1
|
Segaran A, Grant A, Heer M. Renal autotransplant for transitional cell carcinoma in a congenital solitary pelvic kidney. ANZ J Surg 2023; 93:752-753. [PMID: 35972733 DOI: 10.1111/ans.17989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/17/2022] [Accepted: 08/04/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Anjelee Segaran
- Newcastle Transplant Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Alexander Grant
- Department of Urology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Munish Heer
- Newcastle Transplant Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
- Hunter Transplant Research Foundation, Newcastle Transplant Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| |
Collapse
|
2
|
Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
Collapse
Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
| |
Collapse
|
3
|
Saeed B. Cancer and Infection Screening in Potential Living Donors. EXP CLIN TRANSPLANT 2022; 20:24-29. [DOI: 10.6002/ect.donorsymp.2022.l18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
4
|
Piana A, Andras I, Diana P, Verri P, Gallioli A, Campi R, Prudhomme T, Hevia V, Boissier R, Breda A, Territo A. Small renal masses in kidney transplantation: overview of clinical impact and management in donors and recipients. Asian J Urol 2022; 9:208-214. [PMID: 36035353 PMCID: PMC9399547 DOI: 10.1016/j.ajur.2022.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/24/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022] Open
Abstract
Kidney transplantation is the best replacement treatment for the end-stage renal disease. Currently, the imbalance between the number of patients on a transplant list and the number of organs available constitutes the crucial limitation of this approach. To expand the pool of organs amenable for transplantation, kidneys coming from older patients have been employed; however, the combination of these organs in conjunction with the chronic use of immunosuppressive therapy increases the risk of incidence of graft small renal tumors. This narrative review aims to provide the state of the art on the clinical impact and management of incidentally diagnosed small renal tumors in either donors or recipients. According to the most updated evidence, the use of grafts with a small renal mass, after bench table tumor excision, may be considered a safe option for high-risk patients in hemodialysis. On the other hand, an early small renal mass finding on periodic ultrasound-evaluation in the graft should allow to perform a conservative treatment in order to preserve renal function. Finally, in case of a renal tumor in native kidney, a radical nephrectomy is usually recommended.
Collapse
|
5
|
Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
6
|
Yang F, Jiang H, Gao X, Chen H, Zhao W, Zhu Y, Han L, Zeng L, Zhang L, Chen R. Multiorgan Transplant From a Donor With Solid Renal Masses: An Initial Experience and Clinical Considerations. Transplant Proc 2021; 53:2503-2508. [PMID: 34482997 DOI: 10.1016/j.transproceed.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/29/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with early-stage renal cell carcinoma (RCC) are considered to be eligible donors. Although preliminary experience in using kidneys of specific pathologic types, mainly those with small renal masses (SRMs), have been established, multiorgan utilization of the same donor with SRMs is limited. METHODS One deceased donor whose left-side kidney was diagnosed with Fuhrman grade I RCC was included. The tumor mass in the kidney was removed through partial nephrectomy according to the gold standard. Then, 3 transplant surgeries were performed, in which 1 recipient accepted kidney transplant after tumor exeresis, 1 simultaneous heart-kidney (the contralateral one) transplant, and 1 liver transplant. Recipients were followed up according to our standard protocol for renal cancers. (All allografts were allocated in compliance with the Declaration of Helsinki and the Declaration of Istanbul.) RESULTS: After 32 months, no radiographic findings showed any morphologic changes of the lesion, and all patients were in good condition, with neither tumor recurrence nor allograft rejection or infection. No complaints such as pain, oliguria, dyspnea, nausea, or fatigue were recorded. CONCLUSIONS To the best of knowledge, this initial work takes the lead in elaborating the organ utilization of multiorgan donors with SRMs. We hope the experience will provide support for cross discussion concerned with multiorgan transplant from tumor-affected donors in clinical practices, further expand the donor pool and address the donor shortage problem.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Lin Han
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Li Zeng
- Department of Organ Transplantation
| | | | - Rui Chen
- Department of Organ Transplantation.
| |
Collapse
|
7
|
Castañeda-Millán DA, García-Perdomo HA, Alcaraz A. Is it Possible to Use Kidneys with Small Renal Masses for Transplant? A New Strategy to Face Kidney Graft Shortage for Transplantation in Ibero-America. Rev Urol 2021. [DOI: 10.1055/s-0041-1730897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Herney Andrés García-Perdomo
- Division of Urology. Department of Surgery. School of Medicine. UROGIV Research Group. Universidad del Valle. Cali, Colombia
| | - Antonio Alcaraz
- Urology and Kidney Transplantation Department. Hospital Clinic de Barcelona. University of Barcelona. Barcelona, Spain
| |
Collapse
|
8
|
Abstract
Living kidney donation represents the best treatment for end stage renal disease patients, with the potentiality to pre-emptively address kidney failure and significantly expand the organ pool. Unfortunately, there is still limited knowledge about this underutilized resource. The present review aims to describe the general principles for the establishment, organization, and oversight of a successful living kidney transplantation program, highlighting recommendation for good practice and the work up of donor selection, in view of potential short- and long-terms risks, as well as the additional value of kidney paired exchange programs. The need for donor registries is also discussed, as well as the importance of lifelong follow up.
Collapse
|
9
|
Alechinsky L, Abdessater M, Parra J, Malaquin G, Huot O, Bastien O, Barrou B, Drouin SJ. Retrieved but not transplanted kidneys: how to limit the losses? A retrospective national study. Transpl Int 2021; 34:1845-1852. [PMID: 33570752 DOI: 10.1111/tri.13844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/18/2020] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
Despite the organ shortage, a significant number of deceased donor kidneys are retrieved but not transplanted (RNTK). This study aims to describe and analyze the main causes of potential grafts discard and to propose adequate solutions. We collected data from the Cristal database of the French Biomedicine Agency about RNTK over one year. Expert opinion was taken from urologists with extensive expertise in renal transplantation. They retrospectively analyzed each record to assess the appropriateness of each graft refusal and subsequent kidney discard. Of 252 kidneys were retrieved but not transplanted in France over one year. The main reasons for discard were vascular abnormalities in 43.7% (n = 110), suspicion of malignant tumor in 18.7% (n = 47), and severe histological lesions on preimplantation biopsy in 12.3% (n = 31). The reason for kidney refusal was undetermined in 4.8% (n = 12). Iatrogenic lesions were responsible for 26.2% (n = 66). Overall, 46.0% (n = 16) and 25.0% (n = 63) of the grafts were, respectively, properly and improperly denied, and the analysis was not possible in 29.0% (n = 73). In total, 36.9% of RNTK could have been transplanted. Reduction of iatrogenic lesions, improvement of microsurgical repair skills, and proper histological examination are necessary to reduce the number of RNTK. A prospective study applying the proposed principles is undoubtedly essential to complete this work.
Collapse
Affiliation(s)
- Louise Alechinsky
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| | - Maher Abdessater
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| | - Jerôme Parra
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| | | | - Olivier Huot
- Agence de la Biomédecine, Saint Denis la Plaine Cedex, France
| | - Olivier Bastien
- Agence de la Biomédecine, Saint Denis la Plaine Cedex, France
| | - Benoit Barrou
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| | - Sarah J Drouin
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| |
Collapse
|
10
|
Musquera M, Sierra A, Diekmann F, Perez M, Mercader C, Peri L, Esforzado N, Paredes D, Alcaraz A. Increasing kidney grafts for transplantation. World J Urol 2020; 39:2795-2800. [PMID: 33000340 DOI: 10.1007/s00345-020-03463-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/18/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The current pool of organs available for transplantation does not cover requirements, for this reason non-standard risk donors need to be incorporated into the pool. In this way, donors with small renal tumour are considered for transplantation after bench tumour excision. The aim of our study was to analyse our experience in using these grafts for transplantation. MATERIALS AND METHODS Retrospective analysis from our prospective accrued database of donors with incidental renal mass used for kidney transplantation between January 2007 and August 2018. RESULTS Twenty kidney transplantations were performed, thirteen cases received the affected kidney (after tumour removal) and seven the contralateral kidney; from six living and eleven deceased donors. Donor and recipient median age was 58 years (range 22-82) and 56.5 years (range 38-74), respectively. Mean tumour diameter was 12.7 mm (SD 9.5). Tumours resulted in two benign lesions and fifteen renal cell carcinoma. Surgical margins were negative. Two cases presented with bleeding after reperfusion was solved without repercussion. One case presented with immediate vein thrombosis. None of them present delayed graft function. After a 69 month follow-up none of the donors or the recipients presented tumour recurrence. CONCLUSIONS Kidneys with small incidental tumours seem to be a good option for kidney transplantation in selected patients after bench surgery excision with good functional and oncologic results. More studies and longer follow-up are needed to confirm these results.
Collapse
Affiliation(s)
- Mireia Musquera
- Hospital Clinic de Barcelona, Instituto Clínic de Nefrología y Urología, Urology, Villarroel 170, 08036, Barcelona, Spain.
| | - Alba Sierra
- Hospital Clinic de Barcelona, Instituto Clínic de Nefrología y Urología, Urology, Villarroel 170, 08036, Barcelona, Spain
| | - Fritz Diekmann
- Hospital Clinic de Barcelona, Instituto Clínic de Nefrología y Urología, Nefrology, Villarroel 170, 08036, Barcelona, Spain
| | - Meritxell Perez
- Hospital de Terrassa. Torrebonica, s/n, 08227 Terrassa, Barcelona, Spain
| | | | - Lluis Peri
- Hospital Clinic de Barcelona, Instituto Clínic de Nefrología y Urología, Urology, Villarroel 170, 08036, Barcelona, Spain
| | - Nuria Esforzado
- Hospital Clinic de Barcelona, Instituto Clínic de Nefrología y Urología, Nefrology, Villarroel 170, 08036, Barcelona, Spain
| | - David Paredes
- Hospital Clinic de Barcelona, Coordination Unit, Villarroel 170 Barcelona, 08036, Catalunya, Spain
| | - Antonio Alcaraz
- Hospital Clinic de Barcelona, Instituto Clínic de Nefrología y Urología, Urology, Villarroel 170, 08036, Barcelona, Spain
| |
Collapse
|
11
|
He B, Ng ZQ, Mou L, Delriviere L, Jaques B, Tuke J, Musk GC, Lim W. Long-term outcome of kidney transplant by using restored kidney grafts after tumour ex vivo excision - a prospective study. Transpl Int 2020; 33:1253-1261. [PMID: 32589771 DOI: 10.1111/tri.13682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/26/2020] [Accepted: 06/22/2020] [Indexed: 01/10/2023]
Abstract
The aim of this study is to report long-term outcomes of kidney transplantation by using the kidney graft after a small tumour ex vivo excision. A structured programme was established to use the restored kidney graft from urological referral after radical nephrectomy. The criteria were defined as tumour size ≤3 cm, margin clear on frozen section and recipients aged ≥60 years or those on the urgent list for transplantation as a result of imminent lack of dialysis access. The recipients were followed up regularly for surveillance of tumour recurrence. Between February 2007 and February 2018, 28 recipients had kidney transplantation by using the restored kidney grafts. The tumour size was 2.6 ± 0.7 cm. The follow-up was median 7 years without evidence of tumour recurrence. The patient and graft survival was satisfactory. Kidney transplantation by using restored kidneys after a small tumour excision is a novel source for selected recipients. The long-term patient and graft survival is satisfactory. Although there is a risk of tumour recurrence, it is rare event. Together with literature review, we would support use of kidney graft after a small tumour excision for selected recipients.
Collapse
Affiliation(s)
- Bulang He
- WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Faculty of Health and Medical Sciences, Medical School, The University of Western Australia, Crawley, WA, Australia.,Alfred Hospital, Monash University, Prahran, Vic., Australia
| | - Zi Qin Ng
- WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Lingjun Mou
- WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Luc Delriviere
- WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Faculty of Health and Medical Sciences, Medical School, The University of Western Australia, Crawley, WA, Australia
| | - Bryon Jaques
- WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Faculty of Health and Medical Sciences, Medical School, The University of Western Australia, Crawley, WA, Australia
| | - Jonathan Tuke
- School of Mathematical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Gabrielle C Musk
- Animal Care Services, The University of Western Australia, Crawley, WA, Australia
| | - Wai Lim
- Faculty of Health and Medical Sciences, Medical School, The University of Western Australia, Crawley, WA, Australia.,Department of Nephrology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| |
Collapse
|
12
|
Kidney Transplantation From Donors with Resectable Renal Cell Carcinoma: Two Case Reports. Transplant Proc 2020; 52:737-739. [PMID: 32139277 DOI: 10.1016/j.transproceed.2020.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/03/2020] [Accepted: 01/22/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The existence of renal cell cancer (RCC) in a donated kidney may cause some confusion for clinicians. We aim to present our clinical experiences with 2 recipients who received an RCC-containing kidney from their living related donors. METHODS Two male patients received a kidney containing resectable size RCC from their living related donors. The recipients were discharged with well-functioning kidneys and currently are being monitored on standard follow-up protocols, and there is no evidence of RCC in their grafts. RESULTS The kidneys with resectable sizes of renal cell carcinoma were transplanted to the recipients after nephron-sparing surgery, with no sign of recurrent RCC in the 12-month follow-up period. CONCLUSIONS In the era of transplantation, the shortage of organ sources is the major barrier for the provision of organs to recipients. To enhance the graft donation pool, kidneys with resectable size RCC might be used in providing grafts to patients with end-stage kidney disease.
Collapse
|
13
|
Warren H, Olsburgh J. Management of Renal Cell Carcinoma and Other Renal Masses in the Kidney Graft. Curr Urol Rep 2020; 21:8. [PMID: 32048068 DOI: 10.1007/s11934-020-0959-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Renal masses in the kidney graft pose an important clinical dilemma, balancing graft function against the need for cancer control. RECENT FINDINGS Donor origin cancers in the renal graft can be classified as 'donor transmitted' or 'donor derived'. The landmark TracerX Renal changed our understanding of renal cell carcinoma oncogenesis, demonstrating that key mutations in childhood lead to clinically apparent tumours in later life. Identified pre-operatively, contemporary evidence suggests that masses excised prior to transplantation result in acceptable oncologic safety and graft function. Identified post-operatively management mirrors that for a mass in a solitary kidney in the non-transplant population, with focus on a nephron-sparing approach. With growing number of kidney transplants each year, ageing donors, and increasing graft survival, masses in the renal graft are likely to become a more prevalent clinical conundrum.
Collapse
Affiliation(s)
- Hannah Warren
- Department of Transplant Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK.
| | - Jonathon Olsburgh
- Department of Transplant Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
14
|
Assessment of Restored Kidney Transplantation Including the Use of Wider Criteria for Accepting Renal Donors After Cancer Excision. Transplant Direct 2019; 5:e498. [PMID: 31773051 PMCID: PMC6831121 DOI: 10.1097/txd.0000000000000946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 11/26/2022] Open
Abstract
The transplantation of kidneys after cancer excision (restored kidney transplantation, RKT) warrants further evaluation as a source of kidneys for transplantation. We determined whether larger cancers can be safely transplanted, the risks of adverse events from RKT, and whether RKT confers a survival advantage for patients waiting for transplantation.
Collapse
|
15
|
Tran AP, Martins PN, Papazian ZG, Vanguri VK, Movahedi B, Fan PY, Bodziak KA, Yates JK, Sokoloff MH, Bozorgzadeh A. Transplantation of Renal Allograft After Removal of Renal Cell Carcinoma: Case Report and Review of the Literature. EXP CLIN TRANSPLANT 2019; 19:732-735. [PMID: 31580237 DOI: 10.6002/ect.2018.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With the rising incidence of end-stage renal disease in the United States, patients needing renal transplants are waiting longer for increasingly scarce grafts. Formerly, the general practice was to avoid organs with tumors for transplant because of the risk of malignancy transmission to the recipient. However, with comprehensive donor selection and a small-sized primary tumor, the positive outcomes of transplant outweigh the risks of transmission after a partial nephrectomy. In our case, a 31-year-old woman, the daughter of the recipient, underwent a laparoscopic nephrectomy with an existing 8-mm tumor later confirmed as renal cell carcinoma. An ex vivo tumor enucleation was performed before the allograft was transplanted into the 69-year-old patient with endstage renal disease. At last follow-up, graft function has remained excellent with no evidence of local recurrence or metastasis in both the donor and recipient. Here, we describe our case and perform a literature review on the incidence and management of renal allografts with incidentally detected renal cell carcinoma during transplant.
Collapse
Affiliation(s)
- Anthony P Tran
- From the Department of Surgery, Division of Organ Transplantation, University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Cristea O, Warren J, Blew B, Rowe N. Transplanting kidneys from donors with small renal masses - a strategy to expand the donor pool. Can Urol Assoc J 2019; 14:E32-E38. [PMID: 31348749 DOI: 10.5489/cuaj.5926] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Renal transplantation is the optimal treatment for end-stage renal disease, but organ demand continues to outstrip supply. The transplantation of kidneys from donors with small renal masses (SRMs) represents a potential avenue to expand the donor pool. We reviewed all published cases of transplants from donors with SRMs and we present followup data, best practices, and outline an actionable series of steps to guide the implementation of such transplants at individual centers. METHODS A detailed literature search of the MEDLINE/PubMed and SCOPUS databases was performed. Thirty unique data sets met inclusion criteria and described the transplantation of tumor-ectomized kidneys; nine data sets described the transplantation of contralateral kidneys from donors with SRMs. RESULTS A total of 147 tumorectomized kidneys have been transplanted. Pathology revealed 120 to be renal cell carcinomas (RCCs), of which 116 were stage T1a (0.3-4 cm). The mean followup time was 44.2 months (1-200). A single suspected tumor recurrence occurred in one patient nine years post-transplantation and it was managed with active surveillance. Twenty-seven kidneys have been transplanted from deceased donors with contralateral renal masses. Pathology revealed 25 to be RCCs, of which 19 were confirmed to be stage T1 (<7 cm). The mean followup time was 46.7 months (0.5-155). One recipient developed an RCC and underwent curative allograft nephrectomy. CONCLUSIONS Careful use of kidneys from donors with SRMs is feasible and safe, with an overall recurrence rate of less than 1.5%. The use of such kidneys could help alleviate the organ shortage crisis.
Collapse
Affiliation(s)
- Octav Cristea
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada.,University of Ottawa, Ottawa, ON, Canada
| | - Jeff Warren
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada.,University of Ottawa, Ottawa, ON, Canada
| | - Brian Blew
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada.,University of Ottawa, Ottawa, ON, Canada
| | - Neal Rowe
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada.,University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
17
|
Pavlakis M, Michaels MG, Tlusty S, Turgeon N, Vece G, Wolfe C, Wood RP, Nalesnik MA. Renal cell carcinoma suspected at time of organ donation 2008-2016: A report of the OPTN ad hoc Disease Transmission Advisory Committee Registry. Clin Transplant 2019; 33:e13597. [PMID: 31104323 DOI: 10.1111/ctr.13597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/04/2019] [Accepted: 05/08/2019] [Indexed: 12/28/2022]
Abstract
All 179 reports to the OPTN of potential renal cell carcinoma (RCC) transmission from 1/1/2008 through 12/31/2016 were reviewed. Cases were divided into those with donor tumor known or suspected at time of transplant (N = 147 donors), and those in which tumor was initially found after transplant (N = 32). We sought to understand the risk of transplanting either the affected kidney, the contralateral kidney or non-renal organs from donors with a suspected/confirmed unilateral RCC. In the case of RCC found prior to transplant, transplantation of 21 kidneys following excision of tumor, 47 contralateral kidneys and 198 non-renal organs was performed. No cases of RCC transmission were documented in this population. An additional six cases of live donor kidney transplantation involving resection of RCC were reported, also without transmission. Six of 9 other recipients in whom the diagnosis of RCC became available after implantation underwent allograft nephrectomy and 3 received tumor resection. No recurrent RCC was documented. Given the low rate of transmission and available treatment options, consideration should be given to judicious use of organs from donors with small solitary RCC.
Collapse
Affiliation(s)
- Martha Pavlakis
- Transplant Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Susan Tlusty
- United Network for Organ Sharing, Richmond, Virginia
| | - Nicole Turgeon
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Gabriel Vece
- United Network for Organ Sharing, Richmond, Virginia
| | - Cameron Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | | | - Michael A Nalesnik
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
18
|
Hevia V, Hassan Zakri R, Fraser Taylor C, Bruins HM, Boissier R, Lledo E, Regele H, Budde K, Figueiredo A, Breda A, Yuan CY, Olsburgh J. Effectiveness and Harms of Using Kidneys with Small Renal Tumors from Deceased or Living Donors as a Source of Renal Transplantation: A Systematic Review. Eur Urol Focus 2019; 5:508-517. [DOI: 10.1016/j.euf.2018.01.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/03/2018] [Accepted: 01/25/2018] [Indexed: 11/17/2022]
|
19
|
Bellini MI, Gopal JP, Hill P, Nicol D, Gibbons N. Urothelial carcinoma arising from the transplanted kidney: A single-center experience and literature review. Clin Transplant 2019; 33:e13559. [PMID: 30942927 DOI: 10.1111/ctr.13559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/14/2019] [Accepted: 03/20/2019] [Indexed: 01/07/2023]
Abstract
Urothelial carcinoma (UC) is a malignancy predominantly arising in the bladder. Upper tract UC (UUC) is uncommon, accounting only for 5-10% of the cases. High incidence of neoplasms is associated with immunosuppressive therapy; thus, UCs of the transplanted grafts often lead to a more aggressive treatment, in order to withdraw completely the immunosuppression. It significantly affects the patient quality of life, meaning return to dialysis, along with the worse life expectancy. We present our single-institution experience of this rare malignancy in two mid-age kidney transplant recipients, with UCs successfully treated with radical nephroureterectomy: G3 pT3 N0 + G3 pT1 N0 in the first patient and G3 pT2 N0 in the second one. We also review the previous literature focusing on stage of presentation and treatment for the affected kidney transplant patients.
Collapse
Affiliation(s)
| | | | - Peter Hill
- Renal Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - David Nicol
- Royal Marsden NHS Foundation Trust, London, UK.,Institute of Cancer Research London, London, UK
| | - Norma Gibbons
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
20
|
Lim SY, Kim MG, Park KT, Jung CW. Experiences of renal transplants from donors with renal cell carcinoma after ex vivo partial nephrectomy. Ann Surg Treat Res 2017; 92:361-364. [PMID: 28480182 PMCID: PMC5416927 DOI: 10.4174/astr.2017.92.5.361] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/13/2016] [Accepted: 11/29/2016] [Indexed: 12/28/2022] Open
Abstract
Purpose Routine evaluation of kidney donors occasionally reveals an incidental renal mass with an otherwise satisfactory kidney function. The use of such a kidney with an enhancing mass for transplantation is a matter of debate owing to a possible risk of transmission of donor malignancies. We report our experience of kidney transplants from donors with renal cell carcinoma, after ex vivo resection of the renal mass. Methods Two women aged 44 and 56 years were diagnosed with enhancing renal masses measuring 0.9 cm and 0.7 cm, respectively, during donor evaluation for kidney transplantation. Both patients and their families were informed of a potential risk of recurrent renal cell carcinoma following transplantation. Results Renal function test results of both donors satisfied the living donor selection criteria. Laparoscopic live donor nephrectomy was performed with ex vivo resection of renal masses on the bench table. Immediate pathological analysis revealed a renal cell carcinoma with a margin of normal renal parenchyma before transplantation. Regimens based on mammalian target of rapamycin inhibitors, which are known for their antitumoral properties, were used for immunosuppression in both recipients. None of the recipients showed recurrence or metastasis during the follow-up period, which was longer than 3 years after transplantation. Conclusion In light of the ongoing shortage of kidney donors, kidneys with small renal cell carcinoma could be considered for transplantation after appropriate removal of the lesion, with a very low risk of recurrent disease.
Collapse
Affiliation(s)
- Sung Yoon Lim
- Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Myung Gyu Kim
- Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Kwon Tae Park
- Department of Surgery, Korea University Medical College, Seoul, Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University Medical College, Seoul, Korea
| |
Collapse
|
21
|
Timsit MO, Kleinclauss F, Mamzer Bruneel M, Thuret R. Le donneur vivant de rein. Prog Urol 2016; 26:940-963. [DOI: 10.1016/j.purol.2016.09.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 08/29/2016] [Accepted: 09/01/2016] [Indexed: 01/10/2023]
|
22
|
McGregor TB, Rampersad C, Patel P. Expanding living kidney donor criteria with ex-vivo surgery for renal anomalies. Can Urol Assoc J 2016; 10:301-305. [PMID: 27800047 DOI: 10.5489/cuaj.3841] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Renal transplantation remains the gold standard treatment for end-stage renal disease, with living donor kidneys providing the best outcomes in terms of allograft survival. As the number of patients on the waitlist continues to grow, solutions to expand the donor pool are ongoing. A paradigm shift in the eligibility of donors with renal anomalies has been looked at as a potential source to expand the living donor pool. We sought to determine how many patients presented with anatomic renal anomalies at our transplant centre and describe the ex-vivo surgical techniques used to render these kidneys suitable for transplantation. METHODS A retrospective review was performed of all patients referred for surgical suitability to undergo laparoscopic donor nephrectomy between January 2011 and January 2015. Patient charts were analyzed for demographic information, perioperative variables, urological histories, and postoperative outcomes. RESULTS 96 referrals were identified, of which 81 patients underwent laparoscopic donor nephrectomy. Of these patients, 11 (13.6%) were identified as having a renal anomaly that could potentially exclude them from the donation process. These anomalies included five patients with unilateral nephrolithiasis, four patients with large renal cysts (>4 cm diameter), one patient with an angiomyolipoma (AML) and one patient with a calyceal diverticulum filled with stones. A description of the ex-vivo surgical techniques used to correct these renal anomalies is provided. CONCLUSIONS We have shown here that ex-vivo surgical techniques can safely and effectively help correct some of these renal anomalies to render these kidneys transplantable, helping to expand the living donor pool.
Collapse
Affiliation(s)
| | | | - Premal Patel
- Section of Urology; University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
23
|
Thuret R, Kleinclauss F, Terrier N, Timsit MO. [Deceased donation in renal transplantation]. Prog Urol 2016; 26:909-939. [PMID: 27727092 DOI: 10.1016/j.purol.2016.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 08/23/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To review epidemiologic data's and medical results of deceased donation in renal transplantation. MATERIAL AND METHODS Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, "brain death; cardiac arrest; deceased donation; organ procurement; transplantation". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 2498 articles, 8 official reports and 17 newspaper articles were identified; after careful selection 157 publications were eligible for our review. RESULTS Deceased donation may involve either brain death or non-heartbeating donors (NHBD). Organ shortage led to the procurement of organs from expanded-criteria donors, with an increased age at donation and extended vascular disease, leading to inferior results after transplantation and underlining the need for careful donor management during brain death or cardiac arrest. Evolution of French legislation covering bioethics allowed procurement from Maastricht categories II and recently III non-heartbeating donors. CONCLUSION The increase of organ shortage emphasizes the need for a rigorous surgical technique during procurement to avoid loss of transplants. A history or current neoplasm in deceased-donors, requires attention to increase the pool of organs without putting the recipients at risk for cancer transmission. French NHBD program, especially from Maastricht category III, may stand for a potential source of valuable organs.
Collapse
Affiliation(s)
- R Thuret
- Service d'urologie et transplantation rénale, CHU de Montpellier, 34090 Montpellier, France; Université de Montpellier, 34090 Montpellier, France.
| | - F Kleinclauss
- Service d'urologie et transplantation rénale, CHRU de Besançon, 25030 Besançon, France; Université de Franche-Comté, 25030 Besançon, France; Inserm UMR 1098, 25030 Besançon, France
| | - N Terrier
- Service d'urologie et transplantation rénale, CHU de Grenoble, 38000 Grenoble, France
| | - M O Timsit
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
| |
Collapse
|
24
|
Ogawa Y, Kojima K, Mannami R, Mannami M, Kitajima K, Nishi M, Ito S, Mitsuhata N, Afuso H. Transplantation of Restored Kidneys From Unrelated Donors After Resection of Renal Cell Carcinoma: Results From 10 Patients. Transplant Proc 2016; 47:1711-9. [PMID: 26293039 DOI: 10.1016/j.transproceed.2015.06.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/02/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE To relieve the chronic shortage of donor kidneys, we conducted a prospective kidney transplantation trial using kidneys removed from 10 unrelated patients (51 to 79 years of age) who had undergone nephrectomy for small renal cell carcinoma (1.5 to 3.9 cm) of low-to-moderate complexity based on RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior location relative to polar lines) nephrometry (objective description helpful for operative indication and planning). METHODS Donors were selected from among 15 patients who opted to undergo nephrectomy for small renal cell carcinoma. A total of 76 dialysis patients 34 to 85 years of age who agreed to undergo restored kidney transplantation were recruited as transplant candidates. RESULTS In stage 1 (5 cases), high-risk patients were selected without human leukocyte antigen testing, and accelerated acute rejection occurred in 4 of 5 recipients. This trial was subsequently extended with human leukocyte antigen testing, and an additional 5 patients were enrolled in stage 2. Eight recipients, including 4 recipients with a history of renal transplantation, experienced rejection; 1 patient resumed dialysis 35 months after transplantation. The most recent serum creatinine levels ranged from 1.10 to 3.19 mg/dL in the 9 recipients with functioning grafts and from 0.84 to 4.68 mg/dL in the 10 donors. No tumor recurrence was noted at 32 to 58 months after surgery in either the recipients or the donors. CONCLUSIONS Restored kidney transplantation using kidneys with a small renal tumor seems suitable for carefully selected high-risk recipients and, in particular, elderly kidneys can also function well. Avoiding cancer transmission, fair recipient selection, close follow-up, and a well-organized tracking system warrant further study.
Collapse
Affiliation(s)
- Y Ogawa
- Department of Urology, Tokyo-West Tokushukai Hospital, Akishima-city, Tokyo-to, Japan.
| | - K Kojima
- Department of Urology, Uwajima Tokushukai Hospital, Uwajima-city, Japan
| | - R Mannami
- Department of Urology, Uwajima Tokushukai Hospital, Uwajima-city, Japan
| | - M Mannami
- Department of Urology, Uwajima Tokushukai Hospital, Uwajima-city, Japan
| | - K Kitajima
- Department of Urology, Kagoshima Tokushukai Hospital, Kagoshima-city, Japan
| | - M Nishi
- Department of Urology, Saint Martin's Hospital, Sakaide-city, Japan
| | - S Ito
- Department of Urology, Kure-Kyosai Hospital, Kure-city, Japan
| | - N Mitsuhata
- Department of Urology, Kure-Kyosai Hospital, Kure-city, Japan
| | - H Afuso
- Department of Urology, Okinawa Chubu Tokushukai Hospital, Okinawa-city, Japan
| |
Collapse
|
25
|
|
26
|
Abstract
The shortage of donors in the face of the increasing number of patients wait-listed for renal transplantation has prompted several strategies including the use of kidneys with a tumor, whether found by chance on harvesting from a deceased donor or intentionally removed from a living donor and transplanted after excision of the lesion. Current evidence suggests that a solitary well-differentiated renal cell carcinoma, Fuhrman nuclear grade I-II, less than 1 cm in diameter and resected before grafting may be considered at minimal risk of recurrence in the recipient who, however, should be informed of the possible risk and consent to receive such a graft.
Collapse
|
27
|
Pandanaboyana S, Longbotham D, Hostert L, Attia M, Baker R, Menon K, Ahmad N. Transplantation of liver and kidney from donors with malignancy at the time of donation: an experience from a single centre. Transpl Int 2015; 29:73-80. [DOI: 10.1111/tri.12693] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/12/2015] [Accepted: 09/18/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Sanjay Pandanaboyana
- Division of Surgery; Department of Transplantation; St James's University Hospital; Leeds UK
- Department of Surgery; Faculty of Medical and Health Sciences; University of Auckland; Auckland New Zealand
| | - David Longbotham
- Division of Surgery; Department of Transplantation; St James's University Hospital; Leeds UK
| | - Lutz Hostert
- Division of Surgery; Department of Transplantation; St James's University Hospital; Leeds UK
| | - Magdy Attia
- Division of Surgery; Department of Transplantation; St James's University Hospital; Leeds UK
| | - Richard Baker
- Department of Nephrology; St James's University Hospital; Leeds UK
| | - Krishna Menon
- Division of Surgery; Department of Transplantation; St James's University Hospital; Leeds UK
| | - Niaz Ahmad
- Division of Surgery; Department of Transplantation; St James's University Hospital; Leeds UK
| |
Collapse
|
28
|
Giessing M. [Urological follow-up and development of cancer after renal transplantation]. Urologe A 2015; 54:1393-401. [PMID: 26459582 DOI: 10.1007/s00120-015-3910-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The number of renal transplant recipients is rising, as well as graft and recipient survival. The mainstay of urological follow-up is to ensure urine transport and voiding function; also, the diagnosis and treatment of urological malignancies following renal transplantats is growing in importance. As urological malignancies are one of the three most common tumors following renal transplantation (RT), meticulous and regular urological evaluation is a central part of follow-up care after RT. RECOMMENDATIONS Urological evaluation following RT must ensure correct urine transport and voiding function. Transplant ureter strictures, relevant ureteral reflux and voiding dysfuntion (e.g., neurologic dysfunction, benign prostate hypeplasia) must be excluded or treated. Urinary tract infection (UTI), which can be life threatening in the immunosuppressed transplant recipient, must be diagnosed and treated consequently and for an adequate period of time. Prophylaxis of UTIs is indicated in patients with recurrent symptomatic UTI as well as in the initial 6 months following renal transplantation. Asymptomatic bacteriuria must not necessarily be treated. The incidence of urological malignancies like renal cell carcinoma, urothelial cancer of the bladder, and penile carcinoma is increased following RT, while the incidence of prostate and testis cancer is the same as in the nontransplant population. Surgical and nonsurgical treatment options do not differ from the normal population. Adaptation, cessation, or switching of the immunosuppressive regimen in case of urologic malignancy must be decided on the individual recipient basis.
Collapse
Affiliation(s)
- M Giessing
- Universitätsklinik für Urologie, Heinrich Heine-Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| |
Collapse
|
29
|
Utility of MRI in the Characterization of Indeterminate Small Renal Lesions Previously Seen on Screening CT Scans of Potential Renal Donor Patients. AJR Am J Roentgenol 2015. [PMID: 26204282 DOI: 10.2214/ajr.14.13956] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether MRI could more confidently characterize indeterminate small renal lesions (< 15 mm) previously seen on CT scans of potential renal donor patients and whether such characterization could impact surgical management and donor candidate status. MATERIALS AND METHODS After dedicated contrast-enhanced renal CT examinations of a population of renal donor patients identified indeterminate small renal lesions (< 15 mm), dedicated renal MRI examinations were performed for 55 of those patients. Two radiologists used consensus reading of established MRI characteristics to characterize indeterminate small lesions as simple cysts, hemorrhagic cysts, angiomyolipomas, or solid renal masses. RESULTS A total of 94 indeterminate small renal lesions were detected on CT. MRI was able to confidently diagnose 93 of those lesions, including 83 cysts, eight hemorrhagic cysts, and two angiomyolipomas. MRI directly affected the surgical management of four of the patients (7%). CONCLUSION For potential renal donor patients, MRI can be an effective means of characterizing lesions that are deemed to be too small to characterize by CT. MRI can also potentially alter the surgical management and donor status of this group of patients.
Collapse
|
30
|
|
31
|
Khurram MA, Stamp S, Sheerin NS, Rix D, Cunningham AC, Carter N, Talbot D. Behaviour of transplanted tumours and role of matching in rejection. Transpl Immunol 2015; 32:121-5. [DOI: 10.1016/j.trim.2015.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/19/2015] [Accepted: 02/20/2015] [Indexed: 01/14/2023]
|
32
|
Kirchner VA, T Liu P, Pruett TL. Infection and Cancer Screening in Potential Living Donors: Best Practices to Protect the Donor and Recipient. CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-014-0049-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
33
|
Organ transplantation from donors (cadaveric or living) with a history of malignancy: Review of the literature. Transplant Rev (Orlando) 2014; 28:169-75. [DOI: 10.1016/j.trre.2014.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 03/15/2014] [Accepted: 06/11/2014] [Indexed: 12/11/2022]
|
34
|
Lledó-García E, Riera L, Passas J, Paredes D, Morales JM, Sánchez-Escuredo A, Burgos-Revilla FJ, de Andrés Belmonte A, Oppenheimer F, Rodríguez-Ferrero ML, Solé M, Matesanz R, Valentín M, Pascual J. Spanish consensus document for acceptance and rejection of kidneys from expanded criteria donors. Clin Transplant 2014; 28:1155-66. [PMID: 25109314 DOI: 10.1111/ctr.12434] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2014] [Indexed: 01/20/2023]
Abstract
In the recent years, more than 60% of available deceased donors are either older than 50 yr or have significant vascular comorbidities. This makes the acceptance and rejection criteria of renal allografts very rigorous, especially in cases of younger recipients, and at the same time encourages live donations. In our country, there is a lack of homogeneity in the percentages of use of expanded criteria donor (ECD) allografts between the different autonomous communities. Furthermore, the criteria vary greatly, and in some cases, great importance is given to the biopsy while in others very little. In this study, we present a unified and homogenous criteria agreed upon by consensus of a 10-member Panel representing major scientific societies related to renal transplantation in Spain. The criteria are to be used in accepting and/or rejecting kidneys from the so-called ECDs. The goal was to standardize the use of these organs, to optimize the results, and most importantly to provide for the maximum well being of our patients. Finally, we believe that after taking into account the Panel's thorough review of specific scientific literature, this document will be adaptable to other national renal transplant programmes.
Collapse
|
35
|
Corbera S, Ikezawa S, Bell MD, Wexler BE. Physiological evidence of a deficit to enhance the empathic response in schizophrenia. Eur Psychiatry 2014; 29:463-72. [PMID: 24630376 DOI: 10.1016/j.eurpsy.2014.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 12/24/2013] [Accepted: 01/19/2014] [Indexed: 12/30/2022] Open
Abstract
Empathy is crucial for maintaining effective social interactions. Research has identified both an early-emotional sharing and a late-cognitive component of empathy. Although considered a functionally vital social cognition process, empathy has scarcely been studied in schizophrenia (SZ). We used event-related potentials (ERPs) to study the temporal dynamics of empathic response in 19 patients with SZ and 18 matched healthy controls (HC) using an empathy for physical pain paradigm. Participants responded to pictures of hands in neutral and painful situations in an active empathic condition and one manipulated by task demands. Additionally, subjective ratings of the stimuli and empathic self-reports were collected. People with SZ had (1) decreased early-emotional ERP responses to pictures of others in pain; (2) decreased modulation by attention of late-cognitive ERP responses; (3) lower ratings of perspective taking and higher ratings of personal distress which were both related to decreased modulation of late-cognitive empathic responses; (4) a significant relationship between high affective overlap between somebody else's pain and their own pain and decreased modulation of late-cognitive empathic responses; (5) a distinct relationship between regulatory deficits in late-cognitive empathy and functioning. Patients had present but reduced early and late empathy-related ERPs. Patients also reported increased personal distress when faced with distress in others. The late ERP responses are thought to be associated with self-regulation and response modulation. The magnitude of these late responses was inversely associated with reported levels of personal distress in both patients and controls. Additionally, regulatory deficits in cognitive empathy were highly related with deficits in functioning. Decreased ability to regulate one's own emotional engagement and response to emotions of others may be an important source of distress and dysfunction in social situations for patients with schizophrenia.
Collapse
Affiliation(s)
- S Corbera
- Connecticut Mental Health Center, Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06508, USA; Olin Neuropsychiatry Research Center, Institute of Living, Hartford Hospital, 200, Retreat Avenue, Hartford, CT 06106, USA.
| | - S Ikezawa
- Connecticut Mental Health Center, Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06508, USA; Division of Neuropsychiatry, Yowa Hospital, 3-5-1 Kamigoto, Yonago, Tottori 6830841, Japan
| | - M D Bell
- Connecticut Mental Health Center, Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06508, USA; VA Connecticut Healthcare System, Psychology Service 116B, VACHS, 950, Campbell Avenue, West Haven, CT 06516, USA
| | - B E Wexler
- Connecticut Mental Health Center, Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06508, USA
| |
Collapse
|
36
|
He B, Mitchell A, Lim W, Delriviere L. Restored kidney graft from urologist referrals for renal transplantation. Transplant Proc 2013; 45:1343-6. [PMID: 23726568 DOI: 10.1016/j.transproceed.2012.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 12/04/2012] [Indexed: 01/17/2023]
Abstract
BACKGROUND A new transplantation program using kidneys after a small tumor excision was initiated in Western Australia in February 2007. The aim of this study was to report the outcomes over 5 years. METHODS Local urologists were encouraged to refer the kidney to the transplantation service when considering a radical nephrectomy. Recipients are selected according to strict criteria. Between February 2007 and February 2012 24 of 30 referred kidneys were restored for transplantation. Average donor age was 53.4 (range, 32-75) years while the recipients were 66.3 (range, 57-80) years. Twenty-one kidneys were restored after excision of a small tumor (<3.3 cm) and 3 kidneys were restored after being obtained from patients who had experienced complicated ureteric injuries secondary to laparotomy and colectomy. RESULTS Nineteen of 24 grafts displayed immediate function, 4 had delayed function, and 1 had nonfunction. The first 3 patients developed urinary leakages, which all resolved by subsequent management. One graft showed a pseudoaneurysm on the day 1 Doppler ultrasound, requiring interventional embolization. All patients but 1 have been off dialysis with satisfactory graft function; creatinine (Cr) levels ranged from 70 μmol/L to 330 μmol/L. There was no tumor recurrence on close follow-up from 6 to 55 months (median, 26). Three patients died due to other medical issues. CONCLUSION Kidneys could be restored from urologic disease for transplantation after excision of a small tumor with satisfactory outcomes at an average follow-up of 26 months. Frozen section is necessary to ensure the clearance of the tumor prior to transplantation. A modification of the surgical technique has minimized urine leakage and pseudoaneurysm formation after tumor resection.
Collapse
Affiliation(s)
- B He
- Western Australia Liver-Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia.
| | | | | | | |
Collapse
|
37
|
Khurram MA, Wilson C, Vasdev N, Manas D, Talbot D, Rix D. Therapeutic kidney donation: a potential source of precious organs. JOURNAL OF CLINICAL UROLOGY 2013. [DOI: 10.1016/j.bjmsu.2012.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The number of patients awaiting a renal transplant considerably exceeds the number of organ grafts available. A successful kidney transplant is the most clinically and cost effective treatment for patients with end stage renal disease. A proportion of patients currently die awaiting a renal transplant as their continues to be a global deficiency of renal allografts. Efforts continue to be made in order to improve the current situation of waiting lists and there is now an urgent clinical need to explore potential new sources to increase the number of renal allografts for transplantation. We describe a successful case of a renal transplant with a kidney removed for benign aetiology and transplanted into a patient who was on the cadaveric renal transplant waiting list for 6 years. We predict that this of ‘Altruistic domino donation’ concept could potentially reduce the waiting list for cadaveric renal transplantation and more importantly become a valuable source for new renal allografts.
Collapse
Affiliation(s)
| | - Colin Wilson
- Department of Transplantation, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Nikhil Vasdev
- Department of Transplantation, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Derek Manas
- Department of Transplantation, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - David Talbot
- Department of Transplantation, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - David Rix
- Department of Transplantation, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| |
Collapse
|
38
|
Khurana K, Modlin C. Intraoperative Management of Renal Allograft Venous-Calyceal Fistula and Incidental Renal Cell Carcinoma During Renal Transplantation: A Case Report. Transplant Proc 2013; 45:3421-3. [PMID: 24182828 DOI: 10.1016/j.transproceed.2013.07.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 07/08/2013] [Indexed: 12/18/2022]
|
39
|
Yu N, Fu S, Fu Z, Meng J, Xu Z, Wang B, Zhang A. Allotransplanting donor kidneys after resection of a small renal cancer or contralateral healthy kidneys from cadaveric donors with unilateral renal cancer: a systematic review. Clin Transplant 2013; 28:8-15. [PMID: 24118586 DOI: 10.1111/ctr.12262] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2013] [Indexed: 12/25/2022]
Affiliation(s)
- Nengwang Yu
- Urology Department; General Hospital of Jinan Military Command; Jinan China
| | - Shuai Fu
- Department of Thoracic Medical Oncology; Beijing Cancer Hospital; Beijing China
| | - Zhihou Fu
- Orthopedics Department; General Hospital of Jinan Military Command; Jinan
| | - Jianzhong Meng
- Blood purification Department; General Hospital of Jinan Military Command; Jinan
| | | | - Baocheng Wang
- Oncology department; General Hospital of Jinan Military Command; Jinan China
| | - Aimin Zhang
- Urology Department; General Hospital of Jinan Military Command; Jinan China
| |
Collapse
|
40
|
Xiao D, Craig JC, Chapman JR, Dominguez-Gil B, Tong A, Wong G. Donor cancer transmission in kidney transplantation: a systematic review. Am J Transplant 2013; 13:2645-52. [PMID: 24034231 DOI: 10.1111/ajt.12430] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/03/2013] [Accepted: 07/05/2013] [Indexed: 01/25/2023]
Abstract
Transplantation of any biological material from a donor to a host will carry some inherent risk of disease transmission. Our aims were to summarize the totality of the published evidence about donor cancer transmission among kidney transplant recipients and to determine the cancer-specific survival of these patients. We systematically reviewed all case reports, case series and registry studies that described the outcomes of kidney transplant recipients with donor cancer transmission published to December 2012. A total of 69 studies with 104 donor-transmitted cancer cases were identified. The most common transmitted cancer types were renal cancer (n = 20, 19%), followed by melanoma (n = 18, 17%), lymphoma (n = 15, 14%) and lung cancer (n = 9, 9%). Patients with melanoma and lung cancers had the worst prognosis, with less than 50% of recipients surviving after 24 months from transplantation. Recipients with transmitted renal cancers had the best outcomes, with over 70% of recipients surviving for at least 24 months after transplantation. Overall, the risk of donor transmission of cancer appears low, but there is a high likelihood of reporting bias. Our findings support the current recommendations for rejecting organs from donors with a history of melanoma and lung cancer, but suggest that the use of donor kidneys with a history of small, incidental renal cell cancer may be reasonable.
Collapse
Affiliation(s)
- D Xiao
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | | | | | | | | | | |
Collapse
|
41
|
|
42
|
Role of MDCT angiography in selection and presurgical planning of potential renal donors. AJR Am J Roentgenol 2013; 199:1035-41. [PMID: 23096176 DOI: 10.2214/ajr.11.8058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the prevalence and types of renal and extrarenal abnormalities that preclude renal donation or lead to alteration of the surgical approach on the basis of abdominal CT angiography (CTA) in a large group of potential renal donors. MATERIALS AND METHODS In this retrospective study, 654 potential renal donors undergoing dual-phase CTA were identified from January 2005 to January 2009. The CT reports were systemically reviewed by two radiologists to determine the presence of renal and extrarenal abnormalities. The operative notes of the renal donors were reviewed by one radiologist to determine whether the presence of renal pathology had affected the surgical approach. In the candidates who did not proceed to kidney donation, the reasons that precluded kidney donation were abstracted from the transplant database. RESULTS Four hundred seventeen potential donors (269 men and 385 women; mean age, 44.0 years; age range, 17-79 years) proceeded to renal donation and 237 did not. The most common renal abnormalities were cysts (34%) and renal stones (4.4%). Renal artery disease was identified in 3.4% of potential donors, including renal artery stenosis, possible fibromuscular dysplasia, and renal artery aneurysm. Suspicious renal masses were incidentally found in 0.5% of potential donors. The most common extrarenal pathology was an incidental adrenal nodule (2.6%). Other significant extrarenal pathology identified included gallbladder mass (0.2%), Crohn disease (0.2%), ovarian mass (0.2%), and possible sarcoidosis (0.2%). Although renal and extrarenal abnormalities were present in 41% of potential renal donors, abnormalities seen on CT only contributed to exclusion of 27 potential donors (4.1%). The most common reason for exclusion was the presence of renal stones or scarring (1.8%). Significant CT findings also contributed to the selection of the right kidney in 29 donors, most commonly due to presence of ipsilateral vascular disease or complex left vascular anatomy. CONCLUSION Renal parenchymal and vascular abnormalities are common in asymptomatic potential kidney donors. Although most of these represent incidental CT findings, abnormalities can exclude potential renal donors and alter the surgical approach in a small minority of cases.
Collapse
|
43
|
Living-donor transplantation after excision of unrecognized renal cancer diagnosed after transplant. Pediatr Nephrol 2012; 27:2319-21. [PMID: 22806562 DOI: 10.1007/s00467-012-2255-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 06/12/2012] [Accepted: 06/12/2012] [Indexed: 01/20/2023]
Abstract
BACKGROUND Published data on kidneys transplanted after resecting small renal cancers during the transplantation surgery are very rare and, to the best of our knowledge, no pediatric cases have been reported in the literature. CASE-DIAGNOSIS/TREATMENT Our patient was diagnosed with a bilateral Wilms tumor when he was 15 months old. A total bilateral nephrectomy was required to control the disease. Two years later, a human leukocyte antigen (HLA)-identical living-donor transplant from his father was performed. A small mass in the father's left kidney was diagnosed as an angiomyolipoma during the pretransplant donor evaluation. During the surgery, the mass was excised and the kidney implanted. One week later, the pathological study revealed the mass to be a clear cell renal carcinoma. After joint discussion, the urologic and nephrologic teams and the family decided to maintain the transplant, managing the patient with monotherapy based on rapamycin and close ultrasound control. To date, 8 years after transplantation, no signs of malignancy have been detected, and renal function is normal. CONCLUSION This is the first reported pediatric case of a living-donor graft with a small renal carcinoma excised in the operating room. No malignancy has been observed in 8 years of follow-up.
Collapse
|
44
|
Abstract
Laparoscopic donor nephrectomy has been widely accepted in living donor kidney transplantation. Ectopic kidneys are sometimes encountered during the living donor workup. Ectopic kidneys have been utilized successfully for kidney transplant. However, all these donor nephrectomies were performed by open surgery. We report a successful case of laparoscopic donor nephrectomy for ectopic kidney. The literature was reviewed and the technique points were emphasized.
Collapse
Affiliation(s)
- B He
- WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Nedlands, Australia.
| | | |
Collapse
|
45
|
Valente M, Furian L, Rigotti P. Organ Donors with Small Renal Cancer: Report of 3 Cases. Transplant Proc 2012; 44:1846-7. [PMID: 22974852 DOI: 10.1016/j.transproceed.2012.06.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
46
|
|
47
|
Flechner SM, Campbell SC. The use of kidneys with small renal tumors for transplantation: who is taking the risk? Am J Transplant 2012; 12:48-54. [PMID: 22054494 DOI: 10.1111/j.1600-6143.2011.03794.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The ever-increasing disparity between the number of organs available for transplant and the need for organs drives further exploration into the use of compromised or marginal donors. There is now an emerging advocacy for the use of kidneys with existing tumors, which may be rendered tumor free after surgical excision and reconstruction. This practice is based on reliable data that renal cancers <3 cm in diameter behave with minimal malignant potential and likelihood of transmission to the immunosuppressed recipient. However, in the case of live donors this creates a potential ethical conflict between those treating patients with renal masses and those with an interest in renal donation. The best available treatment for patients with a small renal tumor is a form of nephron-sparing tumor excision or ablation, as this approach provides for the maximum amount of residual kidney function and enhances survival. Thus, patients newly diagnosed with small renal tumors should be referred to centers with expertise in nephron sparing techniques, not transplant centers. In the case of an individual undergoing a live donor evaluation in which a small renal tumor is detected, a careful analysis of risk and benefit for the potential donor and the recipient is indicated.
Collapse
Affiliation(s)
- S M Flechner
- The Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
| | | |
Collapse
|
48
|
Ogawa Y, Mitsuhata N, Nishi M, Mannami R, Mannami M. One proposal to solve the organ shortage crisis in full understanding of donor-transmitted malignancies in kidney transplantation. Am J Transplant 2012; 12:259-60. [PMID: 22053993 DOI: 10.1111/j.1600-6143.2011.03804.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
49
|
|
50
|
Vasdev N, Khurram MA, Thomas D, Soomro N, Talbot D, Rix D. THE DEVELOPING CONCEPT OF USING ELECTIVE BENIGN AND MALIGNANT KIDNEYS FOR RENAL TRANSPLANTATION. BJU Int 2011; 108:627-8. [DOI: 10.1111/j.1464-410x.2011.10559.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|