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1 J Korean Soc Transplant 2009;23: DOI: /jkstn Original Article 단일기관에서교환이식프로그램을이용한배우자간신장이식및부부간신장이식의결과 한양대학교의과대학외과학교실 임진규ㆍ김민수ㆍ권오정 The Results of Spousal Donor Kidney Transplantation Via Exchange Donor Program and Direct Spousal Donor Kidney Transplantation in Living Donor Kidney Transplantation: Single Center Experience Jin Kyu Lim, M.D., Min Soo Kim, M.D. and Oh Jung Kwon, M.D. Departments of Surgery, College of Medicine, Hanyang University, Seoul, Korea Background: The shortage of living related and deceased donor groups is one of the major problems of kidney transplantation. We examined the results of spouse and spousal exchange among living kidney transplantation. Methods: Living donor kidney transplants at a single center between 1991 and 2005 were studied, retrospectively (n=593). We compared the graft rates of 24 spousal, 53 spousal exchange transplantations with those of 125 sibling, 142 other living related donor (LRD) or 249 other living unrelated donor (LURD) procedures. We analyzed graft rate, acute rejection rate among each groups. Results: The 5, 10 year graft rates of spousal donor were 75.0%, 69.2%, those of other LURD and spousal exchange were 74.6%, 64.5% (P=0.80) and 86.6%, 84.8% (P=0.11), those of sibling and other LRD were 82.3%, 75.9% (P=0.37) and 75.7%, 65.4% (P=0.84). Spousal exchange donor were more good graft rates rather than other LRD and LURD (P=, ). Acute rejection rates of spousal donor were not significant difference among sibling, other LRD and LURD groups. But acute rejection rates of spousal exchange donor (22.6%) were lower than spousal (45.8%) and other LURD (38.7%) (P=0.04, 0.04). In the multivariate analysis of donor groups, other LRD and LURD groups were associated with a high relative odds of graft (odds ratio 2.88±0.38 (P=0.02), 2.35±0.37 (P=)) compared to spousal exchange donor groups. Conclusions: The spousal exchange donors had more good graft rates than other LRD and LURD groups and spousal donors were as good as other living donors. We expect that the spousal and spousal exchange transplantations are one of the good programs for donor pool expansion. Key Words: Spousal donor, Kidney transplantation, Spousal exchange donor 중심단어 : 부부간공여, 신장이식, 배우자간교환이식 서론 신장이식은말기신부전을가진환자에서생명연장을위한중요한방법의하나이다.(1) 그러나신장이식을위한공여신장의부족현상은큰문제로부각된다. 사체공 책임저자 : 권오정, 서울시성동구행당동 17 한양대학교병원외과, Tel: , Fax: ojkwon@hanyang.ac.kr 접수일 : 2009 년 5 월 27 일, 심사일 : 2009 년 8 월 28 일게재승인일 : 2009 년 8 월 28 일 여신장이식보다생체공여신장이식의결과가우월하다는결과는많이보고되었다.(2) 따라서세계적으로생체공여신장을이용한신장이식의수는점점증가 (3) 하고있으나, 지속적인생체공여프로그램의확장에도불구하고신장이식의수요는공급을초과하고있다.(4) 생체공여신장이식에서혈연공여자와비혈연공여자간의공여신장생존율은공여자와수여자의요인과독립적으로차이가없다.(5) 따라서비혈연공여자신장이식이부족한공여신장의확장을위한중요한방법으로고려되고있다. 최근연구결과에따르면생체공여신장이식에서부부간신장이식의생존율이다른비혈연또는혈연신장 J Korean Soc Transplant June 2009 Volume 23 Issue 2

2 이식의생존율과차이가없음을보이고있으며,(6-10) 교환이식또한혈연신장이식과이식신장생존율의차이가없다고보고되고있다.(11) 본연구에서는생체공여신장이식중부부간신장이식과배우자간교환이식및혈연또는다른비혈연공여자신장이식의이식신장생존율, 급성신이식거부율및이식후합병증을비교분석하였다. 대상및방법본연구는 1991년부터 2005년까지본원이식센터에서시행된신장이식수여자중사체신장이식환자 18명, 추적관찰이불가능한환자 14명을제외한생체신장이식환자 593명을대상으로하였다. 관찰대상은부부간신장이식 (n=24), 배우자간교환이식 (n=53), 부부간신장이식과배우자간교환이식을제외한나머지비혈연간신장이식 (n=249), 형제간신장이식 (n=125), 형제를제외한다른혈연간신장이식 (n=142) 으로나누어분석하였다. 수술후이식신장의기능상실여부는혈중크레아티닌수치, 신사구체투과율및신장초음파검사를통하여확진하였으며, 급성이식거부는신장이식시행후 6개월이내에발생한경우를포함하였다. 수술후발생한합병증은바이러스성, 결핵성, 곰팡이성, 세균성감염으로분류하여분석하였다. 각신장이식환자간의기초자료는공여자및수여자의나이 (50세미만, 50세이상 ), 성별 ( 남자, 여자 ), 체질량지수 (BMI, , 25 30, 30) 를분석하고, 수여자의 Human leukocyte antigen (HLA) matching 개수 (0 2, 3 4, 5 6), 신장이식전투석기간 (1년미만, 1 3년, 3년이상 ), 신장이식수술시기 ( 년, 년 ) 로나누어분석하였다. 각신장이식환자간의기초자료에대한비교는분산분석 (ANOVA) 으로통계처리후다중비교로사후분석을시행하여각군간의차이를확인하였다. 이식신장의생존율은 Kaplan-Meier method로계산하였고생존곡선의검정은 log-rank test를사용하였다. 생존율에대한다변량분석은 Cox s proportional hazard model을사용하였으며모든검사결과의유의수준은 P<0.05 일경우통계적으로유의한것으로판단하였다. 통계학적분석은 SPSS 통계프로그램윈도우용 12판 (SPSS, Inc., Chicago, IL, USA) 를이용하여처리하였다. 결과 1) 신장이식환자의기초자료전체대상환자 593예중부부간신장이식군 24예 (4.0%), 배우자간교환이식군 53예 (8.9%), 나머지비혈연간신장이식군 249예 (41.9%), 형제간신장이식군 125예 (21.1%), 형제를제외한다른혈연간신장이식군은 142 예 (23.9%) 였다. 공여자의나이는 50세미만이 76.2%, 50 세이상이 23.8% 이었으며중간연령은 40.1세였고, 수여자의나이는 50세미만이 83.0%, 50세이상이 17.0% 이었으며중간연령은 38.4세였다. 공여자의성별은남자가 55.6%, 여자가 44.4% 이었고수여자의성별은남자가 66.4%, 여자가 33.6% 이었다. HLA matching의개수는혈연신장이식의경우에비혈연신장이식의경우보다의미있게많은것으로나타났고 (P<0.05), 신장이식수술전투석기간은 1년이내의경우가높은비율로나타나는경향을보였다. 신장이식수술을시행한시기는 1998 년이전에시행한경우가더많았으며, 신장이식수술후합병증은바이러스성감염의경우가높게나타났다. 공여자와수여자간의 BMI 비교에서는두그룹모두에서 BMI 구간의비율이가장높게나타났다 (Table 1). 2) 이식신장의생존율신장이식수술후 5년및 10년이식신장의생존율은부부간신장이식군은 75.0%, 69.2% 이었다. 부부간신장이식과비교하여배우자간교환이식군의경우 86.8%, 84.8% (P=0.11), 다른비혈연신장이식군의경우 74.6%, 64.5% (P=0.80), 형제를제외한다른혈연신장이식군의경우 75.7%, 65.4% (P=0.84), 형제간신장이식군의경우 82.3%, 75.9% (P=0.37) 로부부간신장이식군과비교하여통계적으로의미있는차이는보이지않았다. 배우자간교환이식군의이식신장생존율은각각 86.8%, 84.8% 로다른비혈연신장이식군 (P=) 이나형제를제외한다른혈연신장이식군 (P=) 보다유의하게높았으며, 형제간신장이식군 (P=0.22) 및부부간신장이식군 (P=0.11) 과는의미있는차이는보이지않았다 (Table 2). 각그룹간의이식신장의생존율을통합하여생존곡선으로표현하였다 (Fig. 1). 급성신이식거부율은부부간신장이식군이 45.8% 로형제간신장이식군 (26.4%), 형제를제외한다른혈연간신장이식군 (27.5%), 다른비혈연간신장이식군 (35.1%) 보다높게나왔으나통계적인의의는없었다 (P=0.06, 0.07, 0.44) 또한배우자간교환이식군은 22.6% 로부부간신장이식군및다른비혈연간신장이식군과비교하여유의하게낮았으며 (P=0.04), 형제간및형제를제외한혈연간신장이식군과는통계적으로의미가없었다 (P=0.60, 0.50) (Table 2). 각변수군에따른단변량분석에서공여자의나이가 J Korean Soc Transplant June 2009 Volume 23 Issue 2

3 Table 1. Baseline characteristics of donor groups, n (%) Type Sibling Other LRD Spouse Spousal exchage Other LURD Donor age Donor sex Recipient age Recipient sex Recipient HLA matching (n) Time on dialysis (year) Preemptive 0 1 >1 3 >3 Transplant period (year) Infection Viral Other Fungal Tuberculosis Recipient BMI 25 <30 30 Donor BMI 25 < (84.0)* 20 (16.0) 58 (46.4)* 67 (53.6) 119 (95.2)* 6 (4.8) 40 (32.0) 85 (68.0) 33 (26.4)* 66 (52.8) 26 (20.8) 26 (20.8)* 57 (45.6) 28 (22.4) 14 (11.2) 77 (61.6)* 48 (38.4) 13 (10.4) 5 (4.0) 2 (1.6) 13 (10.4) 84 (67.2) 26 (20.8) 2 (1.6) 8 (6.4)* 82 (65.6) 30 (24.0) 5 (4.0) 87 (61.3)* 55 (38.7) 60 (42.3) 82 (57.7) 110 (77.5)* 32 (22.5) 57 (40.1) 85 (59.9) 22 (15.5)* 107 (75.4) 13 (9.2) 26 (18.3) 56 (39.4) 40 (28.2) 20 (14.1) 95 (66.9) 47 (33.1) 16 (11.3) 4 (2.8) 1 (0.7) 2 (1.4) 25 (17.6) 91 (64.1) 22 (15.5) 4 (2.8) 6 (4.2) 86 (60.6) 46 (32.4) 4 (2.8) 18 (75.0) 6 (25.0) 15 (62.5) 9 (37.5) 16 (66.7) 8 (33.3) 9 (37.5) 15 (62.5) 15 (62.5) 7 (29.2) 2 (8.3) 4 (16.7) 10 (41.7) 9 (37.5) 1 (4.2) 17 (70.8) 7 (29.2) 6 (25.0) 2 (8.3) 20 (83.3) 2 (8.3) * 11 (45.8) 13 (54.2) 48 (90.6) 5 (9.4) 37 (69.8)* 16 (30.2) 41 (77.4) 12 (22.6) 16 (30.2) 37 (69.8) 27 (50.9) 26 (49.1) 2 (3.8)* 22 (41.5) 11 (20.8) 18 (34.0) 33 (62.3) 20 (37.7) 6 (11.3) 1 (1.9) 8 (15.1) 36 (67.9) 7 (13.2) 2 (3.8) 38 (71.7) 12 (22.6) 3 (5.7) Abbreviations: LRD, Living related donor; LURD, Living unrelated donor. *,,,,, P<0.05 between two groups. 194 (77.9) 55 (22.1) 93 (37.3) 156 (62.7) 206 (82.7) 43 (17.3) 77 (30.9) 172 (69.1) 135 (54.5) 112 (45.0) 2 (2.6) 25 (10.0) 71 (28.5) 79 (31.7) 74 (29.7) 182 (73.1)* 67 (26.9) 37 (14.9) 7 (2.8) 3 (1.2)) 2 (0.8) 45 (18.1) 160 (64.3) 38 (15.3) 6 (2.4) 13 (5.2) 149 (59.8) 76 (30.5) 11 (4.4) 50세미만인경우 (P=0.04), 수여자의나이가 50세이상인경우 (P=), 수여자의성별이여성인경우 (P=), HLA matching 개수가많은경우 (P=0.02), 수술전투석을하지않은경우 (P=) 에서이식신장의생존율이더좋은결과를보였으며, 1998년이후에신장이식수술을시행한경우 (P=) 도더좋은이식신장의생존율을보였다 (Table 3). 단변량분석에서이식신장의생존율에유의한차이를보이는요인을이용하여다변량분석을시행한결과배우자간교환이식군보다형제를제외한다른혈연신장 Table 2. Graft rate and rate of acute rejection Sibling Other LRD Spouse Spousal exchange Other LURD 5 yr graft yr graft * * Rate of acute rejection (%) * * Abbreviations: LRD, Living related donor; LURD, Living unrelated donor. *P<0.05 compared to spousal exchange donor transplantation. J Korean Soc Transplant June 2009 Volume 23 Issue 2

4 Table 3. Univariate graft analysis of donor groups and outcomes Type 5 yr graft 10 yr graft P-value Fig. 1. Graft rates of living donor kidney transplantation. LRD: Living related donor, LURD: Living unrelated donor. 이식군 (2.88±0.38, P=0.02) 이나다른비혈연신장이식군 (2.35±0.37, P=) 에서이식신장생존율의상대위험도 (Hazard ratio) 가유의하게높게분석되었다 (Table 4). 고찰 신장이식은수술술기의발달, 면역억제제의발달로말기신부전환자의가장좋은치료방법의하나로선호되고있으나늘어나는신장이식대기자에비해공여되는신장이더부족하기때문에해결해야할문제로부각되고있다. 우리나라의경우국립장기이식관리센터의보고 (12) 에의하면 2007년전체 928예의신장이식중뇌사자 280예 (30.2%) 의신장이식이이루어져뇌사자신장이식이낮은비율로이루어지고있음을보이고있다. 또한국내에서 2005년생체신장이식 589예중비혈연신장이식은 146예 (24.8%) 이었고이중공여신장이타인의경우 53예 (9.0%), 부부의경우 54예 (9.2%) 이었으며, 2007년 648예의신장이식중비혈연신장이식은 173예 (26.7%) 이었고이중공여신장이타인의경우 44예 (6.8%), 부부의경우 100예 (15.4%) 로나타났다.(12) 이렇듯뇌사자장기기증이부족한국내실정에서신장이식은생체공여신장이식이주를이루었으며, 신장이식수술이필요한환자가늘어남에따라혈연신장이식뿐만아니라비혈연신장이식공여자확보를위한노력이필요하다. 신장이식에서 HLA mismatching은결과에중요한영향을미치는것으로잘알려져있다.(1,13) 혈연신장이식과비교하여비혈연신장이식에서 HLA mismatching은더많은수에서나타난다. 본연구에서도배우자를포함한비혈연신장이식의경우에형제를포함한혈연신장이식 Donor age Donor sex Recipient age Recipient sex Recipient HLA matching (n) Recipient time on dialysis (year) Preemptive 0 1 >1 3 >3 Transplant period(year) Recipient BMI >=25 <30 >=30 Donor BMI >=25 <30 >= Univariate analysis was performed using the Kaplan-Meier method with a Log-rank test. 의경우보다 HLA mismatching의수가더높게나타났으며, HLA matching의수가클수록이식신장생존율의위험도는더낮은것으로나타났으나 (P=), 최근에여러단일센터연구결과에서비혈연신장이식에서더높은 HLA mismatching을보임에도불구하고혈연신장이식과비혈연신장이식사이에공여신장생존율은비슷한결과를보인다고보고하고있다.(14,15) 또한이식신장생존율과관련된인자중, 유등 (16) 은수술전투석을받지않은군에서신이식생존율이높은것으로보고하였으며, 이는본연구에서도수술전투석을받지않은군에서이식신장생존율이높은것으로나타났다. 그리고수여자 J Korean Soc Transplant June 2009 Volume 23 Issue 2

5 Table 4. Multivariate graft analysis of donor groups and outcomes Type Graft failure (HR) 95% confidence interval Lower Upper P-value Donor type Sibling Other LRD Spouse Spousal exchange Other LURD Donor age Recipient age Recipient sex Recipient HLA matching (n) Recipient time on dialysis (year) Preemptive 0 1 >1 3 >3 Transplant period (year) Abbreviations: LRD, Living related donor; LURD, Living unrelated donor. Multivariate analysis was performed using the Cox proportional hazard regression model. The model included adjustment for the following factors associated with graft in univariate analysis with P< 연령에따른비교에서는 50세이상의군에서이식신장의생존율이높은것으로나타났고 (P=), 이는 Jassal 등 (17) 이보고한바와같이고령군에서신이식거부율이적기때문일것으로생각되나본연구자료에서는두연령군간에신이식거부율의통계적인차이는나타나지않았고, 고령군에서 HLA matching의수가상대적으로많은점등이영향을주었을것으로생각된다. Terasaki 등 (9) 은부부간신장이식이다른비혈연신장이식과비교하여비슷한신장이식결과를보이고있다고보고하였고, 본연구에서도부부간신장이식과다른비혈연신장이식 (P=0.11, 0.80) 이나, 혈연신장이식 (P=0.37, 0.84) 과통계적으로차이가없는결과를나타내었다. 그러나본연구가수여자의 PRA (Panel Reactive Antibody), 신장이식의과거력, 공여자및수여자의심혈관계질환, 수혜자에게사용된면역억제제등을고려하지않고이식신장의생존율을분석하였고, 다른혈연및비혈연신장이식의예에비해적은수의부부간신장이식의예 를비교하여결과에다소제한이있을수있다. 부부간신장이식에서공여자가남편인경우에다른생체신장이식보다공여신장생존율이더좋은결과를보인보고가있으나,(7,18) 본연구에서는고려대상에포함되지않았다. 부부간신장이식은 ABO 혈액형이불일치하는경우또는수혈, 임신, 이식의기왕력등의전감작으로인한림프구적합시험에양성이나타나는경우등에의해신장이식에장애가될수있다.(19) 이러한장애점을극복하기위한방법으로교환이식 (20,21) 과탈감작화시키는방법 (22) 등을고려할수있다. Mahendran과 Veitch(23) 는여러가지교환이식프로그램을이용한공여자확대모델을제시하였다. 박등 (20) 은공여자교환프로그램을통해신장이식후 5년신장이식환자생존율및이식신장생존율에서비슷한결과를보였음을보고하였고, 또다른연구에서공여자교환프로그램을통한신장이식이비혈연신장이식중에서차지하는비율이 4.2% 에서 46.6% 까 J Korean Soc Transplant June 2009 Volume 23 Issue 2

6 지늘어나이식공여자확장에도움이되었다고보고하였다.(21) 본연구에서도배우자간교환이식 53예의경우두쌍의부부사이에단순교환을이용하여신장이식을시행하였고배우자간교환이식이부부를제외한다른비혈연신장이식이나형제를제외한혈연간신장이식에비하여좋은결과를보였으며, 이는전체생체신장이식에서 8.9% 를차지한다. 따라서부부간에신장이식이적합하지않은경우에다른부부와의교환이식방법이이식공여자확대에도움이될것으로생각된다. 하지만 Mathieson 등 (24) 은부부간신장이식에있어서윤리적인문제를지적하였고, 일부에서는신장이식이인간의장기를상품으로여길수있으며, 부부간에있어신장의공여가자칫자발적인공여를가장하여강요될수있음을경고하였다.(25) 이러한문제점은배우자간교환이식에서도마찬가지일것이다. 그러나부부간신장이식을통해결혼생활의유대감이더돈독해지고남편과부인으로서각자의역할에더충실해지고, 부부관계및자녀들과의관계가더좋아질수있다는보고도있다.(26,27) 부부간신장이식이나배우자간교환이식의경우다른혈연신장이식의경우처럼병원에입원하여퇴원할때까지이미감정적으로친밀한관계를계속유지할수있으며, 같은날같은의료팀에의해수술을받음으로써서로의지할수있다는점을간과할수없다. 이러한내용을산술적으로표현할수는없지만객관적인설문지등을통하여평가하고분석한다면신장이식에대한환자의두려움을줄여주고안정적인신장이식환경을조성하는데도움이될것이다. 결론본연구에서부부간신장이식은다른생체신장이식과이식신장생존율의차이가없었고, 배우자간교환이식에서부부를제외한다른비혈연신장이식이나형제를제외한혈연간신장이식에비하여좋은결과가나타났다. 이러한점에서부부간신장이식이적합하지않은경우배우자간교환이식이공여신장을확장할수있는유용한방법중하나라고할수있을것으로보여진다. 더나아가부부간신장이식및배우자간교환이식의의학적, 윤리적제한점을극복하고제도적으로보완하여공여신장의확장을위한연구가계속되어야할것으로생각한다. REFERENCES 1) Port FK, Wolfe RA, Mauger EA, Berling DP, Jiang K. Comparison of probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 1993;270: ) Matas AJ, Payne WD, Sutherland DE, Humar A, Gressner RW, Kandaswamy R, et al. 2,500 living donor kidney transplants: a single-center experience. Ann Surg 2001;234: ) Cecka JM. The OPTN/UNOS Renal Transplant Registry Clin Transpl 2003; ) Xue JL, Ma JZ, Louis TA, Collins AJ. Forecast of the number of patients with end-stage renal disease in the United States to the year J Am Soc Nephrol 2001;12: ) Voiculescu A, Ivens K, Hetzel GR, Hollenbeck M, Sandmann W, Grabitz K, et al. Kidney transplantation from related and unrelated living donors in a single German centre. Nephrol Dial Transplant 2003;18: ) Wyner LM, Novick AC, Streem SB, Hodge EE. Improved success of living unrelated renal transplantation with cyclosporine immunosuppression. J Urol 1993;149: ) Terasaki PI, Cecka JM, Gjertson DW, Cho YW. Spousal and other living renal donor transplants. Clin Transpl 1997; ) Kikuchi K, Narumi Y, Hama K, Iwamoto H, Uchiyama M, Kozaki K, et al. Kidney transplantation from spousal donors. Transplant Proc 2000;32: ) Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High rates of kidney transplants from spousal and living unrelated donors. N Eng J Med 1995;333: ) Lee SH, Huh KH, Kim SJ, Joo DJ, Ju MK, Kim MS, et al. Clinical outcomes of spousal donor kidney transplantation: single center experience. J Korean Soc Transplant 2008;22: ) Shin EJ, Kwon OJ. The outcome of renal transplantation using exchange donor program. J Korean Soc Transplant 2007;21: ) Korean Network for Organ Sharing (KONOS) Annual Data Report [Internet]. Seoul: KONOS, 2008:15. Available from: 13) Takemoto SK. HLA matching in the new millennium. Clin Transpl 2003; ) Kizilisik AT, Ray JB, Nylander WA, Langone AJ, Helderman JH, Shaffer D. Kidney transplantation in a Veterans Administration medical center: 40 years experience. Exp Clin Transplant 2004;2: ) Simforoosh N, Basiri A, Fattahi MR, Einollahi B, Firouzan A, Pour-Reza-Gholi F, et al. Living unrelated versus living related kidney transplantation: 20 years experience with 2155 cases. Transplant Proc 2006;38: ) Yoo SW, Kwon OJ, Kang CM. Preemptive living-donor renal transplantation: outcome and clinical advantages. Transplant Proc 2009;41: ) Jassal SV, Opelz G, Cole E. Transplantation in the eld- J Korean Soc Transplant June 2009 Volume 23 Issue 2

7 erly: a review. Geriatr Nephrol Urol 1997;7: ) Shames BD, D Alessandro AM, Pirsch JD, Knechtle SJ, Odorico JS, Becker YT, et al. Living-unrelated renal transplantation at the University of Winsconsin. Clin Transpl 2001: ) Tang S, Lui SL, Lo CY, Lo WK, Cheng IK, Lai KN, et al. Spousal renal donor transplantation in Chinese subjects: a 10 year experience from a single centre. Nephrol Dial Transplant 2004;19: ) Park K, Moon JI, Kim SI, Kim YS. Exchange donor program in kidney transplantation. Transplantation 1999;67: ) Park K, Lee JH, Huh KH, Kim SI, Kim YS. Exchange living-donor kidney transplantation: diminution of donor organ shortage. Transplant Proc 2004;36: ) Joo DJ, Kim MS, Ahn HJ, Ju MK, Jeun KO, Kim HJ, et al. The result of renal allograft which lymphocyte crossmatch is negatively converted by pretransplant plasmapheresis and IV gamma-globulin. J Korean Soc Transplant 2006;20: ) Mahendran AO, Veitch PS. Paired exchange programmes can expand the live kidney donor pool. Br J Surg 2007; 94: ) Mathieson PW, Jolliffe D, Jolliffe R, Dudley CR, Hamilton K, Lear PA. The spouse as a kidney donor: ethically sound? Nephrol Dial Transplant 1999;14: ) Lawrence R. Abuse or live related kidney transplantation. Nephrol Dial Transplant 1997;12: ) Watanabe T, Hiraga S. Influence on family psychodynamics on spousal kidney transplantation. Transplant Proc 2002;34: ) Spital A. Do U.S. transplant centers encourage emotionally related kidney donation? Transplantation 1996;61: J Korean Soc Transplant June 2009 Volume 23 Issue 2

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar