Navigating Living Kidney Donation and Transplantation Among South Asian Canadians: The ACTION Project

RATIONALE & OBJECTIVE

South Asian (SA) Canadians with kidney failure have a 50%-77% lower likelihood of kidney transplant and are less likely to identify potential living donors (LDs). This study aimed to identify health system-, patient-, and community-level barriers and facilitators for accessing LD kidney transplantation in the SA community to inform the development of health system- and community-level interventions to address barriers.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

20 SA recipients of an LD or deceased-donor kidney transplant, 10 SA LDs, and 41 general SA community members.

ANALYTICAL APPROACH

In-depth multilingual interviews were conducted with recipients and LDs. Gender-, language-, and age-stratified focus groups were conducted with general SA community members. Summative content analysis was used to analyze the data.

RESULTS

Hesitancy in approaching potential donors, fear about the health of potential LDs, information gaps, language barriers, and challenges evaluating out-of-country donors were highlighted as significant barriers by recipients, and financial concerns and information gaps were identified by donors. Cultural barriers in the SA community were highlighted by donors, recipients, and community members as critical factors when considering donation and transplant; women and elderly SA Canadians highlighted nuanced challenges. Participants reported generally a favorable perception of their health care teams, citing SA representation in the teams as important to providing culturally and linguistically sensitive care.

LIMITATIONS

Limited geographic, race, and cultural representation and reliance on virtual data collection.

CONCLUSIONS

This study highlights several culturally relevant barriers to donation and transplant that are potentially modifiable through patient-, health system-, and community-focused engagement and education.

Alkaline phosphatase to treat ischaemia-reperfusion injury in living-donor kidney transplantation: APhIRI I feasibility pilot study

AIMS

Ischemia-reperfusion injury (IRI) during kidney transplant procedures is associated with adverse outcome. Alkaline phosphatase (AP) is an enzyme that has the potential to dampen IRI. Prior to this study, it had not been tested in the setting of kidney transplantation. This study aimed to evaluate the safety and feasibility of peri-procedural AP administration in living donor kidney transplantation.

METHODS

In this double blind, randomized, placebo-controlled, single-center pilot study, all eligible recipients of living donor kidneys were asked to give informed consent. AP (bRESCAP) or a placebo was administered intravenously over 24 hours after the transplantation procedure. The primary outcome-graft function at 1 year-was represented by iohexol measured glomerular filtration rate (mGFR). Serum and urine biomarkers within seven days after surgery were used as surrogate markers of kidney function and injury.

RESULTS

Eleven patients were enrolled of whom five were treated with bRESCAP and six with placebo. After 1 year, mGFR was not different between groups. No specific adverse events were observed in the bRESCAP group. Urine expression of injury biomarkers CCL14, NGAL and Cystatin C was lower in the bRESCAP group at day seven. This was statistically significant.

CONCLUSION

This study illustrates that bRESCAP treatment is feasible in kidney transplantation, might have a dampening effect on IRI induced renal inflammation, and raises no safety concerns. Future research will evaluate the effects of bRESCAP treatment in donation after circulatory death kidney transplantation where IRI is more pronounced.

Prediction models for the recipients' ideal perioperative estimated glomerular filtration rates for predicting graft survival after adult living-donor kidney transplantation

Introduction

The impact of the perioperative estimated glomerular filtration rate (eGFR) on graft survival in kidney transplant recipients is yet to be evaluated. In this study, we developed prediction models for the ideal perioperative eGFRs in recipients.

Methods

We evaluated the impact of perioperative predicted ideal and actual eGFRs on graft survival by including 1,174 consecutive adult patients who underwent living-donor kidney transplantation (LDKT) between January 2008 and December 2020. Prediction models for the ideal perioperative eGFR were developed for 676 recipients who were randomly assigned to the training and validation sets (ratio: 7:3). The prediction models for the ideal best eGFR within 3 weeks and those at 1, 2, and 3 weeks after LDKT in 474 recipients were developed using 10-fold validation and stepwise multiple regression model analyzes. The developed prediction models were validated in 202 recipients. Finally, the impact of perioperative predicted ideal eGFRs/actual eGFRs on graft survival was investigated using Fine-Gray regression analysis.

Results

The correlation coefficients of the predicted ideal best eGFR within 3 weeks and the predicted ideal eGFRs at 1, 2, and 3 weeks after LDKT were 0.651, 0.600, 0.598, and 0.617, respectively. Multivariate analyzes for graft loss demonstrated significant differences in the predicted ideal best eGFR/actual best eGFR within 3 weeks and the predicted ideal eGFRs/actual eGFRs at 1, 2, and 3 weeks after LDKT.

Discussion

The predicted ideal best eGFR/actual best eGFR within 3 weeks and the predicted ideal eGFRs/actual eGFRs at 1, 2, and 3 weeks after LDKT were independent prognostic factors for graft loss. Therefore, the perioperative predicted ideal eGFR/actual eGFR may be useful for predicting graft survival after adult LDKT.

Adult Living-Donor Kidney Transplantation, Donor Age, and Donor-Recipient Age

INTRODUCTION

Owing to organ shortage, the number of kidney transplantation (KT) involving older adult living donors is increasing. We aimed to investigate the effects of living-donor age and donor-recipient age differences on KT outcomes.

METHODS

This single-center, retrospective cohort study involved 853 adult LDKTs performed between January 2008 and December 2018. Recipients were stratified into the following 5 groups based on donor age and donor-recipient age difference: donor age, 30 to 49 years and age difference, -10 to 15 years; donor age, 50 to 69 years and age difference, -10 to 15 years; donor age, 50 to 69 years and age difference, 15 to 40 years; donor age, 70 to 89 years and age difference, -10 to 15 years; and donor age, 70 to 89 years and age difference, 15 to 40 years (groups 1, 2, 3, 4, and 5, respectively). As a primary outcome, the risk of graft loss was investigated. The secondary outcomes were postoperative estimated glomerular filtration rates (eGFRs) and mortality rates of recipients.

RESULTS

Group 4, representing KT between older adult donors and older adult recipients, had the highest graft loss risk and mortality. The eGFRs of the recipients from donors aged 70 to 89 years (groups 4 and 5) were significantly lower than those from donors in the other groups. Although the differences in the eGFR between groups 4 and 5 were not significant, the eGFR of group 4 was lower than that of group 5 at 6 months post-KT.

CONCLUSION

LDKTs from older adult donors to older adult recipients resulted in the worst graft survival and mortality rates.

Multiple Vessel Living-Donor Kidney Transplantation: A Retrospective Comparison of 210 Patients

Background: The use of living-donor kidney allografts with multiple vessels continues to rise in order to increase the donor pool. This requires surgeons to pursue vascular reconstructions more often, which has previously been associated with a higher risk of developing early post-transplant complications. We therefore wanted to investigate the prognostic role of using living-donor renal allografts with a single artery (SA) vs. multiple arteries (MA) at the time of transplant.

Methods: We retrospectively analyzed a cohort of 210 consecutive living-donor kidney transplants performed between January, 2008 and March, 2019, and compared the incidence of developing postoperative complications and other clinical outcomes between SA vs. MA recipients.

Results: No differences were observed between SA (N = 161) and MA (N = 49) kidneys in terms of the incidence of developing a postoperative (or surgical) complication, a urologic complication, hospital length of stay, delayed graft function, estimated glomerular filtration rate at 3 or 12 mo post-transplant, and graft survival.

Conclusions: The use of live-kidney allografts with MA requiring vascular reconstruction shows excellent clinical outcomes and does not increase the risk of developing postoperative complications or other adverse outcomes when compared with SA renal allografts.

Non-simultaneous kidney exchange cycles in resource-restricted countries without non-directed donation - a prospective single-center cohort study

Recent reports suggest that bridge-donor reneging is rare (1.5%) in non-simultaneous kidney exchange chains. However, in developing countries, the non-directed donors who would be needed to initiate chains are unavailable, and furthermore, limited surgical space and resources restrain the feasibility of simultaneous kidney exchange cycles. Therefore, the aim of this study was to evaluate the bridge-donor reneging rate during non-simultaneous kidney exchange cycles (NSKEC) in a prospective single-center cohort study (n = 67). We describe the protocol used to prepare co-registered donor-recipient pairs for non-simultaneous surgeries, in an effort to minimize the reneging rate. In addition, in order to protect any recipients who might be left vulnerable by this arrangement, we proposed the use of standard criteria deceased-donor kidneys to rectify the injustice in the event of any bridge-donor reneging. We report 17 successful NSKEC resulting in 67 living-donor kidney transplants (LDKT) using 23 bridge-donors without donor renege and no intervening pairs became unavailable. We propose that NSKEC could increase LDKT, especially for difficult-to-match sensitized pairs (25 of our 67 pairs) in countries with limited transplantation resources. Our study confirms that NSKEC can be safely performed with careful patient-donor selection and non-anonymous kidney exchanges.

Investigating Ethnic Disparity in Living-Donor Kidney Transplantation in the UK: Patient-Identified Reasons for Non-Donation among Family Members

There is ethnic inequity in access to living-donor kidney transplants in the UK. This study asked kidney patients from Black, Asian and minority ethnic groups why members of their family were not able to be living kidney donors. Responses were compared with responses from White individuals. This questionnaire-based mixed-methods study included adults transplanted between 1/4/13–31/3/17 at 14 UK hospitals. Participants were asked to indicate why relatives could not donate, selecting all options applicable from: Age; Health; Weight; Location; Financial/Cost; Job; Blood group; No-one to care for them after donation. A box entitled ‘Other—please give details’ was provided for free-text entries. Multivariable logistic regression was used to analyse the association between the likelihood of selecting each reason for non-donation and the participant’s self-reported ethnicity. Qualitative responses were analysed using inductive thematic analysis. In total, 1240 questionnaires were returned (40% response). There was strong evidence that Black, Asian and minority ethnic group individuals were more likely than White people to indicate that family members lived too far away to donate (adjusted odds ratio (aOR) = 3.25, 95% Confidence Interval (CI) 2.30–4.58), were prevented from donating by financial concerns (aOR = 2.95, 95% CI 2.02–4.29), were unable to take time off work (aOR = 1.88, 95% CI 1.18–3.02), were “not the right blood group” (aOR = 1.65, 95% CI 1.35–2.01), or had no-one to care for them post-donation (aOR = 3.73, 95% CI 2.60–5.35). Four qualitative themes were identified from responses from Black, Asian and minority ethnic group participants: ‘Burden of disease within the family’; ‘Differing religious interpretations’; ‘Geographical concerns’; and ‘A culture of silence’. Patients perceive barriers to living kidney donation in the UK Black, Asian and minority ethnic population. If confirmed, these could be targeted by interventions to redress the observed ethnic inequity.

Has the UK living kidney donor population changed over time? A cross-sectional descriptive analysis of the UK living donor registry between 2006 and 2017

BACKGROUND

A living-donor kidney transplant is the best treatment for most people with kidney failure. Population cohort studies have shown that lifetime living kidney donor risk is modified by sex, age, ethnicity, body mass index (BMI), comorbidity and relationship to the recipient.

OBJECTIVES

We investigated whether the UK population of living kidney donors has changed over time, investigating changes in donor demographics.

DESIGN

We undertook a cross-sectional analysis of the UK living kidney donor registry between January 2006 to December 2017. Data were available on living donor sex, age, ethnicity, BMI, hypertension and relationship to recipient.

SETTING

UK living donor registry.

PARTICIPANTS

11 651 consecutive living kidney donors from January 2006 to December 2017.

OUTCOME MEASURES

Living kidney donor demographic characteristics (sex, age, ethnicity, BMI and relationship to the transplant recipient) were compared across years of donation activity. Donor characteristics were also compared across different ethnic groups.

RESULTS

Over the study period, the mean age of donors increased (from 45.8 to 48.7 years, p<0.001), but this change appears to have been limited to the White population of donors. Black donors were younger than White donors, and a greater proportion were siblings of their intended recipient and male. The proportion of non-genetically related non-partner donations increased over the 12-year period of analysis (p value for linear trend=0.002).

CONCLUSIONS

The increasing age of white living kidney donors in the UK has implications for recipient and donor outcomes. Despite an increase in the number of black, Asian and minority ethnic individuals waitlisted for a kidney transplant, there has been no increase in the ethnic diversity of UK living kidney donors. Black donors in the UK may be at a much greater risk of developing kidney failure due to accumulated risks: whether these risks are being communicated needs to be investigated.

Perspectives of African-American Family Members about Kidney Failure Treatment

Understanding African-American families' experiences with treatment for kidney failure is necessary for informing the delivery of family-centered care and the design of appropriate interventions. This qualitative study explored treatment-related questions, concerns, and family impacts among African-American family members of patients with pre-kidney failure and kidney failure. Thirty-five family members participated in focus groups stratified by patients' treatment experiences (pre-kidney failure, in-center hemodialysis, peritoneal dialysis, awaiting living-donor kidney transplantation, or post-transplantation). Family members raised questions and concerns about the psychological, lifestyle, and practical aspects of treatment. Similarly, discussions about family impacts emphasized psychosocial effects, lifestyle consequences, and the provision and receipt of support. Efforts to address these questions, concerns, and perceived family impacts through additional research, early and tailored education, and supportive interventions are needed.

Beliefs of UK Transplant Recipients about Living Kidney Donation and Transplantation: Findings from a Multicentre Questionnaire-Based Case-Control Study

Differing beliefs about the acceptability of living-donor kidney transplants (LDKTs) have been proposed as explaining age, ethnic and socioeconomic disparities in their uptake. We investigated whether certain patient groups hold beliefs incompatible with LDKTs. This questionnaire-based case–control study was based at 14 hospitals in the United Kingdom. Participants were adults transplanted between 1 April 2013 and 31 March 2017. LDKT recipients were compared to deceased-donor kidney transplant (DDKT) recipients. Beliefs were determined by the direction and strength of agreement with ten statements. Multivariable logistic regression was used to investigate the association between beliefs and LDKT versus DDKT. Sex, age, ethnicity, religion, and education were investigated as predictors of beliefs. A total of 1240 questionnaires were returned (40% response). DDKT and LDKT recipients responded in the same direction for 9/10 statements. A greater strength of agreement with statements concerning the ‘positive psychosocial effects’ of living kidney donation predicted having an LDKT over a DDKT. Older age, Black, Asian and Minority Ethnic (BAME) group ethnicity, and having a religion other than Christianity were associated with greater degree of uncertainty regarding a number of statements, but there was no evidence that individuals in these groups hold strong beliefs against living kidney donation and transplantation. Interventions should address uncertainty, to increase LDKT activity in these groups.

Family Members' Experiences With Dialysis and Kidney Transplantation

Rationale & Objective

Understanding whether family members’ experiences with patients’ treatment for end-stage kidney disease (ESKD) were expected could guide the development of family-centered interventions that enhance the preparedness of patients and their care partners for kidney replacement therapies. We explored unexpected negative experiences with ESKD treatments among family members of dialysis and posttransplantation patients to identify meaningful directions for family-centered research and clinical care.

Study Design

Qualitative study.

Setting & Participants

8 focus groups comprising 49 family members of dialysis patients and living donor kidney transplant recipients undergoing medical care in Baltimore, MD.

Analytical Approach

Focus groups were stratified by patients’ treatment (in-center hemodialysis, home hemodialysis, peritoneal dialysis, or living donor kidney transplantation) and family members’ self-reported race (African American vs non–African American), resulting in 2 groups per treatment experience. Inductive thematic analysis was used to identify themes in focus group transcripts. Themes shared across different treatment groups were highlighted to provide insight into common experiences.

Results

We identified 4 themes that described family members’ unexpected negative treatment experiences: becoming a care partner (unanticipated responsibilities and sleep disruptions), adverse psychological treatment responses in patients (eg, depression) and family members (eg, anxiety), treatment delivery and logistics (insufficient information, medication regimen, and logistical inconveniences), and patient morbidity (dialysis-related health problems and fatigue). All themes were relevant to discussions in the in-center hemodialysis, peritoneal dialysis, and transplantation groups, whereas psychological responses and morbidity themes did not reflect discussions in home hemodialysis groups.

Limitations

Data collection occurred from 2008 to 2009; family members were recruited through patients undergoing care in 1 geographic area; 1 family member participant per patient.

Conclusions

Family members described a broad range of unexpected negative experiences with ESKD treatments. Efforts to prepare families for ESKD treatments through more family-centered care, early and tailored education, and interventions targeting care partner preparedness, health provider–family member communication, and relationship dynamics in family member–patient dyads are needed.

Transplant center characteristics associated with living-donor kidney transplantation: a cohort study with a hierarchical modeling approach

Transplant center organization, that is a modifiable factor, may affect the access to living-donor kidney transplantation (LDKT). The objective of this study was to identify the center characteristics associated with LDKT using a hierarchical analysis. This was a retrospective multicenter observational study of 8701 patients who received a first renal graft between 2010 and 2014 in 32 transplantation centers of France. Hierarchical modeling was used to estimate the center effect and organization associated with LDKT. Among 8507 patients, 1225 (12%) were transplanted with a LD kidney. There was a transplant center effect on the proportion of LDKT. After adjustment for patient and center characteristics, the random effect variance decreased by 47%. Patients transplanted at a center with more than four nephrologists [1.81 (95% CI: 1.10-2.95)] and more than 1.5 nurse transplant coordinators [1.98 (95% CI: 1.26-3.13)] were more likely to be transplanted with a LD kidney. ABO-incompatible program was associated with LDKT [2.23 (95% CI: 1.22-4.06)]. There was a transplant center effect on the proportion of LDKT that could be decreased by modifiable center characteristics. Our study suggests the importance of the transplant team organization on the LDKT utilization.

Chimerism-based tolerance in organ transplantation: preclinical and clinical studies

Induction of allograft tolerance has been considered the ultimate goal in organ transplantation. Although numerous protocols to induce allograft tolerance have been reported in mice, a chimerism-based approach through donor haematopoietic stem cell transplantation has been the only approach to date that induced allograft tolerance reproducibly following kidney transplantation in man. Renal allograft tolerance has been achieved by induction of either transient mixed chimerism or persistent full donor chimerism. Although the risk of rejection may be low in tolerance achieved via durable full donor chimerism, the development of graft-versus-host disease (GVHD) has limited the wider clinical application of this approach. In contrast, tolerance induced by transient mixed chimerism has not been associated with GVHD, but the risk of allograft rejection is more difficult to predict after the disappearance of haematopoietic chimerism. Current efforts are directed towards the development of more clinically feasible and reliable approaches to induce more durable mixed chimerism in order to widen the clinical applicability of these treatment regimens.

Cystatin-C is associated with partial recovery of kidney function and progression to chronic kidney disease in living kidney donors: Observational study

Donor nephrectomy in living-donor kidney transplantation may result in hyperfiltration injury in remnant kidney; however, its clinical implication in partial recovery of kidney function (PRKF) in remnant kidney and chronic kidney disease (CKD) progression remains unclear. Thus, we investigated the effect of PRKF on CKD development in the residual kidney and the utility of cystatin-C (Cys-C) in evaluating renal function in living-donor kidney transplantation donors.The electronic medical records and laboratory results of 1648 kidney transplant (KT) donors and 13,834 healthy nondonors between January 2006 and November 2014 were reviewed. The predictors of PRKF and CKD diagnosed by Kidney Disease: Improving Global Outcomes (KDIGO) criteria were evaluated by multivariate analysis. CKD risk was compared between KT donors and healthy nondonors using Cox proportional hazard regression analysis following propensity score matching (PSM).The incidence of PRKF for KT donors was 49.3% (813). CKD incidence was 24.8% (408) in KT donors and 2.0% (277) in healthy nondonors. The predictors of PRKF were, male sex (odds ratio [OR], 17.32; 95% confidence interval [CI] 9.16-32.77), age (OR, 1.02; 95% CI, 1.00-1.04; P < 0.001), Cys-C concentration (OR, 1.02; 95% CI, 1.00-1.04; P = 0.02), and preoperative albumin level (OR, 0.49; 95% CI, 0.27-0.89; P = 0.02). The predictors of CKD were age (hazards ratio [HR], 1.04; 95% CI, 1.02-1.05; P < 0.001), Cys-C concentration (HR, 1.024; 95% CI, 1.012-1.037; P < 0.001), and PRKF (HR, 1.41; 95% CI, 1.04-1.92; P = 0.03). After PSM, the risk of progression to CKD was higher in KT donors than in healthy nondonors (HR, 58.4; 95% CI, 34.2-99.8; P < 0.001).Donor nephrectomy is associated with PRKF and progression to CKD. Cys-C is a useful early marker for detecting PRKF and CKD.

Impact of grafting using thin upper pole artery ligation on living-donor adult kidney transplantation: The STROBE study

This study aimed to investigate the impact of grafting using thin upper pole artery ligation for living-donor adult kidney transplantation. Few reports have examined the safety of thin upper pole artery ligation.Between January 2008 and May 2015, 613 consecutive living-donor adult kidney transplantations were performed. We excluded 21 recipients who experienced graft loss due to factors that were unrelated to surgical complications and 3 recipients with grafts treated with arterial reconstruction and thin upper pole artery ligation for 3 arteries. We included 439 kidney grafts with single arteries (Single Artery Group), 123 with reconstructed arteries (Arterial Reconstruction Group) and 27 with ligated thin upper pole arteries (Arterial Ligation Group) in this retrospective cohort study. To evaluate the safety of thin upper pole artery ligation, we compared the Arterial Ligation Group with the Single Artery and Arterial Reconstruction groups. We evaluated the characteristics of the enrolled donors, recipients, and their grafts. Thereafter, we investigated recipients' perioperative and postoperative estimated glomerular filtration rate (eGFR) and complication rates.Significant differences among the 3 groups were identified for donor sex and endoscopic nephrectomy rates. Recipient eGFR and the complication rates were adjusted according to these factors. The perioperative and postoperative eGFR of recipients did not differ significantly in the Arterial Reconstruction and Single Artery groups with low complication rates.Thin upper pole artery ligation is a safe procedure for living-donor adult kidney transplantation and may prevent unnecessary arterial reconstruction and associated complications.

[Applying Mishel's Uncertainty Theory to the Care of a Patient After Living-Donor Kidney Transplantation: A Care Experience]

Kidney transplantation greatly benefits end-stage renal disease patients, as they no longer must bear the torment of hemodialysis. However, the effectiveness of living-donor kidney transplantation is often negatively impacted by various complications, which patients may learn to control through related self-care strategies. However, lack of information on these complications and related strategies may lead to feelings of uncertainty and worries over the prognosis. This article discusses a nursing experience with a patient who underwent living-donor kidney transplantation and who suffered from immense uncertainty and prognosis-related worry. Based on the assessment framework of Mishel's uncertainty theory, the authors identified the cause of the subject's uncertainty and offered thorough information regarding post-transplant care. During the period of care, the subject gained self-care knowledge and skills. Furthermore, he learned to apply self-recording, a technique that enabled him to self-monitor the progress of his disease progress, which reduced his sense of insecurity significantly. Ultimately, the subject turned uncertainty into motivation in order to actively participate in his treatment and to maintain optimum health status.

Outcomes of kidney paired donation transplants in relation to shipping and cold ischaemia time

To assess the impact of shipping distance and cold ischaemia time (CIT) of shipped organs in a kidney paired donation (KPD) programme, we evaluated the outcomes of the initial 100 kidney transplants performed in the Australian KPD programme. In a 44-month period, 12 centres were involved in fifteen 2-way, twenty 3-way, one 4-way and one 6-way exchanges. Sixteen kidneys were transplanted at the same hospital (CIT 2.6 ± 0.6 h) and 84 required transport to the recipient hospital (CIT 6.8 ± 2.8 h). A spontaneous fall in serum creatinine by at least 10% within 24 h was observed in 85% of recipients, with no difference between nonshipped and shipped kidneys. There were two cases of transient delayed graft function requiring dialysis and patient and graft survival at 1 year were 99% and 97%, respectively. There was no difference in recipients of nonshipped compared with shipped kidneys with regard to serum creatinine at 1 month (mean difference (MD) 7.3 μmol/l, 95% CI -20.2 to 34.8, P = 0.59), 1-year graft survival (MD 3.9%, 95% CI -5.4 to 13.2, P = 0.41) or patient survival (MD -2.4%, 95% CI -10.0 to 5.2, P = 0.54). Despite prolonged CIT for interstate exchanges, the programme's decision to ship donor kidneys rather than the donor appears to be safe.

ABO-incompatible living-donor pediatric kidney transplantation in Japan

The Japanese ABO-Incompatible Transplantation Committee officially collected and analyzed data on pediatric ABO-incompatible living-donor kidney transplantation in July 2012. The age of a child was defined as <16 years, and 89 children who had undergone ABO-incompatible living-donor kidney transplantation from 1989 to 2011 were entered in a registry. These data were presented as the Japanese registry of pediatric ABO-incompatible living-donor kidney transplantation at the regional meetings of the International Pediatric Transplantation Association (IPTA) in Nagoya in September 2012 and in Sao Paulo in November 2012.