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Oomen L, Bootsma-Robroeks C, Cornelissen E, de Wall L, Feitz W. Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades. Front Pediatr 2022; 10:856630. [PMID: 35463874 PMCID: PMC9024248 DOI: 10.3389/fped.2022.856630] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Worldwide, over 1,300 pediatric kidney transplantations are performed every year. Since the first transplantation in 1959, healthcare has evolved dramatically. Pre-emptive transplantations with grafts from living donors have become more common. Despite a subsequent improvement in graft survival, there are still challenges to face. This study attempts to summarize how our understanding of pediatric kidney transplantation has developed and improved since its beginnings, whilst also highlighting those areas where future research should concentrate in order to help resolve as yet unanswered questions. Existing literature was compared to our own data of 411 single-center pediatric kidney transplantations between 1968 and 2020, in order to find discrepancies and allow identification of future challenges. Important issues for future care are innovations in immunosuppressive medication, improving medication adherence, careful donor selection with regard to characteristics of both donor and recipient, improvement of surgical techniques and increased attention for lower urinary tract dysfunction and voiding behavior in all patients.
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Affiliation(s)
- Loes Oomen
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Charlotte Bootsma-Robroeks
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
- Department of Pediatrics, Pediatric Nephrology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Elisabeth Cornelissen
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Liesbeth de Wall
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
| | - Wout Feitz
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands
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2
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Safe Renal Transplantation to the Extraperitoneal Cavity in Children Weighing Less Than 15 kg. Transplant Proc 2022; 54:248-253. [DOI: 10.1016/j.transproceed.2021.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/29/2021] [Indexed: 11/22/2022]
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3
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Serrell EC, Su R, O'Kelly F, Semanik M, Farhat WA. The utility of native ureter in the management of ureteral complications in children after renal transplantation. Pediatr Transplant 2021; 25:e14051. [PMID: 34056809 DOI: 10.1111/petr.14051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/26/2021] [Accepted: 03/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ureteral complications after renal transplantation in children are a major source of morbidity. Management is complex and variable. METHODS With IRB approval, health records were retrospectively reviewed of patients who: were <18 years, underwent kidney transplant between 1997 and 2017, had at least 2 years of follow-up, and underwent interventions due to post-transplant ureteral complications. RESULTS Of 136 patients, seventeen (13%) required ureteral intervention due to stricture (n = 3), reflux (n = 12), or both (n = 2). Transplant occurred at median 10.5 years (3.1-14.7). Reconstruction occurred at median 10 months (7-15) after transplant. Pre-existing bladder pathology was present in 6 (35%) patients. Four of five patients with strictures had at least one endoscopic balloon dilation. Ultimate management included reimplantation, ureteroureterostomy of native to transplant ureter, pyeloureterostomy to native ureter, multiple endoscopic interventions followed by a Boari flap, or multiple failed endoscopic interventions. Fourteen patients with VUR underwent reimplantation (n = 5), ureteroureterostomy of native to transplant ureter (n = 4), pyeloureterostomy to native ureter (n = 4), and one underwent endoscopic injection with Deflux of the transplant ureter. Only one patient had a non-functioning graft due to ureteral complication. All patients were alive at follow-up (median 17 years [12-19]). CONCLUSIONS Transplant ureteral reflux and stricture are significant complications following pediatric renal transplantation and may require surgical management. In our population, reflux or stricture requiring ureteral reconstruction occurred in 10% and 4%, respectively. Endoscopic interventions were rarely successful. Native ureters were used for ureteral reconstruction in more than two thirds of patients should be considered in management of ureteral complications.
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Affiliation(s)
| | - Ruthie Su
- University of Wisconsin, Madison, WI, USA
| | - Fardod O'Kelly
- University of Wisconsin, Madison, WI, USA.,University College Dublin, Dublin, Ireland
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4
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O'Kelly F, Lorenzo AJ, Zubi F, De Cotiis K, Farhat WA, Koyle MA. The impact of multiple donor renal arteries on perioperative complications and allograft survival in paediatric renal transplantation. J Pediatr Urol 2021; 17:541.e1-541.e11. [PMID: 33883096 DOI: 10.1016/j.jpurol.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 01/21/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The impact of using allografts with multiple renal arteries in paediatric kidney transplantation has not been clearly established. The aim of this study was to determine whether kidney grafts with multiple arteries pose any adverse effects upon perioperative surgical outcomes, and graft survival up to 12 months post-transplant. OBJECTIVE The objective of this study was to perform a comparative analysis of a minimum of 12-month graft survival and transplant renal function in paediatric renal transplant recipients receiving single versus multiple donor arteries, and to assess perioperative and early post-operative surgical outcomes. STUDY DESIGN A retrospective divisional chart review of 379 transplants performed (2000-2018), of which 90 (23.7%) contained multiple donor arteries. The number of arteries of the graft, donor type, vascular reconstruction technique, occurrence of urological and vascular complications, estimated GFR and graft survival up to 12 months post-transplantation, graft loss and mortality were analysed. Comparisons in baseline characteristics and outcome measures were made between both groups. RESULTS No significant differences were found in age (p = 0.42), BMI (p = 0.39), estimated intraoperative blood loss (p = 0.14), overall (p = 0.63) or warm ischaemic time (p = 0.37). 51.3% patients with multiple donor arteries underwent an ex vivo reconstruction. There were no differences in the site of arterial anastomosis (aorta, external iliac, internal iliac), or anastomotic type (end-side; end-end). Whilst there was a significantly higher post-operative lymphocoele rate in the multiple vessel cohort (p = 0.024), there was no increase in post-transplant urine leaks, rejection episodes, graft loss (1.1% multiple vs 2.1% single), perioperative complications (p = 0.68), or estimated GFR at 1 month (p = 0.9) or at 1 year (p = 0.67). DISCUSSION We demonstrated in this study that there was no significant difference in postoperative complications up to 3 months, eGFR and renal function up to 1 year, and graft survival up to 4 years post transplantation irrespective of allograft type or reconstruction technique. There was however, a higher rate of lymphocoeles in the multiple artery cohort. The results seen here broadly mirror trends seen in adult studies, however, there is little data available from paediatric series. CONCLUSION Our study demonstrates that multiple renal artery allografts - previously been considered to carry a high complication risk - can be safely used for paediatric renal transplantation with equivalent perioperative complications and graft outcomes to single artery allografts.
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Affiliation(s)
- F O'Kelly
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, Canada; Division of Paediatric Urology, Beacon Hospital, University College, Dublin, Ireland.
| | - A J Lorenzo
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, Canada
| | - F Zubi
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, Canada
| | - K De Cotiis
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, Canada; Division of Pediatric Urology, Neymours/duPont Childrens Hospital, Delaware, USA
| | - W A Farhat
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, Canada; Division of Pediatric Urology, American Family Childrens Hospital, Wisconsin, USA
| | - M A Koyle
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, Canada
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ElSheemy MS, Ghoneima W, Aboulela W, Daw K, Shouman AM, Shoukry AI, Soaida S, Salah DM, Bazaraa H, Fadel FI, Hussein AA, Habib E, Saad IR, El Ghoneimy M, Morsi HA, Lotfi MA, Badawy H. Risk factors for urological complications following living donor renal transplantation in children. Pediatr Transplant 2018; 22. [PMID: 29082641 DOI: 10.1111/petr.13083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2017] [Indexed: 11/29/2022]
Abstract
The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy-three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow-up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.
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Affiliation(s)
| | - Waleed Ghoneima
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Waseem Aboulela
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Kareem Daw
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ahmed M Shouman
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ahmed I Shoukry
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Sherif Soaida
- Division of Pediatric Anesthesia, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Doaa M Salah
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Hafez Bazaraa
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Fatina I Fadel
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ahmed A Hussein
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Enmar Habib
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ismail R Saad
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | | | - Hany A Morsi
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Mohammed A Lotfi
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Hesham Badawy
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
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Maison POM, Smit S, McCulloch M, Gajjar P, Nourse P, Thomson D, Muller E, Millar A, Numanoglu A, Kahn D, Lazarus J. Urological complications following unstented pediatric renal transplantation. Pediatr Transplant 2017; 21. [PMID: 28834044 DOI: 10.1111/petr.13045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 11/29/2022]
Abstract
Urological complications which develop post-renal transplantation can be associated with significant morbidity especially in children. We evaluated the occurrence and management of all urological complications in a series of unstented pediatric renal transplants in a tertiary pediatric hospital. We reviewed the medical records of children who underwent unstented renal transplant between January 1996 and December 2014. Postoperative urological complications and the outcomes of their management were analyzed. A total of 160 unstented renal transplants were performed, and 32 urological complications were noted in 29 transplants (18%). There were 20 boys and nine girls with an age range of 2.5 years to 18.4 years. Nine (31%) of these patients had LUTD. The most common complication was VUR occurring in 17 patients (10.6%). Urine leaks occurred in six patients (3.8%) and ureteric obstruction in six patients (3.8%), and three patients (1.9%) had unexplained hydronephrosis. Loss of graft occurred in three patients (1.9%), and one patient died from sepsis post-uretero-ureterostomy. Patients with LUTD had more urological complications (P = .037). Unstenting is feasible in most pediatric renal transplants. LUTD is associated with a higher incidence of urological complications, especially VUR.
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Affiliation(s)
- Patrick Opoku Manu Maison
- Division of Urology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Shaun Smit
- Division of Urology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mignon McCulloch
- Division of Pediatric Nephrology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Priya Gajjar
- Division of Pediatric Nephrology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Peter Nourse
- Division of Pediatric Nephrology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Dave Thomson
- Division of General Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Elmi Muller
- Division of General Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Alastair Millar
- Division of Pediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Alp Numanoglu
- Division of Pediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Delawir Kahn
- Division of General Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - John Lazarus
- Division of Urology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Rodricks N, Chanchlani R, Banh T, Borges K, Vasilevska-Ristovska J, Hebert D, Patel V, Lorenzo AJ, Parekh RS. Incidence and risk factors of early surgical complications in young renal transplant recipients: A persistent challenge. Pediatr Transplant 2017; 21. [PMID: 28670838 DOI: 10.1111/petr.13006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2017] [Indexed: 11/29/2022]
Abstract
There is a paucity of data on the rate of urological and vascular complications in very young children after kidney transplant. We conducted a study on the incidence and risk factors for early post-transplant surgical complications in young recipients (<5 years) over three decades. The primary outcome was any urological or vascular complication within 30 days of transplant, and the secondary outcome was incidence rate of graft failure reported as per 1000 person-years. Risk factors associated with surgical complications were analyzed by logistic regression. There were 22 (26.5%) complications in 21 children with vascular thrombosis being the most common complication. There was no significant difference in the number of complications in period 1 (1985-1994) and period 2 (1995-2014) (P=.1). The incidence rate of graft failure was higher in period 1 (IR 70.8, 95% CI 41.1, 121.9) compared to period 2 (IR 20.7, 95% CI 9.3, 46.0). Cumulative incidence of graft survival at 1, 3, and 5 years' post-transplant was 96.5%, 92.6%, and 90%, respectively, in those without compared to 71%, 65.1%, and 58.6%, respectively, in children with complications. In conclusion, early surgical, especially vascular, complications are quite common in young renal transplant recipients and lead to significantly reduced graft survival.
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Affiliation(s)
- Nathan Rodricks
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Rahul Chanchlani
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Division of Nephrology, McMaster Children Hospital, McMaster University, Hamilton, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Tonny Banh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Karlota Borges
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | | | - Diane Hebert
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Viral Patel
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Armando J Lorenzo
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rulan S Parekh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health, Toronto, ON, Canada
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8
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Chen G, Wang C, Ko DSC, Qiu J, Yuan X, Han M, Wang C, He X, Chen L. Comparison of outcomes of kidney transplantation from donation after brain death, donation after circulatory death, and donation after brain death followed by circulatory death donors. Clin Transplant 2017; 31. [PMID: 28886219 DOI: 10.1111/ctr.13110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are three categories of deceased donors of kidney transplantation in China, donation after brain death (DBD), donation after circulatory death (DCD), and donation after brain death followed by circulatory death (DBCD) donors. The aim of this study was to compare the outcomes of kidney transplantation from these three categories of deceased donors. METHODS We retrospectively reviewed 469 recipients who received deceased kidney transplantation in our hospital from February 2007 to June 2015. The recipients were divided into three groups according to the source of their donor kidneys: DBD, DCD, or DBCD. The primary endpoints were delayed graft function (DGF), graft loss, and patient death. RESULTS The warm ischemia time was much longer in DCD group compared to DBCD group (18.4 minutes vs 12.9 minutes, P < .001). DGF rate was higher in DCD group than in DBD and DBCD groups (22.5% vs 10.2% and 13.8%, respectively, P = .021). Urinary leakage was much higher in DCD group (P = .049). Kaplan-Meier analysis showed that 1-, 2-, and 3-year patient survivals were all comparable among the three groups. CONCLUSION DBCD kidney transplantation has lower incidences of DGF and urinary leakage than DCD kidney transplant. However, the overall patient and graft survival were comparable among DBD, DCD, and DBCD kidney transplantation.
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Affiliation(s)
- Guodong Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Chang Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dicken Shiu-Chung Ko
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jiang Qiu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaopeng Yuan
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lizhong Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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