A Single Center Experience of ABO Incompatible Kidney Transplantation / 대한이식학회지

BACKGROUND: Kidney transplantation (KT) is the optimal treatment for end stage renal disease. However, the relative shortage of organs for transplantation (from human leukocyte antigen- or ABO incompatible [ABOi] living donors) has led to ABOi KT as an accepted method to expand the pool of living kidney donors. To date, reports of the outcomes of ABOi KT are limited; therefore this study aims to evaluate the outcomes of ABOi KT in recipients. METHODS: We identified 45 patients who underwent live-donor ABOi KT between February 2007 and November 2011 at Maryknoll Medical Center. All of them were treated according to the scheduled protocol of plasmapheresis with low dose intravenous immunoglobulin, and low dose rituximab- or tacrolimus-based triple immunosuppressant regimens. Clinical parameters and the incidence of rejections in these patients were analyzed. RESULTS: We had three cases (6.6%) of biopsy-proven acute antibody-mediated rejections and one case (2.2%) of acute cellular rejection, all of which were successfully treated. The median follow-up duration was 20 months (range, 2~59). Antibody depletion was scheduled according to baseline anti-ABO antibody titer (tube method: median immunoglobulin G titer/immunoglobulin M titer 64 [range, 8~4,096]/16 [range, 2~256], respectively). Although there was no patient death, one patient lost his graft due to nonadherence to immunosuppressants. CONCLUSIONS: Our analysis of ABOi KT has shown excellent and promising outcomes. These practices may therefore represent an acceptable option for expanding the pool of living kidney donors.

A case of acute renal failure caused by extrinsic compression of the left renal artery in lymphoma / 대한내과학회지

Malignant lymphomas can involve any organ, but rarely cause acute renal failure as an initial manifestation. Impaired renal function secondary to renal arterial compression by a tumor mass has not been reported. A 50-year-old man was admitted with low back pain, weight loss, and a palpable abdominal mass. He developed non-oliguric acute renal failure secondary to extrinsic compression of the left renal artery by enlarged lymph nodes in the posterior wall of the pelvic cavity. Abdominal computed tomography (CT) showed the complete absence of perfusion of the left kidney due to extrinsic compression of the left renal artery by a huge diffuse large B cell lymphoma (stage IVa, International Prognostic Index score 3). We report a case of malignant lymphoma presenting as acute renal failure due to extrinsic compression of the left renal artery; this was treated successfully with systemic combination chemotherapy

ABO Blood Group Incompatible Living Donor Kidney Transplantation without Splenectomy / 대한이식학회지

BACKGROUND: Serious organ shortage necessitates ABO incompatible (ABOi) kidney transplantation (KT). Recent reports utilizing rituximab instead of splenectomy and tacrolimus (FK)-based triple immunosuppressants showed excellent graft outcome. METHODS AND RESULTS: Thirteen cases of ABOi living donor KT have been performed since Feb. 2007 in our center. Donor and recipient blood group was B to O (n=5), A1 to O (2), AB to B (2), AB to A1 (1), A1 to B (2) and B to A1 (1). Rituximab was given at 4 weeks before transplantation. Plasmapheresis (PP) was initiated at 7~14 days before transplantation with concurrent immunosuppressants. The number of pretransplant PP was 5.7+/-1.4. Posttransplant PP was also performed in 6 patients with higher initial titer of ABO antibody (IgG > or =256; n=2), rapidly rising antibody titer during the critical period of 2 weeks posttransplantation (n=2), or increase in serum creatinine during the critical period while awaiting pathology report of graft biopsy (n=2). Mean number of posttransplant PP in these 6 patients was 2.2+/-1.3. Median IgG anti-ABO antibody titer before precondition, at transplantation, at 2 weeks and at 6 months was 64 (8~512), 2 (1~8), 2 (1~16) and 6 (1~16), respectively. IgM titer at corresponding time point was 16 (2~128). 1 (1~1), 1 (1~2) and 1.5 (1~4), respectively. Median follow up was 8 (5~27) months. No patient or graft was lost. No patient developed acute humoral rejection. Graft function remained stable with latest serum creatinine 1.2+/-0.3 mg/dl. CONCLUSIONS: ABOi living donor KT without splenectomy can be safely performed with the use of current preconditioning and immunosuppressive regimen, and is therefore a valuable option for expanding donor pool and should be actively performed in Korea.

Malignancy in Renal Transplant Recipients / 대한이식학회지

With improved management of infectious and cardiovascular complications of renal transplant recipients, prolonged survival with long-term follow up duration, and increasing age of patients, cancer became an increasingly important cause of morbidity and mortality in transplant patients. Literatures indicate three to fivefold incidence of malignancy in solid organ transplant recipients compared with that of general population. Certain types of malignancy, such as skin cancer, Kaposi's sarcoma, lymphoma, cervical, oral and anogenital cancer, hepatocelluar and renal cell carcinoma are particularly reported to be high in incidence. Reduction of immunosuppressive medication is the first step to be considered for the management, especially for virus-associated cancer. The inhibitor of mammalian target of rapamycin(mTORi) suppresses the growth and proliferation of tumors in various animal models, cured Kaposi's sarcoma and seems to reduce the incidence of de novo malignancies of renal transplant recipients, and is therefore a valuable option for the management of cancer of these patients without increment of the risk of graft rejection.

Immune hemolytic anemia secondary to ABO minor incompatibility in renal recipients / 대한내과학회지

BACKGROUND: Immune hemolysis secondary to ABO minor incompatibility is a rare graft versus host disease in renal recipients, secondary to anti-ABO antibody produced by lymphocytes of donor origin that reacts against recipient RBCs. METHODS: To investigate the incidence and clinical features of immune hemolysis secondary to ABO minor incompatibility in renal allograft recipients, clinical records of 358 renal transplantation performed in Maryknoll Hospital since 1991 were analyzed retrospectively. RESULTS: Fifty four (15%) of 358 renal transplants were ABO minor incompatible. Immune hemolysis secondary to anti-ABO antibody developed in 5 (9.2%) of 54 ABO minor incompatible renal transplant recipients. Immune hemolysis occurred in 3 (13.6%) patients among 22 allografts from blood type O donor to A recipients and 2 (10%) patients among 20 from blood type O donor to B recipients. All 5 patients received cyclosporin with prednisolone, and MMF was administered to one patient additionally. Immune hemolysis developed on 14+/-3 days after renal transplantation and lasted for about 10+/-3 days. The maximum reduction of hemoglobin was 3.3+/-1.0 g/dL. All patients required donor type (blood type O) washed RBCs transfusion (5.0+/-2.6 units per patient) and plasmapheresis were performed in 3 patients (4.0+/-1.0 per patient). All patients recovered without deterioration of graft function. Age, number of HLA mismatch, creatinine at 1 year after transplantation, frequency of acute rejection and serum cyclosporin level during first 2 weeks were not significantly different between hemolysis group (N=5) and non-hemolysis group (N=49). Living unrelated transplantation is associated with increased incidence of immune hemolysis compared with living related transplantation (p<0.01). CONCLUSION: Although immune hemolysis secondary to ABO minor incompatibility is uncommon, we experienced cases with marked reduction of hemoglobin that required a large amount of transfusion. Therefore, this type of immune hemolysis needs to be considered as a differential diagnosis of posttransplant hemolysis. As our center routinely performs donor specific transfusion (DST), the incidence may be higher than that of other centers where DST is not usually given.

A Comparative Study Concerning the Psychopathologies between the Patients with Chronic Renal Failure and Those with Chronic Hepatitis: Focused on Medically-ill Outpatients Compared with Controlled Subjects who Received Medical Examination / 신경정신의학

OBJECTIVES: Although there were many studies examining anxiety and depression in hospitalized medically-ill patients, there were few studies in examining anxiety and depression of non-psychiatric outpatients or comparative studies among the disease categories. Therefore, we wanted to explore 1) psychopathologies in the patients with chronic renal failure and those with chronic hepatitis, 2) differences of psychopathologies by severity, 3) differences of psychopathologies by the duration of illness, and 4) psychiatric consultation. This was the second series of the whole project. METHODS: From March to April 1999, 38 patients with chronic renal failure and 26 patients with chronic hepatitis who visited the medical outpatient department are included in the subject group and 116 persons who visited the health examination center in September 1999 are included in the control group. We reviewed the medical records of the patients and inquired what they thought the causes of their illness were. We evaluated the patients with State-trait anxiety inventory, Beck depression inventory, Symptom checklist-90-Revision. RESULTS: In state anxiety, 62.2% of the patients with chronic renal failure fell into the anxious group, which is somewhat greater than the 52.0% of those with chronic hepatitis. The rates in both subjects are significantly higher than that of the control group. 16.7% of the patients with chronic renal failure were depressed, which is somewhat greater than the 9.1% found in chronic hepatitis. The rates in both subjects showed no significant difference from that of the control group. When the state anxiety scores were compared during the duration of the illness, it was found to be relatively higher during the early phase of disease in both the chronic renal failure patients and the chronic hepatitis patients. In the depression, the scores were found to be relatively higher in the chronic renal failure patients when the duration of illness was between 1 to 5 years compared to other duration groups, while the patients of chronic hepatitis were found to be relatively constant. Most frequently, 36.2% of the patients with chronic renal failure and 24.3% of those with chronic hepatitis thought the cause of their illness to be 'psychological', but the rates of psychiatric consultation in both subjects are 5.7%, 7.7% respectively. CONCLUSIONS: Our results suggest that proper psychiatric interventions are not being conducted yet and more cooperative and integrative roles are required among psychiatrists and internists.

Efficacy and Safety of Lamivudine on Hepatitis B after Renal Transplantation / 대한신장학회잡지

Renal graft recipients with hepatitis B virus(HBV) infection are at increased risk of fatal outcome, when 1they have serological evidence of active viral replication, such as HBV-DNA and/or HBeAg. Some patients have been treated successfully with interferon. But the major drawback of this therapy is acute rejection. Lamivudine is a potent inhibitor of hepatitis B virus replication. The aim of this study was to determine the efficacy and safety of lamivudine therapy in HBsAg positive renal recipients with active viral replication. Of the 20 HBsAg positive renal transplants, 12 patients with positive HBV-DNA, determined by hybridization method, were given lamivudine. The doses of lamivudine ranged from 37.5 to 150mg/day according to the graft function of patients. Alanine aminotransferase(ALT), aspartate aminotransferase (AST), HBsAg, HBeAg, anti-HBe, HBV-DNA and creatinine were regularly monitored. Lamivudine was well tolerated without significant side effect. Viral replication was effectively suppressed, as evidenced by negative conversion of serum HBV-DNA in 11 of 12 patients and reduction in HBV-DNA titer in 1 patient. In 3 patients who stopped lamivudine due to economic reason, HBV-DNA promptly increased to high titer, but decreased to undetectable level after retrial of medication. In 2 patients with initial negative conversion of HBV-DNA and under continued medication, HBV-DNA reappeared at 7 and 16 months respectively after initiation of lamivudine, with deterioration of hepatic function in 1 patient. These patients with lamivudine-resistant mutant continued medication with persistent low titer of HBV-DNA and without further aggravation of hepatic dysfunction. Lamivudine seems to inhibit HBV replication effectively in HBV-infected renal recipients and seems to be helpful in delaying the progression of liver disease. However, the optimal duration of treatment and long term efficacy and safety remain to be determined.

Steroid Withdrawal(SW) with Simultaneous Administration of Mycophenolate Mofetil(MMF) in Renal Recipients / 대한신장학회잡지

Long term use of steroid induces multiple side effects and morbidity. However, SW has been reported to be associated with increased incidence of acute and chronic rejection, and subsequently reduced graft outcome. MMF inhibits the proliferation and functions of lymphocytes, decreases the incidence of acute rejection in organ transplants, and therefore may decrease the graft rejection associated with SW. We tried to withdraw steroid from 21 renal transplants treated with prednisolone and cyclosporine, who had clinically significant steroid induced side effects. Reasons for SW were diabetes in 15 patients (pre-transplant DM 4 and post-transplant 11), moon face 4 and avascular necrosis of femur 2. Prednisolone was tapered at a rate of 2.5mg every 2 weeks and was discontinued. MMF, 1.0-2.0g/day, was initiated at the beginning of SW. The time interval between transplantation and SW was 26+/-5 (1.5-67) months. Mean age was 48(28-61). Two patients developed MMF-induced GI side effects, and were returned to previous immuno- suppressants. In 1 patient, serum creatinine increased during SW, and steroid was re-administered with the restoration of renal function. In 18(86%) of 21 patients, therefore, steroid was successfully with-drawn. At the follow up of 17+/-1(13-24) months after SW, 1 patient with drug incompliance developed chronic rejection. The rest showed stable renal function. Steroid can be safely withdrawn from renal transplants by simultaneous administration of MMF. The long-term safety, however, needs to be evaluated by prolonged follow up studies.

Donor Specific Transfusion 24 Hours Prior to(-24h DST) Living Donor Renal Transplantation / 대한신장학회잡지

The goal of the immunologic maneuvering for organ transplantation may be the donor specific immune tolerance rather than non-specific immunosuppression. Although DST is one of the most extensively studied methods for donor specific immune hyporesponsiveness, it is not widely used in recent years because of possible sensitization and overall improvement of graft survival without DST. Several human and animal studies showed that -24h DST with concomitant cyclosporine administration improved graft survival. -24 DST may not induce adverse sensitization that preclude subsequent transplantation and the procedure is simple and does not delay the operation in living donor transplantation. Between Feb. 1994 and Jan. 1997, 33 patients received 100-200ml of fresh whole blood from the kidney donor 1 day before transplantation. Twenty donors were living related and 13 donors were non- related. Mean age was 40(22-52). Two patients was diabetic. All but one received primary allograft. Cyclosporine and prednisolone were the primary immunosuppressants that started 2-3 days before transplantation. Acute rejection occurred in 11 recipients(33.3%). Acute rejection tended to occur earlier. Eight of 11 first episodes were within 3 days post- transplant, which were all recovered by either steroid pulse or OKT3. Mean follow up was 35 months. Two patients died with functioning graft. Three-year graft survival rate was 93.9%. There was no immunologic graft loss. We conclude that -24h DST may be a valuable option of immune modulation for renal transplantation with no demonstrable adverse reaction. It's beneficial effect needs to be confirmed by a larger controlled study.

A Case of Acute Pancreatitis as a Complication of Systemic Lupus Erythematosus / 대한신장학회잡지

Systemic lupus erythematosus, an autoimmune disease with multisystem involvement, has been reported to be associated with a number of gastrointestinal complications and symptoms such as nausea, vomiting, and abdominal pain. However, acute pancreatitis only rarely has been reported as a complication of SLE. We report a case of SLE presenting drug unrelated acute pancreatitis as a initial manifestation.

A Case of Anti-Glomerular Basement Membrane Antibody Associated Crescentic Glomerulonephritis with Positive Antineutrophilic Cytoplasmic Antibody / 대한신장학회잡지

A 63-year-old woman presented to the hospital with gross hematuria and acute renal failure. Kidney function deteriorated rapidly and progressively. A renal biopsy revealed segmental or circumferential crescents associated with linear deposits of immunoglobulin G, typical of anti-glomerular basement membrane disease. Both c-ANCA and anti-GBM antibody were detected in serum. She was treated with hemodialysis, plasmapheresis, high dose steroid and cyclophosphamide. However, she died 7 weeks after treatment because of pneumonia, without recovery of renal function. Serologic positivity of both ANCA and anti-GBM antibody are becoming more frequently recognized in rapidly progressive glomerulonephritis. The influence of c-ANCA on the clinical course of anti-GBM glomerulonephritis remains to be determined.

Surgical Complications in 250 Renal Transplants: Clinical Course and Outcome / 대한이식학회지

The surgical technique of renal transplantation has been well established, but surgical complications are not uncommon and still be important factors in postoperative mortality and morbidity. From August 1990 to May 1998, we performed 250 consecutive renal transplantations at Maryknoll hospital. The authors analyzed the kinds and incidences of surgical complications in a single center by using information from hospital records. The results were as follows: 1. The overall surgical complication rate was 9.6% (24 episodes in 250 cases). 2. These were composed of 6 vascular, 8 urologic, 4 lymphatic, and 6 wound complications. 3. Vascular complication included renal artery stenosis in 1 case and bleeding and hematoma in 5 cases. 4. Urologic complication included urine leakage in 4 cases, ureter stenosis in 2 cases and bladder stone in 2 cases. 5. Lymphatic complication was all lymphoceles. 6. One case in which renal artery stenosis had occured progressed to graft loss after 4 years later. There was no complication related mortality. 7. 1 year, 3 year and 5 year graft survival rate was 97.2%, 94.8% and 90.0%, respectively. and patient survival rate was 98.0%, 95.6% and 94.7%, respectively.

Risk Factors and Clinical Characteristics of Post-Renal Transplant Diabetes Mellitus / 대한신장학회잡지

To investigate the risk factors and clinical characteristics of postrenal transplant diabetes mellitus (PTDM), we reviewed the records of 177 renal allograft recipients in Maryknoll Hospiatal whose allografts had functioned longer than 6 months. Nineteen patients (10.7%) developed PTDM at 5.0+/-7.8 (1-52) months; 9 (47%) of these within 1 month. PTDM patients were older than nondiabetic renal transplants (42+/-2 vs 37+/-1 years, P<0.05). Body mass index tended to be higher in PTDM (23.5+/-1.0 vs 21.8+/-0.3kg/m2, P=0.09). Number of acute rejections (0.6+/-0.2 vs 0.5+/-0.1) and serum creatinine at 1 year after transplantation (1.2+/-0.8 vs 1.3+/-0.3mg/dL) were not different. Fasting (103.6+/-10.4 vs 84.4+/-1.6mg/dL, P<0.05) and postprandial (189.2+/-24.8 vs 118.6+/-2.3 mg/dL, P<0.01) blood sugars, measured before transplantation, were higher in PTDM. CsA blood level at 1 month posttransplantation was higher in PTDM (350+/-34 vs 279+/-8ng/mL, P<0.05). Fasting serum insulin was significantly higher (28.2+/-12.2 vs 7.3+/-2.0 microunit/dL, P<0.05) and serum C-peptide tended to be higher in PTDM patients compared with euglycemic renal recipients (6.3+/-1.6 vs 3.8+/-0.9ng/dL, P=0.08). All the PTDM patients were treated by either insulin or oral agent; 15 of 19 required no treatment after 4.7+/-6.9 months. In conclusion, prevalence of PTDM was 10.7%. PTDM patients were older. Body mass index was tended to be higher. Fasting and postprandial blood sugars, measured before transplantation, were higher in PTDM. Faslting serum insulin was higher and C-peptide tended to be higher in diabetics. These results suggested that increased insulin resistance plays a major role in the pathogenesis of PTDM.

Living-Donor Renal Transplantations, Analysis of Risk Fanctors Influencing the Outcome of 190 Cases

We have performed 190 renal transplantations from August 1990 to June 1996. No cadaveric donor was used and all except one were first grafts. We conducted a clinical analysis, especially concerning the factors affecting acute rejection and graft function at 1 year. The results were as follows : 1) The mean ages of donor and recipient were 35.3 years and 37.4 years respectively. The ratio of male to female was 1.4 : 1 and 1.5 : 1, respectively. 2) One hundred and six cases(55.8%) were living unrelated donors and eighty four cases(44.2%) were living related donors. 3) One hundred and sixty six potential recipients were given 3 donor specific transfusions(DST), started about 5 weeks prior to transplantation with cyclosporin coverage. Six of these patients(3.6%) developed sensitization by DST that precluded the subsequent transplantation and the remaining 160 patients received the kidney from the blood donors. Another 28 recipients were given DST 24 hours prior to operation. 4) Most of initial acute rejection episodes(71 episodes, 95%) appeared within the first month of post-transplantation. 5) We analyzed the possible factors affecting the incidence of acute rejection. Donor age and HLA incompatibility were significant statistically(p<0.05). 6) Multiple regression analysis showed that a number of acute rejection episodes(p<0.001) was the only independent risk factor for the graft function at 1 year. 7) Overall graft and patient survival rate were 97.2% and 98.6% at 1 year, 94.1% and 95.5% at 3 years.

A clinical analysis of 80 renal transplantation / 대한이식학회지

No abstract available.

Prevalence of anti-HCV in hemodialysis patients / 대한신장학회잡지

No abstract available.