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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2003  |  Volume : 14  |  Issue : 4  |  Page : 481-486
Early Results and Complications of 210 Living Donor Nephrectomies


Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, India

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   Abstract 

The aim of this study is to evaluate the early complications seen after donor nephrectomy in living donor renal transplantation. Between November 1989 and June 1998, 270 living donor nephrectomies were performed at the Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Sixty donor records which were incomplete were discarded from this study. A questionnaire with relevant queries was prepared and sent to all the donors. The information sought included age, gender, marital status, drug addiction and smoking, blood pressure, blood group, serological tests, blood tests for hematology and biochemistry, coagulation profile, urine reports, nephrectomy site, duration of anesthesia, intra-operative and early post-nephrectomy complications, hypertension, respiratory and genitourinary complications, water and electrolyte imbalance, hemorrhage, and wound infection. Statistical analysis was done using Fox Pro and SPSS software. It was noted that females donated more kidneys to there relatives (p < 0.05) and had a higher prevalance of anemia (p < 0.01). More males were addicted to smoking and/or opium than females (p < 0.01), and fewer addicts donated their kidneys (p < 0.05). The site of nephrectomy was similar between men and women. Complications were significantly greater in addicted donors (p < 0.05). Hemorrhage occurred more commonly in association with right nephrectomy (p < 0.05), while wound infection occurred more commonly in men (p < 0.05). There were no deaths. Our results suggest that living donor nephrectomy is safe and is assosiated with minor complications causing little morbidity and no mortality.

Keywords: Live donor, Nephrectomy, Complications, Kidney, Transplantation

How to cite this article:
Shamsa A, Rasulian H, Mahdi M P, Kadkhodayan A, Yarmohammadi A A, Parizadeh R. Early Results and Complications of 210 Living Donor Nephrectomies. Saudi J Kidney Dis Transpl 2003;14:481-6

How to cite this URL:
Shamsa A, Rasulian H, Mahdi M P, Kadkhodayan A, Yarmohammadi A A, Parizadeh R. Early Results and Complications of 210 Living Donor Nephrectomies. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2019 Aug 23];14:481-6. Available from: http://www.sjkdt.org/text.asp?2003/14/4/481/32987

   Introduction Top


Renal transplantation is the best treatment for end-stage renal disease (ESRD) offering cost effectiveness and good quality of life. The source of donor kidneys include cadavaric and living donors. In our institution, the only source is live donor, mostly unrelated. The aim of this study was to evaluate demo­graphic data of donors, their pre-treatment status and post-nephrectomy complications.


   Materials and Methods Top


Between November 1989 and June 1998, 270 living donor nephrectomies were performed at the Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. The incomplete records of 60 donors were discarded from this study. Statistical analysis was made using Fox Pro and SPSS software. A questionnaire was prepared and categorized into four parts: a) individual chara­cteristics, b) evaluation of donors regarding past medical history, clinical and laboratory tests, c) information concerning nephrectomy, and d) post-operative complications.

The questionnaire included the following: Age, sex and marital status of the donor, relationship to the recepient, history of addi­ction to cigarattes or opium, blood group, blood tests for hematology, biochemistry, serology for hepatitis B, VDRL, anti-HIV antibody, coagulation times, urinalysis and culture, x-ray chest, electrocardiogram, abdominal ultra­sound as well as intravenous urogram and angiogram. The number of renal arteries on either side and the site on which nephrectomy was performed was also noted. The method of surgery, lumbar or abdominal, and the duration of anesthesia was noted. Specific complications post-nephrectomy noted included: fever, hyper­tension, respiratory, cardiac, genitourinary and gastrointestinal complications, thromboem­boli, fluid and electrolyte imbalance, anesthetic complications, hemorrhage and requirement of blood transfusion and wound infection.


   Results Top


There were 159 (75.7%) males and 51 (24.3%) females; their mean age being 29.4 years (18-51 Years). The mean age of male donors was 28.7 years and that of female, was 31.5 years. Thus, there was a significant difference between males and females with regard to age at donor nephroctomy (p < 0.05).

Information regarding marital status was available in 116 donors. Of them, 98 donors (84.5%) were married at the time of surgery and 18 (15.5%) were single. Among the male donors, there were 61 (52.6%) married and 15 (12.9%) single, while among the females, 37 (31.9%) were married and three (2.6%) were single.

There was no statistical difference between married or single donors (p > 0.05).

Relation Between Recipient and Donor

The relationship was not clear in 10 donors. Of the remaining, there were 51 (25.5%) related and 149 (74.5%) unrelated. Of the 51 related donors, 47 were genetically related to the recipient while four were emotionally related. Females donated more kidneys to their relatives than males (p < 0.05); there was no significant relationship between marital status and donation of kidneys to relatives (p > 0.05).

Addiction and Smoking

A total of 126 of the 210 donors did not give clear-cut data about addiction and smoking. In the remaining, it was as follows: of the 56 males, nine (10.7%) were addicted to opium, 22 (26.2%) to cigerette smoking while 25 (29.8%) had no addiction. Of the 28 females only one was a heavy smoker while the remaining had no addictions.

Males were addicted to opium more signi­ficantly than females (p < 0.01) but among the donors who had donated their kidney to relatives, none were addicted to opium (p < 0.05).

The mean blood pressure of the donors before operation was 120/74 mm Hg; and the mean temperature was 36.9 0 C. The distribution of blood group and Rh is given in [Table - 1].

The hepatitis B Surface antigen (HBSAg) and antibody to human immunodeficiency virus (HIV) were looked for in 171 donors; and all were negative. Serologic test for syphilis was performed in 171 cases, and it was positive in two. The tuberculin skin test was performed in 162 donors and there were 43 (20.5%) positive cases. The mean white blood cell count before operation was 6918/ml (3300-13900). There were six cases with mild leukocytosis (more than 11000). The mean hematocrit (Hct) in males and females was 46.6 and 39.9 respectively. The mean, median, minimum and maximum levels of hemoglobin (Hb) in males were 15.67, 16, 9, and 18 respectively. In females, it was 12.93, 13, 8 and 16 respectively. In male donors, the Hb was normal, low and high in 141 (91%), five (3.2%) and nine (5.8%) respe­ctively. This figure in female donors was 36 (73.5%), 11 (22.4%) and two (4.1%) respectively.

There was a statistically significant diffe­rence between Hct and Hb in male and female donors ( p < 0.01). Six (3.8%) males were anemic (Hb < 13.5 g/dl, Hct < 40) and 10 (19.6%) females had anemia with Hb < 11.5 g/dl and Hct < 36%. Blood tests including sugar, cholesterol, triglycerides, urea and creati­nine and electrolytes were normal in all donors.

Coagulation tests were performed in 208 donors. It was slightly abnormal in 25 (12%) cases. Urinalysis and urine culture, perfor­med in all donors, revealed no abnormalities.

X-ray chest, electrocardiogram and intra­venous urogram were normal in all the study donors. Reports of 39 angiographies were not found; among the remaining 171 cases, there were multiple renal vessels (2 or more) in 6.3% and 9.9% in right and left kidneys respectively.

Nephrectomy Site

In 205 cases in whom records were available, 159 (77.6%) nephrectomies were performed on the left side and 46 (22.4%) on the right. Nine (4.3%) cases were operated through the abdominal route and 201 (95.7%) through the lumbar route. The site of nephre­ctomy was not statistically different between men and women (p > 0.05). Whenever there was a kidney with multiple vessels, the kidney on the opposite site was removed. The mean duration of anesthesia during surgery was 2 hours and 57 minutes (2-4 hours) in the study cases.

Surgical Complications

There were 19 (9%) complications that occurred during nephrectomy. This included 15 pleural perforations (5 cases needed chest tube insertion), two cases of peritoneal perforation and one complication each in the renal artery and adrenal vein. There was no statistical significance between sex of the donor and site of nephrectomy (p > 0.05). In the abdominal approach, there were no surgical complications.

Early Post-nephrectomy Complications

There were overall 71 (34%) complications in 63 (30%) donors. A total of 55 donors had a single complication each, five donors had two complication each and two donors had three complications each. Early post­nephrectomy complications are summarized in [Table - 2].

There was no statistical difference between male and female donors, right and left nephrectomies, and donors' age among these complications (p > 0.05). The incidence was greater in addicted donors (p < 0.05). There were no instances of thromboembolism, cardiovascular or neuropsychological com­plications.

Fever occurred in 47 (22.4%) donors. The temperature was between 38-390 C (mean 38.250 C). It occurred mostly in the first three days post-surgery and the causes are given in [Table - 3].

Hypertension

The blood pressure went up temporarily in eight donors after nephrectomy (mean 158/ 100). This was probably due to stress and settled down by the fourth day after surgery without any specific medications.

Respiratory Complications

Respiratory complications occurred in 14 (6.7%) donors [Table - 4].

None of the patients who underwent nephre­ctomy by the abdominal route developed respiratory complications. Also, there were no significant correlation between occurrence of respiratory complications and gender, age or side of nephrectomy of the donor (p > 0.05).

Genitourinary Complications

There were five genitourinary complications (2.4%) which included urinary tract infection (UTI)in three (1.4%) and epididymitis in two donors (1%). In all five, these compli­cations occurred after left nephrectomy; however, it was not significantly related to age of the donor (p > 0.05).

Water and Electrolyte Imbalance

A total of 26 (12.4%) donors had mild water and electrolyte imbalance. This included dehydration in four (1.9%), hyponatremia in 20 (9.5%), and combined hyponatremia and hypokalemia in two donors (0.9%). These changes did not seem to be related to side of nephrectomy or duration of anesthesia (p > .05).

Hemorrhage

Hemorrhage occurred in eight (3.9%) donors following nephrectomy. It occurred during surgery in five cases (2.4%) and early post­surgery in three cases (1.5%). All these patients2 except one2 could be managed with blood transfusions alone. One patient with early hemorrhage needed, besides transfusion, suture ligature of the artery. Hemorrhage was more commonly associated with right nephrectomy (p < 0.05); there was no corre-lation with the sex of the patient (p > 0.05).

Wound Infection

There were 26 (12.4%) episodes of wound infection after nephrectomy. The infection was mild in 23 (11%) while three (1.4%) had abscess formation. The occurrence of wound infection was not related to the side of nephrectomy (p > 0.05), but occurred more commonly in males (p < 0.05).


   Discussion Top


Renal transplantation is the ideal treatment for patients with ESRD, both economically and in respect to quality of life. [1],[2] Living donor nephrectomy is a safe procedure with little morbidity and no mortality. Renal function amongst the donors after live donor nephrectomy is a matter of debate. However, long-term studies have shown that there is no renal function deterioration. [3] A recent paper from the Cleveland Clinic Foundation has demonstrated that renal function is well-preserved even 25 years after live donor nephrectomy. [4],[5] The first kidney transplant in Iran was performed in 1968 at the Namazi Hospital, Shiraz University, and later in the Mashhad University of Medical Sciences, Ghaem Hospital, in 1989. Since then, more than 12,000 kidney transplants have been performed in various centers in Iran, nearly all from living related and unrelated donors. Although cadaveric organ donation is not prohibited in Iran, neither for relegious nor legal reasons, it is rarely performed due to of many logistic reasons.

In the era of cyclosporine, the one-year graft survival in living donor kidney reci­pients is greater than those from cadaver donors. [6] Because of shortage of related donors, it has become essential to harvest kidneys from unrelated or emotionally related donors.

There are several approaches for donor nephrectomy. These include the lumbar, the thoraco-abdonominal and the anterior abdominal approaches. [7],[8],[9] We performed the initial nine donor nephrectomies through the abdominal approach and the remaining 210 through the lumbar approach. We did not encounter any mortality in our series. In a large series of living donor nephrectomies in the United States, the mortality rate was 0.03%, major complications occurred in 1.8% and minor complications including wound infection, respiratory infection, UTI and pneumothorax, occurred in 10-20% [6] of the donors.

In another study, major complications such as femoral thrombosis, pancreatic injury and splenic laceration [10] were reported after living donor nephroctomy. We did not see any such major compli­cations in our study.

Recently some authors have described laparoscopic live donor nephrectomy [11] which is a matter of debate and a challenging issue. It is said that the intra-operative blood loss, post-operative pain, length of hospita­lization and time to return to normal activities is significantly lower in laparoscopic versus standard open live donor nephrectomy. However, long-term follow-up evaluation is required.

More recently Ko and Cosimi [12] have summarized the complications of more than 2000 living donor nephrectomies in a table [Table - 5].

Thus, the overall intra-operative and early complications of living donor nephrectomy in this series [12] was nearly 51%, compared to 34% in our series. The majority of compli­cations encountered by us were minor complications in the form of wound infection and fever. These complications are generally preventable and also easily treatable with the use of pre- and post­operative antibiotics.


   Conclusion Top


Living donor nephrectomy in our center was accompanied with minor complications, very little morbidity and no mortality.

 
   References Top

1.Barry JM. In: Campbell's Urology, Walsh PC et al (eds), vi, 7 th ed., Philadelphia, WB Saunders, pp. 505-514, 1998.  Back to cited text no. 1    
2.Flye WF. Renal transplantation in, M. Wayne Flye (ed.) Principles of organ transplantation. Philadelphia, Saunders 264-293, 1989.  Back to cited text no. 2    
3.Kasiske BL. The evaluation of prospective renal transplants recipients and living donors. Surg Clin of North Am 1998;78:27-39.  Back to cited text no. 3    
4.Goldfarb DA, Martin SF, Braun WE, et al. Renal outcome 25 years after donor nephre­ctomy. J Urol 2001;166:2043-7.  Back to cited text no. 4    
5.Novick GD. Majority of kidney donors remain healthy after 25 years. Urology News 2002;9:7.  Back to cited text no. 5    
6.Sankari BR Wyner LM, Streem SB. Living unrelated donor renal transplantation. Urol Clin North Am 1994;21 (2):293-7.  Back to cited text no. 6    
7.Bennett AH, Harrison JH. Experience with living familial renal donors. Surg Gynecol & Obstet 1974;139 : 894-8.  Back to cited text no. 7    
8.Ruiz R, Novick AC, Braun WE, Montague DK, Stewart BH. Transperitoneal live donor nephrectomy. J Urol 123:819, 1980.  Back to cited text no. 8    
9.Streem SB, Novick AC, Steinmuller DR, Graneto D. Flank donor nephrectomy: efficiency in the donor and recipient. J Urol 1989;141:1099-101.  Back to cited text no. 9    
10.Cosimi AB. Donor and donor nephrectomy in kidney transplantation., Morris PT (ed), 4 th ed., Philadelphia, WB Saunders, 56-70, 1994.  Back to cited text no. 10    
11.Hensman C, Lionel G, Hewett P, Rao MM. Laparoscopic live donor nephrectomy: the preliminary experience. Aust NZ J Surg 1999;69:365-8.  Back to cited text no. 11    
12.Ko DSC, Cosimi AB. The Donor and donor nephrectomy. In Morris PT (ed.), 5 th Ed. Philadelphia, WB Saunders, 89-105, 2001.  Back to cited text no. 12    

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Correspondence Address:
A Shamsa
Department of Urology and Kidney Transplantation, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad
India
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PMID: 17657120

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