CARE OF LIVING ORGAN DONORS
The first living donor transplantation was performed in 1954,
when a kidney was transplanted from a person to his twin brother.[33]
The lack of effective immunosuppressive treatment at that time prohibited the use
of cadaveric organs. With the introduction of immunosuppressive drugs, improved
long-term graft survival was achieved, and the use of cadaveric donors rapidly accelerated
in most Western countries. However, in Japan, transplantation from cadaveric donors
has not been well accepted, mainly because of cultural and ethical concerns. Indeed,
not until 1997 was legislation passed in Japan that allowed organ donation from selected
brain-dead donors.[34]
Organ transplantation from
living donors has become an important, well-developed alternative for patients with
end-stage organ disease there.[35]
However, the
benefits to both donor and recipient must outweigh the risk associated with the donation
and transplantation of a living donor organ.[36]
In general, living donors are very healthy and almost exclusively
classified as American Society of Anesthesiologists (ASA) grade I or II patients.
In the past, donors were most often relatives of the prospective recipient. More
recently, however, candidates unrelated to the recipient are increasingly being accepted
as donors. By the time that they are determined to be eligible for donation, donors
have undergone an extensive medical, psychological, and social evaluation.[37]
[38]
A significant number of living donor and recipient
pairs are turned down during the screening process for medical and nonmedical reasons
(e.g., social or psychological concerns) that may affect the donor or recipient.
There has been considerable discussion with respect to recipient selection and living
donor participation. One of the major concerns surrounding living organ donation
is the potential for great harm to be inflicted on entirely healthy individuals who
undergo major surgery for purely altruistic reasons. The ethical and psychiatric
aspects (e.g., coercion of the donor) of living organ donation, particularly liver
donation, continue to be widely examined and discussed.[36]
[39]
[40]
[41]
[42]
[43]
In addition,
the quality of life after organ donation and the financial impact on the donor are
of great concern.[44]
[45]
Organ donation from living donors has significant advantages over
cadaveric organ donation. Unlike cadaveric donors, living donors are always hemodynamically
stable, and the procedure can be planned on an elective basis. In addition, the
cold ischemia time of the organ can be significantly reduced from that associated
with cadaveric donors. Perhaps the most important advantage of living donor transplantation
is the significant reduction in time spent on the waiting list to receive a cadaveric
organ.
Living Kidney Donor
Renal transplantation with organs from living donors has rapidly
been increasing over recent years. In the past, donor nephrectomy was performed
by the traditional approach through a subcostal lateral incision, by minimal-incision
nephrectomy, or by the laparoscopic approach. However, laparoscopic live donor nephrectomy
is increasingly replacing the traditional open approach through a subcostal lateral
flank incision. The laparoscopic approach has been shown to be advantageous with
regard to decreased postoperative pain, time of hospitalization, recovery, and improved
cosmetic results.[46]
[47]
This approach will continue to be used with increased frequency because of the need
to maximize patient satisfaction among those who choose to donate their kidneys.
Morbidity after living kidney donation is low, and the type of
complication (e.g., reoperation, ileus, readmission to the hospital) is dependent
on the surgical technique. Matas and coauthors reported 2 donor deaths and 1 donor
who has remained in a persistent vegetative state during a series of 10,828 living
kidney donations between 1999 and 2001.[48]
In
addition, Ellison and colleagues caution that the long-term risks may not yet be
apparent and that long-term follow-up data are needed.[49]
Either kidney can be used for donation; however, the left kidney is usually preferred
because of better surgical exposure and a longer vascular supply. The patient is
placed in either a right or left lateral position with the table flexed and the kidney
rest elevated. Invasive monitoring is not required, and one or two large peripheral
intravenous lines suffice. Some centers will have 2 U of blood (frequently autologous)
available in the operating room in case of injury to major vascular structures, which
would require emergency exploratory laparotomy. To maintain good diuresis, fluid
administration is generous (10 to 20 mL/kg/hr), even with minimal blood loss in most
cases. The preferred type of fluid in this setting is not known because no human
trial has yet addressed this issue. In the absence of scientific data, most centers
use isotonic crystalloids. The anesthetic technique in these healthy patients is
similar or identical to that used for laparoscopic procedures. Similarly, the potential
complications seen during any laparoscopic procedure (e.g., pneumothorax, subcutaneous
emphysema) can be encountered during this procedure. The first phase of the procedure
consists of mobilization of the colon followed by the upper portion of the kidney,
with subsequent identification and dissection of the ureter, renal vein, and artery.
Division of the adrenal vein is also performed.[50]
The surgeon may request administration of furosemide or mannitol (or both) during
the operation to maintain adequate urine output. Shortly before the renal vessels
are clamped, intravenous heparin (3000 to 5000 IU) is administered. Protocols may
vary among institutions, and close communication with the transplant surgeon is essential.
After complete mobilization of the kidney and clamping of the vascular structures,
the kidney is retrieved by either a hand-assisted or non-hand-assisted[51]
technique through a small periumbilical or infraumbilical incision under direct laparoscopic
vision. In the case of previous heparin administration, protamine may then be administered
to normalize coagulation. After the kidney is removed, the surgical field is inspected
once again for bleeding. Closure, as in all laparoscopic cases, is rapid, and care
should be taken to maintain reversibility of neuromuscular blocking agents at the
conclusion of the procedure. Postoperative pain is usually mild to moderate and
can easily be managed in most cases with supplemental intravenous opioids in the
immediate postoperative period. Placement of an epidural catheter is not indicated.
 |
