- Email: [email protected]
Increasing the Donor and Recipient Pool—Expanded Criteria in Living Kidney Donors
Increasing the Donor and Recipient Pool—Expanded Criteria in Living Kidney Donors A. Kocot and M. Giessing ABSTRACT To increase the donor and recipient pool in living related renal transplantation, kidneys from expanded criteria living donors are used more frequently to reduce the general problem of organ shortage. This article presents an overview of the current literature concerning this topic to further improve donor selection and transplant decision making. N DECEASED KIDNEY DONATION, the graft outcome and survival are implicated by the quality of the donated organ. Compared to expanded donor criteria in deceased donors, donor safety for living donors is a most important issue before expanding donor criteria.1 Donors with specific medical abnormalities need careful management postoperatively including assessment of long-term outcomes.2 In addition to the common expanded donor criteria3,4—age, obesity, hypertention, decreased glomerular filtration rate (GFR), proteinuria, and microscopic hematuria— donors with anatomical specifications like obstruction of the ureteropelvic junction, kidney stones, renal cysts, and complex vascular anatomy may be evaluated as possible candidates for living kidney transplantation.
I
MATERIALS AND METHODS We performed a Medline and PubMed research concerning expanded donor criteria in living kidney transplantation. We also included recommendations from international guidelines of urologic scientific societies.
RESULTS Expanded Living Donor Criteria
Iordanous et al5 presented the first systematic review and meta-analysis to examine the impact of living donor age and other expanded criteria on recipient outcomes. In most studies, living expanded criteria donors were defined as having any of the following features prior to the time of renal donation: (1) age over 60 years; (2) obesity: body mass index either ⬎ 30 kg/m2 or ⬎ 35 kg/m2; (3) hypertension: blood pressure above 140/90 mm Hg or on blood pressure medication; (4) low GFR (as defined by the authors); (5) proteinuria: either ⱖ 150 mg/d or ⱖ 300 mg/d; or (6) microscopic hematuria. All of these criteria can be evaluated preoperatively. Two key findings emerged in this study: First, as well-documented among deceased donors, recipi-
ents of kidneys from younger donors showed appreciably better outcomes than those from older donors. However, 8 of the 12 studies included in the meta-analysis reported no significant difference between kidneys from older versus younger donors concerning graft and recipient survivals after living donation (Table 1). Second, there is a remarkable lack of data concerning expanded criteria living donors for renal transplantation. The number of studies involving donors with a low GFR or hypertension is limited. Studies of donor obesity, proteinuria, or microscopic hematuria are practically nonexistent. This disconnect between the number of individuals with expanded criteria being accepted as donors and a lack of knowledge on recipient outcomes will be important topics in future research. Renal Cysts
The acceptance of a living donor kidneys bearing solitary or multiple cysts can result in posttransplant complication due to the natural history of the disorders. Veroux et al6 were one of the first to report a case in which a kidney from a potential family donor with a 6-cm cyst in her left kidney and mild hypertension was successfully transplanted with satisfactory renal function at one year. The donor regained normal blood pressure, resulting in a win-win situation for donor and recipient. In this early report before the era of expanded criteria in renal transplantation, the authors concluded that—with careful examination of potential livFrom the Department of Urology and Pediatric Urology (A.K.), Julius-Maximilians-University Medical School, Würzburg, Germany, and Department of Urology (M.G.), Heinrich Heine University Hospital Duesseldorf, Düsseldorf, Germany. Address reprint requests to Arkadius Kocot, MD, Department of Urology and Paediatric Urology, Julius-Maximilians-University Medical School, Oberduerrbacher Strasse 6, 97080 Wuerzburg, Germany. E-mail: [email protected]
© 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2013.02.025
Transplantation Proceedings, 45, 1245–1247 (2013)
1245
1246
KOCOT AND GIESSING Table 1. Meta-Analysis of 5-Year Outcomes5: Composite Outcome of Graft and Recipient Survivals
Source
Mean* Follow-up (ys)
Comparison: Recipients of Living Donors ⬎ 60 vs Donors ⬍ 60 Years
Fauchald, 1991 Langle, 1992 Shmueli, 1994 Cecka, 1995 Lezaic 1995 Kostakis, 1997 Singh, 1998 Shimmura, 1999 Cecka, 2001 Ivanovski 2001 Toma 2001 Naumovic, 2005
NR 3.3 7.4 NR NR 2.4 NR 5.2 NR NR NR 3.6
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Ref.
13 14 15 16 17 18 19 20 21 22 23 24
Significant Difference in the Composite Outcome of Graft and Recipient Survival in Living Kidney Donation
Yes No No Yes Yes No No No No Yes No No
*Median or midpoint if mean not reported; follow-up time for recipients of kidneys from older donors. NR, not reported.
ing donors—at that time the existing donor selection criteria can be expanded to include certain donors who were previously excluded from living related renal transplantation. On this topic Grotemeyer et al7 in the largest report to date evaluated long-term recipient results among 25 living donors with renal cysts. The authors retrospectively reviewed donor and recipient records for all living donor kidney transplants performed in their institution between 1997 and 2008. They analyzed serum creatinine and urea levels as well as ultrasound scans for cyst size and morphology at hospital discharge as well as at 12 and 24 months posttransplantation. There was no cyst-related complication or renal dysfunction. Unroofing or excision of the cyst was generally not performed. Based on this experience, the authors concluded that kidneys presenting cystic lesions may be considered for living related renal transplantation in specific situations. Kidney Stones
The Amsterdam forum1 provided recommendations concerning incidentally diagnosed renal calculi in living donors. These donors should be screened for metabolic stoneforming abnormalities. An asymptomatic potential donor with a history of a single stone may be suitable for kidney donation when fulfilling specific conditions—absence of hypercalcuria, hyperuricemia, or metabolic acidosis; cystinuria or hyperoxaluria; urinary tract infection; multiple stones or nephrocalcinosis on computed tomography scan. It is not known whether stone formers who donate a kidney show worse renal function compared to stone formers with two kidneys in situ. However, a recurrent stone disease may not affect the function of a remaining kidney if it is carefully monitored. Stone formers who should not donate are those with nephrocalcinosis on X-ray, bilateral stone disease, or stone types that show high recurrence rates and are difficult to prevent: cystine and struvite stones; stones associated with inherited or other systemic disorders; stones in the setting of inflammatory bowel disease. Potential donors
with recurrent stone disease while on appropriate treatment should be excluded from donation as well. Several studies have been published concerning management of stone-bearing kidneys prior to renal transplantation. In a retrospective analysis of their living donor cohort, Vasdev et al8 showed the efficiency of ex vivo ureteroscopy using on-table and bench techniques. The calculi were extracted in all three cases using a 7.5-French flexible ureteroscope either prior to transplantation (n ⫽ 2) or after revascularization (n ⫽ 1). In this small series of patients (n ⫽ 5) renal calculi were successfully removed at the time of living related transplantation. It was technically feasible without compromising ureteral integrity or renal allograft function. The largest series published to date concerning this topic comprises 23 patients.9 Basket extraction and holmium laser lithotripsy were used during ex vivo ureteroscopy. The authors reported no intraoperative complications after a mean treatment time of 6.2 minutes (range, 3–10). Median serum creatinine level of recipients at 1 month and 1 year were 1.4 ⫾ 1.8 mg/dL and 1.3 ⫾ 0.6 mg/dL respectively. At a median follow-up of 63 ⫾ 47.2 months, there were no transplant urinary calculi among the recipients.
Malignancy and Living Donors
According to the report of the Amsterdam Forum on the care of live kidney donors,1 a prior history of the following malignancies usually excludes living related kidney donation: melanoma, testicular cancer, renal cell carcinoma, choriocarcinoma, hematologic malignancy, bronchial cancer, breast cancer, and monoclonal gammopathy. A prior history of malignancy may only be acceptable for donation if prior treatment of the malignancy does not decrease renal reserve or place the donor at increased risk for end-stage renal disease. A prior history of malignancy usually excludes living kidney donation but may be acceptable if the specific cancer is curable and the potential transmission of the cancer can reasonably be excluded: for example, colon
EXPANDED CRITERIA IN LIVING KIDNEY DONORS
cancer (Dukes A, more than 5 years ago), nonmelanoma skin cancer, or carcinoma in situ of the cervix. Complex Vascular Anatomy in Living Related Kidney Transplantation
To increase the available donor pool, organs with multiple arteries have been included in several studies of living related renal transplantation procedures with the expectation of similar graft outcomes compared with organs bearing single arteries. Kok et al10 prospectively collected 288 living kidney donations and transplantations. Vascular anatomy at operation was compared with that revealed by magnetic resonance imaging or subtraction angiography to investigate the consequences of multiple vessels. In conclusion, multiple arteries did not affect clinical outcomes of open donor nephrectomy (n ⫽ 103). For laparoscopic donor nephrectomy (n ⫽ 185), multiple arteries were associated with longer operative times (245 versus 221 minutes, P ⫽ .023) and increased blood loss (225 versus 220 mL, P ⫽ .029). Neither multiple arteries nor vascular reconstructions influenced recipient creatinine clearance or ureteral complication rate. However, accessory arteries to the lower pole were associated with an increased rate of ureteral complications (47% versus 14%, P ⫽ .01). While there have been many studies related to the effects of laparoscopic versus open technique on graft function, there are only a limited number that include the impact of multiple arteries on graft function. Some studies have reported higher rates of surgical and medical complications after transplantation with multiple artery grafts; other reports suggest no difference related to rejection rate as well as patient or graft survival between cases with multiple versus single arteries.11 Obstruction at the Ureteropelvic Junction
Only a few case reports describe potential living donors with obstruction at the ureteropelvic junction.12 Further data with larger cohorts and long-term results after pyeloplasty during or after living related renal transplantation or pyeloplasty at the time of transplantation using the native recipient ureter for a ureteropelvic anastomosis are nonexistent. In conclusion multiple attempts to increase the donor and recipient pools in living related renal transplantation have been presented over the last decades. Beside the common expanded donor criteria (age, obesity, hypertention, decreased GFR, proteinuria and microscopic hematuria), donors with further anatomical specifications like obstruction at the ureteropelvic junction, kidney stones, renal cysts, and complex vascular anatomy should be evaluated as possible donor candidates. Not only recipient outcomes, but the impact on donor health status must be investigated in future studies. REFERENCES 1. Delmonico F: A Report of the Amsterdam Forum on the Care of the Live Kidney Donor: Data and Medical Guidelines. Transplantation. 2005;79:S53.
1247 2. Young A, Storsley L, Garg AX, et al: Health outcomes for living kidney donors with isolated medical abnormalities: a systematic review. Am J Transplant. 2008;8:1878. 3. Nyberg SL, Matas AJ, Kremers WK, et al: Improved scoring system to assess adult donors for cadaver renal transplantation. Am J Transplant. 2003;3:715. 4. Metzger RA, Delmonico FL, Feng S, et al: Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3(suppl 4):114. 5. Iordanous Y, Seymour N, Young A, et al: Recipient outcomes for expanded criteria living kidney donors: the disconnect between current evidence and practice. Am J Transplant. 2009;9:1558. 6. Veroux P, Veroux M, Puliatti C, et al: Living transplantation using a kidney with a large cyst as curative treatment of donor’s hypertension. Nephrol Dial Transplant. 2002 Dec;17(12):2258 – 2260. 7. Grotemeyer D, Voiculescu A, Iskandar F, et al: Renal cysts in living donor kidney transplantation: long-term follow-up in 25 patients. Transplant Proc. 2009;41:4047. 8. Vasdev N, Moir J, Dosani MT, et al: Endourological management of urolithiasis in donor kidneys prior to renal transplant. Source. ISRN Urol. 2011;2011:242690. Epub 2011 Jun 22 9. Schade GR, Wolf JS, Faerber GJ: Ex-vivo ureteroscopy at the time of live donor nephrectomy J Endourol. 2011;25:1405. 10. Kok NF, Dols LF, Hunink MG, et al: Complex vascular anatomy in live kidney donation: imaging and consequences for clinical outcome. Transplantation. 2008;85:1760. 11. Genc V, Karaca AS, Orozakunov E, et al: Multiple renal arteries challenge in laparoscopic donor nephrectomy: how far can we go? J Korean Surg Soc. 2011;80:272. 12. Ho TP, El-Sheikh MF, Talbot D: Case report: living related renal transplantation with a donor kidney with pelviureteric junction obstruction using an Anderson-Hynes pyeloplasty. Transplant Proc. 2002;34:1193. 13. Fauchald P, Sodal G, Albrechtsen D, et al: The use of elderly living donors in renal transplantation. Transplant Int. 1991;4:51. 14. Langle F, Sautner T, Grunberger T, et al: Impact of donor age ongraft function in living-related kidney transplantation. Transplant Proc. 1992;24:2725. 15. Shmueli D, Nakache R, Lustig S, et al: Renal transplant from livedonors over 65 years old. Transplant Proc. 1994;26:2139. 16. Cecka JM: Living donor transplants. Clin Transpl. 1995;363– 377. 17. Lezaic V, Djukanovic L, Blagojevic-Lazic R, et al: Living related kidney donors over 60 years old. Transplant Int. 1996;9:109. 18. Kostakis A, Bokos J, Stamatiades D, et al: The 10 years single center experience of using elderly donors for living related kidney transplantation. Geriatr Nephrol Urol. 1997;7:127. 19. Singh AK, Sharma RK, Agrawal S, et al: Long-term allograft survival in renal transplantation from elderly donors. Transplant Proc. 1998;30:3659. 20. Shimmura H, Tanabe K, Ishikawa N, et al: Influence of donor renal reserve on the long-term results of living kidney transplantation from elderly donors. Transplant Proc. 1999;31:2874. 21. Cecka JM: The UNOS renal transplant registry. Clin Transpl. 2001;1–18. 22. Ivanovski N, Popov Z, Kolevski P, et al: Use of advanced age donors in living renal transplantation—is it justified? Transplant Proc. 2001;33:1227. 23. Toma H, Tanabe K, Tokumoto T, et al: Timedependent risk factors influencing the long-term outcome in living renal allografts: donor age is a crucial risk factor for long-term graft survival more than 5 years after transplantation. Transplantation. 2001;72:940. 24. Naumovic R, Djukanovic L, Marinkovic J, et al: Effect of donor age on the outcome of living-related kidney transplantation. Transpl Int. 2005;18:1266.
I
MATERIALS AND METHODS We performed a Medline and PubMed research concerning expanded donor criteria in living kidney transplantation. We also included recommendations from international guidelines of urologic scientific societies.
RESULTS Expanded Living Donor Criteria
Iordanous et al5 presented the first systematic review and meta-analysis to examine the impact of living donor age and other expanded criteria on recipient outcomes. In most studies, living expanded criteria donors were defined as having any of the following features prior to the time of renal donation: (1) age over 60 years; (2) obesity: body mass index either ⬎ 30 kg/m2 or ⬎ 35 kg/m2; (3) hypertension: blood pressure above 140/90 mm Hg or on blood pressure medication; (4) low GFR (as defined by the authors); (5) proteinuria: either ⱖ 150 mg/d or ⱖ 300 mg/d; or (6) microscopic hematuria. All of these criteria can be evaluated preoperatively. Two key findings emerged in this study: First, as well-documented among deceased donors, recipi-
ents of kidneys from younger donors showed appreciably better outcomes than those from older donors. However, 8 of the 12 studies included in the meta-analysis reported no significant difference between kidneys from older versus younger donors concerning graft and recipient survivals after living donation (Table 1). Second, there is a remarkable lack of data concerning expanded criteria living donors for renal transplantation. The number of studies involving donors with a low GFR or hypertension is limited. Studies of donor obesity, proteinuria, or microscopic hematuria are practically nonexistent. This disconnect between the number of individuals with expanded criteria being accepted as donors and a lack of knowledge on recipient outcomes will be important topics in future research. Renal Cysts
The acceptance of a living donor kidneys bearing solitary or multiple cysts can result in posttransplant complication due to the natural history of the disorders. Veroux et al6 were one of the first to report a case in which a kidney from a potential family donor with a 6-cm cyst in her left kidney and mild hypertension was successfully transplanted with satisfactory renal function at one year. The donor regained normal blood pressure, resulting in a win-win situation for donor and recipient. In this early report before the era of expanded criteria in renal transplantation, the authors concluded that—with careful examination of potential livFrom the Department of Urology and Pediatric Urology (A.K.), Julius-Maximilians-University Medical School, Würzburg, Germany, and Department of Urology (M.G.), Heinrich Heine University Hospital Duesseldorf, Düsseldorf, Germany. Address reprint requests to Arkadius Kocot, MD, Department of Urology and Paediatric Urology, Julius-Maximilians-University Medical School, Oberduerrbacher Strasse 6, 97080 Wuerzburg, Germany. E-mail: [email protected]
© 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2013.02.025
Transplantation Proceedings, 45, 1245–1247 (2013)
1245
1246
KOCOT AND GIESSING Table 1. Meta-Analysis of 5-Year Outcomes5: Composite Outcome of Graft and Recipient Survivals
Source
Mean* Follow-up (ys)
Comparison: Recipients of Living Donors ⬎ 60 vs Donors ⬍ 60 Years
Fauchald, 1991 Langle, 1992 Shmueli, 1994 Cecka, 1995 Lezaic 1995 Kostakis, 1997 Singh, 1998 Shimmura, 1999 Cecka, 2001 Ivanovski 2001 Toma 2001 Naumovic, 2005
NR 3.3 7.4 NR NR 2.4 NR 5.2 NR NR NR 3.6
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Ref.
13 14 15 16 17 18 19 20 21 22 23 24
Significant Difference in the Composite Outcome of Graft and Recipient Survival in Living Kidney Donation
Yes No No Yes Yes No No No No Yes No No
*Median or midpoint if mean not reported; follow-up time for recipients of kidneys from older donors. NR, not reported.
ing donors—at that time the existing donor selection criteria can be expanded to include certain donors who were previously excluded from living related renal transplantation. On this topic Grotemeyer et al7 in the largest report to date evaluated long-term recipient results among 25 living donors with renal cysts. The authors retrospectively reviewed donor and recipient records for all living donor kidney transplants performed in their institution between 1997 and 2008. They analyzed serum creatinine and urea levels as well as ultrasound scans for cyst size and morphology at hospital discharge as well as at 12 and 24 months posttransplantation. There was no cyst-related complication or renal dysfunction. Unroofing or excision of the cyst was generally not performed. Based on this experience, the authors concluded that kidneys presenting cystic lesions may be considered for living related renal transplantation in specific situations. Kidney Stones
The Amsterdam forum1 provided recommendations concerning incidentally diagnosed renal calculi in living donors. These donors should be screened for metabolic stoneforming abnormalities. An asymptomatic potential donor with a history of a single stone may be suitable for kidney donation when fulfilling specific conditions—absence of hypercalcuria, hyperuricemia, or metabolic acidosis; cystinuria or hyperoxaluria; urinary tract infection; multiple stones or nephrocalcinosis on computed tomography scan. It is not known whether stone formers who donate a kidney show worse renal function compared to stone formers with two kidneys in situ. However, a recurrent stone disease may not affect the function of a remaining kidney if it is carefully monitored. Stone formers who should not donate are those with nephrocalcinosis on X-ray, bilateral stone disease, or stone types that show high recurrence rates and are difficult to prevent: cystine and struvite stones; stones associated with inherited or other systemic disorders; stones in the setting of inflammatory bowel disease. Potential donors
with recurrent stone disease while on appropriate treatment should be excluded from donation as well. Several studies have been published concerning management of stone-bearing kidneys prior to renal transplantation. In a retrospective analysis of their living donor cohort, Vasdev et al8 showed the efficiency of ex vivo ureteroscopy using on-table and bench techniques. The calculi were extracted in all three cases using a 7.5-French flexible ureteroscope either prior to transplantation (n ⫽ 2) or after revascularization (n ⫽ 1). In this small series of patients (n ⫽ 5) renal calculi were successfully removed at the time of living related transplantation. It was technically feasible without compromising ureteral integrity or renal allograft function. The largest series published to date concerning this topic comprises 23 patients.9 Basket extraction and holmium laser lithotripsy were used during ex vivo ureteroscopy. The authors reported no intraoperative complications after a mean treatment time of 6.2 minutes (range, 3–10). Median serum creatinine level of recipients at 1 month and 1 year were 1.4 ⫾ 1.8 mg/dL and 1.3 ⫾ 0.6 mg/dL respectively. At a median follow-up of 63 ⫾ 47.2 months, there were no transplant urinary calculi among the recipients.
Malignancy and Living Donors
According to the report of the Amsterdam Forum on the care of live kidney donors,1 a prior history of the following malignancies usually excludes living related kidney donation: melanoma, testicular cancer, renal cell carcinoma, choriocarcinoma, hematologic malignancy, bronchial cancer, breast cancer, and monoclonal gammopathy. A prior history of malignancy may only be acceptable for donation if prior treatment of the malignancy does not decrease renal reserve or place the donor at increased risk for end-stage renal disease. A prior history of malignancy usually excludes living kidney donation but may be acceptable if the specific cancer is curable and the potential transmission of the cancer can reasonably be excluded: for example, colon
EXPANDED CRITERIA IN LIVING KIDNEY DONORS
cancer (Dukes A, more than 5 years ago), nonmelanoma skin cancer, or carcinoma in situ of the cervix. Complex Vascular Anatomy in Living Related Kidney Transplantation
To increase the available donor pool, organs with multiple arteries have been included in several studies of living related renal transplantation procedures with the expectation of similar graft outcomes compared with organs bearing single arteries. Kok et al10 prospectively collected 288 living kidney donations and transplantations. Vascular anatomy at operation was compared with that revealed by magnetic resonance imaging or subtraction angiography to investigate the consequences of multiple vessels. In conclusion, multiple arteries did not affect clinical outcomes of open donor nephrectomy (n ⫽ 103). For laparoscopic donor nephrectomy (n ⫽ 185), multiple arteries were associated with longer operative times (245 versus 221 minutes, P ⫽ .023) and increased blood loss (225 versus 220 mL, P ⫽ .029). Neither multiple arteries nor vascular reconstructions influenced recipient creatinine clearance or ureteral complication rate. However, accessory arteries to the lower pole were associated with an increased rate of ureteral complications (47% versus 14%, P ⫽ .01). While there have been many studies related to the effects of laparoscopic versus open technique on graft function, there are only a limited number that include the impact of multiple arteries on graft function. Some studies have reported higher rates of surgical and medical complications after transplantation with multiple artery grafts; other reports suggest no difference related to rejection rate as well as patient or graft survival between cases with multiple versus single arteries.11 Obstruction at the Ureteropelvic Junction
Only a few case reports describe potential living donors with obstruction at the ureteropelvic junction.12 Further data with larger cohorts and long-term results after pyeloplasty during or after living related renal transplantation or pyeloplasty at the time of transplantation using the native recipient ureter for a ureteropelvic anastomosis are nonexistent. In conclusion multiple attempts to increase the donor and recipient pools in living related renal transplantation have been presented over the last decades. Beside the common expanded donor criteria (age, obesity, hypertention, decreased GFR, proteinuria and microscopic hematuria), donors with further anatomical specifications like obstruction at the ureteropelvic junction, kidney stones, renal cysts, and complex vascular anatomy should be evaluated as possible donor candidates. Not only recipient outcomes, but the impact on donor health status must be investigated in future studies. REFERENCES 1. Delmonico F: A Report of the Amsterdam Forum on the Care of the Live Kidney Donor: Data and Medical Guidelines. Transplantation. 2005;79:S53.
1247 2. Young A, Storsley L, Garg AX, et al: Health outcomes for living kidney donors with isolated medical abnormalities: a systematic review. Am J Transplant. 2008;8:1878. 3. Nyberg SL, Matas AJ, Kremers WK, et al: Improved scoring system to assess adult donors for cadaver renal transplantation. Am J Transplant. 2003;3:715. 4. Metzger RA, Delmonico FL, Feng S, et al: Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3(suppl 4):114. 5. Iordanous Y, Seymour N, Young A, et al: Recipient outcomes for expanded criteria living kidney donors: the disconnect between current evidence and practice. Am J Transplant. 2009;9:1558. 6. Veroux P, Veroux M, Puliatti C, et al: Living transplantation using a kidney with a large cyst as curative treatment of donor’s hypertension. Nephrol Dial Transplant. 2002 Dec;17(12):2258 – 2260. 7. Grotemeyer D, Voiculescu A, Iskandar F, et al: Renal cysts in living donor kidney transplantation: long-term follow-up in 25 patients. Transplant Proc. 2009;41:4047. 8. Vasdev N, Moir J, Dosani MT, et al: Endourological management of urolithiasis in donor kidneys prior to renal transplant. Source. ISRN Urol. 2011;2011:242690. Epub 2011 Jun 22 9. Schade GR, Wolf JS, Faerber GJ: Ex-vivo ureteroscopy at the time of live donor nephrectomy J Endourol. 2011;25:1405. 10. Kok NF, Dols LF, Hunink MG, et al: Complex vascular anatomy in live kidney donation: imaging and consequences for clinical outcome. Transplantation. 2008;85:1760. 11. Genc V, Karaca AS, Orozakunov E, et al: Multiple renal arteries challenge in laparoscopic donor nephrectomy: how far can we go? J Korean Surg Soc. 2011;80:272. 12. Ho TP, El-Sheikh MF, Talbot D: Case report: living related renal transplantation with a donor kidney with pelviureteric junction obstruction using an Anderson-Hynes pyeloplasty. Transplant Proc. 2002;34:1193. 13. Fauchald P, Sodal G, Albrechtsen D, et al: The use of elderly living donors in renal transplantation. Transplant Int. 1991;4:51. 14. Langle F, Sautner T, Grunberger T, et al: Impact of donor age ongraft function in living-related kidney transplantation. Transplant Proc. 1992;24:2725. 15. Shmueli D, Nakache R, Lustig S, et al: Renal transplant from livedonors over 65 years old. Transplant Proc. 1994;26:2139. 16. Cecka JM: Living donor transplants. Clin Transpl. 1995;363– 377. 17. Lezaic V, Djukanovic L, Blagojevic-Lazic R, et al: Living related kidney donors over 60 years old. Transplant Int. 1996;9:109. 18. Kostakis A, Bokos J, Stamatiades D, et al: The 10 years single center experience of using elderly donors for living related kidney transplantation. Geriatr Nephrol Urol. 1997;7:127. 19. Singh AK, Sharma RK, Agrawal S, et al: Long-term allograft survival in renal transplantation from elderly donors. Transplant Proc. 1998;30:3659. 20. Shimmura H, Tanabe K, Ishikawa N, et al: Influence of donor renal reserve on the long-term results of living kidney transplantation from elderly donors. Transplant Proc. 1999;31:2874. 21. Cecka JM: The UNOS renal transplant registry. Clin Transpl. 2001;1–18. 22. Ivanovski N, Popov Z, Kolevski P, et al: Use of advanced age donors in living renal transplantation—is it justified? Transplant Proc. 2001;33:1227. 23. Toma H, Tanabe K, Tokumoto T, et al: Timedependent risk factors influencing the long-term outcome in living renal allografts: donor age is a crucial risk factor for long-term graft survival more than 5 years after transplantation. Transplantation. 2001;72:940. 24. Naumovic R, Djukanovic L, Marinkovic J, et al: Effect of donor age on the outcome of living-related kidney transplantation. Transpl Int. 2005;18:1266.