Intravenous Immunoglobulin Treatment in a Kidney Transplant Patient with Chronic Antibody-Mediated Rejection / 대한신장학회지

A 66-year-old male was admitted for increasing azotemia. He was diagnosed with chronic antibody- mediated rejection and had received a livingdonor renal transplant from his 32-year-old son prior to his admission. The peritubular capillaries of his kidney were diffusely positive on C4d immunostaining. It is known that there is an agreement between C4d staining and serological and histopathological data during rejection that is thought to have a humoral component. The role of alloantibodies in chronic renal allograft deterioration and the corresponding morphologic changes have been increasingly recognized during the recent years. However the treatment guidelines for chronic antibody-mediated rejection have not yet been established. Intravenous immunoglobulin (IVIG) has been shown to decrease the titers of anti-HLA antibodies in highly sensitized patients awaiting transplant. There are also numerous proposed mechanisms regarding how IVIG exerts its immunomodulatory action. As we have experienced chronic antibody-mediated rejection and how IVIG treatment improves renal function, we recognize that IVIG has the potential to be used for treating certain subgroups of chronic allograft nephropathy patients with positive C4d staining and anti-HLA antibodies.

De Novo Renal Artery Aneurysm Presenting 12 Years after Transplantation: Ex Vivo Repair and Allograft Autotransplantation / 대한신장학회지

Although renal artery aneurysms (RAAs) rarely occur, rupture of RAAs may be life-threateningand result in nephrectomy. To date, there has been only one case report providing histologic evidence of a true aneurysm in a transplanted renal artery. We report here a 51-year-old male with a de novo trueaneurysm in a donor renal artery that was detected 12 years postoperatively. This RAA was corrected by ex vivo repair and allograft autotransplantation.

Comparison of Erythropoietic Effect between Epoetin-alpha and Darbepoetin-alpha in Hemodialysis Patients: A Randomized Crossover Study / 대한신장학회지

PURPOSE: We aim to compare the erythropoietic effects of epoetin-alpha (EA, 4000 IU SC thrice a week) with those of darbepoetin-alpha (DA, 60ug IV weekly, conversion rate to EA=200:1). METHODS: Forty one stable hemodialysis patients were enrolled in this randomized crossover study. After a washout period of erythropoietin stimulating agents (ESA), the patients with hemoglobin (Hb) level of 11.0 g/dL, we stopped ESA. When Hb level decreased to 30% change in EA efficiency relative to DA efficiency. CONCLUSION: There was no significant difference in erythropoietic parameters for both EA and DA.

Spontaneous Subcapsular Hematoma on a Transplanted Kidney / 대한신장학회지

A 41-year-old female was admitted for a subcapsular hematoma of her graft kidney six weeks after she underwent a kidney transplant. No report on subcapsular hematomas of graft kidneys has been published in Korea. Subcapsular hematoma of graft kidneys is one of a few very rare causes of bleeding. The clinical manifestations of subcapsular hematoma are the abrupt onset of flank pain or upper abdominal pain, nausea, anorexia, dizziness, and decrease in hemoglobin. If it is diagnosed late, it can result in renal insufficiency, hypovolemic shock, and even death. During the authors' management of a subcapsular hematoma of a renal graft, pure red cell aplasia induced by the parvovirus B19 was found to coexist. Bone marrow suppression, immunosuppressants and other drugs, bleeding, iron deficiency, and renal graft function insufficiency can result in anemia after a kidney transplant. Even though pure red cell aplasia is a rare cause of anemia, it should not be forgotten that pure red cell aplasia induced by parvovirus B19 infection can cause anemia after a kidney transplant.

A Case of Interstitial Pneumonitis Associated with Sirolimus Treatment in Renal Transplantation Recipient / 대한신장학회지

Sirolimus is a promising immunosuppressive drug for renal transplantation to avoid nephrotoxicity of calcineurin inhibitor. However, it has been associated with uncommon but, important pulmonary toxicity. We present a case of sirolimus related dyspnea with abnormal chest radiographic finding in a 63 year old male renal transplantation recipient. There was no evidence of bacterial, fungal, or viral infection. Dose reduction of sirolimus resulted in a significant improvement of the symptoms and chest radiographic finding.

A case of lactic acidosis caused by thiamine deficiency / 대한내과학회지

Lactic acidosis commonly occurs in association with shock. We encountered lactic acidosis in a patient with normal blood pressure. The patient was a 17 year-old man with acute lymphocytic leukemia. He was admitted for bone marrow transplantation. During hospitalization, he relied on total parenteral nutrition due to his poor oral intake. On the 37th day after admission, he developed lactic acidosis without an episode of hypotension or any causative medication. Because vitamins were not included in the parenteral nutrition, we prescribed thiamine replacement, and this corrected the acidosis within a few hours. Thiamine (in its active derivative) is a coenzyme for pyruvate dehydrogenase; thus, its deficiency causes accumulation of pyruvate and lactate. This case suggests that thiamine deficiency should be included in a differential diagnosis of lactic acidosis in patients who are on total parenteral nutrition without vitamin supplementation.

Immunohistochemical Profile of Acute Cellular Rejection in Renal Allograft

BACKGROUND: We wanted to find an adjunctive marker(s) in renal allograft biopsies for predicting acute cellular rejection (ACR), and so the expression patterns of immune-related molecules were compared between ACR, borderline ACR and non-ACR cases. METHODS: The expression patterns of Fas ligand (FasL), HLA-DR, granzyme B, caspase-3, CD56, interferon stimulated growth factor-3 (ISGF-3), and CD53 were assessed via immunohistochemical study in 75 allograft biopsies from patients with ACR (n=19), borderline ACR (n=22), and non-ACR (n=34). RESULTS: Compared to those of the non-ACR group, the ACR group revealed an elevated number of FasL positive interstitial inflammatory cells, HLA-DR positive tubular inflammatory cells, cytoplasmic caspase-3 positive tubular epithelial cells, granzyme B positive interstitial mononuclear inflammatory cells and CD53 positive interstitial inflammatory cells. The expression patterns of the borderline ACR group were similar to those of non-ACR group, except for the intensity of FasL in the tubular epithelial cells. CONCLUSIONS: Immunohistochemical investigations of the adjunctive markers FasL, HLA-DR, granzyme B, caspase-3 and CD56 can be useful for making the diagnosis of ACR.

A Case of Infective Endocarditis due to Staphylococcus lugdunensis / 감염과화학요법

Staphylococcus lugdunensis is a coagulase-negative staphylococcus (CNS) that is commonly found on the human perineal skin. Contrary to other CNS, S. lugdunensis is a rare contaminant in cultures and has the potential to cause clinically significant infections, including infective endocarditis. Infective endocarditis due to S. lugdunensis have been known to resemble endocarditis due to S. aureus because of its aggressive clinical course and high mortality. We report a case of infective endocarditis caused by S. lugdunensis in a 21-year-old woman. She was cured of the infection with surgical and antibiotic therapy.

A Case of Infective Endocarditis due to Staphylococcus lugdunensis / 감염과화학요법

Staphylococcus lugdunensis is a coagulase-negative staphylococcus (CNS) that is commonly found on the human perineal skin. Contrary to other CNS, S. lugdunensis is a rare contaminant in cultures and has the potential to cause clinically significant infections, including infective endocarditis. Infective endocarditis due to S. lugdunensis have been known to resemble endocarditis due to S. aureus because of its aggressive clinical course and high mortality. We report a case of infective endocarditis caused by S. lugdunensis in a 21-year-old woman. She was cured of the infection with surgical and antibiotic therapy.

A Case of Diffuse Large B-cell Lymphoma in a Kidney Transplant Recipient / 대한신장학회잡지

Posttransplant lymphoproliferative disorders (PTLD) is an infrequent but serious complication of transplantation. Previous studies have suggested the terms of reference, "early PTLD" (referring to PTLD that occurs within 1 year of transplantation) and "late PTLD" (PTLD that occurs after 1 year). Early PTLD generally involves a single organ or nodal region and often responds favorably to a decrease in immunosuppression. Late PTLD tends to be disseminated, responds less frequently to a decrease in immunosuppression, and has a dismal prognosis. We encountered a diffuse large B-cell lymphoma in a 44-year-old man who underwent kidney transplantation over 10 years ago, in 1995. In situ hybridization for Epstein-Barr virus showed positive results in tumor cell. With decreased immunosuppressants and chemotheraphy, he is currently in complete remission.

Outcome of Intensive Medical Treatments in Patients with Infected Severe Necrotizing Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: Infection of pancreatic necrosis is one of the leading cause of death in patients with severe necrotizing pancreatits. Because of high mortality rate up to 50%, immediate surgical debridement including pancreatectomy is recommended. However, early surgical treatment still showed high mortality rate and better treatment strategy is required. This study was conducted to evaluate the outcomes of early intensive non-surgical treatments in patients with infected necrotizing pancreatitis. METHODS: This study was based on retrospective analysis of 71 patients with acute severe necrotizing pancreatitis (APACHE II score>or=8, or Ranson's score>or=3, and pancreatic necrosis on CT scan), who were admitted to medical center during past 16 years. Infection of pancreatic necrosis was confirmed by fine needle aspiration, and early intensive medical treatments comprised of prophylactic antibiotics coverage, fluid resuscitation, organ preserving supportive measures, and percutaneous catheter drainage were carried out. RESULTS: Among the enrolled patients, infections were suspected in 46 patients, but fine needle aspirations were done only in 32 patients. In 21 patients, infections of necrotic tissue were confirmed by bacteriology, while other 11 patients showed no evidence of bacterial growth. Of 21 patients with infected necrosis, initial surgical interventions were performed in 2 patients, while initial medical treatments were performed in 19 patients. The success rate of medical treatment group in infected necrotizing pancreatitis was 79% (15/19). The mortality rate of medical treatment group and surgical treatment group was 5% (1/19) and 50% (1/2). CONCLUSIONS: Early intensive medical treatment seems to be a good therapeutic strategy, even if the infection has developed in pancreatic necrosis. Further prospective randomized studies are required to confirm this finding.

Skin Necrosis after a Low-Dose Vasopressin Infusion through a Central Venous Catheter for Treating Septic Shock

This is a report on a case of severe skin necrosis in a vasodilatory septic shock patient after the infusion of low-dose vasopressin through a central venous catheter. An 84-year-old male was hospitalized for edema on both legs at Asan Medical Center, Seoul, Korea. On hospital day 8, the patient began to complain of dyspnea and he subsequently developed severe septic shock caused by E. coli. After being transferred to the medical intensive care unit, his hypotension, which was refractory to norepinephrine, was controlled by an infusion of low-dose vasopressin (0.02 unit/min) through a central venous catheter into the right subclavian vein. After the infusion of low-dose vasopressin, severe skin necrosis with bullous changes developed, necessitating discontinuation of the low-dose vasopressin infusion. The patient expired from refractory septic shock. Although low-dose vasopressin can control hypotension in septic shock patients, low-dose vasopressin must be used with caution because ischemic complications such as skin necrosis can develop even with administration through a central venous catheter.