Outcomes of end-stage renal disease patients on the waiting list for deceased donor kidney transplantation: A single-center study

BACKGROUND: Kidney transplantation is an effective renal replacement therapy for patients with end-stage renal disease (ESRD). In this study, we assessed the impact of the baseline characteristics and comorbidities of ESRD patients on the probability of deceased donor kidney transplantation (DDKT) and evaluated the morbidity and mortality during the time spent waiting. METHODS: The study population consisted of 544 ESRD patients on the waiting list for DDKT at Chungnam National University Hospital in South Korea between February 2000 and October 2015. The patients were observed from the date of transplantation list registration to the date of transplantation. Baseline characteristics and comorbidities were investigated together with new-onset comorbidities that occurred during the waiting time. RESULTS: Diabetes mellitus (39.0%), hypertension (25.2%), and glomerulonephritis (21.3%) were the three most common causes of ESRD in this study, and coronary artery disease (9.4%) was the most common comorbidity. The 115 patients (19.3%) who underwent DDKT had a mean waiting time of 1,711 days (768–2,654 days or 4.68 years [2.10–7.27]). Blood groups other than type O, peritoneal dialysis, and nondiabetic ESRD were significantly associated with a higher likelihood of DDKT. Infection was the leading cause of death and the most common comorbidity that arose during the waiting time. Patients who experienced cardiovascular events during the waiting time showed a lower transplant rate compared with those who did not. CONCLUSION: The prevalence of comorbidities was high in renal transplantation candidates. During the often-long waiting time, new comorbidities may occur, with long-term sequelae limiting access to kidney transplantation or resulting in death.

A Comparison of Different Techniques of Two-Dimensional Speckle-Tracking Strain Measurements of Right Ventricular Systolic Function in Patients with Acute Pulmonary Embolism

BACKGROUND: Speckle-tracking echocardiography has been applied to measure right ventricular (RV) systolic function in various diseases. However, variations in strain measurement by different vendors have limited the application of these techniques for assessment of RV function. We sought to compare two methods for the assessment of RV systolic function in patients with acute pulmonary embolism (PE). METHODS: From August 2007 to May 2011, all consecutive PE patients were prospectively included in this cohort study. Global longitudinal strains of RV measured with EchoPAC PC software (GLSRV-EchoPAC; GE Medical Systems) and velocity vector imaging (GLSRV-VVI; Siemens Medical Systems) were recorded on the same set of echocardiographic images. RESULTS: We analyzed a total of 50 patients (12 males, 68 +/- 14 years) with acute PE in this study. GLSRV-EchoPAC and GLSRV-VVI were correlated (r = 0.793, p < 0.001) and they showed significant correlations with conventional echocardiographic parameters of RV systolic function and Log B-type natriuretic peptide (BNP) level. However, GLSRV-VVI only showed significant correlations with cardiac biomarkers as serum creatinine kinase-MB (r = 0.367, p = 0.010) and tropoinin-I concentrations (r = 0.294, p = 0.040). CONCLUSION: GLSRV-VVI and GLSRV-EchoPAC showed significant correlations with conventional echocardiographic parameters of RV systolic function and LogBNP value in patients with PE.

Comparative Analysis of Vascular Endothelial Growth Factor-A, C, D Expression in Colorectal Cancer with Liver Metastasis

PURPOSE: We aimed to investigate the correlations between expressions of angiogenic cytokines VEGF-A, C, D of primary colorectal cancer and liver metastasis. METHODS: We examined paraffin-embedded primary colorectal cancer tissue from 45 patients who had liver resection due to colorectal liver metastasis (metastasis group) and 37 patients who had surgical resection due to colorectal cancer only (control group). In the control group, local recurrence and distant metastasis had not occurred. Immunohistochemical staining for VEGF-A, C and D was performed. We analysed the correlations between expression of VEGF-A, C and D in primary colorectal cancer tissues and clinicopathologic parameters. RESULTS: VEGF-A expressions of primary colorectal carcinoma were not different between the two groups. VEGF-C was more frequently expressed in the metastasis group (P=0.008) but VEGF-D was more expressed in the control group (P=0.003). Patients with VEGF-C negative and VEGF-D positive expression were predominant in the control group (P=0.020). Tumor location, T stage, lymph node metastasis and tumor differentiation were not related with the expressions of VEGF-A, C, D but only preoperative CEA was positively correlated with VEGF-A and C expression. CONCLUSION: Expressions of VEGF-C in primary tumor were more frequent in metastatic colorectal cancer and expressions of VEGF-D were more frequent in nonmetastatic colorectal cancer. More large-scale prospective studies for VEGF-C and D expression in colorectal cancer are necessary.

Technical Feasibility and Early Clinical Outcomes Associated With Distal Filter Device Use for All Carotid Stenting Procedures

BACKGROUND AND OBJECTIVES: Distal filter devices (DFDs) are known to reduce the occurrence of embolic events by capturing embolic debris and thereby preventing intracranial embolization during carotid artery stenting (CAS). However, there are few reports addressing DFD use in CAS procedures. Therefore, we evaluated the technical feasibility and clinical outcomes associated with DFD use in all CAS procedures. SUBJECTS AND METHODS: Between June 2004 and June 2008, all CAS procedures performed at our center were completed with DFD protection. We recorded periprocedural data and watched for new neurologic abnormalities for 24 hours after the procedure. One-month clinical outcomes were also evaluated. RESULTS: A total of 100 carotid lesions in 94 patients (age 68+/-8 years; 79 men) were treated with percutaneous stenting using DFDs (FilterWire EZ(TM), Boston Scientific Co, US). DFD application was successful in all procedures. Periprocedural strokes occurred in five procedures (one major, one minor, and three transient ischemic attacks). The one-month rates of stroke and death were 6% and 2%, respectively. Difficult filter placement occurred in two procedures due to tight stenosis and severe common carotid artery (CCA)-to-internal carotid artery (ICA) angulation. Difficult stent delivery occurred in three instances: one due to severe lesion calcification and two due to proximal tortuosity. The retriever failed to acquire the filter in nine procedures. Four of nine retrieval difficulties were related to severe CCA-ICA angulation. CONCLUSION: DFD use was successful in all CAS procedures, was relatively safe, and had few periprocedural complications.

Antioxidant Effects of Haematococcus Extracts for Ischemia-Reperfusion Injury on Liver of Mice / 한국간담췌외과학회지

PURPOSE: An IRI (Ischemia-reperfusion injury) of the liver is one of the main problems in major liver surgery, liver transplantation and liver trauma, which can lead to liver failure. The mechanism of a liver IRI is supposed to be highly related to the oxygen free radicals (Should the read, "free oxygen radicals"?) made in the course of the damage process. Therefore, antioxidants must be one of the most effective therapeutic modalities for liver IRI. Haematococcus pluvialis contains a lot of astaxanthin, which is known of powerful antioxidant. Since the use of synthetic astaxanthin is not permitted to humans, only naturally produced astaxanthin, such as Haematococcus, is a candidate for use. In this report, the antioxidant effects of a Haematococcus extract has been studied and compared with other antioxidants and synthetic astaxanthin. METHODS: To evaluate the effect of the Haematococcus extract in a liver IRI, the mouse liver IRI model was employed. Following ischemia for 60 minutes, three reperfusion periods were used; 3, 24 and 48 hours. The MDA (malondialdehyde) values in the liver, lungs and serum were all evaluated, and two types of Haematococcus extract compared with other antioxidants and synthetic astaxanthin. RESULTS: In all tissues and serum, the antioxidants all produced lower levels of MDA than in the control. The oil- extracted Haematococcus group had much lower MDA levels compared to the biomass Haematococcus and other antioxidants groups. The effects of synthetic astaxanthin are similar to those of oil-extracted Haematococcus. CONCLUSION: The Haematococcus extract has very potent antioxidant effects compared with vitamin E and Superoxide dismutase (SOD) in protecting the liver from IRI. Oil-extracted Haematococcus is better than biomass Haematococcus, and was even comparable to the effects of synthetic astaxanthin.

Surgical Treatment of Takayasu Arteritis

PURPOSE: Takayasu arteritis is an inflammatory arteriopathy which predominantly affects young females and involves the aorta and its major branches. There is little information on reconstructive arterial surgery for Takayasu arteritis. We aim to evaluate the effectiveness and safety of the operation performed for symptomatic Takayasu arteritis. METHOD: Eighteen patients (5 men and 13 women) with Takayasu arteritis treated surgically from 1985 to 1999 at Seoul National University Hospital were reviewed. RESULT: Hypertension was the main symptom in our patients. Four paitients initially underwent medical treatment. Eighteen patients have undergone 21 vascular procedures for the occlusive arterial disease. Surgical indications included renovascular hypertension (17), cerebrovascular insufficiency (3), and extremity ischemia (1). Twelve patients with renovascular hypertension treated by unilateral or bilateral aortorenal bypass. Six patients have undergone renal autotransplantation. Aorto-aortic bypass was performed in 4 abdominal aortic coarctation. Two patients with cerebrovascular ischemia were treated by aortocarotid bypass. One patient with upper extremity and cerebrovascular ischemia have undergone femoroaxillary bypass and axillovertebral bypass. There were no postoperative mortality or morbidity except acute renal failure in one patients with full recovery. Revision of the initial reconstruction has been required for recurrent renovascular hypertension in two patients. All patients except two showed beneficial effect after procedures for renovascular hypertension. CONCLUSION: Surgical treatment of symptomatic Takayasu arteritis is highly effective and safe. Symptomatic improvement and excellent long-term graft patency can be expected after arterial reconstrucion. Considering their young age, aggressive surgical intervention is needed in the patient with Takayasu arteritis.

The Efficacy and Safety of the Domestic Organ Preservation Solutions, SNU-I and SNU-II, Using the Pig Renal Autotransplantation Model / 대한이식학회지

Organ preservation solutions currently in use have been quite successful clinically, but it is true that improvements can still be made in preservation time and postpreservation function of the graft. The aim of this study is to compare the effectiveness of two domestic organ preservation solutions, SNU-I and SNU-II, with that of UW solution in a swine autotransplantation model. SNU-I is a domestic reproduction of UW solution and SNU-II is an theoretically improved regimen with the addition of pyruvate and aspartate. Unilateral nephrectomy was done in 14 female pigs and the grafts were cold-preserved with UW (n=3), SNU-I (n=6) and SNU-II (n=5) solution for 24 hours before being autotransplanted back to the same animal. The groups were compared in posttransplant serum BUN/creatinine level and in the degree of tissue injury in graft specimens taken 14 days after the transplantation. The peak values for the BUN/creatinine level were the highest in the SNU-II group, reaching 80 mg/dl for BUN and 6.43 mg/dl for creatinine. Those for the UW and SNU-I groups were lower, but the differences were not statistically significant. The tissues were embedded in paraffin, stained with H/E and then were subjected to light microscopic examination (X200). When the degree of tissue injury was scored on the items of tubular necrosis, intratubular cell detachment, and brush border integrity, the SNU-II group displayed higher scores than the other two. The SNU-II group was also given higher scores in the degree and aggressiveness of the inflammatory process, but the difference between the three groups were not statistically significant in all items. In conclusion, UW and SNU-I solutions appear to have the same potency as organ preservation solutions. Further investigations are needed for the efficacy of SNU-II solution, including longer term preservation or warm ischemia models.

The Analysis of Anti-Endothelial Cell Antibody Expression in the Sera of Buerger's Disease Patients Using Enzyme-Linked Immunosorbent Assay

PURPOSE: The pathogenesis of Buerger's disease is unknown and only smoking is considered as an important factor of the occurrence and recurrence of the disease. The development of antiendothelial cell antibody (AECA), a kind of autoantibody against the vascular endothelium, is recognized as a common serological feature in several diseases characterized by immune-mediated vascular damage. The purpose of this study is whether AECAs develop in the sera of patients of Buerger's disease or not and, if develop, to find what relationship exists between the status of the disease and the degree of AECA expression. METHODS: Twenty sera were obtained from 15 patients with Buerger's disease, and 11 from 11 healthy male smokers as controls. Additionally 5 sera from nonsmoking females and 4 from nonsmoking males were tested. Among 5 out of 15 Buerger's disease patients, the blood samples were obtained twice. Statistically there was no age difference between patients and controls. Human umbilical cord vein endothelial cells (HUVEC) were cultured and used as the target of AECA. The expression of AECA was measured with enzyme-linked immunosorbent assay (ELISA) and anti-human peroxidase conjugated goat IgG was used as a secondary antibody. RESULTS: The value of whole patient's group 666 60 vs. controls 88 10, there was statistically significant (P<0.05); a group of active disease status 797 61 vs. remission 423 60, higher in active group (P<0.05); smokers in patients 732 73 vs. quit-smokers 544 94, higher in smokers, but not significant; no difference was observed between healthy females and males regardless of smoking history. CONCLUSION: The AECA seems to be closely related with Buerger's disease and the measurement of AECA expression with ELISA may be considered as a useful tool for the diagnosis of Buerger's disease and as a helpful predictor of occurrence and relapse of the disease.

The Analysis of Anti-Endothelial Cell Antibody Expression in the Sera of Buerger's Disease Patients Using Enzyme-Linked Immunosorbent Assay

PURPOSE: The pathogenesis of Buerger's disease is unknown and only smoking is considered as an important factor of the occurrence and recurrence of the disease. The development of antiendothelial cell antibody (AECA), a kind of autoantibody against the vascular endothelium, is recognized as a common serological feature in several diseases characterized by immune-mediated vascular damage. The purpose of this study is whether AECAs develop in the sera of patients of Buerger's disease or not and, if develop, to find what relationship exists between the status of the disease and the degree of AECA expression. METHODS: Twenty sera were obtained from 15 patients with Buerger's disease, and 11 from 11 healthy male smokers as controls. Additionally 5 sera from nonsmoking females and 4 from nonsmoking males were tested. Among 5 out of 15 Buerger's disease patients, the blood samples were obtained twice. Statistically there was no age difference between patients and controls. Human umbilical cord vein endothelial cells (HUVEC) were cultured and used as the target of AECA. The expression of AECA was measured with enzyme-linked immunosorbent assay (ELISA) and anti-human peroxidase conjugated goat IgG was used as a secondary antibody. RESULTS: The value of whole patient's group 666 60 vs. controls 88 10, there was statistically significant (P<0.05); a group of active disease status 797 61 vs. remission 423 60, higher in active group (P<0.05); smokers in patients 732 73 vs. quit-smokers 544 94, higher in smokers, but not significant; no difference was observed between healthy females and males regardless of smoking history. CONCLUSION: The AECA seems to be closely related with Buerger's disease and the measurement of AECA expression with ELISA may be considered as a useful tool for the diagnosis of Buerger's disease and as a helpful predictor of occurrence and relapse of the disease.

A Pseudoaneurysm of Superior Mesenteric Artery: Successfully Treated by Aorto-Mesenteric Bypass: A case report

Aneurysms of superior mesenteric artery (SMA) represent an uncommon but important vascular disease. High mortality rates from rupture of aneurysm and thrombosis of SMA are reported. These lesions are most often infectious in etiology. In the case of relatively abundant collaterals, aneurysm exclusion or SMA ligation is a safe surgical method to prevent serious complications. But in insufficient collaterals, stent-grafting of aneurysm or reconstruction of mesenteric blood flow is unavoidable. Recently we treated a 49-year-old man with SMA pseudoaneurysm and its large orifice located at near the enlarged jejunal branch which is a main collateral of mesenteric blood flow.

Infections of Renal Transplantation Recipients in Cyclosporin Era / 대한이식학회지

Adding to the previous reports about the infectious complications in renal transplant recipients in azathioprine era, we conducted this retrospective study to analyse the incidence and pattern of posttransplant infections in cyclosporin era and its impact on graft and patient survival. Among 482 patients who performed renal transplantation (tpl) from Mar. 1985 to Dec. 1997 at Seoul National University Hospital, 133 infections developed in 105 patients (21.8% incidence). These infections were grouped into 3 categories; Perioperative (infection within first month after tpl: N=19), Early (infection between 1 to 6 months after tpl: N=24), and Late (infection more than 6 months after tpl: N=87). According to the anatomical site of infection, skin (49 cases) was the most common site of infection, followed by lung (36), oropharynx (13), urinary tract (12). Regarding the etiologic organisms of microbiologically documented 108 infections, viral infections were most common (60.2%), followed by bacterial (22.2%), fungal (14.8%), and others (2.8%). In viral infections, Varicella zoster virus infection was most common (58%). Bacterial infections included 12 Mycobacteral infections, 10 Gram (-), and 2 Gram (+) bacterial infections. In fungal infections, tinea was most common in 8 cases, followed by candidiasis in 3, cryptococcosis in 2, and aspergillosis in 1. Incidence of rejection episode was statistically higher in patients with infection than those without infection (40.0% vs 28.4%; p=0.023). Among 28 mortalities, infection-related deaths were 7. In conclusion, aggressive diagnostic strategies including invasive procedures to characterize the organisms and specific treatment is the best way to reduce the morbidity and mortality.

Popliteal Arterial Disease

PURPOSE: The popliteal artery is the site of uncommon conditions such as popliteal artery entrapment syndrome (PAES), adventitial cystic disease (ACD) and aneurysmal disease. Because of their rarity, these nonatheromatous conditions are often not diagnosed until they reach an advanced stage. We conducted this retrospective study to analyse the clinical characteristics of popliteal arterial disease and to establish a proper diagnostic and therapeutic strategy. METHODS: Among the 31 patients who underwent an operation for popliteal arterial disease between Jan. 1986 and Dec. 1998 in SNUH, 14 patients with isolated popliteal arterial disease were included in this study, excluding 17 patients with combining significant arterial disease in other area. The symptoms, risk factors for vascular disease, laboratory findings, radiologic findings and the patency rate after operation were analyzed. RESULTS: The mean age of the patients were 38 years (12~64) and male-to-female ratio was 13:1. There were 6 cases of PAES, 2 cases of popliteal aneurysms, ACD and thromboangiitis obliterans respectively, and 1 case of atherosclerosis obliterans and embolism each. Arteriography was performed in all cases and duplex sonogram (5 cases), CT (2), CT angiography (3), and MR angiography (2) was performed additionally. For treatment of the arterial occlusion, bypass or interposition graft was done in all cases. Along with the arterial reconstruction, division of medial head of gastrocnemius muscle was done in 4 cases of PAES, excision in 1 case of ACD, and aneurysmectomy in 1 case of popliteal aneurysm. Patency rates of the graft after 1 and 3 years were 92% and 80.9% respectively. There was no limb or patient loss. CONCLUSION: Isolated occlusive disease of popliteal artery is mostly nonatheromatous condition such as PAES or ACD. Therefore those diseases should be suspected in young patient with leg ischemia without other risk factor for systemic vascular disease. Duplex ultrasound and CTA or MRA are accurate diagnostic tools to differentiate the lesions and make the proper therapeutic plan.

Tourniquet Occlusion Technique for Infrapopliteal Artery Revascularization

Refinements in surgical technique have resulted in significant improvement in the patency rates of infrapopliteal artery revascularizations, but the cumulative patency rate were still low. Possibly the principle cause for the late graft failure was the constricting scar formation around the distal anastomosis following surgical injury. Thus we adopted a nondissection method, using pneumatic tourniquet occlusion technique, to simplify the procedure of distal anastomosis and to lessen the surgical injury. Six patients underwent infrapopliteal artery revascularizations with this method. Three of them were diagnosed with arteriosclerosis obliterans and the others with thromboangiitis obliterans. Tourniquet pressures of 350 mmHg were applied from 32 to 60 minutes. All patients were given systemic anticoagulants. The distal anastomoses were performed to peroneal artery in three cases, posterior tibial artery in two, and anterior tibial artery in one. Hemostasis was adequate in all cases and no alternative occlusive devices were required. There were no complications attributable to the use of the pneumatic tourniquet. Therefore we suggest that tourniquet occlusion technique may simplify the infrapopliteal artery revascularization and minimize surgical injury at the distal anastomosis contributed to the long-term patency of the distal bypass.

Arterial Thoracic Outlet Syndrome (TOS) with Multiple Distal Embolization: A case report

Thoracic outlet syndrome (TOS) is an uncommon condition which is caused by compression of subclavian artery, vein or brachial plexus in the region of thoracic outlet area, which is composed by the first rib, clavicle, anterior and middle scalene muscles and other connective tissue. In arterial TOS, chronic arterial compression causes arterial stenosis, poststenotic dilatation, aneurysm formation, intramural thrombus and peripheral arterial embolism. We present herein a case of arterial TOS patient with multiple distal embolization. The patient was 43-year old male with crutch ambulation because of sequelae of polioviral infection in his youth. His chief complaint was discoloration and gangrenous change of five right digits for 1 month. A rudimentary first right rib was found in simple chest X-ray. Angiographic findings were stenosis and poststenotic dilatation of right subclavian artery, multiple peripheral arterial embolic obstructions and numerous collateral vessel formation. Right thoracoscopic sympathectomy (T2), resection of the abnormal first rib and the abnormal axillary arterial segment was performed through the supraclavicular and transaxillary incision, then interpositional graft with saphenous vein was done for arterial reconstruction. A minor lymphatic fluid collection around the area of operation occurred, but it was easily controlled by percutaneous drainage. The gangrenous wounds of digits were improved after restoration of blood circulation.

Comparison of the Tolerability and Safety of Microemulsion Cyclosporine Versus Conventional Cyclosporine in Primary Living-Related Renal Allograft Recipients / 대한이식학회지

A microemulsion formulation of cyclosporine (CsE) is more bioavailable than conventional cyclosporine (CsA) in renal transplants. Because the risk of acute and chronic rejection is related inversely to cyclosporine bioavalability and cyclosporine has a low therapeutic window, these benefits of CsE with an improved pharmacokinetic profile on clinical efficacy are also of interest. To assess the long-term safety and tolerability of CsE, this comparable study was performed. One hundred thirty one primary living donor renal recipients were included in this study. They were divided two groups in the CsE group (N=50) and CsA group (N=81) who had been received either CsE or CsA as a main immunosuppressant since their transplantation for two years. There were no differences between two groups in initial dose at that time of transplantation, target trough level, strategies of anti-rejection therapy. Acute rejections occurred less frequently in CsE group than CsA group (9/50 vs. 28/81, p=0.041). No significant differences were noted in incidence of chronic rejection, graft loss, drug-associated com plications such as hypertension, diabetes mellitus, infection and survival rates of grafts and patients. Renal function, as measured by serum creatinine levels was comparable over time in both groups. The mean daily doses of CsE were higher than CsA group since post-transplant six months, but, no significant differences in trough levels between the two grups. There were marked decreases in standard deviation of daily doses and trough level those meant inter-individual variations in CsE group compared to those of CsA group. In conclusion, despite the more predictable and stabilized pharmacokinetic benefits in CsE group, no significant increases in the incidence of drug-associated adverse effects were observed within post-transplant two years. The safety, tolerability, efficacy of CsE and CsA were comparable.