Nephrol Dial Transplant (2003) 18: 2648–2654

DOI: 10.1093/ndt/gfg482

Original Article

Risks and complications in 160 living kidney donors who

underwent nephroureterectomy

Michael Siebels1,2, Jannis Theodorakis1,2, Nikolaus Schmeller4, Stefan Corvin1,2,

Nouhad Mistry-Burchardi3, Guenther Hillebrand3, Dominic Frimberger1, Oliver Reich1,
Walter Land2 and Alfons Hofstetter1

1
Department of Urology, 2Division for Transplant Surgery and 3Division of Nephrology, Klinikum Grosshadern,
Ludwig-Maximilians-University, Munich, Germany and 4Department of Urology, Landeskrankenanstalten Salzburg,
Austria

Abstract complication rate. In the post-operative follow-up

Background. The rate of living donor renal transplan- period of 0.5–62 months (mean: 38 months), renal
tations has increased. However, in view of the possible function remained stable in all donors.
complications, the question as to whether the condi- Conclusions. Living donor nephrectomy appears to
tion of the recipient justifies operation of the donor still be a safe intervention in specialized centres, where
remains unanswered. The present retrospective study it entails a low morbidity for the donor. Even in
evaluates the perioperative and post-operative risks high-risk donors, long-term complications were not
and complications for the donor at a single major observed.
transplantation centre.
Methods. From 1994 to 2001, 160 live donor nephro- Keywords: complications; living donor nephrectomy;
ureterectomies were performed. The median age of living donor renal transplantation; nephroureterectomy
living donors was 51 years (range 21–77 years); 19
patients were older than 61 years. After confirming
blood group compatibility and negative cross-match,
donors underwent an extensive medical and psycho- Introduction
logical examination. Comorbidities and anatomical
features of the donor were evaluated and the impact Living donor renal transplantation has become
they may have on the outcome was determined. increasingly common in Germany. Nevertheless, the
The nephroureterectomies were performed trans- operations on healthy persons continue to be contro-
peritoneally, with the right kidney being preferred. versial in professional and public debates. The undis-
Pre-operative, intraoperative and post-operative com- puted medical benefit for the recipient can only be
plications were documented. Serum creatinine levels as justified when freedom of choice and optimal protec-
well as new-onset proteinuria or hypertension were tion for the donor in respect of morbidity and mortality
used as criteria for assessing long-term renal function. can be assured. Large-scale multicentre studies [1],
Results. Complications were observed in 41 donors: 35 detailed surveys of the literature [2] as well as progress
were minor and six were major (splenectomy; revisions reports of various centers have shown that short-term
due to liver bleeding, incarcerated umbilical hernia or and long-term outcomes after living donor renal
infected pancreatic pseudocyst; pneumothorax; and transplantation are favourable for the donor [3–6].
acute renal failure). No patient died. Multiple arteries Although cases of hypertension and proteinuria have
(14 patients), significant renal artery stenosis (two been reported, the numbers are small and the patients
patients) and additional risk factors (e.g. increased can usually be controlled by conservative measures
age and previous operations) did not affect the [5–9]. Recent data from Sweden even found renal
donors to have a higher life expectancy compared with
the rest of the population [10], most likely due to the
selection of especially healthy persons as living donors.
Correspondence and offprint requests to: Michael Siebels, MD,
Department of Urology, Klinikum Grosshadern, Ludwig-
However, it is crucial that life expectancy of renal
Maximilians-University, Marchioninistrasse 15, D-81377 Munich, donors does not seem to be reduced compared with
Germany. Email: [email protected] age-matched groups. Despite these promising data,

ß 2003 European Renal Association–European Dialysis and Transplant Association

Risks and complications in living kidney donors 2649
unilateral nephroureterectomy in living donors does Table 1. Donor characteristics (n ¼ 160)
entail risks [11]. To ensure safety and freedom of
choice, the German transplant law requires both donor Patients (n)
and recipient to be fully informed about the procedure,
long-term outcome and possible perioperative and Age (years)
post-operative risks and complications. In order to 18–20 0
make a qualified decision, the donor and recipient 21–30 11
31–40 27
should have the right to request information about 41–50 36
the experience and results of the transplant centre 51–60 67
performing the operation. 61–70 14
The present study reviews possible pre-operative 71–80 5
problems and the management of perioperative and Sex
Male 62
post-operative complications of live donor nephrect- Female 98
omy at a single major transplantation centre. Donor kidney
Left 56
Right 104
Creatinine (mean ± SD)
Subjects and methods Pre-operative 0.88 ± 0.12 mg/dl
Post-operativea 1.45 ± 0.52 mg/dl

Patients a
One patient with acute renal failure (creatinine maximum:
6.42 mg/dl) is included.
From October 1994 to October 2001, 160 healthy donors
underwent a unilateral nephroureterectomy for related and
non-related transplantation. Potential donors <18 years
were excluded. After confirmation of blood group compat- for the nephroureterectomy, whereas the following 153
ibility and negative cross-match, the donors underwent an operations (done by the same surgeon, J.T.) were performed
intensive medical and urological examination. Coronary transperitoneally with the patient in an overextended supine
artery disease was usually considered to be an exclusion position.
criterion, whereas mild hypertension (controlled with a single After the kidney of the non-heparinized donor was
oral medication) was not. An angiography was performed in removed, the organ was handed to a second team immedi-
all donors prior to the operation to document the condition ately starting the arterial gravitational perfusion with cold
and number of renal arteries. The finding of multiple arteries Euro-Collins solution (0–4
C) (warm ischaemia: 0.5–1.5 min).
of the donor kidney was not regarded as an exclusion Routine placement of intraperitoneal and subcutaneous
criterion, but the kidney with fewer arteries was selected wound drainage was discontinued in the last series of
preferentially for donation. Human lymphocyte antigen 47 patients. The right kidney was usually preferred, unless
typing was performed for all potential donors. After contraindicated by vascular or other anatomy. The average
confirmation of their medical suitability, donor and recipient duration of operation was 2.45 h (range 2–4 h). The mean
were seen by a psychologist to ensure that the decision to post-operative stay was 8 days (SD ±2 days).
donate a kidney was voluntary and that their relationship
was emotional and close. All donors participated in the
Munich Prospective Study concerning the expected life- Renal function measurements
changes shortly before and factual changes 1 year after
For each patient, serum creatinine and 24 h urine creatinine
transplantation, with strict psychological care/evaluation
clearance values were obtained at baseline. To assess total
prior to and after transplantation that was conducted by
renal plasma flow as well as its relative distribution between
the Department of Psychology.
the two kidneys, renal scans using mercaptoacetyltriglycine as
radiolabelling agent were taken in all patients. Additionally,
inulin clearances were tested for clarification if necessary.
Donor characteristics and selection of donor organs Furthermore, every patient was tested for microalbuminuria
The median age of living donors was 51 years (range 21–77 (three times). Patients suspected of having renal disease or
years), with the majority of donors being between 31 and decreased renal function as determined by repeatedly
60 years old. Nineteen patients were older than 61 years. increased threshold values in either of the tests or by
The ratio of male to female donors was 1:2. Renal function confirmed microalbuminuria were excluded from donor
was normal in all patients (Table 1). nephrectomy. Patients were checked for diabetes mellitus by
oral glucose challenge. Virological workup included hepatitis
A, B, and C, HIV, HHV-8, CMV and EBV.
Donor nephroureterectomy, perfusion and preparation Post-operatively, serum creatinine values were determined
daily until discharge. Later on, however, patients could be
of the donor organ
persuaded to come in for routine serum creatinine checks
At the beginning of our living donor renal transplantation only with difficulty, so those values are few. In theory, 24 h
programme, the donor operation generally preceded the creatinine clearances, 24 h blood pressure measurement,
operation on the recipient. Later on, both operations were microalbuminuria testing and renal scans were to be repeated
carried out simultaneously. For the first seven patients (done annually, but we were able to obtain creatinine clearances on
by the same surgeon, N.S.), a flank incision was chosen a regular basis only in a minority of donors.
2650 M. Siebels et al.
Results renal cell carcinoma (pT1, G1). Because of its size,
it was impossible to detect the tumor pre-operatively
Perioperative and post-operative complications either by sonography or by helicoidal computerized
tomography (CT) scan. Post-operative tumour staging
None of the donors died. To date, all donors exam- (e.g. helicoidal abdominal CT scan) showed no signs of
ined have fully recovered. Major complications were metastases. In all three patients, no late sequelae of
observed in six patients (3.8%) (Table 2). Splenectomy, these complications have been noted in the interim.
secondary liver haemorrhage requiring immediate
revision and pancreatic pseudocyst with consecutive
infection developing after injury to the pancreas were Vascular anomalies of the donor organ
all due to severe adhesions. An incarcerated umbilical
Arterial vascular conditions were regular in 144 donors,
hernia occurred shortly after nephroureterectomy and
but 16 patients (10%) presented with arterial vascular
was repaired without complications. A transient acute
anomalies (Table 3). The most frequent form of vessel
renal failure episode involving the non-transplanted
reconstruction consisted of joining at least two arteries
kidney in one donor caused an increase of serum
by means of the ‘common channel technique’. When
creatinine up to 6.42 mg%, which normalized sponta-
a third artery was present, a separate anastomosis was
neously. A post-operative pneumothorax, probably
performed.
due to central vein catheter, required thoracic drainage
In two pre-operatively hypertensive donors, a
and healed without sequelae.
significant renal artery stenosis was found by angio-
There were several minor complications. Ten donors
graphy (Figure 1 left) and in one of these cases, an
experienced an intraoperative haemorrhage of neigh-
additional pole artery was detected. In both patients,
bouring organs, including the spleen, pancreas and/or
the stenosing parts were excised during the ex vivo
adrenal glands. All these episodes could be successfully
preparation and the vessels anastomosed with the
stopped at the time of operation. One of the donors
arteries of the recipient (Figure 1 right). Both donors
suffered severe intra-operative bleeding. The post-
were normotensive after the operation.
operative diagnostic workup revealed severe bleeding
diathesis caused by factor XII deficiency (16% of the
standard).
Table 3. Renal arteries in 160 related live kidney donors
Of note, the nephroureterectomy was discontinued
intraoperatively in three further patients. A 35-year-old
Patients (n)
donor (excessive tobacco consumption of 20–40 ciga-
rettes per day) developed severe bronchospasm during
induction of anaesthesia. A 62-year-old donor suffered Normal 144
Two arteries 9
an acute cardiac arrest after entering the abdominal Three arteries 4
cavity. The kidney of a 31-year-old donor revealed Pole artery in main artery 1
a suspicious 2 mm capsular spot after exposure. Renal artery stenosis 2
Intraoperative biopsy showed a primary chromophil (1  additional pole artery)

Table 2. Perioperative and post-operative complications after 160 related live donor nephroureterectomies (n ¼ 41)

Minor complications Major complications Minor and major

n (%) n (%) complications in
patients >61 years
n (%)

UTI (Escherichia coli) 16 (10%) 5 (3.1%)

Unknown fever (antibiotics) 7 (4.4%) 2 (1.3%)
Splenic haemorrhages 5 (3.1%) 1 (0.6%)
Blood transfusion 5 (3.1%) 2 (1.3%)
Pneumonia 4 (2.5%) 1 (0.6%)
AG haemorrhages 3 (1.9%) 0
Severe scar pain 2 (1.3%) 0
Pleural effusion 2 (1.3%) 0
Slight pulmonary oedema (1 day) 2 (1.3%) 1 (0.6%)
Pancreatic haemorrhage 2 (1.3%) 0
Wound infection 1 (0.6%) 0
Splenectomy 1 (0.6%) 0
Liver bleeding (2nd OP) 1 (0.6%) 0
IUH (2nd OP) 1 (0.6%) 1 (0.6%)
PP þ infection (2nd OP) 1 (0.6 %) 1 (0.6%)
Pneumothorax 1 (0.6%) 0
ARF (transient) 1 (0.6%) 0
Total 49 (21.9%) 6 (3.8%)

AG, adrenal gland; ARF, acute renal failure; IUH, incarcerated umbilical hernia; OP, operation; PP, pancreatic pseudocyst.
Risks and complications in living kidney donors 2651

Fig. 1. (Left) Lower pole artery and significant renal artery stenosis of a right donor kidney caused by renal hypertension. (Right) Sufficient
anastomosis of both arteries after transplantation into the left fossa iliaca. Note two JJ catheters with which the double ureter was stented.
Both donor and recipient were normotensive after operation.

Additional operations
For two donors, additional operations prior to
nephroureterectomy were necessary. In one case, a
cholecystectomy was performed due to symptomatic
cholecystolithiasis and gallbladder hydrops. In the
other, a contralateral adrenalectomy was performed
to remove a benign adenoma of the adrenal cortex.
Neither perioperative nor post-operative complications
were observed.

Post-operative kidney function

Hypertension. Blood pressure after donor nephrec-
tomy was monitored by 24 h blood pressure mea- Fig. 2. Renal function measured by serum creatinine (prior to the
surement (mean minimum value: 100/65 mmHg; mean operation n ¼ 160, 1 week post-operation n ¼ 160, after 1 year
maximum value: 125/80 mmHg; mean day-time value: n ¼ 135, after 2 years n ¼ 128, after 3 years n ¼ 122, after 4 years
n ¼ 115, after 5 years n ¼ 108 and after 6 years n ¼ 102).
125/80 mmHg; mean night-time value: 110/60 mmHg).
Seven out of 100 (7%) patients (age >60 years),
from whom data were available from 24 h blood albuminuria) with 55–110 mg/24 h. Severe proteinuria
pressure measurements, suffered from mild hyperten- was not seen in any case.
sion (mean: 145/95 mmHg) and were treated success- Renal function (Figure 2). Renal function was normal
fully with a single oral antihypertensive medication, in all patients prior to the operation (mean serum
mostly -blockers (mean: 130/80 mmHg). However, creatinine: 0.88 mg/dl). Post-operatively, serum crea-
in five out of seven patients, mild hypertension (con- tinine peaked at 1.45 mg/dl in the first week and
trolled with a single oral medication) had been noted then fell to 1.2 mg/dl. This value remained stable
prior to the operation. Severe hypertension was not within the observation period. Renal function with
encountered. one kidney returned to 73% of the initial values with
Proteinuria. A one-plus positive urine dipstick was two kidneys. Nevertheless, serum creatinine was
found in six out of 110 (6%) patients tested. In eight >1.2 mg/dl (maximum: 1.8 mg/dl) in 30% of the
patients (five out of these were >60 years), 24 h urine patients, but has not deteriorated further in recent
collection showed non-significant proteinuria (micro- years.
2652 M. Siebels et al.
Discussion Laparoscopic live donor nephrectomy has been
performed in many specialized centres worldwide. In
Potential risks of living donor kidney transplantation the mean time, there are several techniques for
continue to be the main topic of every public and laparoscopic kidney resection, including the trans-
professional discussion in this field and have to be peritoneal or retroperitoneal, strictly laparoscopic or
addressed when obtaining informed consent from the hand-assisted approach. Laparoscopic procedures
donor and the recipient. The risks associated with seem to have some advantages, e.g. with regard to the
donating a kidney are doubtless smaller than those rates of complication or the short hospital stay, and
entailed in paragliding or mountaineering. Neverthe- the preliminary results concerning graft function are
less, complications do occur and can be as harmless as encouraging. However, long-term data are not avail-
a urinary tract infection (UTI) or as dramatic as an able at present. The authors have extensive experience
intraoperative cardiac arrest. and have followed up a large patient group since 1994.
In response to the questions and concerns of the The complication rate in this special patient group (e.g.
donor in the setting of pre-operative counselling, many old patients, multiple vessels and pre-operative
we propose a grading system of possible risks and risks) was low and the hospital stay was not much
complications under the following six headings. longer compared with laparoscopic operations. Further
studies are necessary to determine whether long-term
follow-up for the recipients and the donors is favour-
able when comparing laparoscopic procedures with
Minor and frequent complications after conventional techniques [17]. Routine placement of
nephroureterectomy (e.g. minor intraoperative intraperitoneal and subcutaneous wound drainage was
haemorrhages, wound healing problems, UTIs discontinued in the last series of 47 patients in order to
and scar pain) reduce post-operative pain and infection. Seven
patients developed unexplained fever that subsided
The first category of risks comprises complications after empirical antibiotic treatment. Despite intensive
that are completely reversible after conservative diagnostic investigations, no cause could be found.
intervention. Their total of 21.9% in our study is Eight patients experienced less significant pulmonary
representative and comparable with series of other complications, including pleural effusions and mild
centres [6]. In other series [3], only severe or major pulmonary oedema, probably caused by fluid overload
complications are documented, so that the overall in the recovery area.
complication rate seems to be lower compared with that
in our study in which all, including minor, complica-
tions are reported. Minor complications occurred in
0.6–10% of patients, which is very low compared Severe, rare complications and complications which
with other urological operations and is in some cases might be expected when a nephroureterectomy
lower than data published to date [5,12]. Yet, even in is carried out under difficult conditions (e.g.
cases with minor problems, preventative measures are intraoperative injuries of neighbouring organs,
necessary, as the patient with factor XII deficiency such as those due to substantial intra-abdominal
shows. Despite thorough pre-operative evaluation, not synechia)
all possible problems can be precluded. Consequently,
careful post-operative care is crucial. This category comprises three cases. One is a case of
Minor complications also include ongoing late splenectomy together with removal of the left kidney
wound and scar pain. Current studies show evidence and the second is a case in which surgical revision
that extraperitoneal standard access of flank incision, became necessary due to post-operative haemorrhage
especially when combined with a rib excision for better of the liver following right nephrectomy. In the third
access, may be the reason [13,14]. In a prospective case, surgical revision was necessary due to the devel-
randomized study of 104 living donors, the flank opment of a pancreatic pseudocyst with subsequent
incision was compared with a transabdominal ventral infection after injury of the pancreas. This was caused
access [15]. No significant differences with regard to by severe adhesions between the pancreas and kidney,
cold ischaemia, duration of operation, etc. were found. probably due to pancreatitis that had not been detected
The rate of minor complications in the flank incision pre-operatively. After appropriate treatment, all patients
group was 17%, vs 11% for the transabdominal remained stable and without complications during
incision. Additionally, the transabdominal approach follow-up. In addition, 10 patients experienced less
allows better access to the renal vessels. Therefore, our critical complications consisting of intraoperative
group switched to the abdominal access after seven haemorrhages of the neighbouring organs, including
patients. So far, we have not experienced any additional the spleen, pancreas and/or suprarenal glands, all of
risks in terms of incidental splenectomy [13], post- which could be successfully stopped. All these patients
operative intestinal obstruction or bowel adhesion [16]. had more or less severe intra-abdominal adhesions.
However, it remains an open question as to whether Serious complications can be inevitable, especially
major complications, such as liver or pancreas injury, in cases of serious adhesions. Therefore, relevant
could have been avoided by a classical flank incision. information regarding the potential donors’ previous
Risks and complications in living kidney donors 2653
operations is crucial. The higher surgical risks in respect Risks arising from the donor organ
of unexpected intra-abdominal adhesions should be
discussed with the potential donors. The informed con- Vessel anomalies (e.g. multiple renal arteries and renal
sent should state whether the planned donor nephro- artery stenosis) can technically jeopardize the successful
ureterectomy should be cancelled intraoperatively if transplantation of the donor organ on the part of the
risks are greater than anticipated. recipient, explaining why some transplantation centers
refuse to transplant kidneys with multiple arteries
[6,20]. In our experience multiple arteries are not a
contraindication for live donor nephrectomy if care-
Severe, rare and non-predictable complications fully evaluated and monitored post-operatively. The
before, during or after the nephroureterectomy refusal to perform a donor nephrectomy is especially
(e.g. intraoperative acute cardiac arrest) difficult to accept for highly motivated donors. After
all, multiple blood vessels supplying the kidneys are to
This category of risks comprises three cases: a be expected in 25–40% of potential donors. For the
temporary cardiac arrest, a heavy bronchial spasm patients reported in our series who had multiple renal
after initiating anesthesia and a post-operative acute arteries on both sides, the kidney with the smaller
renal failure. Extensive post-operative assessment of number of arteries was chosen for transplantation.
the pulmonological, cardiological, nephrological or Additionally, the pre-operatively diagnosed single
urological systems was unable to explain these inci- artery supply was found intraoperatively to be a
dents. Creatinine normalized spontaneously over time duplicated artery supply in four patients and the
after the operation. All three patients are meanwhile pre-operatively diagnosed duplicated artery turned
recovered and free of symptoms. out to be a triple artery supply in two additional
The lesson learned from this category is that patients. In these cases, the transabdominal access
even healthy potential donors in whom a thorough proved to be especially opportune. As a result of the
pre-operative medical examination is unremarkable technical difficulties and the increased perioperative
must be informed about such rare but life-threatening care of donors with multiple arteries, the transplanta-
complications [18]. The likelihood of unexpectedly tion of these organs should be reserved to centres with
finding a malignant tumour (e.g. renal cell carcinoma) greater experience. Although we had 19 patients >61
as well as the very unlikely possibility of death years old, we detected no increased complication rate in
from the consequences of the operation should be this subgroup (Table 2).
discussed.

Long-term donor evaluation

Severe, predictable complications after
nephroureterectomy due to increased clinical Donation had no significant long-term effect in the
risks known pre-operatively (e.g. post-operative majority of our donors. In the post-operative follow-up
pneumonia due to advanced age and obesity) period of 0.5–62 months (mean: 38 months), the long-
term renal function remained stable in all donors.
Our experience with donors from this category has Although other authors have reported an increased
shown that they can be operated on without an incidence of hypertension and proteinuria combined
increased rate of complications when intensified peri- with living donor nephrectomy, in our series the
operative measurements are taken [19]. The easiest way incidence of these complications was very low and
of reducing risks and complications is to exclude occurred mainly in the older donors. This phenomenon
patients with known risk factors, a policy applied may be equally prevalent in the normal population.
by many transplantation centres. The decision, Rehabilitation of all donors was good to excellent.
however, becomes more difficult when the donor is After the very brief hospitalization, 95% of all donors
highly motivated. In one case, a 65-year-old patient, in could go back to work or could perform their daily
excellent mental condition is resolved to sacrifice a chores within 4 weeks.
kidney for his diseased wife, despite being told that
there is a 30–50% probability of myocardial infarction
resulting from coronary heart disease. The conflict Conclusions
between self-determination of the patient and the
doctor’s sense of responsibility has to be addressed by Living donor transplantation entails a calculable risk
a multidisciplinary team, including psychologists and for the donor. Compared with other operations, it also
anaesthesiologists. With regard to the future devel- has a very low morbidity and mortality. In spite of
opment of living donor renal transplantation, the additional risk factors (e.g. advanced age, difficult
following question arises: Which criteria, especially vessel conditions and necessary secondary operations),
considering the progress of intensive care, are to be the rate of complications in our patients was not higher
considered if one is going to accept donors with than reported in other publications. Nevertheless,
predictably raised risks? living donor renal transplantation is not without
2654 M. Siebels et al.
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Therefore, a complete and carefully performed medi- Burns JR. Short-term and long-term changes in renal function
after donor nephrectomy. J Urol 1991; 145: 11–13
cal examination of the donor as well as strict and
9. Hakim RM, Goldszer RC, Brenner BM. Hypertension and
responsible judgement of indications are mandatory. proteinuria: long-term sequelae of uninephrectomy in humans.
Last but not least, donors need to be informed about Kidney Int 1984; 25: 930–936
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Groth CG. Kidney donors live longer. Transplantation 1997;
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Received for publication: 22.11.02

Accepted in revised form: 30.7.03