| 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 2020 Jan 19];14:481-6. Available from: http://www.sjkdt.org/text.asp?2003/14/4/481/32987
| Introduction|| |
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|| |
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|| |
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.
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.
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].
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 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).
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 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).
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|| |
Renal transplantation is the ideal treatment for patients with ESRD, both economically and in respect to quality of life. , 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.  A recent paper from the Cleveland Clinic Foundation has demonstrated that renal function is well-preserved even 25 years after live donor nephrectomy. , 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.  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. ,, 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%  of the donors.
In another study, major complications such as femoral thrombosis, pancreatic injury and splenic laceration  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  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  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  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|| |
Living donor nephrectomy in our center was accompanied with minor complications, very little morbidity and no mortality.
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Department of Urology and Kidney Transplantation, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]