[Biomarkers in testicular cancer.] / Biomarcadores en cáncer de testículo.

OBJECTIVE: To review the current situationof biomarkers used in the diagnosis, prognosis,treatment response and relapse of testicular cancer. METHODS: A non systematic review was performedof clinical guidelines and articles published within thelast years regarding biomarkers in testicular cancer. RESULTS: The most commonly used biomarkersare alphafetoprotein (AFP) and beta human corionicgonadotropin (ß-HCG).The enzyme lactate dehydrogenase (LDH) is presentin multiple tissues and is elevated in advancedgerminal tumors. A few micro molecules of RNA (micro-RNA) have demonstrated to be specifically elevatedin testicular germinal tumors. However, its clincalbenefit, as well as its standardization is currently underinvestigation. CONCLUSIONS: Classic biomarkers AFP, ß-HCG,and LDH are of some utility confirming the diagnosisif they are elevated. However, its limited sensibility isnot enough to rely the diagnosis on themselves. Thereare promising results with Micro-RNA but its daily usedoes not seem imminent.

OBJETIVO: .-Revisar la situación actualde los biomarcadores utilizados en el diagnóstico, pronóstico,monitorización de la respuesta al tratamiento,y detección de la recidiva del cáncer de testículo.MÉTODOS:.- Realizamos una revisión no sistemáticatanto de guías de práctica clínica como de artículospublicados en los últimos años sobre los biomarcadoresen cáncer de testículo, en conjunto, y cadauno en particular. RESULTADOS: .- Los dos marcadores más extendidosy utilizados son la alfafetoproteína (AFP), y la Betagonadotropina coriónica humana (ß-HCG).La lactato deshidrogenasa (LDH) es una enzimapresente en diversos tejidos y que se encuentra elevadaen algunos tumores germinales, especialmenteen estados más avanzados. Algunas moléculas pequeñasde ácido ribonucleico circulante en sangre (Micro-RNA) han demostrado estar elevadas de maneramás constante y específica en los tumores germinalestesticulares. Sin embargo su utilidad práctica aún estáen evaluación, así como su sistematización para facilitarla extensión de su uso. CONCLUSIONES: .- Los marcadores clásicos AFP,ß-HCG, y LDH son de cierta utilidad confirmatoria encaso de estar elevados. Pero su limitada sensibilidadno permite fundamentar en ellos el diagnóstico. Losresultados obtenidos con los Micro-RNA son muchomás prometedores, sin embargo su incorporación a lapráctica diaria no parece inminente.

Biomarcadores en cáncer de testículo / Biomarkers in testicular cáncer

OBJETIVO: Revisar la situación actualde los biomarcadores utilizados en el diagnóstico, pronóstico, monitorización de la respuesta al tratamiento,y detección de la recidiva del cáncer de testículo.MÉTODOS:.- Realizamos una revisión no sistemática tanto de guías de práctica clínica como de artículos publicados en los últimos años sobre los biomarcadores en cáncer de testículo, en conjunto, y cadauno en particular.RESULTADOS:.- Los dos marcadores más extendidos y utilizados son la alfafetoproteína (AFP), y la Betagonadotropina coriónica humana (β-HCG).La lactato deshidrogenasa (LDH) es una enzimapresente en diversos tejidos y que se encuentra elevada en algunos tumores germinales, especialmenteen estados más avanzados. Algunas moléculas pequeñas de ácido ribonucleico circulante en sangre (Micro-RNA) han demostrado estar elevadas de maneramás constante y específica en los tumores germinalestesticulares. Sin embargo su utilidad práctica aún estáen evaluación, así como su sistematización para facilitar la extensión de su uso.CONCLUSIONES:.- Los marcadores clásicos AFP,β-HCG, y LDH son de cierta utilidad confirmatoria encaso de estar elevados. Pero su limitada sensibilidadno permite fundamentar en ellos el diagnóstico. Losresultados obtenidos con los Micro-RNA son muchomás prometedores, sin embargo su incorporación a lapráctica diaria no parece inminente. (AU)

OBJECTIVE: To review the current situation of biomarkers used in the diagnosis, prognosis, treatment response and relapse of testicular cancer.METHODS: A non systematic review was performedof clinical guidelines and articles published within thelast years regarding biomarkers in testicular cancer.RESULTS: The most commonly used biomarkersare alphafetoprotein (AFP) and beta human corionicgonadotropin (β-HCG).The enzyme lactate dehydrogenase (LDH) is present in multiple tissues and is elevated in advancedgerminal tumors. A few micro molecules of RNA (micro-RNA) have demonstrated to be specifically elevated in testicular germinal tumors. However, its clincalbenefit, as well as its standardization is currently under investigation.CONCLUSIONS: Classic biomarkers AFP, β-HCG,and LDH are of some utility confirming the diagnosisif they are elevated. However, its limited sensibility isnot enough to rely the diagnosis on themselves. Thereare promising results with Micro-RNA but its daily usedoes not seem imminent. (AU)

Recommendations to Balance Benefits and Risks Of Thromboprophylaxis and to Avoid Central Venous-access Devices During First-line Chemotherapy in Men with Metastatic Germ Cell Tumors: The European Association Of Urology Testicular Cancer Panel Position in 2021.

Men with metastatic germ cell tumors undergoing chemotherapy are at high risk of venous thromboembolic events and low risk of bleeding. A central venous-access device should be avoided whenever possible. Thromboprophylaxis may be prescribed after balancing the risks and benefits for each individual patient.

[Effect of surgical approach on radical nephrectomy outcomes: Comparative study between open and laparoscopic nephrectomy.] / Influencia de la vía de acceso para la nefrectomía radical en el tratamiento del cáncer renal: estudio comparativo entre cirugía abierta y cirugía laparoscópica.

OBJECTIVE: The aim of this study is to evaluate the influence of laparoscopy in patients with renal cancer treated with radical nephrectomy in terms of surgical time, hospital stay, postoperative complications and survival.MATERIAL AND METHODS: Retrospective study of 570 patients with renal cancer treated with radical nephrectomyin stage ≤pT3a. Differences between groups were analysed using ANOVA test for quantitative variables and Chi squared test for qualitative. In order to evaluate possible risk factors for longer hospital stay and surgical time, multivariate analysis was performed (lineal regression). For complications we performed binary logistic regression. Overall survival (OS), recurrence free survival (RFS) and cancer specific survival (CSS) were estimated using Kaplan Meier and compared using Log Rank test. Univariate and multivariate analysis was performed using Cox regression in order to identify independent risk factors for overall, cancer specific and recurrence mortality. RESULTS: Two cohorts: 361 (63.3%) open radical nephrectomies (ORN) and 209 (36.7%) laparoscopic (LRN). Surgical time was longer in LRN (p=0.001) globally. After the period when the learning curve was over these differences were no longer significant. Hospital stay was shorter in LRN (p=0.0001). cT stage (p=0.005) and surgical access (p=0.001) acted as independent risk factors for longer surgical time. 33,5% (121 patients) of the ORN had some sort of postoperative complication vs. 11% (23 patients) in the LRN group (p=0.0001). These differences were observed in the Clavien-Dindo's grade II group. Independent risk factors for postoperative complications observed were: ASA≥III (OR=1.82, p=0.004) and stage pT3a (OR=2.29,p=0.0001). Laparoscopy acted as a protective factor for complications (OR=0,26, p=0.0001). Surgical access did not influence RFS (HR=0.87, p=0.50), CSS(HR=0.69, p=0.12). CONCLUSIONS: Laparoscopic access to RN in patients with renal cancer in ≤pT3a stage increased surgical time only in the first years, reduced hospital stayand postoperative complications and did not influence RFS, OS or CSS.

OBJETIVO: El objetivo del estudio es evaluarla influencia de la laparoscopia en pacientes concáncer renal tratados con nefrectomía radical (NR) en términos de tiempo quirúrgico, estancia media, complicaciones postoperatorias y supervivencia.MATERIAL Y MÉTODO: Análisis retrospectivo de 570 pacientes con cáncer renal tratados con NR en estadio ≤pT3a comparando cohorte de acceso abierto (NRA) y laparoscópico (NRL). Contraste de variables cualitativas con el test de Chi cuadrado y cuantitativas con ANOVA. Para identificar factores de riesgo (FR) de tiempo quirúrgico y estancia media se utilizó regresión lineal multivariante y para complicaciones la regresión logística binaria. Estimación de la supervivencia libre de recidiva (SLR), global (SG) y cáncer específica (SCE) mediante Kaplan-Meier y test de log-rank para analizar las diferencias. Análisis multivariante mediante regresión de Cox para identificar variables predictoras independientes (VPI) de SLR y SCE. Todos los cálculos se han realizado con el paquete estadístico IBM® SPSS® statisticsv-21. RESULTADOS: Dos cohortes: 361 (63,3%) NRA y 209(36,7%) NRL. El tiempo de cirugía fue mayor en NRL (p=0,001) de forma global siendo las diferencias entre ambas en el periodo tras la curva de aprendizaje no significativas. La estancia media fue menor en NRL(p=0,0001). El estadio cT (p=0,005) y la vía de acceso (p=0,001) se comportaron como VPI de prolongación del tiempo quirúrgico. El 33,5% (121 casos) de las NRA presentaron algún tipo de complicación en el postoperatorio, frente al 11% (23 casos) de las NRL (p=0,0001). Esta diferencia se observó en complicaciones tipo II de Clavien. VPI de complicaciones postoperatorias: ASA≥III (OR=1,82, p=0,004) y el estadio pT3a (OR=2,29, p=0,0001). La laparoscopia se comportó como factor protector de complicaciones (OR=0,26, p=0,0001). La vía de acceso no influyó en la SLR (HR=0,87, p=0,50) ni en la SCE (HR=0,69,p=0,12). CONCLUSIONES: El acceso laparoscópico a la nefrectomía radical en pacientes con cáncer renal en estadio ≤pT3a aumentó el tiempo quirúrgico pero solo en los primeros años, presentó menor estancia y complicacionespostoperatorias y no influyó en la SG,SLR y SCE.

Influencia de la vía de acceso para la nefrectomía radical en el tratamiento del cáncer renal: estudio comparativo entre cirugía abierta y cirugía laparoscópica / Effect of surgical approach on radical nephrectomy outcomes: Comparative study between open and laparoscopic nephrectomy

OBJETIVO: El objetivo del estudio es evaluarla influencia de la laparoscopia en pacientes concáncer renal tratados con nefrectomía radical (NR) en términos de tiempo quirúrgico, estancia media, complicaciones postoperatorias y supervivencia. MATERIAL Y MÉTODO: Análisis retrospectivo de 570 pacientes con cáncer renal tratados con NR en estadio ≤ pT3a comparando cohorte de acceso abierto (NRA) y laparoscópico (NRL). Contraste de variables cualitativas con el test de Chi cuadrado y cuantitativas con ANOVA. Para identificar factores de riesgo (FR) de tiempo quirúrgico y estancia media se utilizó regresión lineal multivariante y para complicaciones la regresión logística binaria. Estimación de la supervivencia libre de recidiva (SLR), global (SG) y cáncer específica (SCE) mediante Kaplan-Meier y test de log-rank para analizar las diferencias. Análisis multivariante mediante regresión de Cox para identificar variables predictoras independientes (VPI) de SLR y SCE. Todos los cálculos se han realizado con el paquete estadístico IBM® SPSS® statisticsv-21. RESULTADOS: Dos cohortes: 361 (63,3%) NRA y 209(36,7%) NRL. El tiempo de cirugía fue mayor en NRL (p = 0,001) de forma global siendo las diferencias entre ambas en el periodo tras la curva de aprendizaje no significativas. La estancia media fue menor en NRL(p = 0,0001). El estadio cT (p = 0,005) y la vía de acceso (p = 0,001) se comportaron como VPI de prolongación del tiempo quirúrgico. El 33,5% (121 casos) de las NRA presentaron algún tipo de complicación en el postoperatorio, frente al 11% (23 casos) de las NRL (p = 0,0001). Esta diferencia se observó en complicaciones tipo II de Clavien. VPI de complicaciones postoperatorias: ASA ≥ III (OR=1,82, p = 0,004) y el estadio pT3a (OR=2,29, p = 0,0001). La laparoscopia se comportó como factor protector de complicaciones (OR=0,26, p = 0,0001). La vía de acceso no influyó en la SLR (HR=0,87, p = 0,50) ni en la SCE (HR = 0,69, p = 0,12). CONCLUSIONES: El acceso laparoscópico a la nefrectomía radical en pacientes con cáncer renal en estadio ≤ pT3a aumentó el tiempo quirúrgico pero solo en los primeros años, presentó menor estancia y complicaciones postoperatorias y no influyó en la SG,SLR y SCE

OBJECTIVE: The aim of this study is to evaluate the influence of laparoscopy in patients with renal cancer treated with radical nephrectomy in terms of surgical time, hospital stay, postoperative complications and survival. MATERIAL AND METHODS: Retrospective study of 570 patients with renal cancer treated with radical nephrectomy in stage ≤pT3a. Differences between groups were analysed using ANOVA test for quantitative variables and Chi squared test for qualitative. In order to evaluate possible risk factors for longer hospital stay and surgical time, multivariate analysis was performed (lineal regression). For complications we performed binary logistic regression. Overall survival (OS), recurrence free survival (RFS) and cancer specific survival (CSS) were estimated using Kaplan Meier and compared using Log Rank test. Univariate and multivariate analysis was performed using Cox regression in order to identify independent risk factors for overall, cancer specific and recurrence mortality. RESULTS: Two cohorts: 361 (63.3%) open radical nephrectomies (ORN) and 209 (36.7%) laparoscopic (LRN). Surgical time was longer in LRN (p=0.001) globally. After the period when the learning curve was over these differences were no longer significant. Hospital stay was shorter in LRN (p=0.0001). cT stage (p=0.005) and surgical access (p=0.001) acted as independent risk factors for longer surgical time. 33,5% (121 patients) of the ORN had some sort of postoperative complication vs. 11% (23 patients) in the LRN group (p=0.0001). These differences were observed in the Clavien-Dindo’s grade II group. Independent risk factors for postoperative complications observed were: ASA≥III (OR=1.82, p=0.004) and stage pT3a (OR=2.29, p=0.0001). Laparoscopy acted as a protective factor for complications (OR=0,26, p=0.0001). Surgical Access did not influence RFS (HR=0.87, p=0.50), CSS (HR=0.69, p=0.12). CONCLUSIONS: Laparoscopic access to RN in patients with renal cancer in ≤pT3a stage increased surgical time only in the first years, reduced hospital stay and postoperative complications and did not influence RFS, OS or CSS

[Locally advanced prostate cancer. Definition, diagnosis and treatment.] / Cáncer de próstata localmente avanzado. Definición, diagnóstico y tratamiento.

Prostate cancer is a disease that presents a wide spectrum from low aggressiveness localized to disseminated cancer. Locally advanced prostate cancer (LAPC) is a particularly difficult to manage phase of this spectrum. OBJECTIVES: We review the definition, diagnosis and treatment of this phase of the disease. METHODS: We performed a non systematic literature review of the most relevant features of this pathology. RESULTS: LAPC is more aggressive than organ confined disease. Its clinical diagnosis is not always easy. Local treatment, in spite of being aggressive with potential sequelae, seems to be advantageous in terms of patient survival. CONCLUSIONS: Prostate cancer local staging is currently based on multiparametric magnetic resonance imaging (mpMRI). Local radical treatment with surgery or radiotherapy, with probable addition of systemic treatment, offers promising results for disease control and quality of life improvement.

Cáncer de próstata localmente avanzado. Definición, diagnóstico y tratamiento / Locally advanced prostate cancer. Definition, diagnosis and treatment

El cáncer de próstata es una enfermedad que se presenta en un amplio espectro entre la enfermedad localizada poco agresiva y la diseminada. En ese espectro el cáncer de próstata localmente avanzado (CPLA) es una fase de manejo particularmente complejo. OBJETIVOS: En este artículo trataremos de hacer una revisión de la definición, diagnóstico, y tratamiento de esta fase de la enfermedad. Métodos: Se ha realizado una revisión no sistemática de la literatura de los aspectos más relevantes de la patología. Resultados: El CPLA es una fase del cáncer de próstata más agresiva que la enfermedad organoconfinada, cuyo diagnóstico clínico no siempre es fácil. El tratamiento local de la enfermedad, aunque agresivo y con potenciales secuelas, parece suponer una ventaja en la supervivencia para los pacientes. Conclusión: La estadificación local del cáncer de próstata se basa actualmente en la Resonancia Magnética multiparamétrica (RMNmp). El tratamiento radical local con cirugía o radioterapia (RT), con probable adición de tratamiento sistémico ofrece resultados prometedores para el control de la enfermedad y mejora de la calidad de vida

Prostate cancer is a disease that presents a wide spectrum from low aggressiveness localized to disseminated cancer. Locally advanced prostate cancer (LAPC) is a particularly difficult to manage phase of this spectrum. Objectives: We review the definition, diagnosis and treatment of this phase of the disease.Methods: We performed a non systematic literature review of the most relevant features of this pathology. Results: LAPC is more aggressive than organ confined disease. Its clinical diagnosis is not always easy. Local treatment, in spite of being aggressive with potential sequelae, seems to be advantageous in terms of patient survival. Conclusions: Prostate cancer local staging is currently based on multiparametric magnetic resonance imaging (mpMRI). Local radical treatment with surgery or radiotherapy, with probable addition of systemic treatment, offers promising results for disease control and quality of life improvement

Testicular Tumour Size and Rete Testis Invasion as Prognostic Factors for the Risk of Relapse of Clinical Stage I Seminoma Testis Patients Under Surveillance: a Systematic Review by the Testicular Cancer Guidelines Panel.

CONTEXT: Patients with clinical stage I (CS I) seminoma testis with large primary tumours and/or rete testis invasion (RTI) might have an increased risk of relapse. In recent years, these risk factors have frequently been employed to decide on adjuvant treatment. OBJECTIVE: To systematically review the literature on tumour size and RTI as risk factors for relapse in CS I seminoma testis patients under surveillance. EVIDENCE ACQUISITION: Relevant databases including Medline, Embase, and the Cochrane Library were searched up to November 2016. Randomised controlled trials (RCTs) or quasi-RCTs, prospective observational studies with controls, retrospective matched-pair studies, and comparative studies from well-defined registries/databases were included. The primary outcome was the rate of relapse and relapse-free survival (RFS). The risk of bias was assessed by the Quality in Prognosis Studies tool. EVIDENCE SYNTHESIS: After assessing 3068 abstracts and 80 full-text articles, 20 studies met the inclusion criteria. Although evidence to justify a cut-off of 4cm for size was lacking, it was the most frequently studied. The reported hazard ratio (HR) for the RFS for tumours >4cm was 1.59-2.8. Accordingly, the reported 5-yr RFS ranged from 86.6% to 95.5% and from 73.0% to 82.6% for patients having tumours ≤4 and >4cm, respectively. For tumours with RTI present, the reported HR was 1.4-1.7. The 5-yr RFS ranged from 86.0% to 92.0% and 74.9% to 79.5% for patients without versus those with RTI present, respectively. A meta-analysis was considered inappropriate due to data heterogeneity. CONCLUSIONS: Primary tumour size and RTI are associated with the risk of relapse in CS I seminoma testis patients during surveillance. However, in the presence of either risk factor, the vast majority of patients are cured by orchiectomy alone and will not relapse. Furthermore, the evidence on the prognostic value of size and RTI has significant limitations, so prudency is warranted on their routine use in clinical practice. PATIENT SUMMARY: Primary testicular tumour size and rete testis invasion are considered to be important prognostic factors for the risk of relapse in patients with clinical stage I seminoma testis. We systematically reviewed all the literature on the prognostic value of these two postulated risk factors. The outcome is that the prognostic power of these factors in the published literature is too low to advocate their routine use in clinical practice and to drive the choice on adjuvant treatment in clinical stage I seminoma testis patients.

[Cystic displasia of the testis. Review of literature]. / Displasia quística de rete testis: revisión de la literatura.

OBJECTIVE: Review this pathology nowadays. METHODS: We search in Medline/PubMed database for reviews about cystic dysplasia of the testis. We review and discuss the relevant literature about it. RESULTS: Cystic dysplasia of the testis (CDT) is a rare benign disease, associated with upper urinary tract malformations. Its most frequent clinical manifestation is the increase of testicular size; the presence of cysts is demonstrated by ultrasound. No consensus exists in its treatment, it oftenly requires histological confirmation, performing testicle-sparing surgery. CONCLUSION: CDT needs to be taken into account in the differential diagnosis of childhood testicular tumors.

[Clinical presentation of renal cell carcinoma in renal transplant]. / Presentación clínica del carcinoma de células renales en el trasplante renal.

OBJECTIVES: To analyze the clinical presentation and therapeutic response of renal cell carcinoma (RCC) of the renal graft. METHODS: Analysis of the cases described in our centre and review of current literature. RESULTS: RCC has a higher incidence in transplant patients, affecting the graft in less than 10% of the cases. Detection is usually a casual event during follow-up due to the absence of innervation, although its presentation may be as an acute abdomen in case of breakage of the graft. Conventional treatment consists of transplant nephrectomy, but partial nephrectomy has been performed in recent years with good results. The modification of immunosuppression is a routine measure after treatment. CONCLUSIONS: The incidence of RCC after renal transplants in our series is 0.7%, of which 22% are originated in the graft. The clinical presentation of the primitive RCC of the graft is variable. Partial nephrectomy is technically feasible and oncologically safe in the treatment of RCC of the renal graft.

Displasia quística de rete testis: revisión de la literatura / Cystic displasia of the testis. Review of literature

Objetivo: Revisión de la Displasia Quística de Rete Testis en el momento actual. Material y Métodos: Búsqueda bibliográfica en la base de datos Medline/PubMed del término “Cystic dysplasia of the testis”, con análisis de las revisiones bibliográficas encontradas. Resultados: La displasia quística de rete testis (DQRT) es una rara enfermedad benigna, asociada a malformaciones del tracto urinario superior. Su manifestación clínica más frecuente es el aumento de tamaño testicular, demostrándose la presencia de los quistes ecográficamente. No existe consenso en el tratamiento, optándose en la mayoría de los casos por la confirmación anatomopatológica con conservación del parénquima testicular. Conclusión: La DQRT es una enfermedad que debe ser tenida en cuenta en el diagnóstico diferencial de la masa escrotal infantil (AU)

Objetive: Review this pathology nowadays. Methods: We search in Medline/PubMed database for reviews about cystic dysplasia of the testis. We review and discuss the relevant literature about it. Results: Cystic dysplasia of the testis (CDT) is a rare benign disease, associated with upper urinary tract malformations. Its most frequent clinical manifestation is the increase of testicular size; the presence of cysts is demonstrated by ultrasound. No consensus exists in its treatment, it oftenly requires histological confirmation, performing testicle-sparing surgery. Conclusion: CDT needs to be taken into account in the differential diagnosis of childhood testicular tumors (AU)

Presentación clínica del carcinoma de células renales en el trasplante renal / Clinical presentation of renal cell carcinoma in renal transplant

OBJETIVO: Analizar la presentación clínica y la actitud terapéutica ante la afectación del injerto por un Carcinoma de células renales (CCR).MÉTODOS: Análisis de los casos descritos en nuestro Centro y revisión de la literatura actual.RESULTADOS: El CCR presenta una incidencia superior en los pacientes trasplantados, afectando en menos del 10% al injerto. La ausencia de inervación hace que habitualmente sea un hallazgo casual durante el seguimiento, aunque su presentación puede llegar a ser como un abdomen agudo en caso de rotura del injerto. El tratamiento convencional es la trasplantectomía, realizándose en los últimos años la nefrectomía parcial con buenos resultados. La modificación de la inmunosupresión es una medida habitual tras el tratamiento.CONCLUSIONES: La incidencia de CCR post-TR en nuestra serie es del 0,7%, originándose el 22% de los mismos en el injerto. La presentación clínica del CCR primitivo del injerto es variable. La nefrectomía parcial es técnicamente posible y oncológicamente segura en el tratamiento del CCR del injerto renal(AU)

OBJECTIVES: To analyze the clinical pre-sentation and therapeutic response of renal cell carcinoma (RCC) of the renal graft.METHODS: Analysis of the cases described in our cen-tre and review of current literature.RESULTS: RCC has a higher incidence in transplant patients, affecting the graft in less than 10% of the cases. Detection is usually a casual event during follow-up due to the absence of innervation, although its presentation may be as an acute abdomen in case of breakage of the graft. Conventional treatment consists of transplant nephrectomy, but partial nephrectomy has been performed in recent years with good results. The modification of immunosuppression is a routine measure after treatment.CONCLUSIONS: The incidence of RCC after renal transplants in our series is 0.7%, of which 22% are origi-nated in the graft. The clinical presentation of the primitivaveRCC of the graft is variable. Partial nephrectomy is technically feasible and oncologically safe in the treatment of RCC of the renal graft(AU)