In the paper "Two Hundred One Consecutive Living-Donor Nephrectomies," Shaffer et al1 present their experience with living-donor nephrectomies performed through a standard flank approach. The authors should be congratulated for the excellent results in their series. The low complication rate achieved with the open operation should be viewed as the standard by which all other operative techniques are judged.
Complication rate, however, is not synonymous with morbidity. From the patients' standpoint, pain, time out of work, and inability to perform routine responsibilities, all constitute morbidity. In their series, Shaffer et al do not report the duration or severity of postoperative pain or the length of time until patients return to full activities or employment. Prolonged recuperative time, pain, and cosmetic results can all serve as disincentives to live kidney donation. Our series have shown that when the open flank approach is used, return to full activities and employment average (±SD) 6.2±3.2 and 6.3±3.3 weeks, respectively, and 8±4 weeks for patients with physically demanding jobs.2 This creates significant logistical and financial disincentives. Donors often must forego more than 10% of their annual income and pay out-of-pocket expenses for travel, housing, and child care. It is unknown how many additional live-kidney donors would have come forward over the study period, and how many recipients would have benefitted from living-donor transplantations if some of these disincentives to live donation had been removed.