1-13) were observed among this group of patients, occurring after an average of 230 +/- 9 days (mean +/- ++standard error) postoperatively, with the longest interval to failure being 2529 days. The time-to-failure for revision of a preexistent arteriovenous fistula or prosthetic graft (140 +/- 9 days, n = 449) was significantly (P < 0.0001 ANOVA) shorter than for creation of an arteriovenous fistula (272 +/- 21 days, n = 336) or prosthetic graft (299 +/- 19 days, n = 372) at a new site. Procedures performed in octogenarians tended to fail earlier (178 days). Dialysis access failure tends to recur in patients with a history of previous access problems. The time-to-failure was similar for new prosthetic grafts and arteriovenous fistulas, but twice as long compared to revision of a previous access site.