Objectives: The aim of the present study was to evaluate the short- and intermediate-term outcomes of living-related kidney donors in terms of renal function and postnephrectomy complications at a single center in Pakistan.
Materials and Methods: Our study included healthy donors who underwent unilateral nephroureterectomy for living-related renal transplant procedures at the Sindh Institute of Urology and Transplantation (Karachi, Pakistan) between January 2005 and January 2006.
All patients were evaluated for early posto-perative complications and renal functions at last follow-up. The mean follow-up duration was 1.7 ± 1.3 years.
Results: A total of 256 living-related donors underwent nephroureterectomy during the study period, which included 142 men (55.5%) and 114 women (44.5%). The mean age of donors was 33.7 ± 10.0 years. Most donors were between 21 and 40 years old. Of total donors, most were siblings (n = 143, 55.8%), followed by offspring, parents, and spouses. Left nephrectomy was performed in 206 donors (80.4%) and right in 50 donors (19.5%). There were no deaths during transplant. The mean postoperative hospital stay was 6.37 ± 0.95 days. A total of 38 donors (14.8%) had one or more surgical complication. Hypertension developed in 25 (9.7%) and diabetes mellitus in 9 donors (5%). Creatinine clearance was > 90 mL/min in 96 (41%), 60 to 90 mL/min in 120 (51%), and ≤ 60 mL/min in 18 donors (8%).
Conclusions: Living-related donor nephrectomy remains a valuable source of kidneys for transplant procedures and carries a small risk. With careful donor selection and good surgical management, operative complications can be minimized.
Key words : Complications, Hypertension, Perioperative
Kidney transplant is the treatment of choice for patients with end-stage renal disease (ESRD). Compared with long-term dialysis, kidney transplant procedures are cost-effective, offer improved quality of life, and confer a progressive survival benefit.1,2 While the ESRD population continues to grow, the supply of kidneys for transplant from deceased donors is unlikely to increase significantly, resulting in a large gap between the demand for donor kidneys and supply.3,4 Fortunately, living kidney donation has become an attractive alternative to transplants with deceased donations. With the advent of laparoscopic donor nephrectomy and constantly improving recipient outcomes, the number of living kidney donations has grown by 115% over the past decade.5
From a recipient standpoint, living-donor transplant is regarded as superior to deceased-donor transplant in every respect. Living-donor transplant allows for a full donor evaluation before transplant, elective scheduling of surgery at the time of optimized recipient health, and a minimum graft ischemic time during the transplant operation.6 The major downside of living-donor renal transplant is that it subjects a healthy person to unnecessary surgery, with its attendant risks and a life after surgery with reduced renal mass. Fortunately, donor nephrectomy is a relatively safe procedure. The risk of donor death is most commonly cited as 0.03%, the risk of major complications is from 0.23% to 2.1%, and the risk of minor complications is from 8.0% to 14.7%.7,8
The aim of the present study was to evaluate the short- and long-term outcomes of living-related kidney donors in terms of biochemical parameters and postnephrectomy complications at a single center in Pakistan.
Materials and Methods
This study analyzed 256 healthy donors who were seen at the Sindh Institute of Urology and Transplantation (Karachi, Pakistan) between January 2005 and January 2006 and who underwent unilateral nephroureterectomy for living-related renal trans-plant. Written informed consent was obtained from all patients. The research was conducted in accordance with the ethical standards as outlined in the Declaration of Helsinki, as revised in 2008.
All patients were evaluated for early post-operative complications. After discharge, all patients were followed up in a dedicated clinic where their physical and social well being and medical and surgical complications were noted and treated. For patients without complications, a first follow-up was scheduled 6 months after nephrectomy, with annual visits thereafter. If any intercurrent medical problem arose at any time, the donor was promptly seen in the clinic or hospitalized if necessary. The donor clinic protocol included a complete history with psychosocial assessment and physical examination, including measurement of height, weight, and blood pressure as well as laboratory investigations (eg, serum creatinine level). The mean patient follow-up was 1.7 ± 1.3 years (range, 6 months to 5 years).
Statistical analyses were performed with Statistical Package for Social Sciences (SPSS) version 10.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used. Mean and standard deviation were used for quantitative variables, whereas qualitative data were given in numbers and percents.
Our study included 256 living-related donors who underwent unilateral nephroureterectomy during the study period. Among these, 142 (55.5%) were men and 114 (44.5%) were women (Figure 1). The male-to-female ratio was 1.2:1. The mean age of donors was 33.7 ± 10.0 years (range, 18-67 y). Most donors were between 21 and 40 years old, whereas 63 donors (24.6%) were > 40 years old (Figure 2). Relationship of donors to recipients showed that most were siblings (n = 143, 55.8%), followed by offspring, parents, and spouses (Figure 3). On the basis of intravenous urography and renal angiographic findings, 206 donors (80.4%) underwent left nephrectomy and 50 donors (19.5%) underwent right nephrectomy (Figure 4).
There were no perioperative deaths. The mean postoperative stay was 6.37 ± 0.95 days (range, 4-9 days). A total of 38 donors (14.8%) had 1 or more surgical complication, including pleural and peritoneal tear, polar artery ligation, and vascular mishap. Immediate postoperative complications occurred in 34 donors (14.0%), including pneumothorax, pleural effusion, urinary tract infection, urinary retention, fever, wound infection, and diathermy burn. Long-term surgical complications included mild incisional hernia and nephrolithiasis (Table 1).
In our patient group, 25 donors (9.7%) developed hypertension after donor nephrectomy. Regarding renal function, 96 donors (41%) had creatinine clearance > 90 mL/min, 120 (51%) had levels between 60 and 90 mL/min, and 18 (8%) had levels < 60 mL/min. In our study, 9 donors (5%) developed diabetes mellitus after donating their kidneys. Male-to-female ratio was 1:2 in these patients, and the mean age of patients who developed diabetes mellitus was 38.5 ± 7.2 years, with postnephrectomy follow-up of 1.6 ± 1.5 years. There were 95 donors (37%) who became obese and overweight after donation. This pattern was more marked in female donors.
Renal replacement therapy (RRT) in the form of dialysis is an accepted treatment of ESRD; however, in terms of cost-effectiveness and quality of life, renal transplant is the preferred mode of therapy. In developing countries, dialysis facilities are available at few centers, and transplant centers are still fewer relative to the needs of the population. In fact, RRT correlates well with the economic development of nations. In the United States and Japan, almost all patients needing dialysis on medical grounds receive dialysis. In contrast, in Pakistan, only 15% to 20% of patients needing RRT reach a dialysis facility. One of the major factors for this is an urban bias in health care delivery, with dialysis facilities virtually nonexistent in rural areas where two-thirds of the population resides.
Kidney donation from living donors has allowed successful renal transplants in the early period of its development. It remains the predominant source of organs in developing countries where deceased-donor transplant has yet to establish roots because of the lack of infrastructure or implementation of legal criteria for brain death. Even in developed countries, the increasing demand for kidneys has resulted in growth of unconventional living-donor transplant in recent years.
There are several reasons for using living donors, including superior patient and graft survival rates and optimal timing for transplant. However, the issue of whether living kidney donation is justifiable and the possible risks involving kidney donation, including factors such as increased long-term risk of hypertension, progressive proteinuria, and a pro-gressive decline in renal function of the remaining kidney, have been raised in a number of studies.8,9
Donor follow-up is necessary to ensure that uninephrectomy does not cause any detrimental effects on renal function and cardiovascular status of the donor. It also provides satisfaction and confidence to the transplant team. Developing countries have and will continue to rely heavily on living kidney donations. In the absence of an organized health infrastructure and lack of follow-up culture in such countries, it is imperative that transplant programs initiate such a follow-up. Thus far, data from these regions are limited regarding general health status and development of com-plications among kidney donors.10
Results from our study show that the mean age of donors was low compared with other studies.10 It was also low in comparison with a pilot study from India on 50 living donors.11 Part of the reason for this may be the predominance of sibling donors in our study compared with an Indian study, where parents were predominant donors.11 Our ratio of male-to-female donors was more or less similar to other studies.8-10
Our results regarding immediate postoperative complications are on par with those reported previously in different studies from across the world.12-19 In particular, there were no perioperative deaths, and intermediate-term complications were also low. These results are reassuring and have contributed to the ongoing donations involving living donors at our center. Our dedicated donor follow-up clinic ensures that these complications are detected early and that remedial measures are taken.20,21
There are certain limitations in our study. This is a single center-based study. It is retrospective in nature with short follow-up. Despite these limitations, we believe that this study is a valuable contribution to the scant existing literature on this topic from developing countries.
Living-related donor nephrectomy remains a valuable source of kidneys for transplant and carries a small risk; with careful donor selection and good surgical management, operative complications can be kept low. Donor follow-up and addressing the well-being of donors are essential components of the transplant activity.
Volume : 16
Issue : 6
Pages : 656 - 659
DOI : 10.6002/ect.2017.0140
From the the Departments of 1Urology, 2Nephrology, and
Institute of Urology and Transplantation, Karachi, Pakistan
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare.
Corresponding author: Muhammed Mubarak, Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Pakistan
Phone: +9221 99215752
Figure 1. Distribution of Donors by Sex
Figure 2. Distribution of Donors by Age (in years)
Figure 3. Donor Relationship With Recipient
Figure 4. Nephrectomy Site in Donors
Table 1. Surgical Complications (N = 256)