Does laparoscopic donor nephrectomy put pediatric recipients at risk?

Laparoscopic donor nephrectomy (LDN) was first described in 1995 (1). The technique was quickly adopted by many transplant programs and by 2000, half of the living donor nephrectomies for adult recipients were being performed laparoscopically (2). Concerned there was more enthusiasm than science behind this trend, we conducted the first prospective randomized trial comparing LDN with open donor nephrectomy (ODN) and demonstrated conclusive benefits to the donor with respect to post-operative recovery (3). Outcomes for the LDN adult recipients were comparable as well, though this study was not powered to examine this endpoint. Over the years, multiple large series have been published. While some early series reported higher rates of delayed graft function (DGF) and ureteral complications, the majority of reports have suggested potential benefits to the donor and equivalent outcomes for the recipient compared with ODN. A review of the OPTN/UNOS database of adult kidney recipients transplanted between November 1999 and December 2000 suggested that LDN was associated with similar rates of DGF, acute rejection and one yr graft survival compared with ODN (4). This report also noted that LDN was associated with slower early graft function, though this conclusion is based on a slightly higher discharge creatinine in the LDN recipients who left the hospital slightly earlier than the ODN group. Subsequently, a systematic review of 44 published series, nearly all focusing on adult recipients, concluded the LDN and ODN were similar with respect to short-term donor and recipient outcomes in the adult population (5). From the recipients perspective, at least, the issue seems resolved in adult transplantation. While LDN was quickly embraced as the new standard for adult recipients, there have been concerns regarding the impact on outcomes for pediatric recipients. This largely centers on the decrease in renal blood flow observed with the pneumoperitoneum in LDN (6, 7), and how this could adversely interact with the potential relative hypoperfusion of the adult size kidney in the pediatric recipient (8, 9). These concerns are especially relevant in the smallest pediatric recipients, where such physiologic events could lead to higher rates of DGF, graft thrombosis, and graft loss. Independent of graft loss, reduction in renal blood flow following reperfusion could generate non-specific damage that might increase the risk for subsequent immunologically and non-immunologically mediated injury and therefore compromise graft survival over the long term. Adoption of the LDN approach for pediatric recipients has lagged behind the adult recipient population. Nonetheless, by 2003, 66% of the donor procedures were LDN (2). Initial reports from several centers suggested that outcomes following LDN for pediatric recipients were equivalent to ODN (10–12). More reports have followed, providing additional evidence of recipient equivalent outcomes (13–17). While some suggest that initial graft function, as measured by serum creatinine, is somewhat delayed compared with the ODN group (11), none have demonstrated an impact on long-term outcomes. In these series, the rates of surgical complications, DGF, acute rejection, and graft survival all appear equivalent. While single center studies are reassuring, these reports only reflect a small number of children, and are underpowered to evaluate many of the issues. A review of the OPTN/ UNOS database by Troppmann and colleagues evaluated outcomes for LDN and ODN in pediatric recipients transplanted between January 2000 and June 2002. During this time, 44% of the donor nephrectomies for recipients five yr of age or less, and 50% of those for recipients age six–18 yr, were reported as LDN. In the 212 Pediatr Transplantation 2008: 12: 503–505 Copyright 2008 Blackwell Munksgaard