Laparoscopic or open surgery for living donor nephrectomy.

BACKGROUND: The anterior extraperitoneal approach for living donor nephrectomy has been used in more than 700 living cases in the unit and proved to be safe for the donor. In 1998, laparoscopic nephrectomy was introduced as an option when technically feasible. We found it essential to investigate the consequences of the new technique. SUBJECTS AND METHODS: One hundred living donor kidney transplantations were performed from 1998 to June 2000, 45 with laparoscopic, 55 with open nephrectomy. The donors took part in a structured interview 4 weeks after the donation and their responses were categorized in three classes. RESULTS: In each group, one recipient had delayed initial function. The serum creatinine levels after 3 and 7 days or the GFR values after 6 months did not differ. One graft has been lost following laparoscopic nephrectomy and four after open surgery. For the laparoscopy donors, the median number of post-operative days in hospital was 5.0 days (range 2-9), vs 6.0 (4-8) after open surgery (NS). The requirement of opoid analgesics post-operatively was 5.0 doses (1-22) vs 6.0 (1-38) (P=0.02); and after 4 weeks, 23 of 45 laparoscopic donors were free of pain vs eight of 55 open nephrectomy donors (P=0.0004). Approximately one-third of all donors felt some restriction of physical activity and the majority complained of impaired physical energy. There were no differences between the groups. The duration of sick-leave after laparoscopic surgery was median 6 (2-19) weeks vs 7 (1-16) (NS). CONCLUSIONS: Laparoscopic nephrectomy is safe. Less post-operative pain is a definite advantage for the donor.

Experience with laparoscopic donor nephrectomy at a European transplant centre.

Renal grafts from live donors represent an important source for transplantation of end stage renal failure patients. Postoperative short- and long-term comfort is essential. Laparoscopic nephrectomy was performed in 22 cases. The left kidney was preferred for optimal length of the vessels. One procedure was converted to open surgery because of venous bleeding. Warm ischemia time varied between 4 and 7.5 min. Urine production started peroperatively in all cases, and the renal function was excellent. Shoulder pain 1-3 days postoperatively was observed in seven patients; the rest were comfortable on peroral non-opioid analgesia. The patients were discharged at postoperative days 3-9, and returned to work 2-4 weeks later as compared to 4-8 weeks after open nephrectomy at our centre. Laparoscopic donor nephrectomy in the hands of experienced laparoscopic and transplant surgeons is a safe operation with less discomfort to the living kidney donor.

Cadmium, mercury, and lead in kidney cortex of the general Swedish population: a study of biopsies from living kidney donors.

Cadmium, mercury, and lead concentrations were determined in deep-frozen kidney cortex biopsies taken from 36 living, healthy Swedish kidney donors (18 males and 18 females), who were 30-71 (mean 53) years of age. Information about occupation, smoking, the presence of dental amalgam, and fish consumption could be obtained for 27 of the donors. The samples (median dry weight 0.74 mg) were analyzed using inductively coupled plasma mass spectrometry, and the results were transformed to wet-weight concentrations. The median kidney Cd was 17 micrograms/g (95% confidence interval, 14-23 micrograms/g), which was similar in males and females. In 10 active smokers, the median kidney Cd was 24 micrograms/g, and in 12 who never smoked, it was 17 micrograms/g. The median kidney Hg was 0.29 micrograms/g, with higher levels in females (median 0.54 micrograms/g) than in males (median 0.16 micrograms/g). Subjects with amalgam fillings had higher kidney Hg (median 0.47 micrograms/g, n = 20) than those without dental amalgam (median 0.15 micrograms;g/g, n = 6), but kidney Hg was below the detection limit in some samples. Nearly half of the samples had kidney Pb below the detection limit. The median kidney Pb was estimated as 0. 14 micrograms/g. This is the first study of heavy metals in kidney cortex of living, healthy subjects, and the results are relatively similar to those of a few previous autopsy studies, indicating that results from autopsy cases are not seriously biased in relation to kidney metal concentrations in the general population. Cd concentrations in those who never smoked were relatively high, indicating considerable Cd intake from the diet in Sweden. The effect of dental amalgam on kidney Hg was as expected, although the reason for the difference in Hg levels between males and females is unclear.

Gender differences in a kidney transplant population.

The purpose of this study was to compare female and male kidney transplant recipients. Of 1095 consecutive kidney transplants, 63.7% were to male recipients. Detailed demographic background data and follow-up data were used in the analysis. Female and male recipients were the same age, median 44, range 1-71 years. The male/female ratio was increased in all adult age groups, and most pronounced in the middle-aged. The proportions of first transplants and of preemptive transplants were not different, and 22.0% of men compared with 24.4% of women had living donors. Biopsy-verified chronic glomerulonephritis was found 2.4 times more often in men than in women, unknown diagnosis including non-biopsy-verified chronic glomerulonephritis 2.3 times, and adult dominant polycystic kidney disease 1.8 times. A larger proportion of men than women received antirejection treatment, 59.5% vs 49.5% (P = 0.002). Cumulative survival of patients or grafts was not different, but women > or = 50 years of age tended to have poorer 1-year graft survival than men, 69% vs 78% (P = 0.06). It is concluded that the increased proportion of men in our transplant programme is mainly due to their higher requirement of renal replacement therapy.

Steroid-resistant rejection in kidney-transplanted patients: is ATG treatment for three or ten days preferable?

We carried out a randomized prospective trial to compare a 3-day with a 10-day course of antithymocyte globulin (ATG)-(Fresenius) for treatment of steroid-resistant rejection after renal transplantation. The aim was to study whether a short 3-day course was as safe and effective as the longer 10-day treatment. Thirty patients over a 3-year period were included. Patients that did not respond to treatment after 3 days received additional ATG from day 5 to day 10. The graft survival and the proportion of rejections reversed with the treatment were compared. Fifty percent responded promptly in the 3-day group and a further 29% after additional treatment. In the 10-day group, 62% responded to the treatment. There was no significant difference between the groups. We, therefore, suggest that the standard antirejection treatment with ATG could be shortened without an increased risk of graft failure.

Kidney transplantation to patients with congenital malformations of the distal urinary tract.

Fourteen of 1000 consecutive kidney transplant patients had congenital malformations affecting the bladder or urethra: six had congenital valvulus of the urethra, two congenital sclerosis of the bladder outlet, and six a neurogenic bladder. Pretransplant surgery had been performed in all patients: reimplantation of ureter (n = 11), resection of congenital valvulus (n = 7), and nephrectomy (n = 6). Four patients had an intestinal bladder. Age was 0-17 (median 1) years at diagnosis. Follow-up time was 3-10 (median 5) years. Special transplant surgery techniques were required in five patients. Patient survival after 2 years was 100% and graft survival 93%. No graft was lost due to outflow obstruction, infection or other causes related to the underlying disorder. Late technical problems were seen in two patients. Urinary tract infections were reported in 13 patients before transplantation and in eight after. Results of transplantation were excellent. Infections and surgical problems had a minor impact on outcome.

Hepatitis C superinfection in hepatitis C virus (HCV)-infected patients transplanted with an HCV-infected kidney.

Hepatitis C virus (HCV) genotypes, determined by polymerase chain reaction with type-specific primers, were studied in 5 already HCV-infected patients receiving kidneys from HCV-infected cadaver donors. Three patients were investigated retrospectively using stored pre- and posttransplantation sera and followed 18-28 months after transplantation. Two recipients with HCV genotype 2b infection had received kidneys from 1 genotype 3a-infected donor. In 1 recipient, HCV 2b was replaced by the donor's type; in the other recipient, a prolonged mixed infection of 3a and 2b occurred. Persistent alanine aminotransferase (ALT) elevation (3- to 5-fold) appeared in both patients. The third patient, also HCV 2b infected when transplanted with an HCV 3a-infected kidney, remained infected with HCV 2b only. Two patients, one with HCV genotype 1b and the other with genotype 3a, were followed prospectively with frequent bleeds (initially biweekly) and genotyping over 14 months after they had received kidneys from 1 HCV genotype 1a-infected donor. The HCV 1b-infected recipient remained infected with 1b only and had minimal biochemical signs of liver injury. In the other recipient, mixed infection of 3a and 1a appeared at week 3 and persisted for several weeks, until only genotype 1a could be detected. This patient had elevated ALT levels before transplantation. After onset of mixed infection, ALT levels increased further for several weeks, and returned to pretransplantation levels when only HCV 1a was found. HCV-infected kidneys transplanted into HCV-infected recipients gave 3 different virus patterns. Most patients benefitted in the short term, but some super-infected patients experienced increased liver damage.

Renal transplantation after Cortinarius speciosissimus poisoning.

During the years 1979-1993 22 individuals were intoxicated in Sweden by the mushroom Cortinarius speciosissimus. Nine of them developed end-stage renal failure (ESRF), and we describe five who have received renal transplants. Three were transplanted after 6-9 months on haemodialysis; the other two regained some renal function after 2-6 months on haemodialysis, but had to be restarted on dialysis 24-30 months later and were eventually transplanted. Two patients had kidneys donated by a father and a brother respectively, three had cadaveric organs. All five developed satisfactory renal function with current glomerular filtration rate (GFR) 31-79 ml/min (mean 56.2) after 5-10 (mean 7.0) years. To our knowledge, renal transplantation after Cortinarius poisoning has not been reported before.

Alterations of the post transplant blood lymphocyte phenotype subsets as a marker of rejection in renal allograft recipients.

The postoperative alterations of absolute levels of lymphocyte phenotype subsets in peripheral blood were studied in recipients of living donor renal allografts and in kidney donors. The results were expressed as per cent changes of the preoperative values. The lymphocyte subsets, CD3, CD4 and CD8 cells, decreased to approximately 50% following the surgical trauma, with rapid recovery to preoperative levels within 1 week in kidney donors and in recipients without rejection episodes. In contrast, the T-cell levels in recipients with rejection episodes remained low after 1 week, before clinical signs of rejection, and was predictive for the later occurrence of acute rejection episodes. The T-cell levels in the recipients with rejection episodes remained low during the first 6 weeks, maybe due to the rejection treatments given during this period. The B-lymphocytes were not affected in any of the recipient groups. The alterations observed were not explained by CMV infections, which occurred mainly after the observation period of 6 weeks. In conclusion, the operation per se induced alterations in circulating T-lymphocyte subsets and low T-cell levels after 1 week were predictive of rejection episodes.

Cancer risk after renal transplantation in the Nordic countries, 1964-1986.

The theory that cancer may arise under conditions of reduced immune capacity is supported by observations of humans with immune deficiencies such as occur following organ transplants. However, no study on humans has been done in which the reference population was the same as that in which the cancer cases arose and in which there was a sufficiently long period of follow-up. Information on 5,692 Nordic recipients of renal transplants in 1964-1982 was linked with the national cancer registries (1964-1986) and population registries. Person-years at risk were calculated from the date of first transplantation until death or the end of the study period and were multiplied by the appropriate age- and calender-specific incidence rates to obtain the expected numbers of cancers. Standardized incidence ratios (SIR) were calculated after stratification by a number of recorded variables. Altogether, 32,392 person-years were accrued, and 471 cancers occurred, yielding overall SIR of 4.6 (95% CI, 4.0 to 5.2) for males and 4.5 (95% CI, 4.0 to 5.2) for females. Significant overall 2- to 5-fold excess risks in both sexes were seen for cancers of the colon, larynx, lung and bladder, and in men also for cancers of the prostate and testis. Notably high risks, 10-fold to 30-fold above expectation, were associated with cancers of the lip, skin (non-melanoma), kidney and endocrine glands, also with non-Hodgkin's lymphoma, and in women also with cancers of the cervix and vulva-vagina. Among a number of donor and recipient variables studied, including tissue types and compatibility (ABO, HLA, DR), age below 45 years at the time of transplantation was the most important determinant for increased risk at most sites. Kidney transplantation increases the risk of cancer in the short and in the long term, consistent with the theory that an impaired immune system allows carcinogenic factors to act. The tumor risk is small in comparison with the benefits of transplants, but patients should be followed up for signs of cancer.

Long-term renal allograft function.

Long-term function of transplanted kidneys was measured as 51Cr EDTA clearance (GFR). All kidneys transplanted in 1985 with preserved function after 6 months were again studied after 12, 24, 36, and 60 months. Grafts lost due to the patient's death were excluded. There was no significant GFR difference at 6 months between grafts with continued function (median 42 ml/min, range 15-79 ml/min; n = 69) and those that failed later (median 39 ml/min, range 20-87 ml/min; n = 18). Median GFR of surviving grafts remained stable, but individual variations included reductions by 5-49 ml in 29 patients and increases by 5-33 ml in 22 patients. Nine of the failing grafts showed a continuous but rarely linear decline, while eight had initially increased GFR. The long-term GFR changes were not statistically correlated with the dosage of cyclosporin at 6 months or with later dose reductions. In conclusion, renal transplant function may deteriorate in the long-term but can also improve.

Early renal graft function in recipients treated with the calcium channel blocker felodipine.

Calcium channel blocking agents (CCB) differ in molecular structure and effects. Each must therefore be evaluated separately. Out of 139 patients who received cadaveric kidney transplants between March 1990 and December 1991 22 were treated with the CCB agent felodipine as antihypertensive therapy on admission and post transplant. The early function of their grafts was compared with that of grafts to patients not treated with any CCB agent pre or post transplant (n = 38). There were no other significant differences in patient or donor characteristics. In the felodipine treated group, 18/22 showed immediate onset of graft function vs 20/38 in the non CCB group (p = 0.02). Dialysis post transplant was required by one felodipine-treated patient vs 12 in the non CCB group. Serum creatinine on day 7 was lower in felodipine treated patients, median 155 vs 259 mumol/l. Felodipine treatment did not seem to cause any significant interaction with cyclosporin A (CyA). The frequency and severity of acute rejection did not differ between the groups.

Characterization of the anti-A antibody binding in an ABO-incompatible living donor renal transplantation.

A 57-year-old female, blood group B, with polycystic kidney disease, received an ABO-identical, HLA-A,B,DR 5-mismatched renal allograft in 1986. Due to graft artery thrombosis and vascular rejection, she lost the kidney 6 months after transplantation and developed HLA antibodies with a panel reactivity of 99%. Despite 5 years on a European waiting list for highly immunized patients, she was not offered a second kidney. An attempt to remove her HLA antibodies by plasmapheresis combined with cyclophosphamide therapy did not succeed. Her 53-year-old HLA-identical, but ABO-incompatible sister (blood group A1), was then accepted as a donor. After immunoadsorption on Biosynsorb-A columns, transplantation was performed. The post-transplant course was uneventful without any signs of rejection. Studies on the anti-A antibody binding characteristics before and after immunoadsorption and after transplantation, showed that IgM and IgG antibodies recognizing the A trisaccharide epitope based on the type 1, 2, and 4 core saccharide chains, were effectively removed by Biosynsorb-A adsorption, but the column failed to remove anti-A antibodies recognizing the A type 3 antigen. These antibodies probably requires part of the core saccharide chain for binding. The presence of these antibodies did not seem to influence the outcome of the ABO-incompatible transplantation.