Evaluation and Recovery of Living Kidney Donors following Laparoscopic Donor Nep

[Clark]

http://www.mdnews.com/news/2014_06/evaluation-and-recovery-of-living-kidney-donors-.aspx

Evaluation and Recovery of Living Kidney Donors following Laparoscopic Donor Nephrectomy
By: Vanessa R. Humphreville, MD; Nagaraju Sarabu, MD; Kenneth J. Woodside, MD, FACS

Kidney transplantation offers significant survival and quality of life benefit for patients with end stage renal disease compared to other treatment options of hemodialysis or peritoneal dialysis. However, with increased incidence of end stage renal disease in United States, the gap between the demand and the supply of deceased organs has been steadily increasing. As a consequence, the waiting period to receive a deceased-donor kidney transplant continues to increase.

With living donor transplantation, one can have minimal delay to transplant, which even makes preemptive transplantation possible. In addition, outcomes from living donation are significantly better—both for the expected function of the kidney and continued function of the transplanted kidney over time.

Living donor evaluation has received a great deal of attention at the national level and accordingly government agencies involved (CMS and UNOS) have introduced policies to standardize the evaluation of living donors across all transplant centers in the United States. The evaluation starts with assessment of the donor and recipient blood groups and histocompatibility. However, advances in immunosuppressive therapies have made transplantation across many of these barriers possible, so incompatibility does not necessarily prevent someone from donating. In addition, should the donor and recipient not be compatible, there is still the option of enrolling in the kidney donor exchange program. This initial evaluation is followed by a thorough medical and surgical evaluation to ensure that the potential donor is in good health, has normal kidney function, and is free of potentially transmittable infections, malignancies, or other conditions. In addition, a licensed social worker performs a psychosocial evaluation to ensure the donor is free of coercion, and to identify any potential psychiatric disorders that require intervention prior to donation.

Outcomes from living donation are significantly better (than from deceased donation) — both for the expected function of the kidney and continued function of the transplanted kidney over time.

The first living donor nephrectomy was performed by Dr. Joseph Murray, where a man donated to his identical twin. At that time, laparoscopic technique had not yet been developed, so an open technique with a large flank incision was utilized. Unfortunately, this incision was often complicated by incisional hernias and pain, as well as with long hospital stays. In 1995, laparoscopic technique for donor nephrectomies was developed by Dr. Lloyd Ratner and Dr. Louis Kavoussi. The laparoscopic technique has less post operative pain, shorter hospital stay, less need for post-operative narcotics, earlier return to work and daily activities, and more favorable cosmetic outcome while providing identical recipient outcomes to the open technique.

Computed tomography is used to determine vascular and ureteral anatomy as these can vary from donor to donor. The kidneys are evaluated for cysts, masses, stones, size, or any other abnormality. If both kidneys are equal with single vein, artery, and ureter, no stones or cysts, and of similar sizes, the left kidney is preferred, as it has a longer renal vein and is slightly easier to remove. If the kidneys are of unequal sizes, a split glomerular filtration rate is obtained to be sure the more functional kidney remains within the donor.

There are several laparoscopic technique options. The hand-assisted laparoscopic technique, using a hand port in addition to two small port sites, is the most commonly performed in the United States for living donation. The kidney is removed through the existing hand port site. The “total” laparoscopic technique typically utilizes three port sites, one for the camera and two for working instruments, and can be done intraperitoneally or retroperitoneally. This laparoscopic technique can also be performed through a larger single port or with robotic assistance, such as the da Vinci Surgical System. For these approaches, the kidney is typically removed through a lower abdominal transverse incision or through the larger port site.

Incompatibility does not necessarily prevent someone from donating.

The donor is typically in the hospital for two to five days after the surgery. The major symptoms donors experience after leaving the hospital are incisional pain and fatigue. They are usually able to return to work within four to six weeks. The procedure is safe, but has some risks. In addition to the usual risks for general anesthesia and laparoscopic operations, up to a third of patients may have a small rise in their blood pressure. While there is a remote risk of renal failure, it is still rare. Compared to pre-donation, post-donation pregnancies have a somewhat increased risk of miscarriage and preeclampsia. Long term, kidney donors lead normal lives with normal life spans.

Donors initially have scheduled follow-up typical for post-surgical patients. They are seen by the operating surgeon until they have fully recovered from the operation. Donors should be seen by their primary care physician yearly for the rest of their life, which should include age-appropriate health maintenance and blood pressure checks. In addition, transplant centers follow their donors for a minimum of two years. While the exact nature of the two year follow-up program varies by transplant center, follow-up typically is a combination of phone calls, labs, and possible office visits. Many centers, including our own, incorporate office visits with a transplant physician for two years post-donation when feasible. Donor outcomes, like recipient outcomes, are tracked by the Organ Procurement and Transplantation Network, the national regulatory body.

[Clark]

http://www.postbulletin.com/life/health/medical-edge-living-donor-kidney-donation-starts-with-thorough-evaluation/article_19ab8276-2780-5326-976d-b2b1f4f5b9ad.html

Medical Edge: Living donor kidney donation starts with thorough evaluation

DEAR MAYO CLINIC: What is the process for evaluating whether or not I'm a good candidate to donate one of my kidneys? How long is recovery for the donor?

The first step is to contact the transplant center where the donation would take place. They will perform a thorough medical evaluation to see if you can safely donate a kidney. Recovery from kidney donation surgery usually takes two to three weeks. But you will have some activity restrictions for up to six weeks.

Your kidneys are two bean-shaped organs, each about the size of a fist, in the back of your abdomen on either side of your spine. Kidneys remove extra fluid and waste from your body and help control blood pressure. When a person's kidneys no longer work -- a condition called chronic kidney failure -- a kidney transplant usually is the best treatment option. A transplant often allows people to return to a fully active life.

A kidney for a transplant may come from a deceased donor or from a living donor. Kidneys from living donors usually last longer and work better than those from deceased donors. Living kidney donations are possible because although you have two kidneys, your body can work well with only one.

Many people who consider donating a kidney are family members or friends of someone who needs a kidney transplant. But some people who want to be kidney donors do not have a certain person in mind to receive the kidney. This is called non-directed donation. All potential kidney donors go through the same evaluation process to make sure they can donate safely.

The evaluation starts with an interview or questionnaire to gather information about your background and medical history. You will also talk with a member of the transplant team about the donation process and what to expect.

If the transplant team decides you may be able to be a kidney donor, typically the next step is to have blood tests. If the results of those tests are acceptable, you go through a number of other medical appointments.

The appointments usually include a physical exam, more blood tests, urine tests and imaging studies. You also need tests to check how well your kidneys work. You may need tests to screen for cancer and other existing medical problems, too.

If the results of your evaluation show that you can be a donor, and if you decide it is right for you, then you have surgery to remove one of your kidneys. The surgery takes about one to four hours. At most transplant centers, the procedure is done using laparoscopic surgery. That means instead of one large incision, the surgeon makes several smaller incisions. The surgical instruments are inserted into two of those incisions, and the kidney is removed through another incision.

After kidney donation surgery, most people stay in the hospital for one or two nights. You may have some pain and discomfort after surgery. It can often be managed well with pain medications. Most people can go back to work two to three weeks after surgery. But it may be up to six weeks if you have a job that involves heavy lifting or other manual labor.

Complications after kidney donation surgery are very rare. There is a small risk of infection, bleeding and blood clots. A small group of patients may develop an incisional hernia -- a bulge under the skin that requires a second procedure to repair. The transplant team will talk with you in detail about the possible risks of kidney donation.

Donating a kidney for a transplant is a wonderful act of generosity. Many people are waiting for a kidney transplant. If you are interested in becoming a kidney donor, contact your transplant center, or go online to the United Network for Organ Sharing at www.unos.org for more information. -- Mikel Prieto, M.D.