Hand port-site infection after hand-assisted laparoscopic donor nephrectomy for living-donor kidney transplantation: a retrospective cohort study

Introduction

Because of an extreme organ shortage for transplantation, the number of living-donor kidney transplantations has been steadily increasing (Organ Procurement and Transplantation Network). To reduce the burden on living kidney donors, hand-assisted laparoscopic donor nephrectomy (HALDN) has been developed (Ratner et al., 1995; Wolf, Tchetgen & Merion, 1998). Numerous reports have demonstrated the safety and efficacy of HALDN in donors and recipients (Buell et al., 2002; Nakajima et al., 2012; Rajab & Pelletier, 2015; Kumar et al., 2018; Hiramitsu et al., 2021). However, superficial surgical site infection after HALDN is observed in 4.8%–20.7% of cases (Nakajima et al., 2012; Ahmed et al., 2020; Hiramitsu et al., 2021). A recent report from the United Kingdom demonstrated the efficacy of preoperative antibiotic prophylaxis in preventing superficial surgical site infection after HALDN (Ahmed et al., 2020). Thus, the previous HALDN guidelines,which suggest that preoperative antibiotic prophylaxis for HALDN is unnecessary because the operation is performed aseptically, have now come into question (National Institute for Health and Care Excellence, 2017). However, the impact of operative factors, such as prophylactic subcutaneous drain placement, and preoperative comorbidities, such as hypertension, glucose intolerance, and dyslipidemia that could cause superficial surgical site infection were not investigated in the report (Ahmed et al., 2020). In previous studies, the efficacy of prophylactic subcutaneous suction drain placement has been controversial; however, these studies did not focus on living-donor nephrectomy (Panici et al., 2003; Hellums, Lin & Ramsey, 2007; Baier et al., 2010; Kosins et al., 2013; Coletta et al., 2019). Preoperative comorbidities were identified as risk factors for surgical site infections (Mangram et al., 1999). However, the impact of preoperative comorbidities on surgical site infections has not been investigated in living kidney donors. This study investigated the impact of donor characteristics including preoperative comorbidities and operative factors on hand port-site infection after HALDN. Our aim to assess the impact of donor characteristics was achieved with a retrospective cohort study and statistical analysis using data from donors who underwent HALDN.

Materials & Methods

Results

Study population

A total of 1,260 HALDNs for living-donor kidney transplantation were performed at our hospital during the study period. All donors (n = 1,260) were included in this study and were followed up after HALDN for 1 month to assess the incidence of hand port-site infections. Hand port-site infection was identified in 88 donors (infection group). The remaining 1,172 donors did not experience hand port-site infection (no infection group) (Fig. 1).

Table 1:

Donor characteristics.

		No infection group	Infection group	P-value	Odds ratio	95% CI
		n = 1,172	n = 88			Lower limit	Upper limit
Age (years, IQR)		60.0 (56.0–67.0)	65.0 (63.0–67.5)	0.804***
Sex (male, %)		409	49	<0.001*	2.344	1.513	3.630
Smoking history (%)		507	53	0.002*	1.986	1.276	3.091
Hypertension (%)		347	23	0.490*	0.841	0.514	1.376
Dyslipidemia (%)		688	53	0.779*	1.065	0.684	1.658
Glucose intolerance (%)		290	35	0.003*	2.008	1.284	3.141
Obesity (body mass index ≥30 kg/m2, %)		8	1	0.480**	1.672	0.207	13.525
Preoperative systolic blood pressure (mmHg, IQR)		130.0 (121.0–140.0)	118.5 (113.5–131.0)	0.922***
Preoperative diastolic blood pressure (mmHg, IQR)		75.0 (65.0–86.0)	72.0 (70.0–80.5)	0.375***
Preoperative total cholesterol (mg/dl, IQR)		206.0 (193.0–231.0)	251.0 (205.5–267.0)	0.157***
Preoperative triglyceride (mg/dl, IQR)		171.0 (119.0–198.0)	119.5 (87.5–152.0)	0.111***
Preoperative low-density lipoprotein cholesterol (mg/dl, IQR)		120.0 (107.0–145.0)	156.0 (132.0–170.5)	0.422***
Preoperative fasting glucose level (mg/dl, IQR)		98.0 (95.0–104.0)	97.0 (86.5–106.5)	0.341***
75-g oral glucose tolerance test results (blood glucose level 2 h after glucose administration, mg/dl, IQR)		124.0 (112.0–162.0)	122.0 (105.0–141.5)	0.303***
HbA1c (%, IQR)		5.7 (5.6–5.7)	5.7 (5.6–5.8)	0.023***
Body mass index (kg/m2, IQR)		25.1 (20.4–26.6)	24.3 (22.2–24.8)	0.179***
Kidney laterality (left, %)		1086	84	0.397*	1.663	0.596	4.643
Preoperative eGFR (ml/min/1.73 m2, IQR)		77.8 (66.8–83.8)	67.6 (62.3–71.1)	0.703***
Preoperative urine albumin/Cr ratio (mg/gCr, IQR)		9.86 (5.68–12.35)	6.37 (0.27–13.99)	0.050***
Preoperative antibiotic prophylaxis (%)		643	4	<0.001**	0.039	0.014	0.108
Prophylactic subcutaneous suction drain placement at hand port site (%)		555	21	<0.001*	0.348	0.211	0.576
Countermeasure for hand port-site infection	No preoperative antibiotic prophylaxis or prophylactic subcutaneous suction drain placement at hand-port site	452 (38.6)	68 (77.2)	<0.001*
	Preoperative antibiotic prophylaxis alone	162 (13.8)	2 (2.3)
	Prophylactic subcutaneous suction drain placement at hand-port site alone	73 (6.2)	20 (22.7)
	Preoperative antibiotic prophylaxis and prophylactic subcutaneous suction drain placement at hand-port site	481 (38.2)	2 (0.2)
Operation period	First operation period (January 2008–December 2015, %)	554 (44.0)	78 (6.2)	<0.001**	0.115	0.059	0.224
	Second operation period (January 2016–December 2021, %)	618 (49.0)	10 (0.8)
Follow-up period <1 month (%)		0	0	n.c.

DOI: 10.7717/peerj.14215/table-1

Notes:

CI

confidence interval

IQR

interquartile range

HbA1c

hemoglobin A1c

eGFR

estimated glomerular filtration rate

n.c.

not calculation

Boldface indicates statistically significant results.

*Chi-square test.

**Fisher’s exact test.

***Mann–Whitney U test.

Discussion

This study demonstrated the efficacy of preoperative antibiotic prophylaxis for the prevention of hand port-site infections and showed that prophylactic subcutaneous suction drain placement at the hand port-site may increase the risk of developing hand port-site infections. The preoperative comorbidities were not found to be associated with the risk of developing hand port-site infections.

The incidence of hand port-site infection in this study was 7.0%, which is similar to the results of previous studies (Nakajima et al., 2012; Ahmed et al., 2020; Favi et al., 2020; Hiramitsu et al., 2021; Vaz et al., 2022). All donors showed at least two symptoms for the diagnosis of hand port-site infection. However, only 17.0% of donors were cases of infection confirmed by microbiological testing from the wound.

We investigated hand port-site infection further by analyzing donor factors (including comorbidities, such as hypertension, dyslipidemia, glucose intolerance, and obesity) and operative factors (including operative duration, blood loss, preoperative antibiotic prophylaxis, and prophylactic subcutaneous suction drain placement at the hand port-site). Glucose intolerance was more frequent in the infection group than in the no infection group. No significant differences in the preoperative fasting glucose level or blood glucose level at 2 h after glucose administration in the 75-g oral glucose tolerance test were identified except for HbA1c. According to the living kidney donor guidelines in Japan, living donor candidates with glucose intolerance who meet the marginal criteria are allowed to be considered as a candidate; the marginal criteria include well-managed usage of oral anti-diabetic agents and an HbA1c ≤6.5% and a urine albumin/Cr ratio <30 mg/g Cr. However, candidates receiving insulin were ineligible for donation (Hiramitsu et al., 2020). Since compliance to these guidelines implied that donors with severe glucose intolerance were not included in this study, our multivariate analysis may conclude that glucose intolerance may not be a risk factor for hand port-site infection. Other comorbidities including hypertension, dyslipidemia, and obesity were similar in both groups, which could be because the living kidney donors were selected according to the living kidney donor guidelines in Japan (Hiramitsu et al., 2020). Additionally, according to these guidelines, a blood pressure <140/90 mmHg and BMI ≦30 kg/m² (patients with high BMI were encouraged to reduce weight to achieve BMI ≦25 kg/m²) were recommended. Living donor candidates who did not meet the blood pressure criteria could be a living donor if they met the marginal criteria, which included candidates with hypertension who had maintained their blood pressure at ≦130/80 mmHg and had an albumin/Cr ratio of <30 mg/g Cr. These candidates were ruled out with the following conditions: an organic disorder due to hypertension such as myocardial hypertrophy, changes to the fundus of the eye, and severe aortic calcification. Living donor candidates with a BMI ≦32 kg/m²were allowed to be living kidney donors, and they were encouraged to reduce weight to achieve a BMI ≦25 kg/m². Overall, compliance to these criteria implied that donors with severe dyslipidemia, severe hypertension, and obesity were not included in this study.

Although smoking history was more frequent in the infection group than in the no infection group, the living kidney donors were strictly instructed to stop smoking before the operation to prevent other complications and to maintain the function of the remaining kidney. In this study, current smokers were not included.

The univariate analysis showed that sex, smoking history, and glucose intolerance significantly increase the risk of hand port-site infection. In previous reports, smoking history and glucose intolerance were identified as risk factors for superficial surgical site infection (Mangram et al., 1999; Sørensen, 2012; Martin et al., 2016; Anderson et al., 2017). Based on the multivariate analysis, male sex and prophylactic subcutaneous suction drain placement at the hand port-site significantly increased the risk of hand port-site infection. Smoking history and glucose intolerance may not cause hand port-site infection because living kidney donors were well examined and prepared before the operation according to the living kidney donor guidelines in Japan (Hiramitsu et al., 2020). In our study, only preoperative antibiotic prophylaxis reduced the risk of hand port-site infection, which is consistent with the finding of a previous prospective study in the United Kingdom (Ahmed et al., 2020). However, the previous study did not investigate the effect of prophylactic subcutaneous suction drain placement in living-donor nephrectomy. Moreover, the efficacy of prophylactic subcutaneous suction drain placement in other surgeries is controversial (Panici et al., 2003; Hellums, Lin & Ramsey, 2007; Baier et al., 2010; Kosins et al., 2013; Coletta et al., 2019). A previous study has concluded that prophylactic subcutaneous suction drain placement could cause surgical site infection and noted that the prophylactic subcutaneous suction drain is an entry point for pathogens (Kosins et al., 2013). This finding was in agreement with the results of our study.

After the identification of hand port-site infection, donors were mainly treated with drainage and lavage (78.4%). For the treatment of hand port-site infection, further admission was not identified in this study. The period of hospital stay was similar between the infection and no infection group. Hand port-site hernia was significantly more identified in the infection group than in the no infection group, as previously reported (Favi et al., 2020). As hand port-site infection required additional treatment and had other disadvantages to donors, preoperative antibiotic prophylaxis is critical. For efficient preoperative prophylactic antibiotic selection, preoperative microbiology screening may be appreciated.

The major limitation of this study was its retrospective design, long recruiting period for living donors with multiple changes of preoperative management, the lack of characterization of the pathogens involved, and limited follow-up data. Therefore, large prospective randomized controlled studies, including the preoperative comorbidities of living donors, are warranted. To minimize the impact of a long recruiting period, we divided the study population into two groups, first operation period (January 2008–December 2015) and second operation period (January 2016–December 2021), and performed analyses using the logistic regression models. Nevertheless, this study demonstrated the effects of preoperative donor factors, preoperative antibiotic prophylaxis, and prophylactic subcutaneous suction drain placement on the development of hand port-site infection.

Conclusions

In conclusion, preoperative antibiotic prophylaxis may decrease the incidence of hand port-site infection, whereas prophylactic subcutaneous suction drain placement at the hand port-site may adversely increase the risk of superficial surgical site infection. Moreover, preoperative comorbidities may not cause hand port-site infection in donors who met the living kidney donor guidelines. To prevent these infections, preoperative antibiotic prophylaxis may be required.