Editorial Unilateral Nephrectomy in Living-Related Kidney Donors Is Safe and Beneficial

In this issue of the Proceedings (pages 367 to 374), Anderson and coauthors retrospectively reviewed the experience of kidney donors who had undergone uni-lateral nephrectomy 10 to 20 years previously and con-cluded that unilateral nephrectomy in that defined group of healthy persons was relatively safe. The study focused on long-term renal function and hypertension and not on early postoperative complications such as infection, hemorrhage, or cardiovascular problems. The qualifier "relatively" should be further explored in view of the hypothesis of Brenner and associates1 that a decrease in renal mass subjects the remaining nephrons to an in-creased risk of glomerular capillary hypertension, pro-teinuria, glomerulosclerosis, and renal failure. Although the data of Brenner and colleagues were the result of studies in rodents and have not been corroborated in human beings, the concept is a worrisome one because of the current practice of using healthy living-related persons as kidney donors.

Anderson and colleagues found that hypertension in 19% of the patients at the time of long-term follow-up was no greater than that expected in adults of comparable age and sex in the general population of the United States. Renal function in these patients was stable and not deteriorating; serum creatinine values were approxi-mately 25% above prenephrectomy levels. Proteinuria of pathologic amounts was rare, sporadic, and attributable to the occurrence of disease processes unrelated to the nephrectomy.

Annually in the United States, more than 2,000 healthy relatives of patients with end-stage renal disease are assessed as potential living-related donors, and the kid-neys from this source constitute approximately 30% of the total kidney transplants. Although donors come to the transplant centeroftheirown volition and thus are volun-teers, the surgeon and other medical personnel do not know all the family dynamics that may have prompted the appearance for evaluation. The donor is given every opportunity to express personal feelings about donation confidentially and to decline donation without family disapprobation. If the evaluating physician learns thatthe potential donor has been coerced and, in fact, wishes to decline, the physician may choose to give a medical or immunologic reason for exclusion rather than to disclose

that the donor has refused to undergo the procedure for whatever reason. The actual occurrence of nonmedical exclusion is rare because those persons who have agreed to undergo the initial interview, physical examination, and laboratory testing have already demonstrated a high degree of interest, enthusiasm, and altruism in helping their relative.

The justifications for using living-related donors for kidney transplantation are that (1) a normally function-ing, anatomically normal, readily obtainable organ is available without an indefinite waiting period for a ca-daveric kidney and (2) the long-term allograft and recipi-ent survival is better with the use of such kidneys than with cadaveric organs.2 A counterargument to the first factor is that patients with end-stage renal disease are no longer dying because of lack of organs. Dialysis therapy for patients in the acceptable age range for transplan-tation is actually associated with a slightly lower mor-tality rate than is transplantation. Nonetheless, nephrol-ogists and transplant surgeons prefer transplantation be-cause of the greater likelihood of rehabilitation. Also, the rate at which patients are accepted for treatment of end-stage renal disease exceeds the rate at which kidney transplantations are performed.3 Not all new patients with end-stage renal disease are candidates for transplan-tation; however, restriction to use of only cadaveric kidneys would increase the number of patients on the waiting list and consequently have a compounding effect on the duration of time until a cadaveric kidney was available for an individual patient. Ideally, if enough cadaveric organs were available for transplantation and the results of cadaveric kidney transplantations con-tinued to improve, living-related donors might not have to be used. Neither of these goals has been achieved, and the availability of living-related donors does not seem to be a deterrent to achieving the former goal. Despite rigorous efforts, organs from fewer than half of all pos-sible cadaveric donors are being identified and used.4

In regard to the second justification for use of kidneys from living-related donors, new immunosuppressive agents, particularly cyclosporine, have improved the survival of grafts and patients in cadaveric kidney trans-plantation but have not diminished the difference in graft survival statistics between living-related donors and cadaveric donors.5 Furthermore, donor-specific transfu-sions have improved haplotype-mismatched donor-recipient combinations to achieve results that are equiv-alent to those with HLA-identical siblings. Particularly in analysis of long-term survival (more than 5 years) of grafts

Mayo Clin Proc 60:423-424, 1985 423

424 EDITORIAL Mayo Clin Proc, |une 1985, Vol 60

and patients, transplantation of a kidney from a living-related donor is an advantage to the recipient.

A registry of serious complications and deaths associ-ated with nephrectomy among living-related donors has not been established, although one large transplant cen-ter reported early complications of 17% overall, of which 2.5% were major.6 Mortality from nephrectomy among living-related donors is difficult to determine precisely because all deaths are not reported. The frequency of such deaths reported in 1973 was approximately 0.1 %.7

As previously mentioned, an ideal situation would be to have an ample supply of cadaveric kidneys and to expe-rience continued improvement in the results of transplan-tation of these kidneys so that healthy relatives would not have to undergo unilateral nephrectomy. Until those goals can be attained, the altruistic benefits to the donor should not be discounted.8

Anderson and his colleagues have provided objective evidence that, in a single transplant center with strict criteria for definition of healthy patients, with critical assessment of the safety of undergoing a major surgical procedure, and with use of the donor's physician and not the potential recipient's primary physician, selected per-sons can undergo unilateral nephrectomy with minimal associated risks. The recipients of these organs have initial and long-term benefits from receiving a kidney transplant from a living-related donor, and the donors benefit from their altruism without being subjected to major health risks.

Sylvester Sterioff, M.D. Director of Transplantation Section of Transplantation Surgery

REFERENCES

1. Brenner BM, Meyer TW, HostetterTH: Dietary protein intake and the progressive nature of kidney disease: the role of hemo-dynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease. N Engl J Med 307:652-659, 1982

2. Hellerstedt WL, Johnson WJ, Ascher N, Kjellstrand CM, Knutson R, Shapiro FL, Sterioff S: Survival rates of 2,728 patients with end-stage renal disease. Mayo Clin Proc 59:776-783, 1984

3. End-Stage Renal Disease Program: Medical Information System Facility Survey Tables for 1982. Bethesda, Maryland, Department of Health and Human Services, Health Care Financing Adminis-tration, Bureau of Support Services, 1982

4. Carlson D, Hellerstedt W, Anderson J, Sterioff S, Andersen R, Ascher N: Kidney donor candidacy study. Transplant Proc 17:99, 1985

5. Sutherland DER: Living related donors should be used whenever possible. Transplant Proc 17:1503-1509, 1985

6. Weiland D, Sutherland DER, Chavers B, Simmons RL, Ascher NL, Najarian JS: Information on 628 living-related kidney donors at a single institution, with long-term follow-up in 472 cases. Trans-plant Proc 16:5-7, 1984

7. Leary FJ, DeWeerd JH: Living donor nephrectomy. J Urol 109:947-948, 1973

8. Simmons RC, Klein SD, Simmons RL: Gift of Life: The Social and Psychological Impact of Organ Transplantation. New York, John Wiley & Sons, 1977