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Surgical Wound Dehiscence in Kidney Transplantation: Risk Factors and Impact on Graft Survival. Transplant Proc 2021; 54:27-31. [PMID: 34876270 DOI: 10.1016/j.transproceed.2021.09.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/28/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Surgical wound dehiscence (SWD) is a frequent complication after kidney transplantation (KT) but there is not enough evidence of its impact on graft survival. METHODS A retrospective cohort study including all KT patients with SWD in our center from January 2015 to July 2020 was performed. A case-control study was performed and for each case of SWD, 2 controls were selected (2:1). To identify risk factors for SWD, a logistic regression analysis was carried out and a multivariable Cox regression was used to describe risk factors for graft survival. RESULTS In our center, 503 KT were performed, and 39 patients presented SWD. They were older (62.1 vs 57.1 years; P = .030), most had diabetes mellitus (59% vs 28.6%; P = .002) and their body mass index was higher (31 vs 26.9 kg/m2; P < .001). In multivariable logistic regression analysis, diabetes mellitus (P = .024) and a body mass index ≥30 kg/m2 at time of transplantation (P = .018) were predictors of SWD. A higher rate of delayed graft function was described in SWD (P = .013) and it was associated with a longer hospital stay (20.9 vs 15 days; P = .004). Graft survival was lower in patients with SWD (P = .036). In multivariable Cox regression analysis, time in renal replacement therapy (P = .020) and SWD (P = .028) were predictors of shorter graft survival. CONCLUSION SWD is a risk factor for graft survival. The presence of diabetes mellitus and a higher body mass index are predictors for the appearance of this complication.
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Gioco R, Sanfilippo C, Veroux P, Corona D, Privitera F, Brolese A, Ciarleglio F, Volpicelli A, Veroux M. Abdominal wall complications after kidney transplantation: A clinical review. Clin Transplant 2021; 35:e14506. [PMID: 34634148 PMCID: PMC9285099 DOI: 10.1111/ctr.14506] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 12/16/2022]
Abstract
Introduction Abdominal wall complications are common after kidney transplantation, and although they have a minor impact on patient and graft survival, they increase the patient's morbidity and may have an impact on quality of life. Abdominal wall complications have an overall incidence of 7.7–21%. Methods This review will explore the natural history of abdominal wall complications in the kidney transplant setting, with a special focus on wound dehiscence and incisional herni, with a particular emphasis on risk factors, clinical characteristics, and treatment. Results Many patient‐related risk factors have been suggested, including older age, obesity, and smoking, but kidney transplant recipients have an additional risk related to the use of immunosuppression. Wound dehiscence usually does not require surgical intervention. However, for deep dehiscence involving the fascial layer with concomitant infection, surgical treatment and/or negative pressure wound therapy may be required. Conclusions Incisional hernia (IH) may affect 1.1–18% of kidney transplant recipients. Most patients require surgical treatment, either open or laparoscopic. Mesh repair is considered the gold standard for the treatment of IH, since it is associated with a low rate of postoperative complications and an acceptable rate of recurrence. Biologic mesh could be an attractive alternative in patients with graft exposition or infection.
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Affiliation(s)
- Rossella Gioco
- General Surgery Unit, University Hospital of Catania, Catania, Italy
| | | | | | - Daniela Corona
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | | | | | | | | | - Massimiliano Veroux
- General Surgery Unit, University Hospital of Catania, Catania, Italy.,Organ Transplant Unit, University Hospital of Catania, Catania, Italy
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Surgical site infection prevention and management in immunocompromised patients: a systematic review of the literature. World J Emerg Surg 2021; 16:33. [PMID: 34112231 PMCID: PMC8194010 DOI: 10.1186/s13017-021-00375-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/26/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients. METHODS A systematic review of the literature was conducted. RESULTS Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed. CONCLUSION Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population.
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Ruiz R, Cox T, McKenna GJ, Onaca N, Testa G, Fernandez H, Bayer J, Wall A, Martinez E, Gupta A, DiNubila JM, Jennings N, Wicklund K. Effect of subcutaneous tissue depth on outcomes of kidney transplantation. Proc (Bayl Univ Med Cent) 2020; 34:237-241. [PMID: 33678955 DOI: 10.1080/08998280.2020.1852835] [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: 10/22/2022] Open
Abstract
Although post-kidney transplant (KT) wound complications are associated with elevated body mass index (BMI), BMI is not an accurate surrogate of obesity. On the other hand, subcutaneous depth (SQD) measurement is a direct marker of truncal obesity. We examined outcomes of differing intraoperative SQD measurements in 113 KT-only recipients over 20 months. Recipients' median age was 51 years; median BMI, 28 kg/m2; and mean SQD, 2.9 cm. Patients were stratified into groups of SQD ≤2.5 cm, >2.5-5 cm, and >5 cm. An SQD of >2.5 to 5 cm correlated with a BMI of 30 kg/m2 (obesity) and an SQD >5 cm correlated with a BMI >35 kg/m2 (severe obesity). Degree of SQD was not associated with more frequent technical complications such as fascial dehiscence, lymphocele formation, renal artery thrombosis/stenosis, urine leak, or ureteral stenosis. However, an SQD >2.5 cm was a risk factor for requiring a wound vacuum-assisted closure device. There was no difference in graft or patient survival among the three SQD groups. Obesity, as measured directly by SQD, was not associated with increased technical complications or poor outcomes after KT. As expected, there was a higher incidence of wound complications in the higher SQD groups requiring intervention.
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Affiliation(s)
- Richard Ruiz
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
| | - Thomas Cox
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
| | - Gregory J McKenna
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Nicholas Onaca
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Hoylan Fernandez
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
| | - Johanna Bayer
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Anji Wall
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Eric Martinez
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Amar Gupta
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - J Michelle DiNubila
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
| | - Nicole Jennings
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
| | - Kari Wicklund
- Department of Transplant Surgery, Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
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Treatment of lymphocele with negative pressure wound therapy post inguinal mass excision: A case-report. Int J Surg Case Rep 2019; 66:43-47. [PMID: 31790951 PMCID: PMC6909207 DOI: 10.1016/j.ijscr.2019.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/01/2019] [Accepted: 11/07/2019] [Indexed: 12/04/2022] Open
Abstract
Safe and effective approach for treating inguinal lymphocele. Excision with ligation of lymphatic vessels. Negative pressure wound therapy.
Introduction A lymphocele is defined as an atypical collection of lymphatic fluid not bordered by distinct epithelial lining, which develops in anatomic compartments. Inguinal lymphocele is a common complication of surgery in the inguinal region, with an incidence ranging from 1 to 87 %. This report summarizes the management of an inguinal lymphocele post excision of an inguinal mass. Presentation of case Herein, we present a case in which an inguinal lymphocele developed four months post excision of an inguinal mass, which was later diagnosed as lymphoma and treated with iliac chain radiation therapy. The conservative treatment with lymphocele drainage, compression dressing and prophylactic antibiotic was initially implemented. As the patient did not respond to conservative treatment, the surgical strategy consisted of excision of lymphocele associated with lymphatic ducts ligation. Negative pressure wound therapy completed the treatment. Discussion Non-surgical treatment of lymphocele developing from lymphatic injure during groin dissection is not rarely unsuccessful. Surgical options include lymphocele excision with either ligation of the lymphatic ducts or lymphatic-venous shunts between afferent lymphatics and the collateral branch of great saphenous vein. Vacuum-assisted closure therapy assists the wound healing process by increasing blood flow, removing inhibiting factors of wound healing and decreasing the bacterial count. Conclusion Inguinal lymphocele that is not reabsorbed or does not resolve with conservative treatment should be surgically treated. Lymphocele excision with ligation of lymphatic vessels, followed by negative pressure wound therapy appears to be a safe and effective approach.
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Surgical Site Infections Complicating the Use of Negative Pressure Wound Therapy in Renal Transplant Recipients. Case Rep Transplant 2019; 2019:2452857. [PMID: 31662941 PMCID: PMC6778947 DOI: 10.1155/2019/2452857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/29/2019] [Accepted: 07/30/2019] [Indexed: 11/17/2022] Open
Abstract
Surgical site infections (SSI) of the abdominal wall in renal transplant recipients can on occasion require management with negative pressure wound therapy (NPWT). This is often successful, with a low risk of further complications. However, we describe three cases in which persistent or recurrent surgical site sepsis occurred, whilst NPWT was being deployed in adults with either wound dehiscence or initial SSI. This type of complication in the setting of NPWT has not been previously described in renal transplant recipients. Our case series demonstrates that in immunosuppressed transplant recipients, there may be ineffective microbial or bacterial bioburden clearance associated with the NPWT, which can lead to further infections. Hence recognition for infections in renal transplant patients undergoing treatment with NPWT is vital; furthermore, aggressive management of sepsis control with early debridement, antimicrobial use, and reassessment of the use of wound dressing is necessary to reduce the morbidity associated with surgical site infections and NPWT.
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McKinnon VE, Barkho J, McRae MH. Use of negative-pressure wound therapy and split-thickness skin autograft to cover an exposed renal transplant. BMJ Case Rep 2019; 12:12/9/e231197. [PMID: 31540924 DOI: 10.1136/bcr-2019-231197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Exposure of a renal transplant through the abdominal wall is a rare event. A search of the literature reveals only six documented cases which used skin autograft for coverage, with none reported since 1981, and none which used negative-pressure wound therapy (NPWT) to prepare the recipient bed. This case report demonstrates that NPWT followed by split thickness skin graft is a reconstructive option which is feasible in patients who are at high risk for surgical complications in prolonged flap surgery.
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Affiliation(s)
| | - Jouseph Barkho
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mark H McRae
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Michalski CW, Mohammadi S, Khajeh E, Ghamarnejad O, Sabagh M, Pianka F, Golriz M, Kulu Y, Kallinowski F, Zeier M, Morath C, Diener MK, Büchler MW, Mehrabi A. Prophylactic onlay reinforcement with absorbable mesh (polyglactin) is associated with less early wound complications after kidney transplantation: A preliminary study. J Biomed Mater Res B Appl Biomater 2019; 108:67-72. [PMID: 30897297 DOI: 10.1002/jbm.b.34366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/19/2019] [Accepted: 03/05/2019] [Indexed: 02/05/2023]
Abstract
Incidence of wound complications after kidney transplantation (KTx) is still considerable. Here, we report the impact of prophylactic absorbable polyglactin (Vicryl®) mesh reinforcement on the incidence of short-term post-KTx wound complications. Sixty-nine patients were analyzed; 23 with and 46 without preventive onlay mesh reinforcement. Surgical site infections (SSI) were seen in six (26%) patients in the mesh group and in 17 (37%) patients in no-mesh group. A lower, but not statistically significant, rate of early postoperative wound complications occurred in the mesh group. Wound complications were observed in seven (30%) patients in the mesh group and in 23 (50%) patients in the no-mesh group. There was no association between mesh placement and SSI incidence (odds ratios [OR] 0.60, 95% confidence interval [CI] 0.20-1.82, p = 0.369) and wound complications (OR 0.44, 95% CI 0.15-1.26, p = 0.126). Therefore, we conclude that mesh reinforcement does not increase the risk of SSI and overall wound complications. Long-term outcomes have to be evaluated in a randomized trial setting. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 108B:67-72, 2020.
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Affiliation(s)
- Christoph W Michalski
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sara Mohammadi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mohammadsadegh Sabagh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Frank Pianka
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Friedrich Kallinowski
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Hernia Center, University of Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Christian Morath
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Abdominal wall complications following renal transplantation in adult recipients - factors associated with interventional management in one unit. BMC Surg 2019; 19:10. [PMID: 30665387 PMCID: PMC6341541 DOI: 10.1186/s12893-019-0468-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022] Open
Abstract
Background Abdominal wall surgical site complications following renal transplantation can be challenging to manage. A sub-group of these recipients will require operative management or advanced wound care such as negative pressure wound therapy (NPWT). The aim of this study was to determine if there were any preoperative, intraoperative and postoperative characteristics in our recipients’ cohort which were associated with the requirement for such interventions. Methods A retrospective review of medical records was performed for all recipients who sustained abdominal wall complications following renal transplantation at our centre from 2006 to 2016. Results A total of 64/828 recipients (7.7%) had abdominal wall complications. The mean weight for these patients was 84.9 kg (±16.6 kg) and the mean body mass index was 30.2 (±5.1). Forty-five recipients (70%) had a superficial wound dehiscence while nine (14%) had a complete fascial dehiscence. Operative intervention was required in 13/64 patients (20%) and was more likely to be required in the presence of a fascial dehiscence (9/9, 100%) or a wound collection (10/31, 32%) (p < 0.001, p = 0.021). NPWT was used in 17/64 patients (27%) and was more commonly required in patients with diabetes mellitus (10/24, 42%), a complete fascial dehiscence (5/9, 56%) or evidence of infection (16/44, 36%) (p = 0.039, p = 0.034, p = 0.008). Conclusions The requirement for either operative management or the use of NPWT in the management of abdominal wall complications following renal transplantation in our experience was more common in recipients with diabetes mellitus, and in the setting of either complete fascial dehiscence, abdominal wall wound collections and/ or infection.
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Shrestha BM. Systematic Reviews and Meta-analysis: Principles and Practice. JNMA J Nepal Med Assoc 2019; 57:1-2. [PMID: 31080236 PMCID: PMC8827566 DOI: 10.31729/jnma.3986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Badri Man Shrestha
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
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Chen X, Liu L, Nie W, Deng R, Li J, Fu Q, Fei J, Wang C. Vacuum Sealing Drainage Therapy for Refractory Infectious Wound on 16 Renal Transplant Recipients. Transplant Proc 2018; 50:2479-2484. [PMID: 30316382 DOI: 10.1016/j.transproceed.2018.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 03/03/2018] [Accepted: 04/06/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Refractory infectious wounds on renal transplantation (RT) recipients significantly prolong hospital stay, increase medical costs, and threaten allograft survival. Vacuum sealing drainage (VSD) therapy is a new technique for managing wounds based on the principle of application of controlled negative pressure. The aim of this study was to summarize the efficacy and safety of VSD therapy in the management of refractory infectious wounds following RT. MATERIALS AND METHODS This is a retrospective study of a cohort of 661 consecutive patients who received renal transplants over a period of 3 years in which the data were collected and analyzed retrospectively. RESULTS Out of the 661 patients, 16 (2.4%) developed refractory wound infection following RT. Nineteen organisms were identified by culture from all patients, including 10 patients infected with 1 or more bacteria, 2 patients with fungal infection, and 4 patients with both. Specifically, mucormycosis was demonstrated in 4 patients, pan-resistant Klebsiella pneumoniae in 2 patients, and Acinetobacter baumannii in 2 patients. All 16 patients were treated with VSD therapy for a median of 37 days (range, 6-111 days). The number of VSD sets used ranged from 4 to 28 sets (mean, 11.1 sets). A combination of antibiotics, debridement, and VSD therapy lead to 100% (16 of 16) wound healing. No VSD-relevant adverse events were observed. CONCLUSIONS VSD therapy is an effective and safe adjunct to conventional treatment modalities for the management of refractory wound infection following RT.
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Affiliation(s)
- X Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - L Liu
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - W Nie
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - R Deng
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - J Li
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Q Fu
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - J Fei
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - C Wang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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