Co-morbid conditions that lead to cardiovascular disease, particularly diabetes and hypertension, play a significant role in the development of end stage renal disease (ESRD). Having diabetes, for example, increases your risk of developing high blood pressure and other cardiovascular problems that affect the arteries. Atherosclerosis, the hardening of the arteries, can cause high blood pressure, which in turn can lead to kidney failure.
Available treatment options for the ESRD patient population include hemodialysis, peritoneal dialysis and kidney transplantation. Currently there are more than 200,000 ESRD patients who are potential transplant candidates and more than 100,000 previously transplanted renal recipients with functioning allografts in the United States. The estimated number of patients starting renal replacement therapy each year for ESRD in the United States is about 300 per million population.
Hemodialysis is the predominant form of therapy for adults with ESRD. In the United States it accounts for 60% of all treated patients. Transplantation, however, is the preferred method of treatment for most patients as it is more cost-effective and allows for a return to a more normal lifestyle than dialysis.
There is an extraordinary shortage of suitable kidneys for transplantation into patients with ESRD. Unfortunately, the renal transplant waiting list has grown by more than 13% per year for the last five years, while the number of kidneys from cadaver donors has remained relatively stable at approximately 8,500 per year for the past five years.
In light of the severe cadaver organ donor shortage and increasing wait times, there has been renewed interest in kidney transplants from living donors. When compared with cadaver transplantation, living donor renal transplantation offers a greater probability of total graft survival and less recipient morbidity.
Research has shown that kidneys from living unrelated donors, such as spouses and friends, succeed as well as kidneys obtained from brothers and sisters who share half of the tissue matching antigens (HLA antigens) with the kidney recipient. The success rate of living donor kidneys, no matter what the donor-recipient relationship, is significantly greater than for cadaver kidneys. The estimated half-life (the time after which 50% of transplanted kidneys are still functioning) of cadaver kidneys is 8.6 years while for living donor kidneys it is 14.7 years.
The well-known limitations of standard flank-incision open nephrectomy, combined with the success of other laparoscopic solid organ surgery such as splenectomy and adrenalectomy, provided the impetus to develop a minimally invasive method to remove kidneys from living donors. The advantages of laparoscopic nephrectomy when compared with historical cases of open donor nephrectomy include a decreased analgesic requirement, a decreased length of hospital stay, and an earlier return to work.
As this new technology is explained to potential donors and recipients, there has been a dramatic increase in the willingness among a patient's friends and family to consider the living kidney donation option. In this minimally invasive approach, the surgical dissection is done through four small laparoscopic operating ports. The small incisions are associated with minimal morbidity, and the cosmetic result is excellent.
Laparoscopic living donor nephrectomy, like its counterpart laparoscopic cholecystectomy, represents an important advance in surgical technology. It has significantly eased the discomfort and time required to donate a kidney. The procedure is technically demanding and should only be pursued by surgeons with advanced laparoscopic skills. As this technology encourages increased rates of living kidney donation, significant savings for ESRD medical care and increased worker productivity will be realized by avoiding the disability associated with ESRD.
Dr. John Wegryn
Dr. Wegryn is the Chief of the Division of Laparoscopic Urologic Surgery at SUMMA Health System and is an assistant clinical professor of Urology at Northeastern Ohio Universities College of Medicine. He received his undergraduate degree from Boston College and his medical degree from the Medical College of Ohio. Following medical school, Dr. Wegryn completed a General Surgery and a Urology residency at Case Western Reserve University in Cleveland Ohio. Dr. Wegryn was the first physician to perform laparoscopic kidney surgery in the Akron area and is now intimately involved in the renal transplant program at SUMMA Health System. He has received specialized training in his areas of special interest including laser treatment for prostate disorders, hand-assisted and traditional laparoscopic techniques, as well as robotic laparoscopic assisted radical prostatectomy.
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