Prognostic Significance of Ki-67 Expression in Patients Undergoing Surgical Resection for Gastrointestinal Stromal Tumor / 대한소화기학회지

BACKGROUND/AIMS: Assessment of malignant potential in gastrointestinal stromal tumor (GIST) is still problematic. The maximum tumor diameter and the mitotic index are generally used as an index of malignancy of GISTs. The Ki-67 labeling index has recently been used as an index of cell growth. The aim of this study was to investigate the prognostic value of Ki-67 in GIST. METHODS: We retrospectively reviewed the medical records of 32 patients with GIST who underwent surgical resection at Inje University Seoul Paik Hospital. We analyzed their Ki-67 expression, histologic finding, and prognosis. RESULTS: According to the tumor size and mitotic count, 4 patients were classified as very low risk, 9 patients as low risk, 14 patients as intermediate risk and 5 patients as high risk. The average Ki-67 index was 5.56+/-4.48%. The median follow-up duration was 35.72+/-29.04 months, and local/distant recurrences were observed in 6 (18.7%) patients. The overall cumulative disease free survival rates in patients with Ki-67 index 5% were at 1 year, 2 years, and 5 years were 82.1%, 70.3%, and 46.9%, respectively. There was significant relationship between elevated Ki-67 and disease free survival rate (p=0.007). CONCLUSIONS: Our study suggests that Ki-67 index >5% confers a higher risk of relapse in patients with GIST. Future work should focus on standardization of Ki-67 assessment and specification of its role in making treatment decisions.

Clinical Characteristics of Focal Segmental Glomerulosclerosis Recurrence after Adult Renal Transplantation / 대한이식학회지

BACKGROUND: Recurrence of focal segmental glomerulosclerosis (FSGS) after kidney transplantation is a frequent and still unpredictable complication. Moreover, risk factors for recurrence have not yet been clearly identified. METHODS: We enrolled into our study 2,882 adult kidney recipients who underwent transplantation between April 1979 and April 2009. We retrospectively reviewed clinical manifestations of recurrence of FSGS. RESULTS: Among the 2,784 adult renal recipients, forty four had undergone renal transplantation for primary FSGS. Of the 44, 12 (27.3%) showed recurrent FSGS. Mean duration between transplantation and FSGS recurrence was 22.8+/-37.4 months. There were no significant differences in patient characteristics in the recurrence and non-recurrence groups. The cumulative incidence of FSGS recurrence was 13.8% within 1 year after kidney transplantation and 23.2% within 3 years. The overall graft survival rate in the recurrence group was significantly lower than that of the non-recurrence group (P=0.0018) and non-FSGS group (P=0.0001). Graft failure happened more in the recurrence group (75%) than in the non-recurrence group (37.5%, P=0.042). CONCLUSIONS: We failed to find any significant risk factors for FSGS recurrence after renal transplantation.

Swine Influenza A (H1N1) Infection in Renal Transplant Recipients / 대한이식학회지

BACKGROUND: Novel H1N1 influenza A was a pandemic disease in 2009. However, limited data are available on renal transplant recipients undergoing long-term immunosuppression who contracted novel H1N1 influenza A. METHODS: We analyzed 2,345 patients who had been tested with H1N1 swab real-time reverse transcriptase-polymerase chain reaction test (rRT-PCR) between May 2009 and February 2010. Of them, 30 were kidney recipients who underwent kidney transplantation between April 1979 and 2, May 2009 before the first diagnosis of H1N1 influenza A in Korea. The clinical characteristics, treatment, and outcome of renal transplant recipients with confirmed H1N1 influenza were reviewed retrospectively. RESULTS: A total of 1,543 (66.7%) general patients were swine influenza A confirmed. Of the 30 transplant patients, 19 (63.3%) were confirmed with swine influenza A. The mean age of the general patients at diagnosis of swine influenza A was younger than that of renal recipients (16.5+/-16.1 vs. 39.7+/-11.5 years, P<0.0001). More patients died in the transplant group than in the general patient group even after oseltamivir (Tamiflu) treatment. When comparing the cured group with the dead group of transplant patients, the dead group had a longer duration between symptom manifestation and the beginning of treatment than the cured group (7 [5-7] vs. 2 [1-14] days, P=0.007). The dead group presented more complications such as pneumonia (P=0.009). CONCLUSIONS: H1N1 influenza A can cause severe illness in kidney transplant recipients. We suggest that early diagnosis and treatment with an antiviral agent produces good results in kidney transplant recipients as in the general population.

The Effect of Basiliximab on the Incidence of Acute Renal Allograft Rejection within 1 Year Post-Transplantation

PURPOSE: Basiliximab has become widely used in clinical practice for initial immunosuppression in renal transplantation cases, to reduce the incidence of acute rejection without adverse events. Herein, we report the early outcomes of renal transplantation using basiliximab at a single center. METHODS: This retrospective study included 148 renal allograft recipients at a single center. All patients were followed for longer than 1 year after transplantation, and treated with a calcineurin inhibitor and steroids for maintenance immunosuppression. The use of basiliximab and mycophenolate mofetil (MMF) was optional. We compared the incidence of episodes of acute graft rejection in kidney recipients who were treated with basiliximab as an initial immunosuppressive therapy with those who were treated without basiliximab. RESULTS: Basiliximab was used for initial immunosuppression in 58 patients. Patients maintained immunosuppression with triple (n=69) or double (n=79) regimens including a calcineurin inhibitor (cyclosporine A (n=111) or tacrolimus (n=37)) and methylprednisolone with or without MMF. Thirty-six (24.3%) patients had a rejection episode within 1 year after transplantation and twenty-six (17.6%) patients had an episode of infection. The patients who were treated with basiliximab had fewer rejection episodes (n=11, 18.9%) within the first year after transplantation than the patients who did not take basiliximab (n=25, 27.7%); this difference was not statistically significant. (P=0.245). However, basiliximab significantly affected the number of rejection episodes in the double regimen group (P=0.006), but not the number of rejections in the triple regimen group (P=0.432) and did not affect the number of infection episodes in both groups (P value of double, triple=0.291, 0.772) within one year after transplantation. CONCLUSION: The results of this study suggest that basiliximab might be more useful for graft recipients who are treated with double immunosuppression with a calcineurin inhibitor and steroid than for the recipients with triple immunosuppression including MMF.

Fractional Creatinine Clearance of the Donated Kidney As a Predictor of Graft Function after Living Donor Transplantation / 대한이식학회지

PURPOSE: An insufficient functioning nephron mass might fail to meet the metabolic demands of the recipient and lead to hyperfiltration. This hyperfiltration damage also increase allograft failure rates. During the preoperative evaluation of a potential kidney donor, it is important to estimate the renal function of donated kidney compared with the metabolic needs of the recipient. METHODS: The functional ratio of each kidney was measured using technetium-99m diethylenetriaminepentaacetic acid. The serum creatinine (Scr, mg/dL) and estimated creatinine clearance (Ccr, mL/min/1.73m2) using the Cockcroft-Gault formula were measured and calculated in 82 donors. We excluded recipients who had an episode of rejection, and followed all recipients for more than 12 months posttransplantation. RESULTS: The average functional proportion of the donated kidney was 50.5%+/-4.7% of the total Ccr 83.4+/-18.3 of donors. The Scr of recipients at 1,3,6 and 9months posttransplantation were significantly (P<.05) correlated with the fractional Ccr of thedonated kidney; however Scr at 1 year was not correlated (P=.307). Furth-ermore the Ccr of the recipient at 1, 3, and 6months post transplantation were significantly (P<.05) correlated with fractional Ccr ofthe donated kidney; however the Ccr at 9months and 1 year were not correlated (P=.094 and.141, respectively). CONCLUSION: The Scr and Ccr of recipients within 6 months after transplantation may depend on the functional mass of the donated kidney, which should be estimated prior to kidney donation and compared with the metabolic demands of the potential recipient.

Changes of Glomerular Filtration Rate of Donated and Remnant Kidneys in a Week after Living Donor Kidney Transplantation / 대한이식학회지

PURPOSE: In living donor kidney transplantation, the initial function of donor's kidneys will be split into the function of the donor's remnant kidney and the recipient's implanted kidney. The question whether the function of these remnant and implanted kidneys will change after donation and transplantation was addressed. METHODS: The functional ratio of each kidney using (99m)Tc-Diethylenetriamine pentaacetic acid ((99m)Tc-DTPA) as well as serum creatinine (Scr, mg/dL) and 24-hour urine creatinine clearance (Ccr, mL/min/ 1.73 m(2)) from 100 donors were measured before donation. The kidney function was also calculated using Cockcroft-Gault formula (Ccr-CG, mL/min/ 1.73 m(2)). In donors and recipients, the Scr, Ccr, Ccr-CG were measured within a week after transplantation. RESULTS: The average functional ratio of the implanted kidney versus the remnant kidney before donation was 50.7 : 49.3. In implanted kidneys, the predonation Ccr and Ccr-CG were 56.7+/-9.4 mL/min/1.73 m(2) and 42.0+/-9.9 mL/min/1.73 m(2) which increased to 78.5+/-18.2 mL/min/1.73 m(2) and 53.2+/-16.4 mL/min/ 1.73 m(2) after transplantation. In remnant kidneys, the predonation Ccr and Ccr-CG were 54.5+/-10.9 mL/min/1.73 m(2) and 40.8+/-9.4/min/1.73 m(2) then increased to 68.0+/-14.2 mL/min/ 1.73 m(2) and 53.6+/-11.6 mL/min/1.73 m(2) after donation. CONCLUSION: Kidney transplantation from a living donor should be encouraged based on the total functional benefit of both donors and recipients after kidney donation and implantation.

The Clinical Significance of Routine Screening for the Renal Functional Asymmetry in Potential Live Kidney Donor

PURPOSE: An insufficiently functioning nephron might fail to meet the metabolic demands of a kidney donor, as well as the recipient, and may lead to hyperfiltration. An extreme asymmetry of the functional capacity of donor's bilateral kidneys might result in insufficiency to the recipient or donor. METHODS: Since February 1996, 99mTc-DTPA renal scintigraphy has been routinely included in the evaluation of renal functional asymmetry of a donor. The functional ratio of each kidney, using 99mTc-DTPA, as well as the serum creatinine (Scr) and creatinine clearance (Ccr), were measured and calculated using the 24-hour urine from a hundred donors. RESULTS: A hundred kidney donors were analyzed, including 62 male and 38 female donors. In the healthy donors, the average functional ratios of the left vs. the right kidneys were 52.5 vs. 47.5%. Seventy-three donors donated their left kidney and 27 their right. The Scr of the donors increased from 0.9+/-0.2 to 1.3+/-0.3 mg/dl after the nephrectomy. Both the Ccr in the 24 hour urine and the Ccr obtained using the Cockcroft and Gault formula of the remnant kidney after kidney donation increased from 54.5+/-11.4 to 68.0+/-14.3 ml/min/1.73 m2, and from 40.8+/-9.3 to 53.6+/-11.6 ml/ min/1.73 m2, respectively. CONCLUSION: Attention should be paid to the functional asymmetry of the kidney when choosing a kidney for donation. To protect the remnant kidney of a donor from hyperfiltration damage after donation, it is important to leave an adequate functioning nephron mass to meet the metabolic demands of the donor.

Metabolic Demand and Nephron Supply on Early Graft Function after Living Donor Kidney Transplantation / 대한이식학회지

PURPOSE: Renal allograft mass may potentially affect long term outcome after kidney transplantation. An inadequate renal mass to metabolic demand might trigger hyperfiltration and consequently contribute to the progression of graft nephropathy and failure. METHODS: This is a prospective study with 195 cases of 2 transplant centers. The study population was restricted to live donor transplants except the cases of diabetes, ischemic injury, rejection, and any complication which might result in functional decrease of the kidney graft. Recipient's serum creatinine, 24 hours proteinuria, urine creatinine excretion and creatinine clearance were measured and calculated. Weight of donated kidney, weights and heights of both donors and recipients were recorded and the BSA, LBW, and BMI were calculated. The correlations between each variables were analyzed using Pearson's test, and P<.05 was considered significant. Significantly correlated pairs of variables were included into the linear regression for multivariate test. RESULTS: The amount of urinary excretion of protein is associated with renal mass supply rather than functional demand of recipient. The serum creatinine is associated with the functional balance between the metabolic demand of recipient and renal mass supply from donor. The amount of urinary excretion of creatinine is associated with metabolic demand of recipient rather than renal mass supply. CONCLUSION: Our findings provide direct evidence of a substantial effect of the balance between nephron supply and recipient metabolic demand on early graft function. We suggest that during donor-recipient matching, both the potential sizes of donated kidney and recipient should be considered in terms of early graft function.