document_title: Kidney transplantation

question_text: during a kidney transplant the renal vein of the donor kidney is anastomosed to the

question_tokens: during a kidney transplant the renal vein of the donor kidney is anastomosed to the

text: Kidney transplantation

text: History[edit]

text: One of the earliest mentions about the real possibility of a kidney transplant was by American medical researcher Simon Flexner, who declared in a reading of his paper on "Tendencies in Pathology" in the University of Chicago in 1907 that it would be possible in the then-future for diseased human organs to be substituted for healthy ones by surgery, including arteries, stomach, kidneys and the heart.[3]

text: In 1933, surgeon Dr. Yuriy Voroniy from Kherson in the then Soviet Union, attempted the first human kidney transplant, using a kidney removed six hours earlier from a deceased donor, to be reimplanted into the thigh. He measured kidney function by using a connection between the kidney and the skin. His first patient died two days later, because the graft was incompatible with the recipient's blood group and was thus rejected.[4]

text: It was not until June 17, 1950, when a successful transplant could be performed on Ruth Tucker, a 44-year-old woman who had polycystic kidney disease, by Dr. Richard Lawler[5] at Little Company of Mary Hospital in Evergreen Park, Illinois. Although the donated kidney was rejected 10 months later because no immunosuppressive therapy was available at the time—the development of effective anti-rejection drugs was years away. However, the intervening time provided enough time for Tucker's remaining kidney to recover, resulting in her living an additional five years.[6]

text: The first kidney transplants between living patients were performed in 1952 at the Necker hospital in Paris France, by Dr. Jean Hamburger. Unfortunately, the kidney transplant failed after only three weeks of satisfactory function [7] and later in 1954 in Boston Massachusetts. The Boston transplantation, which was performed on December 23, 1954, at Brigham Hospital, was performed by Drs. Joseph Murray, J. Hartwell Harrison, John P. Merrill and others. The procedure was conducted between identical twins Ronald and Richard Herrick, in order to eliminate any problems of an immune reaction. For this and later work, Dr. Murray received the Nobel Prize for Medicine in 1990. The recipient, Richard Herrick, died eight years after the transplantation procedure.[8]

text: In 1955, Charles Rob, William James "Jim" Dempster (St. Marys and Hammersmith, London UK) carried out the first deceased donor transplant in the United Kingdom, which was unsuccessful. In July 1959, "Fred" Peter Raper (Leeds) performed the first successful (eight months) deceased donor transplant in the UK. One year later, in 1960, the first successful living kidney transplant in the UK occurred, when Dr. Michael Woodruff performed one between identical twins in Edinburgh.[9]

text: Until the routine use of medications to prevent and treat acute rejection that were introduced in 1964, deceased donor transplantation was not performed. The kidney was considered to be the easiest organ to transplant, because: Tissue typing was simple, the organ was relatively easy to remove and implant, live donors could be used without difficulty, and in the event of failure, kidney dialysis was available from the 1940s onward, but not widely available for several decades. Tissue typing was acknowledged to be essential to the success, as early attempts in the 1950s on sufferers from Bright's disease had been very unsuccessful.

text: The major barrier to organ transplantation between genetically nonidentical patients lay in the recipient's immune system, which would treat a transplanted kidney as a "nonself" or foreign body to be attacked, and immediately or chronically reject it. Thus, having medications to suppress the immune system was essential. However, suppressing an individual's immune system places that individual at greater risk of infection and cancer (particularly skin cancer and lymphoma), in addition to the very difficult side effects of the medications.

text: The basis for most immunosuppressive regimens is prednisolone, a corticosteroid. Prednisolone suppresses the immune system, but its long-term use at high doses causes a multitude of side effects, including glucose intolerance and diabetes, substantial weight gain, osteoporosis, muscle weakness, hypercholesterolemia and cataract formation. Prednisolone alone is usually inadequate to prevent rejection of a transplanted kidney. Thus other, nonsteroid immunosuppressive agents are needed, which also allow lower doses of prednisolone.

text: Indications[edit]

text: The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the primary cause. This is defined as a glomerular filtration rate of < 15 ml/min/1.73 m2. Common diseases leading to ESRD include malignant hypertension, infections, diabetes mellitus, and focal segmental glomerulosclerosis. The genetic causes include polycystic kidney disease, a number of inborn errors of metabolism, plus autoimmune conditions such as lupus.

text: Diabetes is the most common known cause of kidney transplantation, accounting for approximately 25% of those in the US. The majority of renal transplant recipients are maintained on dialysis (peritoneal dialysis or hemodialysis) at the time of transplantation. However, individuals with chronic kidney disease who have a living donor available may undergo pre-emptive transplantation before dialysis is needed, while the odds of success are still favorable. If a patient is placed on the waiting list for a deceased donor transplant early enough, they may also be transplanted pre-dialysis.

text: Contraindications and requirements[edit]

text: Contraindications include both cardiac and pulmonary insufficiency, as well as hepatic disease and some cancers. Concurrent tobacco use and morbid obesity are also among the indicators that place a patient at a higher risk for surgical complications.

text: Kidney transplant requirements vary from program to program and country to country. Many transplant programs place limits on age (e.g. the person must be under a certain age, in order to be added to the waiting list), and require that one must be in good health (aside from the kidney disease). Significant cardiovascular disease, incurable terminal infectious diseases and cancer are often considered to be transplant exclusion criteria. In addition, transplant candidates are typically screened to determine if they will be compliant with their medications, which is essential for survival of the transplant. Patients who have mental illness and/or significant on-going substance abuse issues may often be excluded.

text: HIV was at one point considered to be a complete contraindication to transplantation. There was fear that immunosuppressing someone with a depleted immune system would result in the progression of the disease. However, some research seem to suggest that immunosuppressive drugs and antiretrovirals may work synergistically to help both HIV viral loads/CD4 cell counts and prevent active rejection.

text: Sources of kidneys[edit]

text: Since medication to prevent rejection is so effective, donors do not need to be completely similar to their recipient. Most donated kidneys are procured from deceased donors. However, the use of living donors in the United States has been rising in recent years. In 2006, 47% of donated kidneys were from living donors.[10] This varies by country: for example, only 3% of kidneys transplanted during 2006 in Spain came from living donors.[11] In Spain, all citizens are potential organ donors in the case of their death, unless they explicitly opt out during their lifetime,[12] but this is not the case in the US and many other countries worldwide.

text: Living donors[edit]

text: Approximately one in three donations in the US, UK and Israel is now from a live donor.[13][14][15] Potential donors are carefully evaluated, based on medical and psychological grounds. This ensures that the donor is fit for surgery and has no disease that could bring undue risk or likelihood of a poor outcome for either the donor or recipient. The psychological assessment is to ensure the donor gives informed consent and is not coerced. In countries where paying for organs is illegal, the authorities may also seek to ensure that a donation has not resulted from a financial transaction.

text: The relationship the donor has to the recipient has evolved over the years. In the 1950s, the first successful living donor transplants were between identical twins. In the 1960s–1970s, live donors were genetically related to the recipient. However, during the 1980s–1990s, the donor pool was expanded further to emotionally related individuals (spouses, friends). Now the elasticity of the donor relationship has been stretched to include acquaintances and even strangers ('altruistic donors'). In 2009, Minneapolis transplant recipient Chris Strouth received a kidney from a donor who connected with him on Twitter, which is believed to be the first such transplant arranged entirely through social networking.[16][17]

text: The acceptance of altruistic donors has enabled chains of transplants to form. Kidney chains are initiated when an altruistic donor donates a kidney to a patient who has a willing but incompatible donor. This incompatible donor then 'pays it forward' and passes on the generosity to another recipient who also had a willing but incompatible donor. Michael Rees from the University of Toledo developed the concept of open-ended chains.[18] This was a variation of a concept developed at Johns Hopkins University.[19] On July 30, 2008, an altruistic donor kidney was shipped via commercial airline from Cornell to the University of California, Los Angeles, thus triggering a chain of transplants.[20] The shipment of living donor kidneys, computer-matching software algorithms, and cooperation between transplant centers has enabled long-elaborate chains to be formed.[21]

text: In carefully screened kidney donors, survival and the risk of end-stage renal disease appear to be similar to those in the general population.[22] However, some more recent studies suggest that lifelong risk of chronic kidney disease is several-fold higher in kidney donors although the absolute risk is still very small.[23] A 2017 article in the New England Journal of Medicine suggests that persons with only one kidney including those who have donated a kidney for transplantation should avoid high protein diet and limit their protein intake to less than one gram per kilogram body weight per day in order to reduce the long-term risk of chronic kidney disease.[24] Women who have donated a kidney have a higher risk of gestational hypertension and preeclampsia than matched nondonors with similar indicators of baseline health.[25] Traditionally, the donor procedure has been through a single incision of 4–7 inches (10–18 cm), but live donation is being increasingly performed by laparoscopic surgery. This reduces pain and accelerates recovery for the donor. Operative time and complications decreased significantly after a surgeon performed 150 cases. Live donor kidney grafts have higher long-term success rates than those from deceased donors.[26] Since the increase in the use of laparoscopic surgery, the number of live donors has increased. Any advance which leads to a decrease in pain and scarring and swifter recovery has the potential to boost donor numbers. In January 2009, the first all-robotic kidney transplant was performed at Saint Barnabas Medical Center through a two-inch incision. In the following six months, the same team performed eight more robotic-assisted transplants.[27]

text: In 2004 the FDA approved the Cedars-Sinai High Dose IVIG therapy which reduces the need for the living donor to be the same blood type (ABO compatible) or even a tissue match.[28][29] The therapy reduced the incidence of the recipient's immune system rejecting the donated kidney in highly sensitized patients.[29]

text: In 2009 at the Johns Hopkins Medical Center, a healthy kidney was removed through the donor's vagina. Vaginal donations promise to speed recovery and reduce scarring.[30] The first donor was chosen as she had previously had a hysterectomy.[31] The extraction was performed using natural orifice transluminal endoscopic surgery, where an endoscope is inserted through an orifice, then through an internal incision, so that there is no external scar. The recent advance of single port laparoscopy requiring only one entry point at the navel is another advance with potential for more frequent use.

text: Illegal organ trade[edit]

text: In the developing world, some people sell their organs illegally (on the black market), an underground practice that began in small quantities as early as the mid-1980s, as first reported on "60 Minutes" at that time. Then in following years, major newspapers in the U.S., and medical trade journal articles, began reporting an increased incidence of the practice. The incidence because so widespread and notorious, as often reported in "Nephrology News & Issues," that federal legislation in the U.S. to ban the sale of organs and tissues, was proposed by Senator Al Gore, which became federal law in 1984, which was named the "National Organ and Transplant Act." The federal legislation in the U.S. remains in effect to this day.

text: Such potential human donors who are often living in India and Asia, routinely live in what is considered to be grave or extreme poverty[32] and who are therefore exploited by profit-motivated salespersons who may take advantage of the donor's desperate need to survive or pay for such basics as food, medical care and housing. The people who travel to make use of these kidneys are often known as "transplant tourists." This practice is opposed by a variety of human rights groups, including Organs Watch, a group established by medical anthropologists, which was instrumental in exposing illegal international organ selling rings. These patients may have increased complications owing to poor infection control and lower medical and surgical standards. One surgeon has said that organ trade could be legalized in the UK to prevent such tourism, but this is not seen by the National Kidney Research Fund as the answer to a deficit in donors.[33]

text: In the illegal black market, the donors may not receive sufficient after-operation care,[34] the price of a kidney may be above $160,000,[35] middlemen take most of the money, the operation is more dangerous to both the donor and receiver, and the buyer often is infected with hepatitis or HIV.[36] In legal markets of Iran, the price of a kidney is reported to be $2,000 to $4,000.[36][37]

text: An article by Gary Becker and Julio Elias on "Introducing Incentives in the Market for Live and Cadaveric Organ Donations"[38] said that a free market could help solve the problem of a scarcity in organ transplants. Their economic modeling was able to estimate the price tag for human kidneys ($15,000) and human livers ($32,000).

text: Jason Brennan and Peter Jaworski of the CATO Institute have also argued that any moral objections to a market for organs aren't inherent in the market, but rather, the activity itself.[39]

text: Now monetary compensation for organ donors is being legalized in Australia and Singapore. Kidney disease organizations in both countries have expressed their support.[40][41]

text: Deceased donors[edit]

text: Deceased donors can be divided in two groups:

text:
Brain-dead (BD) donors
Donation after Cardiac Death (DCD) donors

text: Although brain-dead (or "heart beating") donors are considered to be dead, the donor's heart continues to pump and maintain the circulation. This makes it possible for surgeons to start operating while the organs are still being perfused (supplied with blood). During the operation, the aorta will be cannulated, after which the donor's blood will be replaced by an ice-cold storage solution, such as UW (Viaspan), HTK or Perfadex. Depending on which organs are transplanted, more than one solution may be used simultaneously. Due to the temperature of the solution, and since large amounts of cold NaCl-solution are poured over the organs for a rapid cooling, the heart will stop pumping.

text: "Donation after Cardiac Death" donors are patients who do not meet the brain-dead criteria, but due to the unlikely chance of recovery, have elected via a living will or through family wishes, to have support withdrawn. In this procedure, treatment is discontinued (mechanical ventilation is shut off). After a time of death has been pronounced, the patient is rushed to the operating room, where the organs are recovered/removed. Storage solution is then flushed through the organs. Since the blood is no longer being circulated, coagulation must be prevented with large amounts of anti-coagulation agents such as heparin. Several ethical and procedural guidelines must be followed; most importantly, the organ recovery team should not participate in the patient's care in any manner until after death has been officially declared.

text: Compatibility[edit]

text: In general, the donor and recipient should be in the ABO blood group and crossmatch (human leukocyte antigen -- HLA) compatible. If a potential living donor is incompatible with his/her recipient, the donor could be exchanged for a compatible kidney. Kidney exchange, also known as "kidney paired donation" or "chains," have recently gained in popularity.

text: In an effort to reduce the risk of rejection during incompatible transplantation, ABO-incompatible and densensitization protocols using intravenous immunoglobulin (IVIG) have been developed, with the aim to reduce ABO and HLA antibodies that the recipient may have to the donor.

text: In the 1980s, experimental protocols were developed for ABO-incompatible transplants using increased immunosuppression and plasmapheresis. Through the 1990s these techniques were improved, and an important study of long-term outcomes in Japan was published.[42] Now, a number of programs around the world are routinely performing ABO-incompatible transplants.[43]

text: The level of sensitization to donor HLA antigens is determined by performing a panel reactive antibody test on the potential recipient. In the US, up to 17% of all deceased donor kidney transplants have no HLA mismatch. However, HLA matching is a relatively minor predictor of transplant outcomes. In fact, living nonrelated donors are now almost as common as living (genetically)-related donors.

text: Procedure[edit]

text: In most cases, the barely functioning existing kidneys are not removed, as removal has been shown to increase the rates of surgical morbidity. Therefore, the kidney is usually placed in a location different from the original kidney. Often this is in the iliac fossa, so it is often necessary to use a different blood supply:

text:
The renal artery of the new kidney, previously branching from the abdominal aorta in the donor, is often connected to the external iliac artery in the recipient.
The renal vein of the new kidney, previously draining to the inferior vena cava in the donor, is often connected to the external iliac vein in the recipient.

text: The donor ureter is anastomosed with the recipient bladder.

text: There is disagreement in surgical textbooks regarding which side of the recipient’s pelvis to use in receiving the transplant. Campbell's Urology (2002) recommends placing the donor kidney in the recipient’s contralateral side (i.e. a left-sided kidney would be transplanted in the recipient's right side) to ensure the renal pelvis and ureter are anterior, in the event that future surgeries are required. In an instance where there is doubt over whether there is enough space in the recipient’s pelvis for the donor's kidney, the textbook recommends using the right side, because the right side has a wider choice of arteries and veins for reconstruction. Smith's Urology (2004) states that either side of the recipient's pelvis is acceptable; however, the right vessels are "more horizontal" with respect to each other and are therefore easier to use in the anastomoses. It is unclear what is meant by the words "more horizontal." Glen's Urological Surgery (2004) recommends placing the kidney in the contralateral side in all circumstances. No reason is explicitly put forth; however, one can assume the rationale is similar to that of Campbell, i.e., to ensure that the renal pelvis and ureter are most anterior, in the event that future surgical correction becomes necessary.

text: Regarding who receives a donated organ, "The organs are distributed locally first, and if no match is found they are then offered regionally, and then nationally, until a recipient is found. Every attempt is made to place donor organs," explains the United Network for Organ Sharing, which contracts to administer the US organ donation procedures at all transplant and procurement centers.

text: On March 21, 1984, UNOS was incorporated as an independent, nonprofit organization, currently based in Richmond Virginia, committed to saving lives through uniting and supporting the efforts of donation and transplantation professionals. Learn more >

text: Also in 1984, in the US, the National Organ Transplant Act (NOTA) called for an Organ Procurement and Transplantation Network (OPTN) to be created and run by a private, nonprofit organization under federal contract. The federal Final Rule provides a regulatory framework for the structure and operation of the OPTN. UNOS was first awarded the national OPTN contract in 1986 by the U.S. Department of Health and Human Services. Today, UNOS continues as the only organization ever to operate the OPTN.

text: As of March 18, 2018, there were 114,859 people waiting for an organ transplant in the US, according to UNOS. For 2017, there were 19,850 kidney transplant procedures, with roughly three times as many deceased donor procedures as living-related: 12,250 vs. 5,628.

text: UNOS reports that:

text: -- 1 organ donor can save up to 8 lives.

text: -- Every 10 minutes another name is added to the national organ transplant waiting list.

text: -- Sadly, an average of 20 people die each day because the organs they need are not donated in time. More than 7,000 candidates died in 2016 while on the wait list, or within 30 days of leaving the list for personal or medical reasons, without receiving an organ transplant.

text: TO REGISTER TO BECOME AN ORGAN DONOR, PLEASE VISIT: https://www.registerme.org

text: Annual kidney transplant procedures that were conducted in the US, according to UNOS, as of March 18, 2018[edit]

text:
To Date
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988

All Donor Types

428,299
3,106
19,850
19,060
17,878
17,109
16,896
16,487
16,816
16,900
16,830
16,521
16,634
17,095
16,485
16,007
15,138
14,781
14,279
13,631
12,767
12,454
11,709
11,411
11,084
10,646
10,359
9,738
9,678
9,416
8,656
8,878

Deceased Donor

282,264
2,143
14,038
13,431
12,250
11,570
11,163
10,868
11,043
10,622
10,442
10,553
10,591
10,660
9,913
9,359
8,668
8,540
8,234
8,126
8,044
8,034
7,776
7,732
7,695
7,639
7,508
7,204
7,282
7,322
6,753
7,061

Living Donor

146,035
963
5,812
5,629
5,628
5,539
5,733
5,619
5,773
6,278
6,388
5,968
6,043
6,435
6,572
6,648
6,470
6,241
6,045
5,505
4,723
4,420
3,933
3,679
3,389
3,007
2,851
2,534
2,396
2,094
1,903
1,817

text: Data subject to change based on future data submission or correction.

text: Annual transplant procedures for all types of organs that were conducted in the US, according to UNOS, as of March 18, 2018[edit]

text:
To Date
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988

All Donor Types

726,952
5,448
34,771
33,610
30,974
29,540
28,955
28,053
28,540
28,662
28,460
27,964
28,366
28,940
28,118
27,041
25,473
24,911
24,239
23,274
22,029
21,524
20,316
19,765
19,396
18,299
17,630
16,134
15,756
15,001
13,140
12,623

Deceased Donor

574,066
4,437
28,588
27,630
24,985
23,720
22,967
22,187
22,518
22,101
21,850
21,746
22,053
22,207
21,213
20,049
18,659
18,292
17,641
17,335
17,010
16,979
16,266
15,983
15,921
15,211
14,732
13,563
13,329
12,878
11,222
10,794

Living Donor

152,886
1,011
6,183
5,980
5,989
5,820
5,988
5,866
6,022
6,561
6,610
6,218
6,313
6,733
6,905
6,992
6,814
6,619
6,598
5,939
5,019
4,545
4,050
3,782
3,475
3,088
2,898
2,571
2,427
2,123
1,918
1,829

text: Kidney-pancreas transplant[edit]

text: Occasionally, the kidney is transplanted together with the pancreas. University of Minnesota surgeons Drs. Richard Lillehei and William Kelly performed the first successful simultaneous pancreas-kidney transplant in the world in 1966.[44] This is conducted in patients who have diabetes mellitus type 1. In those patients, the diabetes is due to destruction of the beta cells of the pancreas and in whom the diabetes has caused renal failure (diabetic nephropathy). This is almost always a deceased donor transplant. Only a few living donor (partial) pancreas transplants have been conducted, though. For individuals who have diabetes and renal failure, the advantages of earlier transplant from a living donor (if available) are far superior to the risks of continued dialysis until a combined kidney and pancreas transplant procedure becomes available from a deceased donor.[citation needed] A patient can either receive a living kidney followed by a donor pancreas at a later date (PAK, or pancreas-after-kidney), or a combined kidney-pancreas from a donor (SKP, simultaneous kidney-pancreas).

text: Transplanting just the islet cells from the pancreas is still in the experimental stage, but the procedure shows promise. This procedure involves taking a deceased donor pancreas, breaking it down, and extracting the islet cells that make insulin. The cells are then injected through a catheter into the recipient and they generally lodge in the liver. The recipient still needs to take immunosuppressants to avoid rejection, but no surgery is required. Most people require 2-3 such injections, and many are not completely insulin-free.

text: Post-operation[edit]

text: The transplant surgery typically takes about three hours.[45] The donor kidney will be placed in the lower abdomen, and its blood vessels are connected to arteries and veins in the recipient's body. When this process is complete, blood will be allowed to flow through the kidney again. The final step is connecting the ureter from the donor kidney to the bladder. In most cases, the kidney will soon start producing urine, and often instantaneously, according to surgeons, depending on its quality.

text: Living donor kidneys normally require 3–5 days to reach normal functioning levels, while cadaveric donations stretch that interval to 7–15 days. Hospital stay is typically for 4–10 days. If complications arise, additional medications (diuretics) may be administered, in order to help the kidney produce urine.

text: Immunosuppressant drugs are used to suppress (block) the immune system from rejecting the donor kidney. These medicines must be taken for the rest of the recipient's life. The most common medication regimen today is a mixture of tacrolimus, mycophenolate and prednisolone. Some recipients may instead be administered cyclosporin, sirolimus or azathioprine. The risk of early rejection of the transplanted kidney is increased if corticosteroids are avoided or withdrawn after the transplantation.[46] Cyclosporin, which was considered to be a major breakthrough immunosuppressive when first discovered in the 1980s, ironically causes nephrotoxicity. That can result in iatrogenic damage to the newly transplanted kidney. Tacrolimus, which is a similar drug, also causes nephrotoxicity. Blood levels of both must be monitored closely. Thus, if the recipient seems to be experiencing declining renal function or proteinuria, a biopsy may be necessary to determine whether this is due to rejection,[47][48] or ciclosporin or tacrolimus intoxication.

text: Imaging[edit]

text: Post-operatively, kidneys are periodically imaged by ultrasound, in order to assess the physiologic changes that often accompany transplant rejection. Imaging also allows the evaluation of supportive structures such as the anastomosed transplant artery, vein and ureter, so as to ensure they are stable in appearance.

text: The major sonographic scale in quantitative ultrasound assessment is with a multipoint assessment of the resistive index (RI), beginning at the main renal artery and vein, then ending at the arcuate vessels. It is calculated as follows:

text: The normal value is ≈ 0.60, with 0.70 being the upper limits of normal.[49]

text: Diet[edit]

text: Kidney transplant recipients are discouraged from consuming grapefruit, pomegranate and green tea products. These food products are known to interact with the transplant medications, specifically tacrolimus, cyclosporin and sirolimus; the blood levels of these drugs may be increased, potentially leading to an overdose.[50]

text: Acute rejection occurs in 10-25% of people after the transplantation procedure is completed, during the first 60 days.[citation needed] Rejection does not necessarily mean the loss of the organ, but it may necessitate additional treatment and medication adjustments.[51]

text: Complications[edit]

text: Problems after a transplant procedure may include:

text:
Transplant rejection (hyperacute, acute or chronic).
Post-operative complication, bleeding, infection, vascular thrombosis and urinary complications.
Infections and sepsis due to the immunosuppressant drugs that are required to decrease the risk of rejection.
Post-transplant lymphoproliferative disorder (a form of lymphoma due to the immune suppressants).
Imbalances in electrolytes, including calcium and phosphate, which can lead to bone problems.
Proteinuria.[48]
Hypertension.
Other side effects of medications including gastrointestinal inflammation and ulceration of the stomach and esophagus, hirsutism (excessive hair growth in a male-pattern distribution) with cyclosporin, hair loss with tacrolimus, obesity, acne, diabetes mellitus type 2, hypercholesterolemia and osteoporosis.

text: A patient's age and health condition before transplantation affect the risk of complications. Different organ transplant centers have different success at managing complications, and therefore, complication rates are different from center to center. For a current list of the 254 approved US organ transplant centers, including phone numbers and some URLs, visit: https://medicalcalendar.org/centers%2C-transplant

text: Regarding longevity of the transplanted organ, the average lifetime for a donated kidney is 10–15 years. When a transplant fails, a patient may opt for a second transplant, and may have to return to dialysis for some intermediary time.

text: Infections due to the immunosuppressant drugs used in people with kidney transplants most commonly occur in mucocutaneous areas (41%), the urinary tract (17%) and respiratory tract (14%).[52] The most common infective agents are bacterial (46%), viral (41%), fungal (13%) and protozoan (1%).[52] Of the viral illnesses, the most common agents are human cytomegalovirus (31.5%), herpes simplex (23.4%) and herpes zoster (23.4%).[52] BK virus is now being increasingly recognized. Infection is the cause of death in about one third of patients who received renal transplants, while pneumonias account for 50% of the patient deaths from infection.[52]

text:
Play media

Postoperative bleeding following kidney transplant as seen on ultrasound[53]

Play media

Postoperative bleeding following kidney transplant as seen on ultrasound[53]

Play media

Postoperative bleeding following kidney transplant as seen on ultrasound[53]

Postoperative bleeding following kidney transplant as seen on ultrasound[53]

text: Prognosis[edit]

text: Kidney transplantation is a life-extending procedure.[54] The typical patient will routinely live at least 10–15 years longer with a kidney transplant than if kept on dialysis.[55] The increase in longevity is greater for younger patients, but even 75-year-old recipients (the oldest group for which there is data) gain an average of at least four more years of life. The transplant recipients are generally considered to have more energy, have to follow a less restricted diet, and experience fewer complications with a kidney transplant than if they remain on conventional dialysis.

text: Some studies seem to suggest that the longer a patient remains on dialysis before the transplant, the less time the kidney will last, or the less opportunity there will be to receive a transplant. It is not clear why this occurs, but it underscores the need for rapid referral to a transplant program. Ideally, a kidney transplant should be pre-emptive, i.e., take place before the patient begins dialysis. The reason why kidneys fail over time after transplantation has been elucidated in recent years. Apart from recurrence of the original kidney disease, also rejection (mainly antibody-mediated rejection) and progressive scarring (multifactorial) play a decisive role.[56] Avoiding rejection by strict medication adherence is of utmost importance to avoid failure of the kidney transplant.

text: At least four professional athletes have made a comeback to their sport after receiving a transplant: New Zealand rugby union player Jonah Lomu, German-Croatian Soccer Player Ivan Klasnić, and NBA basketballers Sean Elliott and Alonzo Mourning.[citation needed]

text: Statistics[edit]

text:
Statistics by country, year and donor type

Country
Year
Cadaveric donor
Living donor
Total transplants

Canada[57]
2000
724
388
7003111200000000000♠1,112

France[58]
2003
7003199100000000000♠1,991
136
7003212700000000000♠2,127

Italy[58]
2003
7003148900000000000♠1,489
135
7003162400000000000♠1,624

Japan[59]
2010
7002208000000000000♠208
1276
7003148400000000000♠1,484

Spain[58]
2003
7003199100000000000♠1,991
60
7003205100000000000♠2,051

United Kingdom[58]
2003
7003129700000000000♠1,297
439
7003173600000000000♠1,736

United States[60]
2008
7004105510000000000♠10,551
7003596600000000000♠5,966
7004165170000000000♠16,517

text: In addition to nationality, transplantation rates differ based on race, sex and income. A study conducted with patients beginning long-term dialysis showed that the socio-demographic barriers to renal transplantation are relevant even before patients are on the transplant list.[61] For example, different socio-demographic groups express different interest and complete pre-transplant workup at different rates. Previous efforts to create fair transplantation policies have focused on patients currently on the transplantation waiting list.

text: Regarding the wait for transplant candidates to receive a new organ: "Once you are added to the national organ transplant waiting list, you may receive an organ that day, or you may wait many years. Factors affecting how long you wait include how well you match with the donor, how sick you are, and how many donors are available in your local area compared to the number of patients waiting," notes UNOS.

text: In the United States, according to the United Network for Organ Sharing (UNOS)

text: -- In 1954, the kidney was the first human organ to be transplanted successfully.

text: -- UNOS manages the national transplant waiting list, matching donors to recipients 24 hours a day, 365 days a year.

text: -- Every transplant hospital in the US must meet specific requirements.

text: -- Transplantation has saved and enhanced the lives of more than 700,000 people in the U.S.

text: -- Each organ type has its own allocation policy, reflecting the unique medical considerations of each type of transplant.

text: In the U.S. health system[edit]

text: Transplant recipients must take immunosuppressive anti-rejection drugs for as long as the transplanted kidney functions. The routine immunosuppressives are tacrolimus (Prograf), mycophenolate (Cellcept), and prednisolone; these drugs typically cost US$1,500 per month. In 1999, the United States Congress passed a law that restricts Medicare from paying for more than three years for these drugs, unless the patient is otherwise Medicare-eligible. Transplant programs may not transplant a patient unless the patient has a reasonable plan to pay for medication after the Medicare expires. However, patients are almost never turned down for financial reasons alone. Half of end-stage renal disease (ESRD) patients only have Medicare coverage.

text: In March 2009, a bill was introduced in the U.S. Senate, SB 565 and in the House, H.R. 145,8 that will extend Medicare coverage of the drugs for as long as the patient has a functioning transplant. This means that patients who have lost their jobs and insurance will not also lose their kidney and be forced back on dialysis. Dialysis is currently receiving $17 billion annually of Medicare funds. Total care of these patients amounts to over 10% of the entire Medicare budget.

text: The United Network for Organ Sharing, which oversees the organ transplants in the United States, allows transplant candidates to register at two or more transplant centers, a practice known as "multiple listing."[62] The practice has been shown to be effective in mitigating the dramatic geographic disparity in the waiting time for organ transplants,[63] particularly for patients who reside in high-demand regions such as Boston.[64] The practice of multiple-listing has also been endorsed by medical practitioners.[65][66]

text: Notable recipients[edit]

text:
Steven Cojocaru (born 1970), Canadian fashion critic, transplants in ???? and 2005
Natalie Cole (1950-2015), American singer, transplant in 2009 (survival: 6 years)
Gary Coleman (1968-2010), American actor, transplant dates unknown
Lucy Davis (born 1973), English actress, transplant in 1997
Kenny Easley (born 1959), American football player, transplant in 1990
Aron Eisenberg (born 1969), American actor, transplant in 2015
Sean Elliott (born 1968), American basketball player, transplant in 1999
Selena Gomez (born 1992), American singer and actress, transplant in 2017
Jennifer Harman (born 1964), American poker player, transplants in ???? and 2004
Ken Howard (born 1932), English artist, transplant in 2000
Ivan Klasnić (born 1980), Croatian footballer, transplant in 2007
Jimmy Little (1937-2012), Australian musician and actor, transplant in 2004 (survival: 8 years)
Jonah Lomu (1975-2015), New Zealand rugby player, transplant in 2004 (survival: 11 years)
George Lopez (born 1961), American comedian and actor, transplant in 2005
Alonzo Mourning (born 1970), American basketball player, transplant in 2003
Kerry Packer (1937-2005), Australian businessman, transplant in 2000 (survival: 5 years)
Charles Perkins (1936-2000), Australian footballer and activist, transplant in 1972 (survival: 28 years)
Billy Preston (1946-2006), American musician, transplant in 2002 (survival: 4 years)
Neil Simon (born 1927), American playwright, transplant in 2004
Ron Springs (1956-2011), American football player, transplant in 2007 (survival: 4 years)[citation needed]
Tomomi "Jumbo" Tsuruta (1951-2000), Japanese professional wrestler, transplant in 2000 (survival: 1 month)


document_title: List of former European colonies

question_text: list the colonial names of the african states

root

text: List of former European colonies

text: North America[edit]

text: Britain and United Kingdom

tag: p

text:
British America

Canadian colonies

Island of St. John
Colony of Newfoundland
Province of Nova Scotia
Province of Quebec
Rupert's Land (A private estate stretching from the Atlantic to the Rocky Mountains, and from the prairies to the Arctic Circle.[1])

"Thirteen Colonies"

New England Colonies:

Province of Massachusetts Bay
Province of New Hampshire
Colony of Rhode Island and Providence Plantations
Connecticut Colony

Province of New York
Province of New Jersey
Province of Pennsylvania
Delaware Colony
Province of Maryland
Colony of Virginia
Province of North Carolina
Province of South Carolina
Province of Georgia

Other North American colonies

Province of East Florida
Province of West Florida
Indian Reserve
Oregon Country (disputed with France)

Bermuda
British Honduras
Mosquito Coast

tag: ul

text: Denmark

text:
Greenland
Norway

text: France

text:
New France
Newfoundland
Île-Royale (Cape Breton Island)

Saint-Domingue (Haiti)

text: Netherlands

text: New Netherlands (Nieuw-Amsterdam / New York)

text: Norway

text:
Greenland
Vinland

text: Portugal

text:
Claim to Labrador
Settlement in Terra Nova (Newfoundland)

text: Russia

text:
North America

Fort Ross, California

text: Spain

text:
Viceroyalty of New Spain (1535–1821)

Las Californias
Nuevo Reino de León
Nuevo Santander
Nueva Vizcaya
Santa Fe de Nuevo México
Nueva Extremadura
Nueva Galicia

Captaincy General of Cuba
Puerto Rico
Santo Domingo (Dominican Republic)
Captaincy General of Guatemala
Costa Rica
El Salvador
East Florida and West Florida
Settlement at Nootka, near Vancouver Island, Canada

text: Sweden

text: New Sweden (Nya Sverige)

text: West Indies and the Caribbean[edit]

text: Brandenburg

text: St Thomas

text: Britain

text:
Bahamas
Barbados
Jamaica
Leeward Islands

Antigua and Barbuda
Dominica
Saint Christopher (St Kitts)-Nevis

Windward Islands

Grenada
Saint Lucia
Saint Vincent and the Grenadines

text: Courland

text: New Courland (Tobago)

text: Denmark-Norway

text:
Saint John
Saint Thomas
Saint Croix

text: France

text:
Anguilla
Antigua and Barbuda
Dominica
Grenada
Haiti
Montserrat
Saint Barthélemy
Nevis
Saint Christophe (St Kitts)
Saint Croix
Saint-Domingue (Haiti)
Sainte-Lucia (St Lucia)
Saint Vincent and the Grenadines
Sint Eustatius
Tobago

text: Knights of Malta

text:
Saint-Barthélemy
Saint Christopher (St Kitts)
Saint Croix
Tortuga (off coast of Haiti)

text: Netherlands

text:
Anegada
New Walcheren (Tobago)
Saint Croix
Tortola
Virgin Gorda

text: Portugal

text: Barbados

text: Spain

text:
Bahamas
Cuba
Island of Hispaniola (Haiti and the Dominican Republic)
Jamaica
Puerto Rico
Trinidad

text: Sweden

text:
Guadeloupe
Saint-Barthélemy

text: South America[edit]

text: Britain

text:
British Guiana

Berbice, Essequibo, Demerara

Falkland Islands
South Georgia

South Sandwich Islands

text: France

text: Brazil (Rio de Janeiro briefly, and São Luís briefly)

text: (see France Antarctique and France Équinoxiale)

text:
Iles Malouines (Falkland Islands)
French Guiana

text: Netherlands

text:
Berbice (Guyana)
Demerara
Surinam (Suriname)
Essequibo
New Holland (Brazil – Half the capitanas)

text: Spain

text:
Perú
New Granada
Río de la Plata

text: Portugal

text:
Brazil
Cisplatina (Uruguay)
French Guiana

text: Africa[edit]

text: Netherlands

text:
Arguin Island (in Mauritania)
Dutch Cape Colony
Dutch Gold Coast (settlements along coast of Ghana, including El Mina)
Dutch Loango-Angola (Luanda, Sonyo and Cabinda)
Gorée (Senegal)
Moçambique (Delagoa Bay)
São Tomé
South Africa

text: Belgium

text:
Belgian Congo (Democratic Republic of the Congo)
Lado Enclave
Ruanda-Urundi (Rwanda and Burundi)

text: Brandenburg

text:
Arguin (in Mauritania)
Brandenburger Gold Coast (coastal settlements in Ghana)

text: Britain

text:
Anglo-Egyptian Sudan (Sudan)
Basutoland (Lesotho)
Balleland (Benin)
Bechuanaland (Botswana)
British East Africa (Kenya)
British Somaliland (northern Somalia)
British Togoland (eastern Ghana)
British Cameroons (split between Nigeria and Cameroon)
British Egypt

Khedivate of Egypt
Sultanate of Egypt
Kingdom of Egypt

Gambia Colony and Protectorate
Gold Coast (Ghana)
Colonial Nigeria

Niger Coast Protectorate
Northern Nigeria Protectorate
Southern Nigeria Protectorate
Colony and Protectorate of Nigeria

Northern Rhodesia (Zambia)
Nyasaland (Malawi)
Sierra Leone Colony and Protectorate
South Africa

British Cape Colony
Colony of Natal
Orange Free State
Transvaal Colony

South-West Africa (Namibia)

Walvis Bay

Southern Rhodesia (Zimbabwe)
Swaziland
Tanganyika Territory (mainland Tanzania)
Uganda Protectorate
Sultanate of Zanzibar (insular Tanzania)

text: Courland

text: St. Andrews Island (in Gambia)

text: Denmark-Norway

text: Danish Gold Coast (coastal settlements in Ghana)

text: France

text:
Albreda (in Gambia)
Dahomey (Benin)
French Algeria
French Cameroons (91% of modern Cameroon)
French Chad
French Congo (Republic of Congo)
French Guinea (Guinea)
French Upper Volta (Republic of Upper Volta, Burkina Faso)
French Somaliland (Djibouti)
French Sudan (Mali)
French Togoland (Togo)
Gabon
Ivory Coast (Côte d'Ivoire)
Malagasy Protectorate
Colonial Mauritania
French protectorate in Morocco (89% of Morocco)
Niger
Oubangui-Chari (Central African Republic)
Senegambia and Niger

Upper Senegal and Niger
Colony of Niger

French protectorate of Tunisia

text: Germany

text:
German East Africa (Burundi, Rwanda, Tanzania)
German South-West Africa (Namibia)
Kamerun (split between Cameroon and Nigeria)
Togoland (split between Togo and Ghana)
Wituland

text: Italy

text:
Italian East Africa

Italian Ethiopia
Italian Eritrea
Italian Somaliland

Italian Libya

text: Portugal

text:
Ajuda (Whydah, in Benin)
Angola
Annobon
Cabinda
Cape Verde
Ceuta
Gorée (in Senegal)
Malindi
Mombasa
Algarve Ultramar (Morocco)

Agadir
Alcacer Ceguer
Arzila
Azamor
Mazagan
Mogador
Safim

Nigeria (Lagos area)
Mozambique
Portuguese Gold Coast (settlements along coast of Ghana)
Portuguese Guinea (Guinea-Bissau)
Quíloa
São Tomé and Príncipe
Tangier
Zanzibar
Ziguinchor

text: Spain

text:
Bona
Bougie
Jerba
Fernando Po and Annobon (insular Equatorial Guinea)
Oran
Port Guinea
Rio Muni (mainland Equatorial Guinea)
Spanish North Africa

Spanish Protectorate in Morocco
Ceuta
Melilla

Spanish West Africa

Río de Oro
Saguia el-Hamra
Tarfaya Strip
Ifni

text: Sweden

text: Swedish Gold Coast (coastal settlements in Ghana)

text: Indian Ocean[edit]

text: France

text:
French Comoros
Isle de France (now Mauritius)
French Madagascar
French Seychelles

text: Netherlands

text: Dutch Mauritius (now Mauritius)

text: Portugal

text:
Laccadive Islands (Lakshadweep)
Maldive Islands
Socotra

text: Middle East[edit]

text: Britain

text:
Aden Protectorate
Bahrain
History of Egypt under the British
Mandatory Iraq
Sheikhdom of Kuwait
Muscat and Oman
Mandatory Palestine
Qatar
South Arabia
Emirate of Transjordan
Trucial States

text: France

text: French Mandate for Syria and the Lebanon

text: Netherlands

text:
Jemen, Al Mukha (Mocca)
Mesopotamia (Iraq, Al Basrah)

text: Portugal

text:
Bandar Abbas
Hormuz
Manama
Muharraq Island
Muscat
Qeshm

text: Russia

text:
Russian Armenia
Russian Azerbaijan
Georgia within the Russian Empire

text: Indian Subcontinent[edit]

text: Austria

text: Nicobar Islands

text: Britain

text:
British India (After independence from Britain,` British India became Pakistan (East and West) and India – later East Pakistan was to become Bangladesh)

Bangladesh
India
Pakistan

Burma (Myanmar)
Ceylon (Sri Lanka)

text: Denmark-Norway

text:
Frederik Oerne Islands (Nicobar Islands)
Serampore
Tranquebar

text: France

text:
India

Pondicherry, Karikal, Yanaon, Mahé, and Chandernagore

text: Netherlands

text:
Bangladesh (Dutch Bengal)
Burma (Myanmar) (Mrohaung (Arakan), Siriangh, Syriam, Ava, Martaban)
Ceylon
India (Dutch Bengal, Suratte, Malabar, Coromandel)

text: Portugal

text:
Bombay
Calicut
Cambay
Cannanore
Ceylon (Cilão)
Chaul
Chittagong
Cochin
Dadra and Nagar Haveli
Daman and Diu
Goa
Hughli
Masulipatnam
Mangalore
Surat
Syriam

text: Asia-Pacific[edit]

text: United Kingdom

text:
Australia

New South Wales
Queensland
South Australia
Swan River Colony/Western Australia
Van Diemen's Land (Tasmania)
Victoria

British Solomon Islands
British Western Pacific Territories
Brunei
Colonial Fiji
Gilbert and Ellice Islands (Kiribati & Tuvalu)
Kingdom of Rarotonga (Cook Islands)
New Zealand

Auckland Islands
New Hebrides

Niue
Malaysia

British Malaya

Federated Malay States
Straits Settlements
Unfederated Malay States

British Borneo

North Borneo
Kingdom of Sarawak

Nauru
Singapore
Territory of Papua and New Guinea
Territory of New Guinea
Western Samoa
Phoenix Islands (part of Kiribati)
Solomon Islands
Territory of Papua
Tokelau
Tonga
Hong Kong
New Hebrides (Vanuatu, condominium with France)

text: Belgium

text: Tientsin (concession territory)

text: France

text:
East Asia

Kwang-Chou-Wan (廣州灣) leased territory, now the city of Zhanjiang (Guangdong province)
French settlements (concessions) in Shanghai, Guangdong, Tianjin, and Hankou
French zone of influence officially recognized by China over the provinces of Yunnan, Guangxi, Hainan, and Guangdong

Indochina

Cambodia
Laos
Vietnam

Annam
Cochinchina
Tonkin

New Hebrides (Vanuatu, condominium with Britain)

text: Germany

text:
Bismarck Archipelago
Caroline Islands (Karolinen)
German Samoa
Jiaozhou Bay (Kiautschou)
Kaiser-Wilhelmsland
Marshall Islands
Nauru
North Solomon Islands
Northern Marianas Islands (Marianen)
Palau

text: Italy

text: Tientsin (concession)

text: Netherlands

text:
Dutch East Indies (Indonesia)
Malacca
Taiwan (Tayowan)

text: Portugal

text:
Flores
Macau
Malacca
Moluccas

Ambon
Ternate
Tidore

Portuguese Timor (Timor-Leste)

text: Russia

text: Spain

text:
Spanish East Indies

Philippines
Marianas Islands (Ladrones)

Guam
Northern Marianas Islands

Caroline Islands

Marshall Islands

text: Europe[edit]

text: Austria

text:
Austrian Netherlands
Saarland or Saar (protectorate)

text: Britain

text:
Corsica (the Anglo-Corsican Kingdom was a protectorate or in personal union with Britain)
Cyprus
Heligoland
Ionian islands
Ireland (Originally as the Lordship of Ireland)
Malta
Menorca

text: Denmark

text:
Danish Estonia
Iceland

text: Greece

text: Magna Graecia

text: Italy

text:
Albania
Dodecanese

text: Norway

text:
Faroe Islands
Hebrides
Iceland
Isle of Man
Orkney
Shetland

text: Russia

text:
Belarus
Finland
Estonia
Latvia
Lithuania
Moldova
Ukraine
Poland
USSR

Baltic States

Estonia
Latvia
Lithuania

Eastern Europe

Belarus
Ukraine
Moldova

Transcaucasia

Georgia
Azerbaijan
Armenia

Central Asia

Kazakhstan
Kyrgyzstan
Tajikistan
Turkmenistan
Uzbekistan

text: Spain

text:
Spanish Netherlands
Crown of Castile
Gibraltar
Crown of Aragon
Duchy of Milan

text: Sweden

text:
Swedish Estonia
Swedish Ingria
Swedish Livonia
Swedish Pomerania


document_title: St. Peter's Square

question_text: who is the designer of the piazza in front of st. peter's basilica

question_tokens: who is the designer of the piazza in front of st. peter 's basilica

text: St. Peter's Square

text: History[edit]

text: The open space which lies before the basilica was redesigned by Gian Lorenzo Bernini from 1656 to 1667, under the direction of Pope Alexander VII, as an appropriate forecourt, designed "so that the greatest number of people could see the Pope give his blessing, either from the middle of the façade of the church or from a window in the Vatican Palace" (Norwich 1975 p 175). Bernini had been working on the interior of St. Peter's for decades; now he gave order to the space with his renowned colonnades, using the Tuscan form of Doric, the simplest order in the classical vocabulary, not to compete with the palace-like façade by Carlo Maderno, but he employed it on an unprecedented colossal scale to suit the space and evoke a sense of awe.

text: There were many constraints from existing structures (illustration, right). The massed accretions of the Vatican Palace crowded the space to the right of the basilica's façade; the structures needed to be masked without obscuring the papal apartments. The obelisk marked a centre, and a granite fountain by Maderno[1] stood to one side: Bernini made the fountain appear to be one of the foci of the ovato tondo[2] embraced by his colonnades and eventually matched it on the other side, in 1675, just five years before his death. The trapezoidal shape of the piazza, which creates a heightened perspective for a visitor leaving the basilica and has been praised as a masterstroke of Baroque theater (illustration, below right), is largely a product of site constraints.

text: Colonnades[edit]

text: The colossal Tuscan colonnades, four columns deep,[3] frame the trapezoidal entrance to the basilica and the massive elliptical area[4] which precedes it. The ovato tondo's long axis, parallel to the basilica's façade, creates a pause in the sequence of forward movements that is characteristic of a Baroque monumental approach. The colonnades define the piazza. The elliptical center of the piazza, which contrasts with the trapezoidal entrance, encloses the visitor with "the maternal arms of Mother Church" in Bernini's expression. On the south side, the colonnades define and formalize the space, with the Barberini Gardens still rising to a skyline of umbrella pines. On the north side, the colonnade masks an assortment of Vatican structures; the upper stories of the Vatican Palace rise above.

text: Obelisk[edit]

text: At the center of the ovato tondo stands an uninscribed Egyptian obelisk of red granite, 25.5 metres tall, supported on bronze lions and surmounted by the Chigi arms in bronze, in all 41 metres to the cross on its top. The obelisk was originally erected at Heliopolis, Egypt, by an unknown pharaoh.

text: The Emperor Augustus (c. 63 BC – 14 AD) had the obelisk moved to the Julian Forum of Alexandria, where it stood until 37 AD, when Caligula ordered the forum demolished and the obelisk transferred to Rome. He had it placed on the spina which ran along the center of the Circus of Nero, where it would preside over Nero's countless brutal games and Christian executions.[citation needed]

text: It was moved to its current site in 1586 by the engineer-architect Domenico Fontana under the direction of Pope Sixtus V; the engineering feat of re-erecting its vast weight was memorialized in a suite of engravings. The Vatican Obelisk is the only obelisk in Rome that has not toppled since ancient Roman times. During the Middle Ages, the gilt ball on top of the obelisk was believed to contain the ashes of Julius Caesar.[5] Fontana later removed the ancient metal ball, now in a Rome museum, that stood atop the obelisk and found only dust. Christopher Hibbert (page 178) writes that the ball was found to be solid. Though Bernini had no influence in the erection of the obelisk, he did use it as the centerpiece of his magnificent piazza, and added the Chigi arms to the top in honor of his patron, Alexander VII.

text: Paving[edit]

text: The paving is varied by radiating lines in travertine, to relieve what might otherwise be a sea of cobblestones. In 1817 circular stones were set to mark the tip of the obelisk's shadow at noon as the sun entered each of the signs of the zodiac, making the obelisk a gigantic sundial's gnomon. Below is a view of St. Peter's Square from the cupola (the top of the dome) which was taken in June, 2007.

text: Spina[edit]

text: St. Peter's Square today can be reached from the Ponte Sant'Angelo along the grand approach of the Via della Conciliazione (in honor of the Lateran Treaty of 1929). The spina (median with buildings which divided the two roads of Borgo vecchio and Borgo nuovo) which once occupied this grand avenue leading to the square was demolished ceremonially by Benito Mussolini himself on October 23, 1936 and was completely demolished by October 8, 1937. St. Peter's Basilica was now freely visible from the Castel Sant'Angelo. After the spina, almost all the buildings south of the passetto were demolished between 1937 and 1950, obliterating one of the most important medieval and renaissance quarters of the city. Moreover, the demolition of the spina canceled the characteristic Baroque surprise, nowadays maintained only for visitors coming from Borgo Santo Spirito. The Via della Conciliazione was completed in time for the Great Jubilee of 1950.

text: Gallery[edit]

text:
St. Peter's Square fountain

St. Peter's Square colonnades and fountain

St. Peter's Square colonnades and lanterns

St. Peter's Square, Borgo and the center of Rome from the dome

St. Peter's Square panorama in rainy conditions

Statues on the colonnades

St. Peter's Square by Viviano Codazzi, 1630

Bernini's fountain, 1675

Re-erection of the obelisk in 1586 took thirteen months

Re-erection of the obelisk

Obelisk with a Christmas Tree


document_title: Love, Simon

question_text: how much money has the movie love simon made

text: Love, Simon

text: Plot[edit]

text: Simon Spier is a closeted gay teenage boy attending high school in a suburb of Atlanta, Georgia. He has a close and loving family: parents Emily and Jack, and sister Nora, as well as three best friends: Nick and Leah, whom he has known most of his life, and newcomer Abby. One day, Leah informs Simon about an online confession of a closeted gay student at their high school, known only by the pseudonym "Blue". As "Jacques", Simon begins communicating with him. The two confide personal details and form a connection. However, their emails are accidentally discovered by another student, Martin, who is infatuated with Abby. After learning his secret, Martin blackmails Simon by threatening to make photos of Simon's emails public and forces Simon to help him win over Abby.

text: Simon begins to suspect that one of his classmates, Bram, is Blue. At a Halloween party, he attempts to connect with Bram, but later Simon walks in on him and a female student making out. Inebriated, Simon is walked home by Leah, who then sleeps over. She speaks vaguely about how she feels that she is fated to love one person very intensely, and Simon believes she is referring to Nick.

text: Later, Simon meets with Abby and Martin at a local diner after Simon convinces them to practice lines together for an upcoming musical. Simon bonds with their server, a classmate named Lyle, and believes that Lyle may be Blue. That night, Simon comes out to Abby and becomes encouraged when she reacts positively. At a school football game, he crosses paths with Lyle; before he can summon the courage to ask if he is Blue, he finds out Lyle is interested in Abby.

text: An upset Simon tells a pestering Martin to either "go big or go home" with Abby. During the national anthem at the football game, Martin seizes the microphone and declares his feelings for Abby, but she admits she does not like him. A humiliated Martin becomes the subject of intense ridicule.

text: On Christmas Eve, Martin impulsively posts Simon's emails on the school gossip site, outing Simon by name. His sister Nora tries comforting him, but Simon shuts her out and does not return his friends' frantic texts. On Christmas morning, Simon comes out to his parents, much to their surprise but acceptance.

text: Nick and Abby, now a couple, angrily confront Simon about the lies he told and learn that he had tried to keep them apart due to Martin's blackmail. Leah confesses she was in love with Simon, not Nick, and is upset he came out to Abby first. After being rejected by his friends, Simon receives a final email from Blue, who is upset that their email discussions have been leaked. He tells Simon that they should stop speaking before deleting his email account. Simon is devastated, having lost his friends as well as the mystery pen-pal he has fallen in love with.

text: At school, Simon tries to determine Blue's identity to no avail. In the cafeteria, Simon and an openly gay student, Ethan, are mocked by classmates. Ethan and Simon bond over the difficulties they have faced coming out.

text: After his parents reach out and comfort him, Simon apologizes to Leah. Simon posts a confession on the gossip site apologising to his friends for the hurt he caused and seeking out Blue and asking him to come forward. After the school musical, Leah, Nick and Abby make amends with Simon and invite him to go to the carnival with them. Waiting for Blue at the school carnival, Simon rides the Ferris wheel, drawing a large crowd of peers, until he runs out of tickets. Martin comes forward and, to make amends, buys him one more ride. Just before the ride begins, Bram sits next to Simon and reveals himself as Blue; the kiss Simon saw with the female student was a drunk misunderstanding. The couple ride the Ferris wheel together and kiss.

text: Simon's life gradually returns to normal and he begins a relationship with Bram. While picking up his friends, and now Bram, for school, Simon disrupts their usual morning routine and suggests that they go "on a little adventure".

text: Cast[edit]

text:
Nick Robinson as Simon Spier
Bryson Pitts as 10-year-old Simon Spier
Nye Reynolds as 5-year-old Simon Spier
Josh Duhamel as Jack Spier, Simon's father
Jennifer Garner as Emily Spier, Simon's mother
Katherine Langford as Leah Burke, one of Simon's best friends
Alexandra Shipp as Abby Suso, one of Simon's best friends
Jorge Lendeborg Jr. as Nick Eisner, one of Simon's best friends
Keiynan Lonsdale as Abraham "Bram" Greenfeld, one of Simon's classmates
Miles Heizer as Cal Price, one of Simon's friends and classmates
Logan Miller as Martin Addison, one of Simon's classmates who blackmails him
Talitha Bateman as Nora Spier, Simon's sister
Skye Mowbray as 6-year-old Nora Spier
Tony Hale as Mr. Worth, the vice principal of the school Simon attends
Natasha Rothwell as Ms. Albright, Simon's drama teacher
Drew Starkey as Garrett Laughlin, one of Simon's classmates
Clark Moore as Ethan, one of Simon's classmates who is openly gay
Joey Pollari as Lyle, a flirty server at a local diner
Mackenzie Lintz as Taylor, one of Simon's classmates

text: Production[edit]

text: Principal photography began on March 6, 2017, in Atlanta, Georgia.[14] Filming officially ended on April 23, 2017.[15]

text: Knowing how expensive the cost of the music would be in the film, Berlanti made the choice to end shooting two days early. Of the decision, he said "I did know that a lot of the film was made in homage to movies that had these great soundtracks that, at my age, you’d play the cassette tape over and over again until it would wear out. The soundtrack was the thing that kept you feeling the emotions of the movie. So it was always on my wish list to have a soundtrack that was reflective of that. It was very expensive so everyone wanted to make sure I was doing the right thing. I wanted more money to be put into the music."[16]

text: Soundtrack[edit]

text:
Love, Simon (Original Motion Picture Soundtrack)Soundtrack album by Various ArtistsReleased
March 16, 2018Genre
Soundtrack, Indie popLength
47 minutesLabel
Sony Music Entertainment
Singles from Love, Simon (Original Motion Picture Soundtrack)

"Alfie's Song"Released: 16 January 2018
"Love Lies"Released: 14 February 2018

tag: table

text: The soundtrack of the film includes music by Bleachers, Troye Sivan, Amy Shark, Brenton Wood, The 1975, Normani and Khalid, among others. The first track released from the soundtrack was "Alfie's Song (Not So Typical Love Song)" by Bleachers.[17][18]

text:
Love, Simon (Original Motion Picture Soundtrack)[18]No.TitleWriter(s)Performed byLength1."Alfie's Song (Not So Typical Love Song)"
Jack Antonoff
Ilsey Juber
Harry Styles
Bleachers3:012."Rollercoaster"
Antonoff
John Hill
Bleachers3:123."Never Fall in Love"
Antonoff
Karen Marie Ørsted
Jack Antonoff and MØ 4."Strawberries & Cigarettes"
Troye Sivan
Antonoff
Alex Hope
Troye Sivan3:215."Sink In"
Ben Berger
Julia Michaels
Ryan McMahon
Amy Shark4:356."Love Lies"
Khalid Robinson
Normani
Charlie Handsome
Jamil "Digi" Chammas
Taylor Parks
Khalid and Normani3:237."The Oogum Boogum Song"
Alfred Smith
Brenton Wood3:078."Love Me"
Adam Hann
George Daniel
Matthew Healy
Ross MacDonald
The 19753:429."I Wanna Dance with Somebody (Who Loves Me)"
George Merrill
Shannon Rubicam
Whitney Houston4:5010."Someday at Christmas"
Ron Miller
Bryan Wells
Jackson 52:4411."Wings"
Nini Fabi
Benjamin Gebert
Haerts4:5812."Keeping a Secret" Bleachers3:2513."Wild Heart"
Antonoff
Hill
Bleachers3:21

text: Charts[edit]

text:
Chart (2018)

Peak position

Australian Albums (ARIA)[19]

82

Canadian Albums (Billboard)[20]

24

UK Soundtrack Albums (OCC)[21]

11

US Billboard 200[22]

37

text: Other songs that appear in the film but are not included on its soundtrack include "Waterloo Sunset" by The Kinks, "No" by Meghan Trainor and "As Long as You Love Me" by Justin Bieber.

text: Release[edit]

text: Love, Simon premiered at the Mardi Gras Film Festival on February 27, 2018, and also screened at the Glasgow Film Festival and the Melbourne Queer Film Festival.[23][24] The film was released by 20th Century Fox in the United States and Canada on March 16, 2018, in Australia and New Zealand on March 29, 2018, in Brazil on April 5, 2018, in the United Kingdom and Ireland on April 6, 2018, in Colombia on April 12, 2018, Mexico on April 13, 2018, and is scheduled to be released in other countries on various dates throughout 2018.[25]

text: Following the film's release, several celebrities, including Jennifer Garner, Kristen Bell, Neil Patrick Harris, Joey Graceffa, Matt Bomer, Robbie Rogers, Benj Pasek, Tyler Oakley, Martin Gero, Andrew Rannells and Jesse Tyler Ferguson bought out entire theaters so that people could see the film for free, because they believe that the film conveys an important message.[26]

text: Home video[edit]

text: The film became available to pre-order on home video on January 17, 2018, and is expected to be released in June 2018.[27][28]

text: Reception[edit]

text: Box office[edit]

text: As of  April 17, 2018[update], Love, Simon has grossed $39.6 million in the United States and Canada, and $11 million in other territories, for a worldwide total of $50.7 million, against a production budget of $17 million, ranking #15 out of all films since 1980 in the teen romance genre, and out-grossing every film in that genre distributed by 20th Century Fox other than The Fault in Our Stars and Romeo + Juliet.[3]

text: Love, Simon held early preview screenings on March 2 and March 9 before its official release on March 16. It grossed $800,000 from 927 theaters on March 9, which Deadline Hollywood considered "strong".[29] In the United States and Canada, the film was released alongside Tomb Raider and I Can Only Imagine, and was projected to gross $10–12 million from 2,401 theaters in its opening weekend.[30] The film made $4.6 million on its first day (including $850,000 from Thursday previews at 2,125 theaters).[31] The film went on to debut at $11.8 million, finishing fifth at the box office; 58% of its opening weekend audience was female and 59% was under 25.[32] In its second weekend the film dropped 33% to $7.8 million, finishing 7th,[33] and in its third weekend made $4.8 million, finishing ninth.[34] In the UK, the film debuted at number four, earning $1.6 million.[35]

text: Critical response[edit]

text: On review aggregator website Rotten Tomatoes, the film holds an approval rating of 92%, based on 157 reviews, with an average rating of 7.5/10. The website's critical consensus reads, "Love, Simon hits its coming-of-age beats more deftly than many entries in this well-traveled genre – and represents an overdue, if not entirely successful, milestone of inclusion."[36] On Metacritic, the film has a weighted average score of 73 out of 100, based on 36 critics, indicating "generally favorable reviews".[37] Audiences polled by CinemaScore gave the film an average grade of "A+" on an A+ to F scale, one of fewer than 80 films in the history of the service to earn such a score.[31]

text: Benjamin Lee of The Guardian gave the film 4/5 stars, calling it a "hugely charming crowd-pleaser".[5] Pete Hammond of Deadline Hollywood gave the film 4/5 stars, stating that audiences "are guaranteed to fall in love with this sweet, funny coming-of-age film".[38]

text: Molly Freeman of Screen Rant gave the film 4/5 stars or an Excellent rating, stating that "Love, Simon is a funny, heartfelt, and truly touching teen romantic comedy that instantly becomes a modern classic for today's generation."[39] Josh Winning of GamesRadar+ gave the film 4/5 stars, describing it as a "warm, sensitive and engaging coming-out-of-ager" and "one of the freshest teen-coms in ages".[40]

text: Meredith Goldstein of The Boston Globe gave the film 3.5/4 stars and stated, "Love, Simon is a sweet, modern romantic comedy that manages to channel the teen movie classics of the late John Hughes, but only the good stuff."[8] Colin Covert of the Star Tribune gave the film 3/4 stars and wrote, "If John Hughes had gone on to make a smart LGBT coming-of-age charmer, most likely it would resemble this."[9]

text: Bruce Demara of the Toronto Star also gave it 3/4 stars, stating "The casting is high quality, the script - with a tantalizing mystery at its heart - is particularly well-crafted and the story hits all the right emotional notes in delivering a funny, warm-hearted and life-affirming tale."[10] Brian Truitt of USA Today gave the film 3.5/4 stars and wrote, "Young and old, jocks and nerds, geeks and freaks, and everyone in between should be able to find something to adore in Love, Simon."[41]

text: Joyce Slaton of Common Sense Media gave the film 4/5 stars and described it as "tender, sweet, and affecting", with the film also receiving The Common Sense Seal, which recognizes movies that offer families an exceptional media experience.[7][42] MJ Franklin of Mashable wrote that "Love, Simon feels like an instant classic that you're going to want to watch again and again."[6]

text: Max Weiss of Baltimore gave Love, Simon 3/4 stars, calling it a "sweet, funny, warm-hearted film".[43] Kevin Scott of Exclaim! gave the film a 7 out of 10 score, noting that the film has the "expected amount of sentimentality that effectively tugs at the heartstrings".[44]

text: Peter Debruge of Variety, while stating that the film is average in execution, praised the content as "groundbreaking on so many levels, not least of which is just how otherwise familiar it all seems".[45] Jesse Hassenger of The A.V. Club gave the film a C+ and wrote that the film "is touching as a gesture", but as entertainment "it's nothing Degrassi hasn't done better".[46]

text: Becky Albertalli, the author of the book, watched an early cut and praised the film, stating: "It's funny and relevant and timeless and charming and honest and painful and so romantic. It says exactly what I wanted the book to say."[47][48]