Status of patients who underwent uninephrectomy in adulthood more than 20 years ago

Ultrastructural changes and nestin expression accompanying compensatory renal growth after unilateral nephrectomy in adult rats

Background

Several renal disorders affect the glomerular podocytes. Compensatory structural and functional changes have been observed in animals that have undergone unilateral renal ablation. These changes occur as a pliant response to quench the increased functional demand to maintain homeostasis of fluid and solutes. Nestin is an intermediate filament protein present in the glomerular podocytes of the adult kidney and is linked with the maintenance of its foot process structure. Structural changes in the podocytes ultimately restructure the filtration barrier. Very few studies related to the ultrastructural and histopathologic changes of the podocytes are documented. The present study aimed to assess the histopathologic changes at the ultrastructural level in the adapted kidney at different time intervals following unilateral renal ablation in adult rats and its relation with nestin.

Methods

Forty-eight rats were divided into four groups (n=12 in each group). The animals of Group A were control naïve rats, while the group B, group C and group D animals underwent left unilateral nephrectomy and the remaining right kidney was removed on days 10, 20 and 30, respectively. Each group included four sham-operated rats, which were sacrificed at the same time as the naïve rats. Each nephrectomized sample was weighed and its sections were subjected to hematoxylin and eosin examination, transmission electron microscopic study as well as immunostaining using the intermediate filament protein nestin.

Results

No difference was found between the kidney sections from the control group and the sham-operated groups. A significant increase in the weight of the right kidneys was noted in groups B, C and D (P<0.001). The ultrastructural adaptive changes seen in the glomeruli of group B were subsequently reduced in groups C and D. This finding corresponded to a similar pattern of nestin expression in the podocytes, which showed significant increase in group B followed by reduced expression in groups C and D. Histopathologic and transmission electron microscopic evaluation of group B showed signs of kidney injury. On the other hand, group C animals showed markedly reduced renal adaptive changes and similar changes were also noted in group D.

Conclusion

Correlation between nestin expression and the ultrastructural changes confirms that nestin has a role in increasing the mechanical stability of the podocytes in order to enhance their morphologic changes in response to the tensile glomerular capillary wall. However, further studies investigating more remote ultrastructural changes and their relation with nestin expression are needed to confirm this relationship.

Non-neoplastic Pathology in Tumor Nephrectomy Specimens

Risk factors for kidney cancers and medical kidney diseases are similar; therefore, it is not surprising that up to 25% of renal cell carcinoma patients have chronic kidney disease prior to nephrectomy and a significant number of patients with normal prenephrectomy renal function markers progress to chronic kidney disease over time. Evaluation of non-neoplastic parenchyma in tumor nephrectomy specimens can identify patients at risk for progression to chronic kidney disease, which is a critical step for early intervention and potential improvement of morbidity and mortality rates in this patient population.

Diagnosing nonneoplastic lesions in nephrectomy specimens

CONTEXT

Nonneoplastic changes are often identified in nephrectomy specimens removed for renal neoplasms. Although they may be of prognostic or therapeutic importance, they are often overlooked. Nephrectomy is also performed for nonneoplastic lesions, the most frequent of which are urinary obstruction and end-stage renal disease, but the tissue diagnosis of these conditions and the implicated clinicopathologic correlation may not be well appreciated.

OBJECTIVE

To outline these nonneoplastic lesions with special attention to important diagnostic caveats and clinicopathologic correlations.

DATA SOURCES

The presented information was derived from literature, personal experience, and review of case materials at the authors' institutions.

RESULTS

Nonneoplastic lesions are seen in most (90%) nephrectomy specimens removed for renal neoplasms. Although these lesions span the spectrum of "medical" kidney diseases, the most frequent of them are hypertensive nephrosclerosis and diabetic nephropathy. Recognition of these diseases is important because they are often first diagnosed and later confirmed clinically. Furthermore, the severity of these lesions may predicate both short- and long-term renal function and thus help guide treatment. Among conditions that necessitate nephrectomy, advanced urinary obstruction, end-stage renal disease, and end-stage renal disease with acquired cystic changes are probably the most frequent. These conditions have characteristic morphologic features, but they may be associated with superimposing lesions previously not well described. These superimposing lesions may create diagnostic confusion; yet, some of them are the reason for nephrectomy. Thus, acute bacterial infection, urine polyp, granulomatous pyelitis, papillary necrosis, massive bleeding, and renal dysplasia can develop against the background of obstructive nephropathy. Renal neoplasms may develop from the background of end-stage renal disease without cystic changes. A renal neoplasm or massive bleeding with or without neoplasm is usually the reason for nephrectomy in kidney with acquired cystic kidney diseases. Thus, while nonneoplastic changes are frequent in nephrectomy specimens, they are often unrecognized. Awareness of these conditions and a familiarity with their diagnostic features as well as the implicated clinicopathologic correlation should help obviate this diagnostic problem.

Acute kidney injury in critically ill newborns: what do we know? What do we need to learn?

Outcomes in critically ill neonates have improved over the past three decades, yet high residual mortality and morbidity rates exist. Acute kidney injury (AKI) is not just an innocent by-stander in the critically ill patient. Research on incidence and outcomes of AKI in the critically ill neonatal population is scarce. The objective of this publication is to (a) review original articles on the short- and long-term outcomes after neonatal AKI, (b) highlight key articles on adults and children with AKI in order to demonstrate how such insights might be applied to neonates, and (c) suggest clinical research studies to fill the gaps in our understanding of neonatal AKI. To date, observational studies suggest high rates of AKI and poor outcomes in critically ill neonates. Neonates with AKI are at risk of developing chronic kidney disease and hypertension. Large prospective studies are needed to test definitions and to better understand risk factors, incidence, independent outcomes, and mechanisms that lead to poor short- and long-term outcomes. Early biomarkers of AKI need to be explored in critically ill neonates. Infants with AKI need to be followed for sequelae after AKI.

[Comparative analysis of renal graft function after open vs. laparoscopic nephrectomy: experimental model]

INTRODUCTION

Living donor renal transplant reports a higher patient and graft survival in comparison to cadaver donor and represents a good alternative facing the current lack of organs for transplant.

GOALS

To analyze comparatively in an experimental model (pig) the influence of ischemia-reperfusion and functional outcome of renal graft retrieved by open Vs laparoscopic nephrectomy.

MATERIAL AND METHODS

30 lab pigs were nephrectomized (left kidney): 15 by laparoscopy and 15 by open surgery, as living donors, in a model of renal autotransplant. Renal blood flow (RBF) was measured by means of an electromagnetic probe and creatinine levels during the first week after the implant.

RESULTS

Comparative analysis of RBF during the immediate 60 min after unclamping showed a significant reduction of average RBF in laparoscopic group in comparison to open group (p < 0.001), with a more evident reduction of RBF in the laparoscopic group during the 5-min period after unclamping (p < 0.001) and a progressive recuperation of RBF during the 1st hour, slowest in laparoscopic group. Creatinine levels in the first week after the transplant decreased progressively from 1.3 to 0.8 mgrs/dl in the open group and from 2 to 1.1 mg/dl in laparoscopic group (p < 0.001).

CONCLUSIONS

Renal grafts retrieved by laparoscopy presents a more evident ischemia-reperfusion syndrome shown by a lower average RBF after unclamping and a significant deterioration of renal function during the first week after transplant.

Surgical management of low-stage renal cell carcinoma: Technology does not supersede biology

OBJECTIVES

To address the concern that laparoscopic radical nephrectomy (LRN) is being applied in cases of small renal masses in which nephron-sparing surgery (NSS) might be more appropriate.

METHODS

From 1998 to 2003, 381 consecutive patients underwent 391 procedures at our institution for renal cell carcinoma, of which 336 were for organ-confined tumors. The temporal trends in the application of LRN and NSS were assessed relative to the clinical stage.

RESULTS

During the transition from early (1998 to 2000) to late (2001 to 2003) experience with laparoscopy, the use of LRN among patients with Stage T1a (4 cm or smaller) lesions remained infrequent (21% and 20%, respectively). In contrast, LRN increased among patients with larger lesions during this same interval (Stage T1b, 36% versus 56%, P = 0.017 and Stage T2, 24% versus 41%, P = 0.056). Concurrently, the use of NSS (open surgical or laparoscopic partial nephrectomy) increased for both Stage T1a (25% and 31% versus 34% and 37%, P = 0.082) and T1b (8% and 6% versus 19% and 5%, P = 0.017) tumors. Multivariate analysis demonstrated that the use of both NSS and LRN increased significantly with time (P = 0.002 and P = 0.001, respectively). Neither NSS nor LRN were associated with a greater risk of perioperative complications relative to radical or open surgery (P >0.05 for both).

CONCLUSIONS

During a 6-year period at our institution, most Stage T1a lesions were managed with NSS, and a significant increase occurred in the use of NSS for Stage T1b tumors, despite the concurrent increasing application of LRN. These findings suggest that oncologic, rather than technologic, concerns were determining our practice patterns.

Evaluation of the Nonneoplastic Pathology in Tumor Nephrectomy Specimens

Pathologic changes in nonneoplastic renal parenchyma of nephrectomy specimens for renal tumors and the significance of these changes with regard to the outcome of contralateral kidney function have not been studied previously. We examined the nonneoplastic renal parenchymal changes in 110 consecutive tumor nephrectomy specimens, and we correlated our findings with patients' clinical information. The material was examined for the presence of any glomerular, tubulointerstitial, or vascular pathology. In our analysis, only about 10% of cases had unremarkable renal parenchyma and vasculature. A further 28% of cases had unremarkable parenchyma, but some degree of vascular sclerosis was noted. The remaining cases (>60%) had evident pathologic abnormalities, most commonly related to vascular disease or diabetes mellitus. Regardless of the type of renal cancer they have, the majority of our cases can be placed in one of three principal groups: 1) unremarkable kidney parenchyma, with or without vascular sclerosis (38%); 2) parenchymal scarring and marked vascular changes, including cases of atheroembolic disease, and chronic thrombotic microangiopathy (28%); and 3) changes related to diabetes mellitus, such as glomerular hypertrophy, mesangial expansion, and diffuse glomerulosclerosis (24%). Follow-up data on serum creatinine 6 months postoperatively were available in a third of our patients. Patients with severe histopathologic findings (parenchymal scarring with >20% global glomerulosclerosis and advanced diffuse diabetic glomerulosclerosis) showed a significant change in serum creatinine from the preoperative period to 6 months after radical nephrectomy (P=0.001), indicative of progressive worsening of renal function; this change is significantly greater than that seen in patients with unremarkable renal parenchyma (P=0.01). We conclude that adequate examination of nonneoplastic renal parenchyma is an important tool in recognizing patients at risk for progressive renal disease after nephrectomy and could be an essential step in providing early preventive and treatment measures and better medical care of patients undergoing nephrectomy for neoplastic processes.

Retroperitoneoscopic Living Related-Donor Nephrectomy: Clinical Outcomes of 50 Consecutive Cases and Comparison with Open Donor Nephrectomy

PURPOSE

To determine whether living related retroperitoneoscopic donor nephrectomy (RDN) is a safe and effective procedure.

PATIENTS AND METHODS

From September 2001 to May 2004, RDN was performed in 50 consecutive patients at our hospital. All patients were followed longitudinally with office visits. Perioperative and postoperative data for these RDNs, including operative time, blood loss, and complications, were compared with those of open donor nephrectomies (ODNs) performed between January 1999 and December 2001.

RESULTS

The RDN was completed in all cases. The average warm ischemia times were 4.1 minutes (range 1.0-8.5 minutes) and 3.5 minutes (range 2.3-5.5 minutes) in the RDN and ODN groups, respectively (P = NS). The mean operative time for RDN was significantly longer than that for ODN (P < 0.001), but patients in the RDN group had significantly shorter hospital stays (P < 0.05). There was no significant difference between the groups in blood loss during operation or number of doses of analgesics administered after the operation. Perioperative and early postoperative complications occurred in 14 patients (28%) in the RDN group and consisted of subcutaneous emphysema in 9, wound infection in 3, and persistent headache in 2 patients. All kidneys removed retroperitoneoscopically functioned immediately. No recipients required post-transplant continuous hemodialysis.

CONCLUSIONS

The RDN is a safe and effective procedure for both donor and recipient. Although the benefits of RDN have been demonstrated, further long-term studies of graft function and patient survival are needed.

Functional evaluation of the remaining kidney in patients after unilateral nephrectomy

BACKGROUND

Unilateral nephrectomy is quite often surgical procedure. The remaining kidney undergoes a sequel of adaptational processes. The aim of the study was to evaluate kidney function in patients subjected to unilateral nephrectomy.

MATERIALS AND METHODS

The study was carried out in 28 subjects allocated into three groups: healthy controls (n = 8) and patients subjected to unilateral nephrectomy evaluated 1 month (n = 10) and 1 year (n = 10) from the surgery. Biochemical as well ultrasonographic and scintigraphic data were recorded.

RESULTS

From all evaluated standard biochemical parameters (creatinine, creatinine clearance, urea, microalbuminuria) significant changes were observed in the case of creatinine and microalbuminuria levels at 1 month, which increased from 0.96 mg/ml to 1.05 mg/dl and from 5.14 mg/24 h to 20.0 mg/24 h, respectively. (99)Tc(m)-DTPA plasma clearance was significantly elevated in patients 1 month after unilateral nephrectomy, by 7.5%, with a decrease by 17% in patients 1 year after surgical procedure, in reference to the control subjects. A significant increase in (99)Tc(m)-EC plasma clearance of patients evaluated 1 year from the operation, by 13% (p < 0.05) in comparison to the control group was seen. RI index markedly increased in nephrectomised patients both after 1 month and 1 year from the operation as compared to the controls, from 0.59 to 0.64 (p < 0.05) and 0.63 (p < 0.05), respectively.

CONCLUSION

Adaptational changes of the remaining kidney are observed in patients 1 month and 1 year after unilateral nephrectomy.

Early glomerular filtration defect and severe renal disease in podocin-deficient mice

Podocytes are specialized epithelial cells covering the basement membrane of the glomerulus in the kidney. The molecular mechanisms underlying the role of podocytes in glomerular filtration are still largely unknown. We generated podocin-deficient (Nphs2-/-) mice to investigate the function of podocin, a protein expressed at the insertion of the slit diaphragm in podocytes and defective in a subset of patients with steroid-resistant nephrotic syndrome and focal and segmental glomerulosclerosis. Nphs2-/- mice developed proteinuria during the antenatal period and died a few days after birth from renal failure caused by massive mesangial sclerosis. Electron microscopy revealed the extensive fusion of podocyte foot processes and the lack of a slit diaphragm in the remaining foot process junctions. Using real-time PCR and immunolabeling, we showed that the expression of other slit diaphragm components was modified in Nphs2-/- kidneys: the expression of the nephrin gene was downregulated, whereas that of the ZO1 and CD2AP genes appeared to be upregulated. Interestingly, the progression of the renal disease, as well as the presence or absence of renal vascular lesions, depends on the genetic background. Our data demonstrate the crucial role of podocin in the establishment of the glomerular filtration barrier and provide a suitable model for mapping and identifying modifier genes involved in glomerular diseases caused by podocyte injuries.

The Prediction of Renal Function 6 Years After Unilateral Nephrectomy Using Preoperative Risk Factors

PURPOSE

Since middle-aged and elderly patients seem to have risk factors affecting renal function, it is important to predict postoperative renal function prior to unilateral nephrectomy (UNx). We evaluated preoperative factors for predicting postoperative renal function in middle-aged and elderly patients with renal cell carcinoma (RCC) treated with radical nephrectomy (RNx).

MATERIALS AND METHODS

In 201 patients who underwent RNx preoperative records and postoperative serum creatinine (SCR) 6 years after nephrectomy were available. Postoperative renal insufficiency was defined as serum creatinine 1.4 mg/dl or greater. The relationship of each preoperative and postoperative factor was analyzed. Logistic regression analysis was performed to evaluate preoperative factors for predicting postoperative SCR 1.4 mg/dl or greater after 6 years.

RESULTS

There was a significant difference in postoperative SCR between female and male patients, and between those with and without hypertension, diabetes and proteinuria (p <0.05). Age, hemoglobin, preoperative SCR, blood urea nitrogen, uric acid and K significantly correlated with postoperative SCR (p <0.05). The increase in SCR during 6 years after UNx was significantly higher in patients with hypertension, diabetes and proteinuria than in their respective counterparts (p <0.05). Multivariate stepwise logistic regression analysis demonstrated that preoperative serum creatinine, hypertension and proteinuria were significant independent factors predicting postoperative renal function 6 years after UNx in patients with RCC (p <0.05).

CONCLUSIONS

Preoperative SCR, hypertension and proteinuria are useful factors for predicting postoperative renal function after RNx in patients with RCC.

Risks and complications in 160 living kidney donors who underwent nephroureterectomy

BACKGROUND

The rate of living donor renal transplantations has increased. However, in view of the possible complications, the question as to whether the condition of the recipient justifies operation of the donor still remains unanswered. The present retrospective study evaluates the perioperative and post-operative risks and complications for the donor at a single major transplantation centre.

METHODS

From 1994 to 2001, 160 live donor nephroureterectomies were performed. The median age of 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 psychological examination. Comorbidities and anatomical features of the donor were evaluated and the impact they may have on the outcome was determined. The nephroureterectomies were performed transperitoneally, with the right kidney being preferred. Pre-operative, intraoperative and post-operative complications were documented. Serum creatinine levels as well as new-onset proteinuria or hypertension were used as criteria for assessing long-term renal function.

RESULTS

Complications were observed in 41 donors: 35 were minor and six were major (splenectomy; revisions due to liver bleeding, incarcerated umbilical hernia or infected pancreatic pseudocyst; pneumothorax; and acute renal failure). No patient died. Multiple arteries (14 patients), significant renal artery stenosis (two patients) and additional risk factors (e.g. increased age and previous operations) did not affect the complication rate. In the post-operative follow-up period of 0.5-62 months (mean: 38 months), renal function remained stable in all donors.

CONCLUSIONS

Living donor nephrectomy appears to be a safe intervention in specialized centres, where it entails a low morbidity for the donor. Even in high-risk donors, long-term complications were not observed.

Laparoscopic live donor nephrectomy--is it safe?

BACKGROUND

Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to open nephrectomy (ODN) for living kidney donation. Concerns have been raised regarding the safety of LDN, the short and long term function of kidneys removed by LDN, and a potential higher incidence of urologic complications in LDN transplant recipients.

METHODS

Between October 1997 and May 1999, 80 LDNs were performed at our center. All patients were followed longitudinally with office visits and telephone interviews. These LDNs were compared with 50 ODN performed from January 1996 to October 1997.

RESULTS

LDN procedures took significantly longer than ODN (4.6 vs. 3.1 hr). However, LDN was associated with significant reduction in i.v. narcotic use, a rapid return to diet, and shorter hospital stay. Of the 80 LDN procedures, a total of 75 (94%) were completed laparoscopically. Five patients were converted to laparotomy: three for hemorrhage and two for complex vascular anatomy. ODN conversion was associated with large donor body habitus and/or obesity. Seven LDN patients had minor complications and 4 had major complications. All major complications consisted of vascular injuries (2 lumbar vein injuries, 1 renal artery, and 1 aortic injury). All patients made complete recoveries. All LDN kidneys functioned immediately posttransplant. We have observed 100% patient and 97% 1-year actuarial graft survival in LDN transplant recipients. There have been no short-or long-term urologic complications in this series.

CONCLUSION

With increasing experience and standardization of technique, LDN is a safe and effective procedure. Patients undergoing LDN demonstrate clinically significant, more rapid postoperative recoveries and shorter hospital stays than ODN patients. Excellent initial graft function and long-term graft survival have been observed with LDN kidneys. Urologic complications can be avoided. LDN has become the preferred surgical approach for living kidney donation at our center.

Anterior-Retroperitoneal Living Donor Nephrectomy: Technique and Outcomes

Of 133 consecutive renal transplants, 61 (46%) were living donor grafts recovered in an anterior-retroperitoneal approach. Donor demographics, operative-anesthetic care, length of stay (LOS), hospital charges, and complications were reviewed with donor and recipient follow-up of 4 to 40 months. Donors included 35 women and 26 men, ages 22 to 61 years (mean, 42.2); thirty-nine were living related and 22 were living unrelated donors. Pretransplant evaluation defined renal anatomy and function (minimal creatinine clearance, 75 cc/minute). Hospital admission occurred the morning of donation. Nephrectomy by the anterior-retroperitoneal approach (no rib resection) was followed by postoperative epidural pain control, early resumption of diet, progressive ambulation, and aggressive pulmonary care. Operating room time door-to-door averaged 2 hours, 43 minutes (range, 1 hour, 45 minutes-3 hours, 55 minutes). Donors were hospitalized for 2 (n = 7), 3 (n = 24), 4 (n = 19), and 5 to 8 (n = 11) days (mean LOS, 3.75; range, 2–8 days). The mean charge for donor hospitalization was $15,329 (range, $10,808–$29,579). One donor required transfusion; another was readmitted for wound drainage and pneumonia treated medically. All donors remain well with normal renal function. One early graft loss (3 days) occurred from arterial intimal dissection; all others gained life-sustaining function. Recipient (98%) and graft (92%) survival was excellent at 4 to 40 months. Anterior-retroperitoneal living donor nephrectomy is safe and effective, permitting hospital LOS of usually <4 days, early recovery, and no lasting complications. Excellent donor and recipient results from this procedure should compel critical assessment of techniques requiring more extensive operative exposure or more costly operating room and hospital approaches to donor surgical management.

Nature and severity of the glomerular response to nephron reduction is strain-dependent in mice

Nephron reduction is an important factor in the development of glomerulosclerosis. In a study of the oligosyndactyly (Os) mutation that causes a congenital 50% reduction in nephron number, we previously found that ROP Os/+ mice developed glomerulosclerosis whereas C57B1/6J Os/+ mice did not. We concluded that the predisposition to glomerulosclerosis depended largely on the genetic background, the ROP being sclerosis-prone whereas the C57 strain was sclerosis-resistant. In the current experiments we asked whether the intensity of the sclerotic response to nephron reduction in the ROP strain was related to the time at which it occurred, ie, a pre- or post-natal event. We also determined whether the absence of lesions in C57 Os/+ mice was caused by a higher threshold for the induction of a sclerotic response in C57 mice. We further examined the relationship between glomerular hypertrophy and sclerosis. C57 +/+, C57 Os/+, ROP +/+, and ROP Os/+ mice were uninephrectomized (NX) at age 10 weeks and followed for 8 weeks. We found no sclerotic changes in NX C57 +/+ and C57 Os/+ mice, despite a 75% reduction in nephron number in the latter. In contrast, both NX ROP +/+ and NX ROP Os/+ mice had glomerulosclerosis, which was more severe in the NX ROP Os/+ mice. Examination of extracellular matrix synthesis and degradation at the mRNA level revealed that synthesis exceeded degradation in ROP Os/+ mice. The lesions in NX ROP +/+ were less severe than in sham-operated ROP/Os mice, suggesting that the timing of nephron reduction affected the amplitude of the sclerotic response in this strain. Following NX, an increase in glomerular volume was found in C57 +/+, ROP +/+, and ROP Os/+ mice. However, NX did not lead to a further increase in glomerular volume in C57 Os/+ mice. We make three conclusions: 1) sclerosis was more severe in the ROP strain when nephron reduction occurred in utero; 2) the absence of glomerulosclerosis in C57 mice was not related to a higher threshold for a sclerosis response in this strain; and 3) whereas glomerular size continued to increase as nephron number decreased in ROP mice, it reached a plateau in C57 mice.

Living-unrelated kidney donation: a single-center experience

For 140 consecutive renal transplants performed from January 1995 to October 1997, 25 (18%) were from living-unrelated donors (15 women, 10 men, aged 25-63, mean 43 yr). All donors had pre-transplant imaging evaluation of renal anatomy following renal function assessment (minimal creatinine clearance 75 cm3/min). Admission to the hospital on the day of donation preceded nephrectomy under general anesthesia using an anterior flank, extra-retroperitoneal approach (no rib resection). Post-operative epidural pain control was used for all but 1 donor. The 25 kidney donors were hospitalized for 2 (n = 1), 3 (n = 12), 4 (n = 7), or 5-8 d (n = 5) (average 3.9 d) and had a mean hospitalization charge of $15,501 (range $10,808-$29,579). One intra-operative hemorrhage required transfusion; 1 late neural-related pain syndrome required outpatient wound exploration. Two kidneys were lost: a husband recipient from repetitive acute rejections at 3 months; a friend recipient from chronic rejection at 2.5 yr; both await cadaver transplant. The other 23 kidneys are functioning with a mean serum creatinine of 1.8 (range 1.0-3.3) at 3-36 months (patient survival 100%; graft survival 92%). While most donors were spouses (8 husbands and 10 wives), friends, distant cousins, in-laws, and adoptive relatives did well as donors and recipients. Transplantation may increase by 20% or more at centers which encourage broad application of living donor nephrectomy.