A successful renal transplant for patients with kidney failure reduces mortality rate when compared to patients who continue dialysis. Organ donation from living donors has significant better results over organ donation from deceased donors. Traditionally the surgical approach for living donor nephrectomy was performed through a subcostal lateral incision. Now, laparoscopic donor nephrectomy has become the method of choice to procure kidneys from living donors, because of the reduced procedure-related morbidity, shorter convalescence period, better cosmetic result and a superior quality of life for the donor compared with open surgery. However, there are concerns about the transient function deterioration of the donor graft, compared to the traditional open procedure. The causes and exact mechanisms of the altered hemodynamic parameters (increase in systemic vascular resistance and a decrease in cardiac output), renal blood flow (a decrease up to 75%, with ! subsequent temporary renal ischemia) and reduced urine output during LDN, and delayed graft function after LDN are probably multifactorial. Various mechanisms, such as venous compression caused by elevated IAP, and the pharmacological action of the absorbed CO2, as well as activation of the sympathetic and neuro-humoral factors have all been suggested to explain these transient adverse renal effects. Therefore, it has been advocated to use vigorous hydration up to 2 l/h of crystalloids during LDN in patients. However, it was shown that this vigorous hydration could not prevent the impaired creatinine clearance as observed after LDN. We developed a protocol that focused on optimal hemodynamic function and low level of preoperative stress. Adequate fluid loading before installation of PP, together with prevention of blood pooling with anti-thrombosis stockings and adjustment of the position, adequate ventilation with the aim to minimize elevated intrathoracic pressures, high dose of sufentanil and adequate depth of anaesthesia results in the prevention of the hemodynamic and renal compromise encountered due to elevated IAP, during LDN. Moreover, the differences in stress response between ODN and LDN have disappeared with this regimen. The use of propofol anaesthesia and the addition of epidural analgesia further reduced the stress response and provided a faster and qualitatively better direct postoperative recovery. In conclusion, the work presented in this thesis shows that the anaesthetist is able to improve the outcome for the donor patient, as well as for the donor kidney.

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J.N.M. IJzermans (Jan) , J. Klein (Jan)
Erasmus University Rotterdam
Erasmus MC: University Medical Center Rotterdam

Mertens Zur Borg, I. (2008, May 28). Anaesthesia and peri-operative care for laparoscopic donor nephrectomy. Retrieved from http://hdl.handle.net/1765/12623