Program aims to attract living kidney donors

Less invasive laparoscopic procedure reduces risk

Attracting living kidney donors for Type 1 diabetics is a major obstacle for any transplant program. Surgeons at Cedars-Sinai Medical Center in Los Angeles are offering a procedure that may increase the number of living donors willing to give up a kidney to help save a life.

Transplant programs in several regions are jumping on the bandwagon to use laparoscopic living donor nephrectomy because it reduces recovery time and complications for the donor and increases the number of donors who may be willing to give a kidney.

The surgery allows the donor kidney to be removed during a video-assisted, minimally invasive procedure through two or three small incisions. "This procedure offers much shorter hospitalization time, much reduced need for pain medication, a significant reduction in the need for blood products in the postoperative period, a much faster return to work, and most importantly, a greater willingness on the part of individuals to consider living donation," says Christopher Shackleton, MD, associate director of Cedars-Sinai’s multi-organ transplant program.

The shorter recovery time is key for many prospective donors, says Shackleton, because they can return to work sooner than they might with a standard nephrectomy.

Another incentive which is "not trivial," he says, is that the resulting scar is as small as 2 or 3 inches, as opposed to a standard nephrectomy scar that is 12 inches long or larger.

"This procedure is fast becoming routine in transplant centers," says Christopher Marsh, MD, assistant director of the transplant program and associate professor of surgery at the University of Washington in Seattle. After about a year’s experience with the procedure, he says, "There is nothing to indicate the procedure is problematic for either the donor or the recipient, but we’ll need to look at it for several years to be sure."

For Marsh, there are several factors that make the laparoscopic procedure attractive. Among them: The hospitalizations time for the donor is reduced by as much as two days, meaning the donor can be out of the hospital two days after the procedure and back to work in as little as two weeks. Part of the reason for the shorter recovery time, Marsh says, is the incision is made through the fascia, so the patient is spared the pain of an incision through the muscle.

The downside of the laparoscopic surgery, which is still under development, is a possible longer operating time and a possible higher risk to the donor kidney. "There may be a higher rate of failure; we aren’t sure yet," says Shackleton.

Marsh says some medical centers are waiting to assess the success other facilities have with the procedure before they begin performing the laparoscopic kidney removals.

Living donors are the "gold standard for superior outcomes," he explains. Living donors are the donors of preference for kidney transplants needed by many diabetics because they are often relatives, so tissue matches are closer, reducing the risk of rejection. Five years after surgery, 85% of kidneys obtained from living donors are still working because of the closer tissue match, as opposed to only 50% of kidneys from cadaver donors.

However, Marsh says, recent research shows there’s a higher success rate from any living donor, indicating a cadaver-donated kidney may be damaged by the process of brain death or by the elapsed time from death to transplant.

The ethical considerations of living donor kidney transplants are considerable, says Shackleton. "Our concern for the safety of the donor is para-mount." A living donor nephrectomy is probably the only major surgical procedure undergone by a patient who doesn’t need it. "We are meticulous in finding out if there has been any coercion, overt or covert," He says. "There absolutely can’t be any arm twisting."

Yet, for the donor, the procedure is one of the safest major surgeries. "We’ve been doing these since the 50s, so there’s a huge experience of people who have donated and lived long, healthy lives. The cumulative experience of complications is zilch," Shackleton says. And the possibility of failure of the donor’s remaining kidney is very small, he adds, because of the intensive work-ups done before a donor is qualified. "There’s really very little reason to be concerned about the donor’s remaining kidney unless it is injured in an accident or something like that," he says.

Mark Deierhoi, MD, professor of surgery and director of the transplantation program at the University of Alabama in Birmingham, has some reservations about the procedure, especially in the hands of an inexperienced surgeon. While the practice is becoming widespread, more as a "marketing tool" than as a procedure that has significant benefits for the donor, Deierhoi says, the University of Alabama does not offer the procedure.

"It’s a highly technical procedure, and it takes about 100 of them before you really get good at it," he says.

His recommendation to physicians considering referrals for laparoscopic living donor nephrectomy: Ask how many times the surgeon has performed the procedure, and ask for the success rate. "If the surgeon has performed fewer than 100 or if the success rate is lower than you think is acceptable, look for someone else.

[Contact Christopher Shackleton at (310) 855-2641.]