Nefrectomia laparoscópica do doador renal: segurança do doador e sobrevida do enxerto

Abstract

Introduction: Laparoscopic donor nephrectomy has been accomplished since 1995. It provides the minimally invasive technique pros by reducing donor morbidity and has been proved similar to open donor nephrectomy concerning graft function. Despite numerous transplant center publications, there are few papers with long-term follow-up and multiple variable analysis. Objective: To determine if laparoscopic right-sided donor nephrectomy results in worse graft function on short and long term. To evaluate risk factors to graft failure and characteristics related to donor safety in a cohort of donor nephrectomies at the Cleveland Clinic Foundation. Method: All the 434 laparoscopic donor nephrectomies from October 1997 to September 2006 at the Cleveland Clinic Foundation were studied. Data from pre, per and postoperative periods were prospectively registered in a database. The first 145 donors received 5000 IU of IV heparin five minutes prior to artery clamping. From 146th donor on, heparin was not administered. There were 47 right-sided nephrectomies and 387 left-sided nephrectomies. Graft failure was the primary outcome, being defined as permanent return to dialysis. Graft and recipient survival, rejection and creatinin levels up to the sixth post transplantation year were the secondary outcomes. Donor safety was evaluated by estimated blood loss, postoperative complications, hemoglobin level drop, creatinin level increase, length of hospital stay, blood transfusion and anomalous bleeding during the nephrectomy. Qui-square test, Students t test, Mann-Whitney U test, Kruskal Wallis test, logistic regression, Kaplan-Meier survival curve (Log-rank) and Cox regression were used for statistical analysis. Result: The donors that received heparin had a greater hemoglobin drop than the ones that did not receive (p=0,015), but did not experience greater estimated blood loss (p=0,91), bleeding (p=0,21) or transfusion rate (p=0,65). The recipients of grafts from donors that received heparin did not have a greater chance of graft failure (p=0,112) or death (p=0,068). The recipients of right-sided kidneys needed more frequently dialysis on first week post transplantation (p=0,03, logistic regression) and had a greater chance of creatinin ! 3,0mgdl on 7o post transplantation day (p=0,008; qui-square and 0,053, logistic regression). On the long term, recipients of right-sided kidneys did not have a greater chance of needing dialysis (p=0,242), rejection (p=0,641) or death (p=0,289). On multivariate analysis, graft failure was associated only to multiple graft arteries (p=0,023, OR 2.43 95% CI 1,13 - 5.24) and recipient age (p=0,005, OR 1,034 95% CI 1,01 - 1,06). The odd of recipient death was only associated with female donor gender (p=0,003, OR 3,969 95%IC 1,335 - 11,801). Both donor and recipient gender influenced creatinin levels up to the 6th post transplantation year, being the worst outcome related to the group of female donor and male recipient. Multiple or anomalous renal vein did not result in worse outcome neither to donors nor to recipients. Conclusion: Heparin use, despite apparently safe to the donors, was not related to better transplant outcome. Right-sided donor nephrectomy resulted in worse early graft function, but on the long term did not differ from left-sided donor nephrectomy. Some risk factors for graft failure after laparoscopic donor nephrectomy are female donor, male recipient, graft with multiple arteries and older recipients. These data could be of use for donor counseling and selection.