BMJ  2006;333:209-210 (29 July), doi:10.1136/bmj.333.7561.209

Editorial

Quality of life after donor nephrectomy

Is better after laparoscopy than the mini incision technique

Ever since the first successful renal transplant involving live identical twins in 1954, increasing emphasis has been placed on minimising morbidity and mortality in the living donor.

For many conditions, traditional open surgery has been replaced by a variety of minimal access techniques, mainly laparoscopy. These have important benefits for patients in terms of less intraoperative loss of blood, lower postoperative morbidity, and quicker recovery and return to normality.^1-4

For living donors of renal transplants it is important to determine which minimal access technique is best in terms of quality of life. In this issue of the BMJ Kok and colleagues report a randomised controlled trial that compares the effect of laparoscopic and mini incision open donor nephrectomy on quality of life in living donors after renal transplant surgery.⁵ The authors found that patients who had laparoscopy had better scores for physical fatigue (MFI-20) and physical function (SF-36) at one year than those who had the mini incision technique. They conclude that in centres with a highly experienced laparoscopic surgeon the laparoscopic technique is superior.⁵

The results of the trial are timely because the incidence of chronic renal failure has increased considerably over the past decade, and the number of organs from cadavers is not sufficient to meet the current demand.⁶ Living donors provide one way of bridging the gap, and their kidneys provide many advantages to the recipient over transplants from cadavers.⁷ The half life of donor kidneys from living relatives is better than that of kidneys from cadavers in most cases. Kidneys from donors with identical HLA groups to recipients have an estimated half life of 26.5 years, those from off-spring 18.7 years, from distant relatives 18.4 years, and from unrelated spouse donors 15.8 years. The estimated half life is 17.3 years for transplants from cadavers with identical HLA groups and 10.9 years for those from cadavers not matched for their HLA groups.⁸

The United Kingdom guidelines for living donor kidney transplantation, prepared by a working party of the British Transplantation Society and the Renal Association, help to standardise clinical management of living donors within the UK (box).⁹

In 2002, the United States Department of Health and Human Services advisory committee on organ transplantation met for similar reasons and arrived at an initial 18 recommendations (now 46), which included a set of ethical principles of consent to being a live organ donor (box). These centred around competency with regard to decision making, willingness, freedom from coercion, medical and psychological suitability, and being fully informed about the risks and benefits for the donor and the recipient, including alternative treatments available to the recipient.

Guidelines and recommendations Main areas covered by UK guidelines Need for and purpose of guidelines and current state of kidney transplantation by living donors Ethical and legal issues, risks to donor, and informing potential donors Evaluation of donor: age and presence of obesity, diabetes, hypertension, proteinuria, pyuria, asymptomatic microscopic haematuria, nephrolithiasis, inherited renal disease, malignancy, and infection HLA matching and donor and recipient crossmatching Perioperative care of the donor and the transplant operation Follow-up of donors and recipients after transplantation High risk recipients and recurrent renal disease Main US recommendations Implement comprehensive list of ethical principles and standards of informed consent Donor advocate to ensure implementation of standards of consent and ethical principles Central funding for database of health outcomes for all live donors Resource centre for potential living donors Donors should be given preference if they require a transplant in the future Increase education and awareness of patients at dialysis centres with regard to options available Research into causes of different rates of success and outcomes in organ transplantation Include organ and tissue donation in the core curriculum of schools and universities Improve the management of donors; identify an advocate from the clinical staff Inform procurement organisations before withdrawal of life support Base the framework for certification on continuous quality improvement Classify failure to identify potential donors in a timely manner as a serious medical error

The committee advised on standards of disclosure that would be included in the donor's informed consent. These comprise 22 fields that cover all aspects of the donor experience, from the reason for donation to the principles of confidentiality. The advisory committee also published two sample documents that covered initial consent for evaluation and consent to surgery.

The shortage of available organs has raised concerns that potential donors could be pressured, perhaps unwittingly, by relatives and overenthusiastic clinicians. Transplant teams must make every effort to ensure that donors are not coerced in any way when making their decision. Even after that decision has been made, potential donors must be screened and told that they may be ineligible for a variety of reasons and that they can change their mind about donating at any time. The process involves psychological assessment and medical consultation, physical examination, laboratory investigations, and an array of imaging tests including some form of renal angiography. Donors must also be warned that these investigations might show up previously undetected pathology.

Before surgery, teams should inform donors about the surgical technique to be used and the expected postoperative course, including any alternative procedures that may become necessary, and the potential morbidity (both physical and psychological) and mortality. Depression, psychological illness, and family conflict are more likely in older donors and those who lack social support, and after rejection of the donated organ.¹⁰ It is important to explain to donors the evidence on outcomes for both donors and recipients. Most living donors are relatives with altruistic reasons for donating who have a strong desire for recipients to do well.

Department of Urology, Ninewells Hospital, University of Dundee, Ninewells Hospital, Dundee DD1 9SY
(nick.townell{at}tuht.scot.nhs.uk)

---

Competing interests: None declared.

Research p 221

References

1. Stage JG, Schulze S, Moller P, Overgaard H, Anderson M, Rebsdorf-Pedersen VB, et al. Prospective randomized study of laparoscopic versus open colonic resection for adenocarcinoma. Br J Surg 1997;84: 391-6.[CrossRef][ISI][Medline]
2. Nguyen NT, Zainabadi K, Mavandadi S, Paya M, Stevens M, Root J, et al. Trends in the utilization and outcomes of laparoscopic versus open appendectomy. Am J Surg 2004;188: 813-20.[CrossRef][ISI][Medline]
3. Aziz O, Constantinides V, Tekkis PP, Athanasiou T, Purkayastha S, Darzi AW, et al. Laparoscopic versus open surgery for rectal cancer; a meta-analysis. Ann Surg Oncol 2006;13: 413-24.[Abstract/Free Full Text]
4. Lewis GRR, Brook NRR, Waller JR, Bains JC, Veitch PS, Nicholson ML. A comparison of traditional open, minimal-incision donor nephrectomy and laparoscopic donor nephrectomy. Transpl Int 2004;17: 589-95.[CrossRef][ISI][Medline]
5. Kok NFM, Lind MY, Hansson BME, Pilzecker D, Mertens zur Borg IRAM, Knipscheer BC, et al. Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial. BMJ 2006;333: 221-4.[Abstract/Free Full Text]
6. United States Renal Data System. USRDS2004. Annual report data report. Bethesda MD: National Institutes of Health, 2004. http://www.qualitytools.ahrq.gov/qualityreport/2005/browse/browse.aspx?id=9318 (last accessed 19 Jul 2006).
7. Roodnat JI, van Riemsdijk IC, Mulder PGH, Doxiadis I, Claas FH, Ijzermans JNM, et al. The superior results of living-donor renal transplantation are not completely caused by selection or short cold ischaemia time: a single-centre, multivariate analysis. Transplantation 2003;75; 2014-8.[CrossRef][ISI][Medline]
8. Cecka JM. The UNOS clinical transplant registry. Clin Transpl 2002: 1-20.
9. British Transplantation Society and the Renal Association. United Kingdom guidelines for living donor kidney transplantation (2000, 2nd ed 2005). http://www.cambridge-transplant.org.uk/program/renal/guidelines.htm (last accessed 18 July 2006).
10. Russell S, Jacob RB. Living-related organ donation: the donor's dilemma. Patient Educ Counsel 1993;21; 89-99.[CrossRef][ISI][Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Article

Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial

Niels F M Kok, May Y Lind, Birgitta M E Hansson, Desiree Pilzecker, Ingrid R A M Mertens zur Borg, Ben C Knipscheer, Eric J Hazebroek, Ine M Dooper, Willem Weimar, Wim C J Hop, Eddy M M Adang, Gert Jan van der Wilt, Hendrik J Bonjer, Jordanus A van der Vliet, and Jan N M IJzermans
BMJ 2006 333: 221. [Abstract] [Full Text] [PDF]