**2.3. Surgical alternatives in life donor nephrectomy**

Regarding the surgical habits and the existing experience, there are several ways of harvesting kidneys from living donors [10-12].

**2.6. Postoperative care**

**2.7. Long term complications**

disease (ESRD) is:

type II diabetes.

fact maintained by hyper filtration.

Postoperative care of a living donor is fairly standard. Adequate postoperative analgesia is a key factor including postoperative complications such atelectasia and pneumonia [15]. Infections should not occur with appropriate antibiotic prophylaxis. The continuous use of leg stoching and sequential compression devices are essential to prevent deep venous thrombosis of the lower limb. Most patients are often ambulatory by postoperative day 1 or 2 and tolerating oral feedings by postoperative day 2 or 3. The donor can be discharged by postoperative day 2 to 6. The renal function of the donor should be assessed periodically after the operation, as some patients experience a 25% increase in serum creatinine level; this should return near baseline by 3 months after the operation. In fact there are no convincing data to suggest that living donors are at any increased long term risk as a result as having donating the kidney.

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The immediate operative risk to the donor can be stated with some certainty but the long terms effects are not completely understood. Follow-up, in general, is reassuringly but incomplete. Most folow-up studies of living kidney donors find no decrease in long term survival. All existing follow-up found an at least 85% survival up to 31 year after donation, compared to a predicted 66% in general population of similar age. The survival advantage at the living donors was attributed to the selection bias of only healthy individual as renal donors and at better follow up for them. Concerns regarding the possibility that donors will develop end stage renal

**•** hyper filtration in the remaining kidney will lead to focal segmental glomerulosclerosis and

**•** the second concern is that donor will develop primary renal disease. The donors who develop primary renal disease will progress to renal failure more quickly because they have a lower than normal renal mass at onset of a primary renal disease. The later concern applies to a family with a history that put them for a risk of renal disease, for example: patient with

Many follow-up studies have noted an increase in hypertension and proteinuria as well as a statistically but not clinically significant increase in serum creatinine. There are studies which found an increase in 20% of patients with blood pressure (15%-48%) [16] but it is not clear if

Another study is finding that 35% of patients are taking anti-hypertensive medications and 23% are having proteinuria compared with 44% and 22% respectively for controls [17]. On the other side, even if the donor has a normal renal function, the glomerular filtration rate is in

One thing is for sure, that in all follow-up studies, majority of the donors which are altruistic donors, drive a tremendous degree of satisfaction and an increased of self esteem for their donation. As a consequence, donors interviewed considered their donation as an act of heroism and generosity with which nothing else in their life can be compared [18]. More than 90% said

renal failure, that is donation per se will cause renal failure,

hypertension is more common to this group than in general population.


### **2.4. Laparoscopic approach for living donor nephrectomy**

The introduction of laparoscopic living kidney donation has been a major advance in organ donation. First introduced with some reticence only in selected centers, this procedures are now the preferred surgical approach in almost all transplant programs in United States and Europe. Usually, the program that offers this kind of procedure have a high rates of living kidney donation. The major benefit of laparoscopic technique includes significant reduction of surgical pain, postoperative convalescence, and recovery time. As a result, the laparoscopic donor nephrectomy has been responsible for expanding the pool of living donors and may account for the increased popularity and frequency of living donation. Long term renal function is not different between open nephrectomy and laparoscopic nephrectomy. About 75% of living donor transplant nephrectomies world wide employ laparoscopic technique, either transperitoneal or retroperitoneal.

#### **2.5. Open living donor nephrectomy**

The traditional method for removing kidney from a living donor has been open surgical technique, in majority of cases using a flank incision. In selected cases in which the donor has motivation which precluded laparoscopic access (e.g. significant prior abdominal surgery), or in some cases of complex vascular anatomy, an open surgical approach is preferred. Some centers advocate the use of open surgery for pediatric patients, although the age of recipient is not universally considered an indication for open renal procurement. Most donor surgeon use a donor flank incision, extra pleural and extra peritoneal above or below the XIIth rib.

As it is in any surgical approach, the kidney must be very carefully dissected to preserve renal veins and periureteral blood supply. Excessive pressure on the renal artery is avoided to prevent a vasospasm. After the renal vessels are securely ligated and divided the kidney is removed and placed in a basin of frozen saline slush to decrease the renal metabolism and after that the vessels are un-ligated and flushed with heparinized solution for both procedures, either laparoscopic harvesting or classic surgery.

### **2.6. Postoperative care**

**2.3. Surgical alternatives in life donor nephrectomy**

140 Current Issues and Future Direction in Kidney Transplantation

**•** Subcostal extraperitoneal approach (left or wright).

**2.4. Laparoscopic approach for living donor nephrectomy**

kidneys from living donors [10-12].

either transperitoneal or retroperitoneal.

either laparoscopic harvesting or classic surgery.

**2.5. Open living donor nephrectomy**

incision.

Regarding the surgical habits and the existing experience, there are several ways of harvesting

**•** Classic transperitoneal approach, either throw midline, or throw a left or right subcostal

**•** Dorsal lumbotomy approach. The incision can be performed either underneath the XIIth

The introduction of laparoscopic living kidney donation has been a major advance in organ donation. First introduced with some reticence only in selected centers, this procedures are now the preferred surgical approach in almost all transplant programs in United States and Europe. Usually, the program that offers this kind of procedure have a high rates of living kidney donation. The major benefit of laparoscopic technique includes significant reduction of surgical pain, postoperative convalescence, and recovery time. As a result, the laparoscopic donor nephrectomy has been responsible for expanding the pool of living donors and may account for the increased popularity and frequency of living donation. Long term renal function is not different between open nephrectomy and laparoscopic nephrectomy. About 75% of living donor transplant nephrectomies world wide employ laparoscopic technique,

The traditional method for removing kidney from a living donor has been open surgical technique, in majority of cases using a flank incision. In selected cases in which the donor has motivation which precluded laparoscopic access (e.g. significant prior abdominal surgery), or in some cases of complex vascular anatomy, an open surgical approach is preferred. Some centers advocate the use of open surgery for pediatric patients, although the age of recipient is not universally considered an indication for open renal procurement. Most donor surgeon use a donor flank incision, extra pleural and extra peritoneal above or below the XIIth rib.

As it is in any surgical approach, the kidney must be very carefully dissected to preserve renal veins and periureteral blood supply. Excessive pressure on the renal artery is avoided to prevent a vasospasm. After the renal vessels are securely ligated and divided the kidney is removed and placed in a basin of frozen saline slush to decrease the renal metabolism and after that the vessels are un-ligated and flushed with heparinized solution for both procedures,

rib, resecting the XIIth rib, or above the XIIth rib (extraperitoneal, extrapleural).

**•** Laparoscopic approach either transperitoneal or retroperitoneoscopic.

Postoperative care of a living donor is fairly standard. Adequate postoperative analgesia is a key factor including postoperative complications such atelectasia and pneumonia [15]. Infections should not occur with appropriate antibiotic prophylaxis. The continuous use of leg stoching and sequential compression devices are essential to prevent deep venous thrombosis of the lower limb. Most patients are often ambulatory by postoperative day 1 or 2 and tolerating oral feedings by postoperative day 2 or 3. The donor can be discharged by postoperative day 2 to 6. The renal function of the donor should be assessed periodically after the operation, as some patients experience a 25% increase in serum creatinine level; this should return near baseline by 3 months after the operation. In fact there are no convincing data to suggest that living donors are at any increased long term risk as a result as having donating the kidney.

### **2.7. Long term complications**

The immediate operative risk to the donor can be stated with some certainty but the long terms effects are not completely understood. Follow-up, in general, is reassuringly but incomplete. Most folow-up studies of living kidney donors find no decrease in long term survival. All existing follow-up found an at least 85% survival up to 31 year after donation, compared to a predicted 66% in general population of similar age. The survival advantage at the living donors was attributed to the selection bias of only healthy individual as renal donors and at better follow up for them. Concerns regarding the possibility that donors will develop end stage renal disease (ESRD) is:


Many follow-up studies have noted an increase in hypertension and proteinuria as well as a statistically but not clinically significant increase in serum creatinine. There are studies which found an increase in 20% of patients with blood pressure (15%-48%) [16] but it is not clear if hypertension is more common to this group than in general population.

Another study is finding that 35% of patients are taking anti-hypertensive medications and 23% are having proteinuria compared with 44% and 22% respectively for controls [17]. On the other side, even if the donor has a normal renal function, the glomerular filtration rate is in fact maintained by hyper filtration.

One thing is for sure, that in all follow-up studies, majority of the donors which are altruistic donors, drive a tremendous degree of satisfaction and an increased of self esteem for their donation. As a consequence, donors interviewed considered their donation as an act of heroism and generosity with which nothing else in their life can be compared [18]. More than 90% said that they would donate if they have it to do over again, and fewer than 10% expressed any regret about donating [19].

This is a dramatic situation which is generated by continuous shortage of organs for trans‐ plantation and by the increasingly donation rate from unrelated living donors. Such a situation require significant changes in the transplantation laws which should permit the increase of

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**•** medical methods are represented by: laparoscopic harvesting, paired kidney exchange, transplantation of grafts with anatomic abnormalities (vascular, urinary tract or fusion), acceptance of patients with low compatibility after a treatment with plasmapheresis and iv

The motives of living donors and the motives of families of deceased donors, are complex and not necessarily always pure altruistic [25]. Spouses and siblings, who act as a living donor, experience a personal reward seeing that the recipient well being is restored. Because the organ donation is a voluntary and valuable act it should be considered as a charitable gift. Society could explicitly thank the organ donors for their gift, as it is done with other charitable contributions, without jeopardizing its altruistic basis. New legislations should embrace

The issue of public incentives to enhance donation is more than just complex but mainly sensitive. From a philosophical point of view, the body is a part of our personality, thus in respect with human dignity it would be wrong to use parts of our body as means only [26]. On the other hand, one may assert that everyone is the rightful owner of his person supporting

Most frequently, the background attitude of general population is to reject incentives for donation but there might be circumstances under which attitudes may change [28]. For instance, when the process became transparent: the amount of compensations are specified or there might be some ethical reasons to do so. The main risk is exploitation of those severe

The valuable exchange of organs is prohibited worldwide, yet there exists national law or regulations which allows incentives for deceased or living donation [30]. Such incentives including financial reimbursement, health care-related reimbursement or other recognition for

Donor medal of honor. Organ procurement organizations must have ceremonies which recognize and appreciate organ donation. A donor medal of honor enacted by a top official of the country expresses the appreciation and gratitude on behalf of the whole community to the

living donors and in the same time to stop the organ trade. Very difficult task.

*2.8.1. Organizing and ethic alternatives to increase the rate of living donation*

ethically acceptable ways to encourage such charitable donation of organs.

the idea that the self can decide over its body like any kind of property [27].

living donors or deceased donors' families have been widely debated [31].

living donors and even to the families of the deceased donor [32, 33].

The rate of living donation can be increased by two methods:

**•** organizing and ethic alternatives,

*2.8.1.1. Incentives for organ donation*

impoverished on a black market [29].

Ig.

#### **2.8. Policies to enhance living donation**

The therapeutic promise of transplanting organs from cadaveric donors has never been kept because the demand for transplantation has by far exceeded the possibilities. The waiting list for transplants continues to grow and in 2005 nearly 5000 patients were removed from the waiting list because of the death. Consequently many patients with end stage organ failure are no longer relaying on waiting list. Than the attention was turning toward living donors others than they have been classically admitted i.e. toward spouses, friends, or even strangers, as possible donors. From medical point of view, these are acceptable alternatives, due to the fact that immunosuppression has eliminated the requirement for a perfect genetic match in order to have a successful transplantation [20]. In many centers world wide, specially US transplantation centers and scandinavian transplant centers, the number of kidneys transplanted from living donors has exceeded the number of kidneys obtained from cadaver donors (over 35%) [21].

Although donors from living donors can be transplanted safely, concerns about the protection of well being of donors has prompted the transplantation community to develop a consensus statement emphasizing that a living donor should be competent, willing to donate an organ, and free of any kind of coercion [22]. More than that, the new reliance on organs from living donor has increased the risk of donation for financial reasons, especially in the case of unrelated donor. It is world-wide admitted that organ donation has to rely on the voluntarism and altruism, and uncompensated family members of the donor.


**Table 3.** Reported kidney transplants performed in USA [OPTN data]

The purchase of organs is explicitly unlawful in Europe, US, as virtually all other countries but the shortage of cadaveric organs has led to a world-wide black market for organs from living donors. That's why patients with sufficient means can travel to distant locations in order to purchase kidneys for transplantation [23, 24].

This is a dramatic situation which is generated by continuous shortage of organs for trans‐ plantation and by the increasingly donation rate from unrelated living donors. Such a situation require significant changes in the transplantation laws which should permit the increase of living donors and in the same time to stop the organ trade. Very difficult task.

The rate of living donation can be increased by two methods:

**•** organizing and ethic alternatives,

that they would donate if they have it to do over again, and fewer than 10% expressed any

The therapeutic promise of transplanting organs from cadaveric donors has never been kept because the demand for transplantation has by far exceeded the possibilities. The waiting list for transplants continues to grow and in 2005 nearly 5000 patients were removed from the waiting list because of the death. Consequently many patients with end stage organ failure are no longer relaying on waiting list. Than the attention was turning toward living donors others than they have been classically admitted i.e. toward spouses, friends, or even strangers, as possible donors. From medical point of view, these are acceptable alternatives, due to the fact that immunosuppression has eliminated the requirement for a perfect genetic match in order to have a successful transplantation [20]. In many centers world wide, specially US transplantation centers and scandinavian transplant centers, the number of kidneys transplanted from living donors has exceeded

Although donors from living donors can be transplanted safely, concerns about the protection of well being of donors has prompted the transplantation community to develop a consensus statement emphasizing that a living donor should be competent, willing to donate an organ, and free of any kind of coercion [22]. More than that, the new reliance on organs from living donor has increased the risk of donation for financial reasons, especially in the case of unrelated donor. It is world-wide admitted that organ donation has to rely on the voluntarism and

**Donor type 1990 2000 2010 relative ratio** Cadaveric 4306 5489 7241 + 1,68

Unrelated living donors 204 804 2516 + 12,33 Total transplants 6400 10990 13518 + 2,11

The purchase of organs is explicitly unlawful in Europe, US, as virtually all other countries but the shortage of cadaveric organs has led to a world-wide black market for organs from living donors. That's why patients with sufficient means can travel to distant locations in order to

1831 4030 3046 + 1,66

59 667 715 + 12,11

the number of kidneys obtained from cadaver donors (over 35%) [21].

altruism, and uncompensated family members of the donor.

**Table 3.** Reported kidney transplants performed in USA [OPTN data]

purchase kidneys for transplantation [23, 24].

regret about donating [19].

Biologically related living donors

Emotionally related living donors

**2.8. Policies to enhance living donation**

142 Current Issues and Future Direction in Kidney Transplantation

**•** medical methods are represented by: laparoscopic harvesting, paired kidney exchange, transplantation of grafts with anatomic abnormalities (vascular, urinary tract or fusion), acceptance of patients with low compatibility after a treatment with plasmapheresis and iv Ig.
