Letter to the Editor: Response to outcomes of “right vs left kidney”

Abstract

We read the comments by Favi and Morabito, published in the recent issue of the World Journal of Transplantation, about our recently published paper and am concerned that our paper is being misrepresented as a debate on donor nephrectomy techniques. Ours is a surgical paper, in which we discussed selection criteria for right kidneys and how to best utilize the vein, because it is the vein length that causes serious technical complications. Despite limitations of our healthcare resources, the excellent donor and recipient outcomes in right kidneys have validated our current donation and transplant techniques.

Key Words: Kidney transplant; Right kidneys; Renal vein; Graft function; Outcomes

Core Tip: The objective of transplantation is to get immediate graft function, whatever the method of kidney recovery, it must however be safe enough to provide a graft that is able to function immediately. Despite our budgetary limitations, we strive to do what is best for our patients. Despite limitations of our healthcare resources, the excellent donor and recipient outcomes in right kidneys have validated our current donation and transplant techniques.

TO THE EDITOR

We read the comments by Favi and Morabito[1], published in the recent issue of the World Journal of Transplantation, about our recently published paper and am concerned that our paper is being misrepresented as a debate on donor nephrectomy techniques. We will try and address the comments.

RESPONSE TO COMMENTS

After reading our comparison of right vs left living donor kidney transplants, Favi and Morabito[1] admit it is a complicated subject that most transplant teams are unfamiliar with. They further admit there is a dread of implanting right kidneys (RKs) from living donors because of the quality of its vein can compromise the venous anastomosis with the risk of technical graft loss[2,3]. The purpose of our paper was to help transplant teams learn from our experience with living donor RKs. Ours is a surgical paper, in which we discussed selection criteria for RKs and how to best utilize the vein, because it is the vein length that is the reason for serious technical complications. The quoted meta-analysis shows RKs to be associated with a significantly higher delayed graft function (DGF) and graft loss[4]. DGF is confirmed if dialysis is needed in the first week, and proves that the risk associated with RKs is technical. The diagnosis of DGF is within the first week but its consequences are observed in the long-term.

With regards to our study limitations[5], we acknowledge that our sample size is small, however, it is similar to the quoted robotic and minimally invasive (MI) nephrectomy series[6,7] and Favi et al’s own study[8]. Our data was prospectively entered and collected retrospectively; this however does not eliminate bias. Our resident donor team being unfamiliar with laparoscopy, we were therefore dependent on the availability of the visiting faculty for this procedure. Since graft losses in the long-term result are not related to surgical technique, they are usually the same for left kidneys and RKs. Possible causes are generally related to immunological events, drug compliance/toxicity, disease recurrence and urological complications. We have shown that if selected and utilized appropriately, outcomes of RKs match that of left kidneys[5].

The objective of our study was not techniques of donor nephrectomy which the authors repeatedly bring up? The robotic and MI techniques have inherent technical constraints[6,7] and getting a rim of cava with these approaches is not possible as current closure devices only work in a straight line and cannot staple or lock along a curve[9]. A curved caval closure is only possible with suturing, and using current MI or robotic techniques for such cases can be dangerous[10-13]. There has been no MI technical breakthrough yet in getting a caval rim in RKs, Turk et al[14] described how they place a Satinsky clamp on the cava via a separate incision and divide the renal vein flush with the caval margin, but without a rim of cava. We agree with the advice of Novasescu that transplant surgeons must have skills to be able to implant RKs with short veins[15]. We have stressed the importance of mobilizing the recipient iliac vein to make anastomosis easier along with bench renal vein dissection to gain more length.

The hand assisted laparoscopic technique is perhaps as invasive as the open technique with access through a large incision and port, but does not compare to the ease of open nephrectomy[16]. One size does not fit all, Pakistan does not have the resources to fund expensive laparoscopic equipment when surgical instruments can be re-used at virtually no cost especially when hospital stay and analgesic requirements are the same. Our open donor procedure takes 2 hours, nerve blocks provide good analgesia and the vast majority of donors are discharged on day 2[17]. Robotic equipment is expensive with unacceptable rates of DGF (11.5%) with consequences for recipients[18]. The role of robotics in organ recovery should not be by default but be linked to demonstrable benefits and compelling evidence[19]. The objective of transplantation is to get immediate graft function, whatever the method of kidney recovery, however, it must be safe enough to provide a graft that is able to function immediately. Despite our budgetary limitations, we strive to do what is best for our patients, our study DGF rate was < 1% for RKs and 0.25% for left kidneys and we feel very strongly that DGF in living donor transplantation should be considered unacceptable[5]. Our study delivers an important message to programs wanting to increase safe living donation by finding that outcomes of RKs were similar to left kidneys if selection criteria for RKs were adhered to, bench dissection of the vein was done to gain length and anastomosis performed with meticulous surgical technique.

CONCLUSION

Despite limitations of our healthcare resources, the excellent donor and recipient outcomes in RKs have validated our current donation and transplant techniques. Contempt for what is old is not wisdom, being aware of one’s resources and doing what’s best for our donors and recipients should be the only concern.