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Minimizing Risks and Morbidity in Live Kidney Donors
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Transplantation Surgery.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Live kidney donors are healthy volunteers who are exposed to major surgical procedure and physical harms with no direct therapeutic benefits. Efforts to minimize their risks and morbidity are therefore of utmost importance. The current thesis describes studies on donor evaluation, surgical procedure and postoperative management of live kidney donors. The overall purpose is to evaluate and possibly improve routines and treatments in order to reduce risks and the overall morbidity of live kidney donors.

In Study I, we evaluated the assessment of kidney function during donor evaluation and found that the accuracy of iohexol glomerular filtration rate (GFR) is compromised by large variations in repeated measurements in presumably healthy donors. We proposed that there is a need for improvement of GFR measurements and that the assessment of predonation kidney function should be more comprehensive, involving GFR, laboratory investigations, functional and morphological examinations and sound clinical judgment. In Study II, we addressed the risk of perioperative venous thromboembolism (VTE) and concluded that expanding the standard screening protocol for VTE to include perioperative venous duplex can potentially decrease the VTE-related morbidity. In studies III and IV, we investigated the impact of hand-assisted retroperitoneoscopic (HARS) nephrectomy on donor safety and perioperative morbidity. The HARS nephrectomy uses the hand-assisted approach, which enables immediate manual compression for hemostasis in case of sudden and severe bleeding. Additionally, the pure retroperitoneal access further increases the safety margin of laparoscopic donor nephrectomy by 1) minimizing the risk of intestinal injury, and 2) exposure of the retroperitoneal nerves, making HARS suitable for continuous infusion of local anesthetics (CILA). CILA effectively reduces the need for opioid consumption and has the potential to totally obviate opiate analgesics postoperatively. Consequently, CILA in combination with HARS reduces morphine-related morbidity and promotes postoperative recovery.

In accordance with these data, we recommend improvement and modification of the donor evaluation process as well as a broad introduction of HARS nephrectomy in combination with CILA to increase the safety margin for live kidney donors.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2010. , p. 63
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 632
Keywords [en]
live donors, morbidity, GFR, donor nephrectomy, postoperative pain treatment, venous thromboembolism, HARS
National Category
Surgery
Research subject
Medicine
Identifiers
URN: urn:nbn:se:uu:diva-134511ISBN: 978-91-554-7972-5 (print)OAI: oai:DiVA.org:uu-134511DiVA, id: diva2:372759
Public defence
2011-01-26, Robergsalen, ingång 40, Akademiska Sjukhuset, 75185 Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2011-01-05 Created: 2010-11-27 Last updated: 2011-03-07Bibliographically approved
List of papers
1. Decentralized glomerular filtration rate (GFR) estimates in healthy kidney donors show poor correlation and demonstrate the need for improvement in quality and standardization of GFR measurements in Sweden
Open this publication in new window or tab >>Decentralized glomerular filtration rate (GFR) estimates in healthy kidney donors show poor correlation and demonstrate the need for improvement in quality and standardization of GFR measurements in Sweden
2007 (English)In: Scandinavian Journal of Clinical and Laboratory Investigation, ISSN 0036-5513, E-ISSN 1502-7686, Vol. 67, no 2, p. 227-235Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Glomerular filtration rate (GFR) is generally accepted as the best overall index of renal function. Thus, all potential live kidney donors are tested to ensure that they have a normal GFR before they are eligible for kidney transplantation. The choice of GFR test is very much dependent on local traditions and may include iohexol, 51Cr-EDTA, inulin, or creatinine clearance based on urine collection, and creatinine clearance calculated from the Cockcroft-Gault or Modification of Diet in Renal Disease (MDRD) equation as well as cystatin C. The aim of this study was to compare the results of GFR measurements performed in all actual live kidney donors who have undergone live donor nephrectomy at the University Hospital in Uppsala, Sweden, between the years 2000 and 2004. MATERIAL AND METHODS: The patients were selected from all parts of Sweden and the measurements were performed at their local hospital. RESULTS: We found large discrepancies between repeated iohexol measurements in these presumably healthy individuals. There was also a poor correlation between iohexol clearance and calculated creatinine clearance using the Cockcroft-Gault (R2=0.046) or MDRD formula (R2=0.045). CONCLUSIONS: The study shows that the standardization and quality of GFR measurements in Sweden have to be improved.

Keywords
Creatinine, Glomerular filtration rate, Human, Iohexol, Kidney, Living donor evaluations
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-10994 (URN)10.1080/00365510600979154 (DOI)000244842400013 ()17366002 (PubMedID)
Available from: 2007-05-09 Created: 2007-05-09 Last updated: 2017-12-11Bibliographically approved
2. Venous thromboembolism in live kidney donors: a prospective study
Open this publication in new window or tab >>Venous thromboembolism in live kidney donors: a prospective study
2008 (English)In: Transplantation, ISSN 0041-1337, E-ISSN 1534-6080, Vol. 86, no 5, p. 659-661Article in journal (Refereed) Published
Abstract [en]

AIM:

The aim of this study was to evaluate risk factors for venous thromboembolism (VTE) and deep vein thrombosis after living donor nephrectomy in a center using extensive preoperative screening and perioperative venous duplex scan.

MATERIAL AND METHODS:

Thrombophilia screening and pre- and postoperative ultrasonographies were performed in 130 consecutive living kidney donors (laparoscopic 105, open 25). Donors were followed prospectively for at least 3 months. All donors received prophylaxis with the low molecular weight heparin enoxaparin and compression stockings. Donors with increased risk received a double dose of enoxaparin and the prophylaxis was continued for 6 weeks. Donors with venous thrombosis at discharge duplex also received prolonged prophylaxis.

RESULTS:

The frequency of thrombophilia was similar to what can be expected in the Swedish population (four with factor V Leiden and one each with protein S deficiency, prothrombin gene mutation, and anticardiolipin antibodies). Preoperative duplex was normal. Three donors had small postoperative deep vein thrombosis. Twelve donors (9.2%) received an intensified and prolonged prophylaxis. No further thromboembolic complications developed in 3 postoperative months.

CONCLUSION:

With the present protocol for preoperative evaluation, perioperative duplex screening, and prophylaxis, the risk of postoperative VTE is low after living donor nephrectomy. Given that 9.2% had risk factors or developed deep vein thrombosis, the extraordinary situation of an operation being performed on a healthy person who has no therapeutic benefit and the low incidence of VTE in the present study, we recommend the presented approach to be implemented more broadly and that further studies are performed in larger cohorts.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-87433 (URN)10.1097/TP.0b013e3181817d36 (DOI)000259361700007 ()18791446 (PubMedID)
Available from: 2008-12-18 Created: 2008-12-18 Last updated: 2017-12-14Bibliographically approved
3. Introducing hand-assisted retroperitoneoscopic live donor nephrectomy: Learning curves and development based on 413 consecutive cases in four centers
Open this publication in new window or tab >>Introducing hand-assisted retroperitoneoscopic live donor nephrectomy: Learning curves and development based on 413 consecutive cases in four centers
Show others...
2011 (English)In: Transplantation, ISSN 0041-1337, E-ISSN 1534-6080, Vol. 91, no 4, p. 462-469Article in journal (Refereed) Published
Abstract [en]

Background: Hand-assisted and retroperitoneoscopic techniques reduce the risk of bleeding and intra-abdominal complications in live donor nephrectomy (LDN). This study reports on our four-centre experience, development and learning curves from the first 413 LDN using a hand-assisted retroperitoneoscopic technique (HARS).

Methods: The first 413 consecutive donors operated on using HARS were included in the study. Donor demographics, peri- and postoperative data, complications, and recipient outcomes have been compiled. The data was analysed as a whole and separately for each centre, looking at centre differences and learning curves over time.

Results: Significant differences were found in donor demographics between centres for the variables: age, BMI, number of arteries, and side of operation. Mean operating time was 170.2 minutes, with significant differences between centres. Operating time was also significantly influenced by learning curves, Sex/BMI, and side of operation. Warm ischemia time differed significantly between centres and was influenced by centre-wise learning and number of arteries. Overall conversion rate was 2.4% and differed significantly between centres. There was no mortality and no intra-abdominal complications. Apart from the conversions and one pulmonary embolism, there were no major intra- or postoperative complications. Overall 3-month graft survival was 99%, with 96% immediate onset of function and 1% ureteral complications.

Conclusions: The HARS technique reduces the risk of intra-abdominal complications. It can be implemented with excellent donor and recipient outcomes despite different population demographics and centre/surgeon-related tradition and experience. Based on our experience, we recommend the technique in order to increase the safety margin of LDN.

Keywords
Hand assistance, Hand-assisted retroperitoneoscopic nephrectomy, Learning curve, Live donor nephrectomy, Living donors, Morbidity, Multicenter, Review, Safety
National Category
Surgery
Research subject
Medicine
Identifiers
urn:nbn:se:uu:diva-134509 (URN)10.1097/TP.0b013e3182052baf (DOI)000287127600017 ()21169880 (PubMedID)
Available from: 2010-11-27 Created: 2010-11-27 Last updated: 2017-12-12Bibliographically approved
4. Efficacy and safety of continuous local infusion of ropivacaine after retroperitoneoscopic live donor nephrectomy
Open this publication in new window or tab >>Efficacy and safety of continuous local infusion of ropivacaine after retroperitoneoscopic live donor nephrectomy
Show others...
2011 (English)In: American Journal of Transplantation, ISSN 1600-6135, E-ISSN 1600-6143, Vol. 11, no 1, p. 93-100Article in journal (Refereed) Published
Abstract [en]

Morphine-based analgesia is effective but can compromise donor safety. We investigated whether continuous infusion of local anesthetics (CILA) can provide sufficient pain control and reduce morbidity related to opiate analgesics after hand-assisted retroperitoneoscopic (HARS) live donor nephrectomy. Forty consecutive live kidney donors underwent HARS and were treated with the ON-Q system providing CILA with 0.5% ropivacaine through two SilvaGard® catheters placed in the retroperitoneal cavity and the rectus sheath, respectively. The case control group consisted of 40 donors matched with regard to sex, age, BMI and surgical technique. All donors were maintained on standardized multimodal analgesia combining nurse-controlled oxycodone treatment and acetaminophen. CILA donors had lower median cumulative consumption of morphine equivalents (CCME) (7 mg [0-56] vs. 42 mg [15-127]; p < 0.0000001), lower incidence of nausea (18 [45%] vs. 35 [87.5%] donors; p < 0.001), shorter time in postoperative care unit (160 vs. 242.5 min; p < 0.001) and shorter hospital stay (4 [4-7] vs. 6 [4-11] days; p < 0.001). In 32.5% of CILA donors the CCME was 0 mg (0% in matched control group, p < 0.001). CILA with 0.5% ropivacaine provides effective postoperative pain relief, reduces the need for opioid treatment and promotes postoperative recovery. Continuous local infusion of ropivacaine provides sufficient analgesia and opioid-sparing effect as well as reduces the incidence of nausea and vomiting after hand-assisted retroperitoneoscopic live donor nephrectomy.

Keywords
Continuous infusion of local anaesthetics, convalescence, donor safety, HARS, pain relief, ropivacaine
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:uu:diva-134510 (URN)10.1111/j.1600-6143.2010.03358.x (DOI)000285783500015 ()21199350 (PubMedID)
Available from: 2010-11-27 Created: 2010-11-27 Last updated: 2017-12-12Bibliographically approved

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