I admire the author's selflessness. At the same time, it seemed easier to be selfless as a teenager, probably for similar reasons for why it's easier to draft 18-year-olds than it is 28-year-olds. Given young persons willingness to sacrifice for the greater cause without realizing that life extends well past your 30s and 40s, I wonder if more shouldn't be done to let young donors think of the risks, so that their naïveté isn't something that the system takes advantage of.
The author's right to ask for better data and tracking of donors. That said, his current worries are likely to be heavily informed by selection bias:
> Five years after the surgery, when I was 23 and getting ready to go to medical school, I began working in a research lab that was looking at kidney donors who had gone on to develop kidney failure. For that research, I talked to more than 100 such donors. In some cases, the remaining kidneys failed; in others, the organ became injured or developed cancer. The more I learned, the more nervous I became about the logic of my decision at age 18 to donate.
If you spend a lot of time talking only to donors where things have gone wrong, yeah, you'll be paranoid. Reminds me of being a cops reporter in which you strongly associate certain neighborhoods with shootings and murders because, professionally, those incidents are the only times you ever visit those neighborhoods.
>At the same time, it seemed easier to be selfless as a teenager, probably for similar reasons for why it's easier to draft 18-year-olds than it is 28-year-olds. Given young persons willingness to sacrifice for the greater cause without realizing that life extends well past your 30s and 40s
I totally agree, the biological basis of this is Pre-frontal Cortex development.
"This brain region has been implicated in planning complex cognitive behavior, personality expression, decision making, and moderating social behaviour. The basic activity of this brain region is considered to be orchestration of thoughts and actions in accordance with internal goals." https://en.wikipedia.org/wiki/Prefrontal_cortex
I can't understand any other context for drafting 18 year olds other than taking advantage of their youth and incomplete development, but avoiding Presentism and the comfort of Mutually Assured Destruction / Pax Americana, I can understand why when the cards are on the table and your entire society is at risk, why you must call all hands, young and old, into Total War a la WW1 or WW2.
As far as donations go, that's got to be a morally gray area as well for all the reasons you mention.
Are shootings and murder common in all neighborhoods? Isn't it correct to strongly associate a neighborhood with shootings and murder if you are repeatedly visiting the neighborhood due to a shooting and/or murder?
But if he is publicly regretting donating a kidney, won't he be preventing many kidneys from being donated?
I just don't him going public with his opinion as a good thing. It may become something he regrets even more than his kidney donation.
Even the reporter and the post's title is irresponsible. If I were just reading through the headlines, it would influence my feelings about donating a kidney.
Instead, the title could have been "Kidney-donating doc pleads: please register as an organ donor" and have similar content in the post, but with the main point being that people should register to be an organ donor if they die.
Kidneys are amazing -- filtering blood, removing excess liquid, regulating blood pressure. And they're redundant! My brother lost one kidney in an accident that also left him paralyzed and with a slew of other problems. Recurring UTI and kidney infections took the other kidney a decade later. When he started on dialysis around 1988, the machine was the size of an Asteroids arcade game. It did half the job of a fist-sized kidney maybe half as well. A few years later, we had a home machine a bit smaller than Asteroids. In 1994, I gave him one of mine (kidneys, not arcade games).
The doctors said if the transplant lasted 10 years, we should be delighted, especially with all his post-accident reconfigured internals. My brother's quality-of-life improved immediately — at least he didn't have to be hooked up to a machine and stationary for several hours at a time. My quality of life was essentially unchanged. The transplant worked well for 22 years. Recurring infections -- kidney, liver, bedsores, staph/mercer -- eventually took their toll. I'm pretty sure I wouldn't have done it for "my stepfather's brother" or the like, but I'm glad I did what I could for my brother when I did. I was 23 at the time and now 46. I drink plenty of liquids. My GP's a nephrologist and I have kidney function tests as part of my annual bloodwork. Maybe I'll be pissed if shit goes wrong as I age. With hope I'm still glad I did what I could when I did. And, with hope, the redundancy remains very good.
There are real risks in the actual donation, of course. And some lifelong things you need to worry about. It does affect treatment of other things. For example, if you happen to have a rotator cuff injury, you can't just take high doses of anti-inflammatory meds for a month. You have to do physical therapy and steroid injections. And, in our wonderful US healthcare system, you'll get near-zero aftercare beyond a few months worth of checkups. You'll have to advocate for yourself for later extra checks on your remaining kidney's health and often have to foot the bill yourself because your overpriced insurance will refuse to pay for it.
Source: Am a kidney donor living in the US that has experienced both of the above and several similar issues
Can you explain the part about injury recovery? Are you not allowed to take the medications because it would stress your kidney too much? (Also, do you mean NSAID drugs, or are there issues with pretty much all anti inflammatories?)
What are some of the things that you find yourself needing to advocate for yourself about? Isn't long term care just annual creatinine level tests (which looks like a simple blood draw)?
My physiology professor told our class to never donate, especially at our age group (18-23). His presentation included some of the complications listed in the article. However, his reasoning was straightforward: Assuming a long lifespan, if you are in the position with your only kidney failing, you're screwed.
He was speaking generally of course. Not every situation has an easy solution and Poulson took a noble route, albeit when he was young and not fully informed. I have heard med students suffering from slight paranoia because they learn all kinds of diseases and their symptoms (as another comment has stated). I wish all the best to Poulson.
There's some down-thread armchair speculation about why humans have two kidneys. I found it interesting, but instead of conniving my own theory did some searching.
The gist of it is that nobody seems to know, but the most simple explanation is that lateral symmetry is common in general because it's more efficiently encoded in the DNA. The organs & structures that don't come in twos are the odd exceptions, not the other way around.
Most probably the kidneys are vital enough yet inexpensive enough to allow a pair to exist. You do not get two hearts because that muscle is very expensive. Also because a vascular injury to a major artery will also end your life. Similar reason for the liver - too expensive and also easy to regenerate from a partial injury. The brain is well protected and partly redundant. Lungs are fully redundant and protected by the ribcage. Spleen is not critical enough, stomach can heal. The pancreas is probably an odd one.
This is going to rub a lot of people the wrong way as unethical, but the best way to incentivize organ donation is if the donors get paid a market price for the organ. The donor is giving up a valuable piece of their body, taking time and large medical risks in surgery, and likely reduced life expectancy.
If you walk through the current process, everyone in the donation gets paid -- doctors, nurses, hospital, pharma -- except the donor.
There are a number of advantages of donors getting paid:
1. The supply market would increase dramatically. Thus many more people receiving organs who would have otherwise died waiting.
2. Heirs to people who have died young, with healthy organs could get paid for donating their organs.
3. Black markets would be dramatically reduced, since people in desperate need of an organ could pay in the open, rather than secretly paying a donor.
4. People without money can legally open a Kickstarter to raise funds for an organ donation.
Note Iran has partially done this, and the results have been very positive [1].
While there is a short fall of viable organs for donation, the issue the author raises here is one of long term risk.
This is what gets brushed aside when the organ donation process is activated. Only now do we have results from long term study of donors and some of them as pointed out by the author are not good at all.
This problem is not confined to kidney donations for instance, is a growing body of evidence that points to long term complications from another medical procedure - laser surgery (lasix). Here many patients suffer degenerative vitreo-reinal changes over time (if you can, avoid it).
It is not actually the case that donors do not benefit from the current process. Outside the US in the largest market for kidney surgeries India, they are paid; as well as in the Thailand and the middle east.
End stage renal disease is one of the worst conditions to die from, and everyone involved with an afflicted patient is desperate for a solution since they suffer almost as much as him/her.
So,No. Paying for organs will not solve this particular problem. But neither will doing nothing.
One solution that can improve the number of donor organs is to make it mandatory that organs from qualified people who die violent or accidental deaths be immediately considered for transplant to those who need them. But you can guess this proposal would be (illogically imo) opposed in many countries.
Edit: On a related note, I have been mulling over an idea for a while for a startup to reduce the cost of dialysis for patients with renal disease. At present, it is prohibitively expensive and some patients require 2 sessions a week. If anyone is interested in joining me, reach out. My email address is in my profile.
One change could make a difference to the availability of transplantable organs in the US: make donation upon death opt-out vs opt-in on drivers' licenses.
There are arguments on both sides of opt-out ("presumed consent"), but even the cons argue more about ethics and lawsuits -- re dead people who clearly no longer need the organs -- than that there'd be more organs available to the living who might.
My initial reaction to this suggestion is horror, in part because I feel strongly that it disincentivizes finding other solutions to serious health issues. I have a condition that accounts for something like a third of all lung transplants and half of all pediatric lung transplants. I find the emphasis on heroic medical interventions instead of improved diet, prevention, etc. to be really horrifying. Pursuing improved diet, prevention, etc. has gotten me extremely good results. I never know how to convince people of that. It happens to be a fact, but it is not acceptable to really say that anywhere at all and the whole thing makes me feel postal at times.
But, please, let's stop parting people out as the easy answer and try a little harder to solve serious medical conditions some other way.
I wish I was at home so I could type out a full reply. I have lots of thoughts on this as I found out my kidneys were failing a short time ago. At least for kidneys I think we need to attack the problem well before it reaches transplant stage. Better proactive screening would help a lot. Some simple medicines would help a bit it given earlier. There is some research on alternatives to transplants. UCSF has plans for an artificial kidney but they are still looking for more funding. There is also some early work to use stem cells to heal kidneys. This stuff needs more research. With a little bit of assistance many could stretch their weakened kidneys through their lifetime. Transplants are not a cure. One has to live with a life of anti rejection drugs with their risks.
But who pays and how do you avoid adverse selection problems? In the study you cited, it sounds like compensation often comes from the recipient (in addition to a payment from the government). This seems like it would skew towards ability to pay on the recipient side, and towards the less affluent on the donor side.
This may be a dumb question, but why are previous kidney donors not given a free pass to the top of the recipient list if they have a problem with their remaining kidney?
They do get priority. But there is still issue of compatibility. And one still needs to take a lifetime of medicines. I myself found my kidneys were failing recently and did a lot of research.
Came here to post exactly that question/suggestion.
I could imagine that it might also be "and can put one blood relative or immediate family member into a high-priority category" to encourage donation/control for the "yeah, but I'm saving mine in case my kid needs one" objection.
Seems like the way to solve this, without opening up market pricing for them. In theory, this would create a marketplace where supply outstrips demand.
That's really what this article seems to boil down to. There doesn't seem to be any concrete data that should lead a completely objective donor to worry. The issue is that the author is not completely objective (nobody is).
I wish they had included another option in the survey. What if you were given a lifetime of free health insurance in lieu of cash? This way, some organization (the govt, AMA, some independent trust) could create a large, insurable pool of all kidney donors.
This scheme would work around the problem of moral hazard in both directions. On the Donor side, donors get a substantial financial reward but not in terms of cash. And if it's true that most kidney donors will live healthy lives on par with the general population, then this pool is no riskier to insure than any large company. In fact it might be a lower risk pool than the general population because the process of selecting the donor candidate involves intensive medical checks. Basically kidney donors are likely to be a healthier sample of the general population than random selection.
On the recipient/govt side, you get better outcomes for a larger number of kidney patients (and thus save lots of money on very expensive Dialysis costs). Financially, recipients (or their insurance providers) can be charged enough to cover the insurance premiums on the pool of donors without encouraging a black-market of organ donations.
It's most likely a win for Insurance companies too since they have to foot a large part of the dialysis bill too.
Honest question. It sounds like the recipient was older so if something were to happen to them (passing from old age, etc) would it be possible to move the kidney back? After all it would be a perfect match... still the same age as the donor, and as long as it hasn't been compromised in any way should still function well.
The organ has had x years in a foreign environment. The new host / donee has taken an ongoing regimen of anti-rejection drugs for the duration to prevent that foreign environment from being overly hostile. The organ is not particularly suitable for re-transplantation even back to the original host.
As a surgeon who is 48, I will say that on my transplant rotation ( I am not a transplant surgeon ) the theory of the safety of donation was in the Vietnam War era data that said that soldiers who lost a kidney from injury were at no increased risk of renal failure as the general public given similar risk factors. I know that if you have hypertension or diabetes, it is near impossible to donate a kidney as they have a high propensity to develop renal failure. I have not researched the literature about the war data, but that is what I was told.
That isn't really a fair comparison. There's a selection bias among kidney donors (they must pass some minimal health requirements) and are at a lower risk than the general population.
I suspect that this regret probably has quite a lot to do with the recipient being the stepfather's brother. I.e. not a blood relative; kind of distant.
Says who? I know many people personally who are closer to their step-families than they are to their blood families. Just because someone donated some of their DNA to produce you doesn't necessarily make them worthy of being family.
Not as distant as you'd think. I could actually see it being that the recipient is close enough you'll get information regularly about the person (i.e. small events that happen), rather than a complete stranger who you'd hear from only occasionally if at all.
I also wonder how much pressure he was under to help because of the match, and how much he felt that he'd be disappointing the people around him if he didn't. I know as a kid that kind of pressure would have weighed on me heavily and has lead me to have some regrets about my past (though nothing nearly this large).
" All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up of 24.9 years. Hazard ratio for all-cause death was significantly increased to 1.30 (95% confidence interval 1.11-1.52) for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 (1.03-1.91), while the risk of ESRD was greatly and significantly increased to 11.38 (4.37-29.6). The overall incidence of ESRD among donors was 302 cases per million and might have been influenced by hereditary factors. Immunological renal disease was the cause of ESRD in the donors. Thus, kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group of non-donors who would have been eligible for donation."
https://www.ncbi.nlm.nih.gov/pubmed/24284516
Hmmm in hindsight this is logical, you got 2 kidneys of a certain size. Expected do 1 job together. And since biology doesn't like wastefulness (as it cost energy, room, and nutrients to maintain) the kidneys are dimensioned to a safe/good size. Now when you remove 1, the other one has to do twice the job. Possibly severely dipping under the safe size.
Well, this article did a good job in scaring me off of donating any organs whatsoever. I currently disallow donating organs upon my death, because I think if I'm a known donor, the doctors might not try as hard to revive me. And now after this, I'm pretty certain I won't take any tests to determine if I'm compatible with anyone needing a kidney.
> I currently disallow donating organs upon my death, because I think if I'm a known donor, the doctors might not try as hard to revive me.
Sorry, but that really is such a nonsensical argument I'm not sure if you're serious. Why would a doctor not want to revive you? So another doctor somewhere could save a patient? Why would that be preferable to saving your life there and then? Why would the doctor risk their own career for that?
I presume that if you're refusing to donate any organs after your death, you'd refuse one if you ever needed one (unless you're a huge hypocrite). In which case, surely scenario A is far less likely than scenario B?
Reading these comments makes me believe the HN crowd no longer believes in human exceptionalism, something I believe fueled our predecessors into building mile long structures over bodies of water, landing on the moon, striving to colonize mars, and other giant leaps of technology. Makes me sad reading these comments.
[+] [-] danso|9 years ago|reply
The author's right to ask for better data and tracking of donors. That said, his current worries are likely to be heavily informed by selection bias:
> Five years after the surgery, when I was 23 and getting ready to go to medical school, I began working in a research lab that was looking at kidney donors who had gone on to develop kidney failure. For that research, I talked to more than 100 such donors. In some cases, the remaining kidneys failed; in others, the organ became injured or developed cancer. The more I learned, the more nervous I became about the logic of my decision at age 18 to donate.
If you spend a lot of time talking only to donors where things have gone wrong, yeah, you'll be paranoid. Reminds me of being a cops reporter in which you strongly associate certain neighborhoods with shootings and murders because, professionally, those incidents are the only times you ever visit those neighborhoods.
[+] [-] criley2|9 years ago|reply
I totally agree, the biological basis of this is Pre-frontal Cortex development.
"The [prefrontal cortex] isn't fully developed and won't be until the person is 25 years old or so." https://www.urmc.rochester.edu/encyclopedia/content.aspx?Con...
"This brain region has been implicated in planning complex cognitive behavior, personality expression, decision making, and moderating social behaviour. The basic activity of this brain region is considered to be orchestration of thoughts and actions in accordance with internal goals." https://en.wikipedia.org/wiki/Prefrontal_cortex
I can't understand any other context for drafting 18 year olds other than taking advantage of their youth and incomplete development, but avoiding Presentism and the comfort of Mutually Assured Destruction / Pax Americana, I can understand why when the cards are on the table and your entire society is at risk, why you must call all hands, young and old, into Total War a la WW1 or WW2.
As far as donations go, that's got to be a morally gray area as well for all the reasons you mention.
[+] [-] jsprogrammer|9 years ago|reply
[+] [-] pavel_lishin|9 years ago|reply
[+] [-] plan6|9 years ago|reply
But if he is publicly regretting donating a kidney, won't he be preventing many kidneys from being donated?
I just don't him going public with his opinion as a good thing. It may become something he regrets even more than his kidney donation.
Even the reporter and the post's title is irresponsible. If I were just reading through the headlines, it would influence my feelings about donating a kidney.
Instead, the title could have been "Kidney-donating doc pleads: please register as an organ donor" and have similar content in the post, but with the main point being that people should register to be an organ donor if they die.
[+] [-] smcnally|9 years ago|reply
The doctors said if the transplant lasted 10 years, we should be delighted, especially with all his post-accident reconfigured internals. My brother's quality-of-life improved immediately — at least he didn't have to be hooked up to a machine and stationary for several hours at a time. My quality of life was essentially unchanged. The transplant worked well for 22 years. Recurring infections -- kidney, liver, bedsores, staph/mercer -- eventually took their toll. I'm pretty sure I wouldn't have done it for "my stepfather's brother" or the like, but I'm glad I did what I could for my brother when I did. I was 23 at the time and now 46. I drink plenty of liquids. My GP's a nephrologist and I have kidney function tests as part of my annual bloodwork. Maybe I'll be pissed if shit goes wrong as I age. With hope I'm still glad I did what I could when I did. And, with hope, the redundancy remains very good.
[+] [-] JohnTHaller|9 years ago|reply
Source: Am a kidney donor living in the US that has experienced both of the above and several similar issues
[+] [-] leodeid|9 years ago|reply
What are some of the things that you find yourself needing to advocate for yourself about? Isn't long term care just annual creatinine level tests (which looks like a simple blood draw)?
[+] [-] snake117|9 years ago|reply
He was speaking generally of course. Not every situation has an easy solution and Poulson took a noble route, albeit when he was young and not fully informed. I have heard med students suffering from slight paranoia because they learn all kinds of diseases and their symptoms (as another comment has stated). I wish all the best to Poulson.
[+] [-] clifanatic|9 years ago|reply
Well... unless you can find a kidney donor, that is...
[+] [-] wbl|9 years ago|reply
[+] [-] labster|9 years ago|reply
[+] [-] avar|9 years ago|reply
The gist of it is that nobody seems to know, but the most simple explanation is that lateral symmetry is common in general because it's more efficiently encoded in the DNA. The organs & structures that don't come in twos are the odd exceptions, not the other way around.
1. https://www.quora.com/Why-is-it-that-humans-(and-many-animal...
2. https://www.reddit.com/r/askscience/comments/po4v6/why_did_w...
[+] [-] AstralStorm|9 years ago|reply
[+] [-] pdq|9 years ago|reply
If you walk through the current process, everyone in the donation gets paid -- doctors, nurses, hospital, pharma -- except the donor.
There are a number of advantages of donors getting paid:
1. The supply market would increase dramatically. Thus many more people receiving organs who would have otherwise died waiting.
2. Heirs to people who have died young, with healthy organs could get paid for donating their organs.
3. Black markets would be dramatically reduced, since people in desperate need of an organ could pay in the open, rather than secretly paying a donor.
4. People without money can legally open a Kickstarter to raise funds for an organ donation.
Note Iran has partially done this, and the results have been very positive [1].
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819484/
[+] [-] colechristensen|9 years ago|reply
5. The quality of organs goes down.
It's been extensively studied for paying for blood donations, and the consensus is widely to discourage the practice.
https://www.statnews.com/2016/01/22/paid-plasma-not-blood/
http://www.radiolab.org/story/308403-blood/
[+] [-] timecube|9 years ago|reply
[+] [-] Lordarminius|9 years ago|reply
This is what gets brushed aside when the organ donation process is activated. Only now do we have results from long term study of donors and some of them as pointed out by the author are not good at all.
This problem is not confined to kidney donations for instance, is a growing body of evidence that points to long term complications from another medical procedure - laser surgery (lasix). Here many patients suffer degenerative vitreo-reinal changes over time (if you can, avoid it).
It is not actually the case that donors do not benefit from the current process. Outside the US in the largest market for kidney surgeries India, they are paid; as well as in the Thailand and the middle east. End stage renal disease is one of the worst conditions to die from, and everyone involved with an afflicted patient is desperate for a solution since they suffer almost as much as him/her.
So,No. Paying for organs will not solve this particular problem. But neither will doing nothing. One solution that can improve the number of donor organs is to make it mandatory that organs from qualified people who die violent or accidental deaths be immediately considered for transplant to those who need them. But you can guess this proposal would be (illogically imo) opposed in many countries.
Edit: On a related note, I have been mulling over an idea for a while for a startup to reduce the cost of dialysis for patients with renal disease. At present, it is prohibitively expensive and some patients require 2 sessions a week. If anyone is interested in joining me, reach out. My email address is in my profile.
[+] [-] smcnally|9 years ago|reply
There are arguments on both sides of opt-out ("presumed consent"), but even the cons argue more about ethics and lawsuits -- re dead people who clearly no longer need the organs -- than that there'd be more organs available to the living who might.
pro: https://sparq.stanford.edu/solutions/opt-out-policies-increa...
con: http://www.hopkinsmedicine.org/news/media/releases/presumed_...
[+] [-] Mz|9 years ago|reply
But, please, let's stop parting people out as the easy answer and try a little harder to solve serious medical conditions some other way.
This is so very UGH.
[+] [-] pkaye|9 years ago|reply
[+] [-] solotronics|9 years ago|reply
[+] [-] minouye|9 years ago|reply
[+] [-] vacri|9 years ago|reply
[+] [-] dexterdog|9 years ago|reply
[+] [-] pkaye|9 years ago|reply
[+] [-] sokoloff|9 years ago|reply
I could imagine that it might also be "and can put one blood relative or immediate family member into a high-priority category" to encourage donation/control for the "yeah, but I'm saving mine in case my kid needs one" objection.
[+] [-] gscott|9 years ago|reply
[+] [-] brianjolney|9 years ago|reply
[+] [-] bcherny|9 years ago|reply
[+] [-] delecti|9 years ago|reply
[+] [-] chetanahuja|9 years ago|reply
On the recipient/govt side, you get better outcomes for a larger number of kidney patients (and thus save lots of money on very expensive Dialysis costs). Financially, recipients (or their insurance providers) can be charged enough to cover the insurance premiums on the pool of donors without encouraging a black-market of organ donations.
It's most likely a win for Insurance companies too since they have to foot a large part of the dialysis bill too.
[+] [-] 51Cards|9 years ago|reply
[+] [-] smcnally|9 years ago|reply
[+] [-] ReallyAnonymous|9 years ago|reply
[+] [-] laxatives|9 years ago|reply
[+] [-] kazinator|9 years ago|reply
[+] [-] Viper007Bond|9 years ago|reply
Or hell, what about adopted children?
[+] [-] simcop2387|9 years ago|reply
I also wonder how much pressure he was under to help because of the match, and how much he felt that he'd be disappointing the people around him if he didn't. I know as a kid that kind of pressure would have weighed on me heavily and has lead me to have some regrets about my past (though nothing nearly this large).
[+] [-] seesomesense|9 years ago|reply
[+] [-] Qantourisc|9 years ago|reply
In short, redundancy != excess
[+] [-] grimmdude|9 years ago|reply
[+] [-] unknown|9 years ago|reply
[deleted]
[+] [-] london888|9 years ago|reply
[+] [-] jimmywanger|9 years ago|reply
What is he writing about? "Sometimes something you do has potential future consequences." Sounds like life.
[+] [-] pfarnsworth|9 years ago|reply
[+] [-] chimprich|9 years ago|reply
Sorry, but that really is such a nonsensical argument I'm not sure if you're serious. Why would a doctor not want to revive you? So another doctor somewhere could save a patient? Why would that be preferable to saving your life there and then? Why would the doctor risk their own career for that?
I presume that if you're refusing to donate any organs after your death, you'd refuse one if you ever needed one (unless you're a huge hypocrite). In which case, surely scenario A is far less likely than scenario B?
[+] [-] cpncrunch|9 years ago|reply
[+] [-] treehau5|9 years ago|reply