Early and Late Recipient Graft Function and Donor Outcome After Laparoscopic vs Open Adult Live Donor Nephrectomy for Pediatric Renal Transplantation

Abstract

Background: Laparoscopically procured live donor kidney grafts are increasingly transplanted into pediatric recipients. The safety and efficacy of this changed surgical practice are unknown. Hypothesis: Outcomes of laparoscopic vs open donor grafts in recipients 18 years and younger are equivalent. Design and Setting: Retrospective review at an academic tertiary care referral center. Patients: Eleven consecutive pediatric recipients of laparoscopically procured kidneys between April 1, 1997, and December 31, 2001, were pair matched for age with 11 recipients of openly procured kidneys between December 1, 1991, and March 31, 1997; the 22 adult donors were also studied. Main Outcome Measures: Recipients: surgical complications, graft function and survival. Donors: perioperative morbidity and length of hospital stay. Results: Twenty (91%) of 22 kidneys were donated by a parent of the recipient. In recipients of laparoscopically procured grafts, we observed significantly lower creatinine clearances and higher creatinine levels on days 1, 4, and 6, but by 1 month, graft function was similar in both groups. No significant differences in surgical complications, delayed function, acute and chronic rejection, and graft survival rates were found. No laparoscopic or open donor required blood transfusion, reoperation, or hospital readmission. One laparoscopic donor (9%) was converted to open nephrectomy. For laparoscopic vs open donors, median operative time was longer (difference, 67 min; P=.08), but median postoperative length of stay was significantly shorter (3 vs 5 days; P=.02). Conclusions: Laparoscopic live donor nephrectomy has no adverse impact on pediatric recipient outcomes. For donors, the laparoscopic operation is safe and the hospital stay is shortened. These results support the continued use of laparoscopically procured live donor kidneys in pediatric renal transplantation.

Laparoscopic (vs. Open) Live Donor Nephrectomy: A UNOS Database Analysis of Early Graft Function and Survival

“…These findings are consistent with the previously discussed single center studies that had reported higher early post-transplant serum creatinine levels in laparoscopic kidney graft recipients (10,13,14). Our findings are in line with, and explained by, experimental observations that pneumoperitoneum decreases cortical renal blood flow, renal vein flow and creatinine clearance, and causes oliguria (15)(16)(17).…”

“…Ratner noted similar significant differences on postoperative days 2 and 3 (13). In one of our previous studies, we found significantly higher creatinine levels in pediatric laparoscopic kidney recipients on day 1 and day 4 (14). Moreover, several additional studies have documented a trend towards higher early post-transplant creatinine levels for laparoscopic graft recipients, albeit not at a statistically significant level (11,19,20).…”

“…But to date, no study has shown a significant difference in rejection rate and long-term survival when comparing laparoscopic to open kidney grafts (2,7,(10)(11)(12)(13)(14)(19)(20)(21)(22). In our analysis, the procurement mode did not affect acute rejection incidence and long-term graft survival either.…”

“…These findings are a priori not surprising, because warm ischemia times in laparoscopic donors are longer (11), and the pneumoperitoneum created during the laparoscopic operation negatively affects renal hemodynamics (15)(16)(17)(18). Slower early function in laparoscopic grafts, however, was not observed on all post-transplant days, did not persist beyond the first month, and did not achieve statistical significance at all time points in all studies (10,11,13,14,19,20). Also, other reports have suggested equivalent early graft function after laparoscopic and open kidney procurement (21,22).…”

“…But subsequent studies have demonstrated that with increasing surgical experience, low technical complication rates can also be achieved with laparoscopic kidneys, regardless whether left or right kidneys (8), or kidneys with anatomical variations, such as multiple renal arteries, are used (9). Second, several investigators have shown slower early post-transplant function for laparoscopic (vs. open) grafts, as measured by delayed function rates (10)(11)(12) and by the recipients' early post-transplant serum creatinine levels (10,13,14). These findings are a priori not surprising, because warm ischemia times in laparoscopic donors are longer (11), and the pneumoperitoneum created during the laparoscopic operation negatively affects renal hemodynamics (15)(16)(17)(18).…”