Quality of Life among End-stage Renal Disease Treatments and Economic Evaluation of Renal Transplantation and Hemodialysis Treatments / 대한이식학회지

BACKGROUND: Although renal transplantation is known as the best treatment for patients with end-stage renal disease, there are few of literature to identify economic evaluation of renal replacement therapies in Korea. This study was conducted to determine the cost-effectiveness of renal replacement treatments, particularly renal transplantation and hemodialysis. METHODS: We used the quality adjusted life year (QALY) calculated from survey data, which was collected from 124 patients who underwent kidney transplantation and 90 patients who were receiving hemodialysis. Medical costs were collected from five hospitals in Korea. The ERA-EDTA registry data (European Renal Association-European Dialysis and Transplant Association) were used for transition probability. A Markov model was used for predicting the cost-utility of transplantation and hemodialysis over the 10-year period. RESULTS: Renal transplantation offers lower cost and better outcome compared to hemodialysis. QALY per year of transplantation patients is higher than that of hemodialysis patients (transplantation 0.9465 vs. hemodialysis 0.8297). Cost per QALY gained is 15,566,000 won in transplantation patients whereas 32,765,000 won per QALY gained in hemodialysis patients was required. CONCLUSIONS: Although cost of first year after transplantation was expensive, over 2 years, transplantation was more effective and less costly than hemodialysis. The results suggest that transplantation is more cost-effective than hemodialysis in Korea.

The Effects of Symptom Distress, Social Support, and Work Change on Liver Transplant Recipients / 대한이식학회지

BACKGROUND: The purpose of this study was to evaluate the factors influencing quality of life (QOL) in liver transplant recipients. METHODS: The subjects of this study were 103 liver recipients who received their follow-up more than 3 months after liver transplantation at one general hospital in Seoul. A questionnaire survey was perfomed from September 1, 2012 to September 30, 2012. QOL and factors were evaluated using SF-36, Transplant Symptom Distress Scale and Multidimensional Scale of Perceived Social Support. RESULTS: Symptom distress, work change after transplant, duration after transplant were significant factors influencing QOL (Cum R2=0.39, F=19.34, P<0.001). Symptom distress was the most important factors related QOL. There were significant differences in QOL according to general characteristics such as education (t=2.16, P=0.033), work change after transplant (t=3.67, P=0.000), duration after transplant (t=2.25, P=0.027), and economic status (t=3.08, P=0.027). CONCLUSIONS: In conclusion, symptom distress had an influence on the QOL of liver transplant recipients. Thus, it is necessary to develop interventions for symptom distress to improve the QOL of liver transplant recipients.

Evaluation of Independent Risk Factors Affecting Renal Allograft Survival by Transplant Era / 대한이식학회지

BACKGROUND: Using long-term (more than 30 years) data from a single center, this retrospective study evaluated changes of independent risk factors affecting renal allograft survival by transplant era. METHODS: Of 3,000 cases of kidney transplantation, 2,708 (90.3%), including their follow-up observations, were reviewed. Transplant era was classified according to immunosuppressive regimens as either early group (transplant serial No. 1~1,500) or recent group (transplant serial No. 1,501~3,000). RESULTS: There was a significant difference observed in pre-transplant clinical manifestations between the early and recent groups. The number of elderly recipients and donors, number of deceased donors, and cases related to pre-transplant diabetes, pre-emptive transplantation, and retransplantation were differed relative to transplant era. The short- and long-term graft survival rate of the recent group improved significantly, and the effect of human leukocyte antigen mismatching and living donor type disappeared in the recent group. Moreover, pre-emptive transplantation and retransplantation were effective only in the recent group. However, non-immunological factors such as elderly recipients and donors, and immunologic factors such as episodes of acute rejection and types of immunosuppressive regimen were persistent independent risk factors affecting graft survival rate. CONCLUSIONS: According to the retrospective survival analysis of a large number of recipients in a single center, risk factors for kidney transplant patients differed by transplant era. However, the independent risk factors associated with elderly recipients and donors (non-immunologic), and episodes of acute rejection, and types of immunosuppressive regimen (immunologic) persisted regardless of transplant era.

A Renal Transplantation and Hemodialysis Cost-Utility Analysis in Patients with End-Stage Renal Disease / 대한이식학회지

BACKGROUND: The purpose of this study was to examine the cost-effectiveness of renal transplantation and hemodialysis among end-stage renal disease patients. METHODS: Empirical data on treatment costs were collected from five hospitals in Korea. We used European Renal Association-European Dialysis and Transplant Association registry data for transition probability. Quality adjusted life year (QALY) values were derived from the literature. A Markov model was used for predicting the cost utility of transplantation and hemodialysis over a 10-year period. RESULTS: Renal transplantation was less costly and resulted in a better outcome than hemodialysis. The cost per QALY gained was 19,450 thousand won in transplantation patients, whereas it was 36,514 thousand won per QALY gained in hemodialysis patients. CONCLUSIONS: Although the cost of the first year after transplantation was expensive, transplantation was more effective over 2 years and was less costly than hemodialysis. The results suggest that transplantation is more cost-effective than hemodialysis in Korea.

A Proposal to Activate Organ Donation: Report of Organ Allocation Study Group / 대한이식학회지

Organ shortage is a serious problem in the field of solid organ transplantation. Increasing number of death on the waiting list, transplant tourism, black market for organ selling are all caused by organ shortage and these eventually causing poor quality of life for patient and family, and may give rise to a serious confusion in domestic transplant system. Since the KONOS launched in the year 2000, some portion of the illegal side of organ supply were corrected but the number of organ donor was hardly to increase. In order to search any solution for this problem, organ allocation study group under the Korean society for organ transplantation was actively worked from August 2008 through February 2009, and got some solution. Among them, amendment of the transplantation law including brain death committee, reporting system of suspected brain dead patients, and set up an independent organ procurement organization system for an effective organ procurement. Organ donation and increasing the number of donor is not a task only for transplant society, but is closely related with quality of life for peoples. This also can change the execution of budget of national medical health insurance. To give a correct understanding about this and activate the nationwide organ donation, the transplant society should have a key role with various medical and nursing society, hospital association, government, national assembly and every voluntary groups.

Pre-transplant Serum Soluble CD30 Level; Correlation with Panel Reactive Antibodies and Lymphocyte Cross Matching / 대한이식학회지

PURPOSE: Serum level of soluble form CD30 (sCD30), a marker for T helper 2-type cytokine-producing T cells, is used as a marker of immunologic status of pre-transplant recipient that can predict graft rejection and graft survival. This study compared pre-transplant serum sCD30 levels with conventional pre-transplant immunologic parameter, such as panel- reactive antibodies (PRA) and lymphocyte cross matching (LCM). METHODS: Adult seventy two patients were enrolled this study. The blood for tests was sampled simultaneously. Measurement of serum sCD30 level was performed using enzyme-linked immunosorbent assay kit (Bender MedSystems, Co. CA, USA). We tested PRA using a commercial ELISA kit (Lambda Cell Tray Lymphocytotoxicity assay)(One Lambda Inc. CA, USA). We established LCM tests for T cells by Modified NIH (National institute center of health)/Johnson's Method/AHG (Anti human globulin), and for B cells by warm test. RESULTS: Mean score of sCD30 was 90.3+/-6.4 U/mL, ranged from 12.2 to 244.4 U/mL. There was no significant correlation between patient's age or sex and sCD30 level. The correlation between sCD30 and mode or duration of dialysis was not statistically significant clinical situation. The result of LCM didn't show significant correlation with sCD30 level (87.3+/-55.7 U/mL in LCM positive group versus 91.9+/-1.3 U/mL in LCM negative group, P=0.696). And sCD30 level equal to or more than 86 U/mL could not predict the positive result of LCM. The positive and negative predictive value of sCD30 to LCM was merely 27.8% and 58.3% (P=0.322). Also the correlation between sCD30 level and PRA was not significant (P=1.0). CONCLUCION: There was no significant correlation between serum sCD30 level and conventional immunologic parameter such as PRA or LCM. That means the pre-transplant monitoring of the sCD30 level can be used as an independent immunologic parameter.

Long-term Change of Renal Function after Donor Nephrectomy for Kidney Transplantation / 대한이식학회지

PURPOSE: Occurrence of renal failure and its related complications such as hypertension are long-term problems after donor nephrectomy for living donor kidney transplantation. We retrospectively reviewed renal function of unilateral kidney donor. METHODS: From 669 living donors for kidney transplantation from December 1998 to October 2006, laboratory data related to renal function are collected from hospital medical record retrospectively in 251 (37.5%) donors who were followed-up after discharge. The selection criteria of donors were: 1) pre-nephrectomy serum creatinine level below 1.5 mg/dL, 2) no radiologic abnormality in bilateral kidney. The donor nephrectomy was performed by conventional open nephrectomy or video assisted minilaparotomy surgery. The estimated glomerular filtration rate (e-GFR) by Modification of Diet in Renal Disease (MDRD) study was used as renal function monitoring parameter. RESULTS: In immediate post-nephrectomy period, e-GFR was decreased to 67.8+/-4.6% of pre-nephrectomy level (93.8+/-9.9 mL/min/1.73 m2). The urinary protein excretion for 24 hours was increased to 255% of pre-nephrectomy level (76.4+/-4.6 mg/day), but cases with proteinuria more than 300 mg per day were only 4 cases (1.7%, 4/251). After 14.0+/-5.2 months follow-up (range: 1~80 months), two cases (0.8%, 2/251) of renal failure (chronic kidney disease stage 5) were found. Relative renal function (post-nephrectomy e-GFR ratio versus pre-nephrectomy e-GFR, %) was increased by post-nephrectomy duration. The mean scores of e-GFR ratio within post-nephrectomy 2 months, 3~11 months, 12~23 months and after 24 months were 64.8+/-10.4%, 66.4+/-9.7%, 69.5+/-10.9% and 75.8+/-17.6% respectively. The relative e-GFR ratio after 24 months was significantly different from those of within 24 months (P<0.0001 by ANOVA). In linear regression analysis, mean increment of e-GFR ratio per post-nephrectomy year was 2.88%. CONCLUSION: In spite of possibility of renal failure, our study shows the long-term compensation of residual renal function after nephrectomy.

Risk Factors Affecting Long-Term Outcome in Kidney Re-Transplantation Recipients / 대한이식학회지

PURPOSE: The aims of this study were to review the result of kidney re-transplantation in comparison with first kidney transplantation, and to identify the prognostic factors affecting long-term outcome at a single center. METHODS: Between April 1979 and January 2006, the total number of renal allografts was 2,495. Among these, 159 cases received second (155 cases) or third (4 cases) transplantation. Demographic characteristics and clinical outcomes of both groups were compared. And we examined the risk factors affecting long-term outcome in re-transplantation recipients. RESULTS: The mean duration of previous graft survival in re-transplantation group was 86.1+/-51.4 (0~215) months. Major cause of the previous graft failure was chronic rejection (n=88, 55.3%). One-, 5-, and 10-year graft survivals of the re-transplantation group and the first transplantation group were 94.1%, 88.9%, 76.0% and 96.0%, 84.8%, 69.1%, respectively without significant difference (P=0.2203). In uni-variate survival analysis, acute rejection experienced group, elderly recipient more than 50 years old, and female gender group showed significant inferior graft survival rate compared to control group. Previous graft survival duration didn't cause significant graft survival difference. Multivariate survival analysis also confirmed that the episodes of acute rejection within 12 months after transplantation (P=0.035, Odd ratio= 2.514), elderly recipient more than 50 years old (P=0.002, odd ratio=3.734), and female gender (P=0.005, Odd ratio= 3.692) were statistically significant independent risk factors affecting graft survival in kidney re-transplantation. CONCLUSION: Long-term outcomes after kidney re-transplantation were not different from that of first kidney transplantation. Therefore, renal re-transplantation could be the treatment of choice even in recipients with previous failed renal allograft.

Clinical Outcome of Renal Transplantation in Patients with Positive Pretransplant Hepatitis B Surface Antigen / 대한이식학회지

PURPOSE: The natural history of renal transplant recipients with positive HBs Ag is still unclear and unpredictable. Liver-related morbidity and mortality after long-term immunosuppression need clinical challenges. We retrospectively investigated the clinical outcome of pre-transplant HBs Ag positive renal recipients in a single transplant center located in endemic area. METHODS: After excluding post-transplant de novo HBV infected, and peri-transplant anti-hepatitis C virus positive recipients, the clinical outcome of 1,816 recipients was examined by the nature of pre-transplant HBs Ag positivity. RESULTS: Pre-transplant HBs Ag positivity was documented in 61 recipients (M/F=47/14). During mean follow up of 71.61+/-54.14 months, 24 recipients died (6 by infection, 12 by hepatic failure, 2 by hepatocellular carcinoma, 2 by other malignancies, 1 by suicide, 1 by gastrointestinal bleeding). In 14 recipients (58.3%), death was related to liver-associated reasons. The 10-year patient survival rates in HBs Ag negative and positive groups were 90.0% and 62.6%, respectively (P<0.0001). The 10-year graft survival rates in HBs Ag negative and positive groups were 82.0% and 55.6%, respectively (P<0.0001). When pre-transplant HBV DNA viral load by PCR was positive or when the level of post-transplant HBV-DNA viral load flared up, we started lamivudine therapy since 1997. Seventeen recipients received daily 100 mg lamivudine. The mean duration of patients survival with (n=17) and without (n=44) lamivudine therapy was 104.3+/-45.6 and 59.0+/-51.2 months, respectively (P= 0.003). The 10-year patient survival rates in patients with and without lamivudine therapy were 80.7% and 55.4%, respectively (P=0.0698). CONCLUSION: Overall patient and graft survival in patients with positive pre-transplant HBs Ag was lower than negative recipients. Although, statistically not significant, lamivudine therapy showed a marginally positive impact on the survival of patients with pre-transplant positive HBs Ag.

Long-term Effect of Steroid-free Immunosuppressive Protocol in Kidney Transplantation / 대한이식학회지

Purpose: Early experience of steroid-free immunosuppressive protocol for kidney transplant recipient was unsatisfactory due to a remarkable incidence of acute rejection. We also attempted steroid-free protocol in 1990, and experienced painful early result. Therefore, steroid-free protocol have not been tried since 1990. Now, we retrospectively reviewed our experience of steroid-free protocol which was performed in 1990, and verified the long-term effect of steroid-free protocol. Methods: Among 149 recipients who underwent living donor kidney transplantation in 1990, 48 recipients with stable graft function were enrolled in this study. Cyclosporine and steroid were administrated as a maintenance immunosuppressive regimen without induction immunosuppression such as anti- lymphocyte antibodies. Steroid was gradually reduced for 6~8 weeks at 2~3 month after transplantation. If acute rejection or graft dysfunction was developed during tapering period or after cessation, steroid was restarted. And such tapering failure and restart group were defined as steroid-free failure group. We compared the clinical outcomes of steroid-free trial group compared with non-trial (control) group. Results: 17 (35.4%) of 48 recipients failed in steroid-free protocol finally. Acute rejection was the most common cause of steroid-free failure by 11 (64.7%) recipients, and most failure (12 recipients, 70.6%) occurred within 1 year after transplantation. Therefore failure group showed significant inferior graft survival rate than steroid-free group (35.3% versus 80.7%, P=0.001). The overall steroid-free trial group showed similar graft survival rate compared with control group. But the steroid-free group showed superior graft survival rate than control without statistical significance (80.7% versus 60.4%, P=0.383). And also showed lower incidence of post- transplant diabetes, hypertension, hyperlipidemia and bone disease without or with significance. Conclusion: The steroid- free protocol without addition of other immunosuppressive agent causes high incidence of acute rejection and poor graft survival. Hwoever, success group to steroid-free protocol shows beneficial effect in graft survival rate and post- transplant complications.

Effects of Early Administration of Vitamin D or Alendronate on the Change of Bone Mineral Density after Renal Transplantation / 대한이식학회지

PURPOSE: The decrease in bone mineral density (BMD) is a major complication after kidney transplantation. This was reported to occur preferentially during the first 6 months. However, the treatment and prevention strategies against a decline of BMD are not yet clear. METHODS: The data on the pre-transplant baseline and post-transplant 1 year BMD were archived and retrieved in 125 renal transplant recipients. The post-transplant changes of the BMD were compared by the baseline status of the BMD and the types of anti-osteoporosis treatment either with a vitamin D agent (alfacalcidiol) (n=18) or alendronate (n=21). Anti-osteoporosis treatment began within 30 days after transplantation, with an oral administration of 0.5 mcg/day vitamin D or 70 mg/week alendronate, and maintained until 1 year after transplantation. RESULTS: Regardless the degree of baseline BMD status, each group (the control, vitamin D, or alendronate group) showed a significant and uniform decrease of BMD during the post-transplant 1 year. The mean change in the spine BMD in the control, vitamin D, and alendronate group was -7.1+/-7.5%, -3.3+/-7.4% and -2.6+/-6.5%, respectively. The femur BMD also changed -5.1+/-7.7%, 1.1+/-5.3% and -1.5+/-8.2%, respectively. The degree of BMD decrease in the treatment groups was significantly lower than that in the control (P=0.014 in spine, P=0.003 in femur). When the severely reduced baseline BMD (T-score of spine or femur < or =-1) subgroups were analysed separately, the treatment groups (-3.7+/-6.5% in vitamin D and -1.1+/-6.4% in alendronate group) showed a significantly less decrease in the spine BMD than the control (-8.2+/-6.2%)(P=0.036). The femur BMD also showed a less decrease in the BMD in the treatment group, but this was not statistically significant (P=0.234). There was no significant difference between the vitamin D and alendronate treatment groups. CONCLUSION: After renal transplantation, early administration of vitamin D or alendronate showed some benefit to reduce the post-transplant decrease of BMD in both spine and femur area.

Prospective Monitoring of Urine Decoy Cell after Kidney Transplantation / 대한이식학회지

PURPOSE: To find the incidence and risk factors for polyomavirus (PV) infection, we monitored urine decoy cell (UDC) after renal transplantation. METHODS: From March 2003 to September 2004, 142 de novo renal recipients were prospectively monitored for UDC at post-transplant 1, 3, 6, 9, 12 months. According to the number of UDC in Cytospin, patients were divided into 3 groups: A (0), B (1~9) and C (> or =10). We decreased immunosuppression (IS) when group C status persisted for more than 1 month or more than 4 UDC was continuously detected for more than 3 months. Differences in demographics and clinical characteristics among the groups were compared. RESULTS: Forty four (31%) patients were found to have positive UDC at least at one examination (30 in group B and 14 in C). The number of patients with positive UDC at postoperative 1, 3, 6, 9, 12 months were 10 (22.7%), 14 (31.8%), 17 (38.6%), 27 (61.3%), 20 (45.4%) respectively with a highest at 9 months. One PV nephropathy was documented by renal biopsy. During the period from January 2001 to December 2002 when we did not prospectively monitor UDC, 7 PV nephropathy cases were documented among 116 recipients. Tacrolimus (Tac) and episode of acute rejection (AR) were significant risk factor for positive UDC (P=0.036, 0.010, respectively). Cumulative incidence of PV infection was significantly different by the use of Tac and episode of AR (P=0.03, 0.013, respectively). CONCLUSION: Use of Tac and episode of AR were risk factor for positive UDC and PV infection. Modulation of IS by the result of UDC monitoring could decrease the development of PV nephropathy after renal transplantation.

Change of Bone Mineral Density after Kidney Transplantation and Factors Influencing Post-transplant Bone Mineral Density Loss

PURPOSE: Osteoporosis is one of the common complications following kidney transplantation which causes profound morbidity. Using the pre-transplant bone mineral density (BMD) data, post-transplant change in the BMD of recipients was retrospectively evaluated. The risk factors affecting the post-transplant BMD changes were also evaluated in this study. METHODS: Between Jan. 1996 and Sep. 2003, 294 kidney transplant recipients were enrolled in this study. The BMD was expressed as the T-score of the spine and femur. The gender, age, the presence of pre-transplant diabetes mellitus, the matching degree of ABO blood types, the mode and duration of dialysis, and the history of previous transplantation were considered as variables possibly affecting the pre-transplant BMD and post-transplant BMD loss. Comparison analysis in each group was performed by a Students t-test or ANOVA. RESULTS: According to the pre-transplant BMD study, the mean of the spine T-score was significantly lower in the retransplant group. The mean femur T-score was also significantly lower in the retransplant group as well as the elderly (more than 45 years) and female recipients. In the 3 years following transplantation, rapid bone loss occurred particularly in the first post-transplant year. After a kidney transplantation, the normal pre-transplant BMD group (T- score>-1.0) showed a significantly higher bone loss than the abnormal pre-transplant BMD group (T-score< or =-1.0). Prolonged pre-transplant hemodialysis (more than 12 months) and a retransplant were risk factors affecting the BMD loss in the first post-transplant year. The early application of anti-osteoporosis management (such as alfacalcidol, alendronate sodium, or risendronate sodium) was effective in ameliorating the post-transplant BMD loss. However, anti- osteoporosis management after the first post- transplant year was not effective. CONCLUSION: A pre-transplant evaluation of the BMD and the significant BMD loss during the first post-transplant year should not be overlooked. Prophylactic management against the bone loss and the treatment of osteoporosis should be started as soon as possible after transplantation in recipients with both normal and abnormal pre-transplant BMD.

Review of Patients who Underwent Renal Transplantation in China / 대한이식학회지

BACKGROUND: The number of patients awaiting for renal allograft is continuously increasing as the kidney donors are limited worldwide. Undesirably, for this reason, more and more patients are currently visiting China for renal allograft worldwide, and Koreans are not an exception in this unhappy environment. METHODS: We analyzed 21 patients who are on follow-up in our hospital after receiving a renal allograft in China and return back to Korea. Surgical complications at the time of their arrival, prevalence of infection and kinds of immunosuppression, and finally their outcome were evaluated. RESULTS: Of 21 patients, 15 patients were male. The age ranges from 30 to 62 years old. At the time of their arrival, 14 were on tacrolimus-, and 7 were on cyclosporine-based triple immunosuppression including mycophenolate mofetil (MMF) and steroids. The doses of MMF were different (1~1.5 g/day in 5, 2 g/day in 15, and 2.5 g/day in 1 patient) center to center in China. Most of patients had received daclizmab for once or twice doses during their stay in China. They recommended further doses in Korea. Acute rejection episode was detected in 3 patients 17, 36, and 39 days after operation. All of them recovered completely after steroid pulse therapy. Three patients developed HCV-RNA-PCR positive C-viral hepatitis and 3 patients developed CMV-IgM positive viral infection. Two patients died during the follow-up. One patient died 15 months after operation due to rapid progression of liver failure after acquiring C-viral hepatitis immediately after renal transplantation. The other patient died 39 day after operation due to systemic sepsis caused by Aureobasidium Pullulans fungal infection. In 2 patients, significant urinary leakage were developed requiring surgical intervention. CONCLUSIONS: Patients who had received renal allograft in China and returned back seem to be exposed more likely and easily to infections and surgical complications. Therefore, at the arrival of patients, strict evaluation of viral, fungal infection should be carried out and net amount of immunosuppression should be tailored.

Time-dependent Effect of Non-immunologic Factors on the Graft Survival and Graft Function in Haplotype Matched Living Donor Renal Transplant Recipients / 대한이식학회지

PURPOSE: In the analysis of risk factors affecting the renal graft survival and graft function, time-dependent effect of each risk factor should be differentiated from net effect of risk factor. We attempted to analyze the impact of immunologic and/or non-immunologic risk factors on the graft function and survival after renal transplantation among the recipients having same immunologic risks at the time of transplantation. METHODS: Three hundred ninety recipients who underwent haplotype matched living related donor kidney transplantation and have been regularly followed-up were retrospectively evaluated in a single center. All recipients were treated with cyclosporine-based double or triple regimens. The graft function was evaluated by serum creatinine (Scr) level and 24 hours urinary excretion of protein every year until 5 years after transplantation. The donor kidney weight/ recipient body weight ratio (KW/BW), donor age/ recipient age ratio (DA/RA), donor-recipient sex (D-R sex) relationship, and episodes of acute rejection (AR) within 1 year were regarded as the potential risk factors affecting the graft survival and function in this study. Kaplan-Meier method and Cox proportional-hazard model were used for survival analysis. ANOVA to evaluate time-point difference of graft function, and repeated measures ANOVA to evaluate the yearly difference of graft function were used. RESULTS: Only the episode of AR was a significant risk factor affecting the graft survival. However, each non-immunologic risk factors (KW/BW, DA/RA, D-R sex) and AR episode persistently showed statistically significant impact on Scr level until 5 years after transplantation. Recipients having lowest KW/BW (1st Q KW/BW) and highest DA/RA (4th Q DA/RA) had experienced accelerated increment of Scr level from 4th year after transplantation. From 3rd year after transplantation, there is a significant correlation between the numbers of non-immunologic risk factor the recipients having had and yearly increment of Scr level. However, episode of AR didn't influence the annual slope of Scr level even 4th year after transplantation. CONCLUSIONS: Non-immunologic risk factors had an detrimental effect on renal graft function, especially from 3rd year after transplantation. To have a better long-term graft function, non-immunologic risk factors should be considered from the time of live donor evaluation for transplantation. From the early period of transplantation, the recipients should be aware of the negative impact of overweight in terms of graft function and other metabolic derangement.

Analysis of Risk Factors Affecting the Graft Survival in Living Unrelated Donor Kidney Transplantation / 대한이식학회지

PURPOSE: Shortage of donor organs is one of the major barriers to transplantation worldwide, especially, in countries where cadaveric organ donation is still limited. To overcome the donor kidney shortage, living unrelated donor renal transplantation should be one of the options to solve this problem. However, the data on the long-term results after unrelated donor renal transplantation and potential risk factors affecting the graft survival are scarce worldwide. We designed this retrospective study to report the long-term results of 967 renal transplants from unrelated donors in a single center. METHODS: From 1979 to June 2002, 2115 kidney transplantations were performed at Yonsei University Medical Center. Among them, a total of 1945 living donor transplants, excluding 55 cadaveric transplants and early 115 transplant who received azathioprine plus prednisone, were identified as a study cohort. The minimum and mean follow- up periods were 12 and 87.8 months, respectively. Of these, 978 transplants received living related donors (LRDs), and 967 patients underwent kidney transplantation using living unrelated donors (LURDs). For the analysis of risk factors affecting the graft survival, a couple of each demographic, immunologic, and clinical variates were included. RESULTS: The actuarial graft survival in the LRD and LURD recipients were 88.26% vs. 83.4% at 5 years, and 72.31% vs. 66.9% at 10 years, respectively. The 10-year patient survival rate for LRD and LURD transplants were 82.6% and 84%, respectively with no significant difference. On the multivariate analysis of LURD recipients, history of acute rejection, recipient age over 55 years, preoperative history of diabetes and hepatitis B viral infection were identified as a significant risk factor affecting the graft survival in LURD renal recipients. CONCLUSION: Excellent long-term patient and graft survivals were achieved among LURD kidney transplant recipients. Long-term outcome of transplants were not differed by the kinds of kidney donors. Renal transplantations using LURDs should be considered as an alternative way to increase the number of available donors.

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.

Kaposi's Sarcoma after Renal Transplantation / 대한이식학회지

PURPOSE: Although renal transplantation is the most effective treatment for end stage renal disease (ESRD), the incidence of malignant tumors due to long-term immunosuppression has been increasing. We experienced 9 cases of Kaposi's sarcoma (KS) after renal transplantation in our institution out of 2250 renal transplant recipients. KS is a rare mesenchymal tumor involving blood and lymphatic vessels. The oncogenesis by human herpesvirus 8 (HHV8) represent important condition for this tumor to develop. METHODS: Clinicopathologic features, treatment results, and prognosis of the 9 patients diagnosed with KS after renal transplantation were analyzed retrospectively. RESULTS: There were 6 male and 3 female patients. The mean age was 41.1 years. The average period until diagnosis of KS after renal transplantation was 60 months (range: 6 months~8 years). Clinical features were variable, but mostly presenting several red- purple papular and nodular tumors. Lesions were found in the lower extremities in 6 patients. Three patients presented with palpable lymph nodes in the neck and inguinal area without any skin lesions. Computed tomography showed diffusely enlarged showed an aggressive course. lymphnodes. Systemic involvement was found in 2 patients. Diagnosis was confirmed by histopathologic studies. Immunohistochemical stains for HHV8 were positive in all patients. Five patients showed regression of lesions after drastic reduction of immunosuppression, local resection and/or radiotherapy. But other 4 patients resistant to therapy. CONCLUSION: KS is a rare tumor and appears to be caused primarily by HHV8 in Korea as well. Reduction or cessation of immunosuppression potentially improves symptoms, but it also increases the risk of chronic graft rejection or graft failure. A large-scale study, accumulating data from transplantation cases in Korea, to understand the relationship between the various types of immunosuppression and KS, and to set guidelines for treatment appears to be necessary in the future.

Bone Mineral Density and Risk Factors in Recipients One Year after Renal Transplantation / 대한이식학회지

PURPOSE: We investigated the change of bone mineral density (BMD) one year after renal transplantation, and examined the risk factors that affect the BMD by performing the dual energy X-ray absorptiometry in Korean adults renal transplants. METHODS: The results of pre-transplant and post-transplant BMD of 99 patients were analyzed in respect to sex, age, method and duration of dialysis before transplantation, immunosuppressive methods, history of previous graft and episode of acute rejection. Alfacalcidol or biphosphonate was not used postoperatively. Data were expressed as T-score and calculated percentage. Uni-variate analysis, T-test and ANOVA were used for the statistical analysis. P values less than 0.05 were considered significant. RESULTS: There were 66 male and 33 female patients. Change of T-score (and percentage) of lumbar vertebra and average of femur area in male were -0.353 (-2.3%) and -0.059 (-1.2%), respectively. Those of female patients were -0.483 (-5.2%) and 0.115 (-1.7%), respectively. The significant loss of BMD in the female lumbar spine was evident. Patients in 20's showed the largest loss of BMD [lumbar spine: -0.739 (-2.3%), femur: -0.206 (-3.1%), compared to other age groups. There were no significant differences by the mode and duration of dialysis, presence of diabetes, degree of HLA matching, history of previous graft, immunosuppression methods, and number of acute rejection episode. However we could accept the positive trend of BMD loss related to the kind of immunosuppression methods and number of acute rejection. CONCLUSION: There was significantly different loss of BMD after renal transplantation by the age and sex of the recipients. Although statistically not significant, kinds of immunosuppression and episode of acute rejection are likely to affect the BMD loss one year after renal transplantation.

Donor Exchange (Swap) Program in Renal Transplantation / 대한이식학회지

PURPOSE: Currently, donor supply for transplantation is in serious shortage. In Korea, numbers of patients with end- stage renal failure have been increasing, while patients who could have a graft kidney are limited because of donor organ shortage. To alleviate this problem, donor exchange (Swap) program was launched in Korea. After the success of direct Swap program between two families, we have developed the Swap-around program to expand the donor pool by enrolling close relatives, spouses, friends of potential recipients and motivated voluntary donors. Herein, we report our results of Swap program. METHODS: Medical records of 918 renal recipients who have undertaken a transplantation surgery between January 1995 to December 2002 in our units, were retrospectively reviewed in terms of donor-recipient relationship and way of donor recruit, episode of acute rejection, and 5-year patient and graft survival. RESULTS: Transplantation was performed in 90 patients (9.8%) by way of Swap program. The percentage Swap patients among the number of unrelated donor renal transplant has been increasing: 4.2% in 1995, 10.4% in 1997, 40.0% in 2000, 44% in 2002. Five year patient/graft survival rates were 92.1%/90.6% in 90 Swap recipients, which were comparable to 94.3%/90.0% in other kinds of living unrelated recipients (n=240), and 94.5%/90.7% in HLA 1-haplotype mismatched related recipients (n=454). Among the groups, incidence of acute rejection was comparable. CONCLUSION: We could achieve some success in reducing the organ shortage with Swap program in addition to current unrelated living donor programs without jeopardizing the graft survival. Potentially exchangeable donors should undergo careful and strict medical and social evaluation as a pre-requisite to rule out the commercialism and conserve health of potential donor and recipients. Expanding Swap program to a regional or national pool could be an option to reduce donor organ shortage in the near future.