Resolution of uremic tumoral calcinosis in a patient on peritoneal dialysis with long-term low-calcium dialysate treatment

Tumoral calcinosis is a rare complication in uremic patients. An in-depth review of published literature suggests that most patients with uremic tumoral calcinosis do not respond to medical treatment. Here, we report the case of a patient on peritoneal dialysis who presented with infected multifocal masses on both hip joints and was successfully treated by medical intervention. The patient was diagnosed with uremic tumoral calcinosis by physical examination and radiologic imaging, and treated with low-calcium dialysis and a non-calcium phosphate binder, sevelamer, without increasing the dose of dialysis. At the 36-month follow-up, the majority of masses had disappeared and the patient was asymptomatic.

Actual 10-year Outcomes of Tacrolimus/MMF Compared with Cyclosporin/MMF in Kidney Transplantation / 대한이식학회지

BACKGROUND: Kidney transplantation is the most effective treatment in patients with chronic kidney disease. Recently, the survival rate of kidney allografts has been markedly increased by the development of immunosuppressants. According to research reports published in Symphony in 2007 and 2009, low dose tacrolimus/mycophenolate mofetil (MMF) showed better results than cyclosporin/MMF in renal function and rejection. METHODS: We compared patient survival rate, graft survival rate, incidence of rejection, and metabolic complications in two groups of patients who received immunosuppressants with either tacrolimus/MMF/steroid or cyclosporin/MMF/steroid. All patients underwent kidney transplants at Keimyung University Dongsan Medical Center between January 1997 and December 2003 with follow-up over 10 years. RESULTS: A total of 180 patients were included in the research (117 patients were treated with tacrolimus/MMF/steroid and 63 patients with cyclosporin/MMF/steroid). The incidence rate of acute rejection was higher in the cyclosporin/MMF/steroid group; however, the difference was not statistically significant. In the case of metabolic complications, new onset diabetes after transplantation was more frequent in the tacrolimus/MMF/steroid group. The cyclosporin/MMF/steroid group appeared to have a higher rate of hypertension and hyperlipidemia. CONCLUSIONS: Overall, no significant differences in patient and graft survival rate were observed between the two groups.

Clinical Outcomes between Living Related and Living Unrelated Kidney Transplantation in ABO-Incompatible Kidney Transplant Recipients / 대한내과학회지

BACKGROUND/AIMS: Kidney transplantation (KT) is the best treatment for end-stage renal disease patients. Although previous studies have demonstrated that the clinical outcome following living related (LR) KT is better than that following unrelated (LUR) KT in ABO-compatible KT recipients, recent studies showed no differences in clinical outcomes between the two treatments. In this study, we compared the clinical outcomes of LR and LUR KT in ABO-incompatible KT recipients. METHODS: From January 2011 to August 2013, 19 cases of ABO-incompatible KT were analyzed retrospectively. Eight kidneys (7 cases of parent-offspring and 1 case of siblings, Group 1) were donated from living-related donors and 11 (all spousal donors, Group 2) from living-unrelated donors. We investigated patient survival, graft survival, acute rejection, graft function, and complications. RESULTS: On Kaplan-Meier analysis, patient and graft survival during follow-up were 87.5% and 87.5% in Group 1; both were 100% in Group 2. Acute rejection, graft function, and medical and surgical complications were not significantly different between the two groups. CONCLUSIONS: The short-term clinical outcomes between LR and LUR KT in ABO-incompatible KT recipients were equivalent. Most domestic cases of LUR KT are from spousal donors and the spousal donor will be a major donor in ABO-incompatible KT patients.

Simultaneous Lung and Liver Aspergillus in a Kidney Transplant Recipient / 대한이식학회지

Invasive opportunistic infection by Aspergillus fungus is life-threatening for kidney transplant recipients. The occurrence of aspergillosis by hematogenous dissemination can affect multiple organs. Despite having a lower incidence rate relative to bacterial or viral infections in kidney transplant recipients, fungal infections produce the highest number of mortalities. We report a simultaneous case of invasive aspergillosis in the lung and liver of a 52-year-old female patient who underwent living donor kidney transplant. She suffered massive blood loss and high-volume transfusions due to postoperative bleeding. One month after transplantation, she reported intermittent coughing without febrile sensation. Computed tomography revealed nodules on the right and left upper lobes of the lung and multiple cystic liver lesions. Based on pathologic findings and culture from aspirate, she was diagnosed with invasive aspergillosis involving the liver and lung. After a 4 month voriconazole treatment the nodules in the lung and liver disappeared.

The Changes of Graft Survival and Causes of Graft Failure after Kidney Transplantation / 대한이식학회지

BACKGROUND: The incidence of acute rejection has decreased with the introduction of new immunosuppressive agents. However, several studies have shown that allograft survival has not clearly improved over the past few decades. METHODS: We reviewed patients who underwent kidney transplantation between 1982 and 2007. We compared the causes of graft loss for three decades: 1982~1990 (period I),1991~2000 (period II), and 2001~2007 (period III), with the clinical characteristics of patients with functioning grafts and patients who lost their allografts. RESULTS: There were 785 recipients with a mean age of 36.1 years, and 65.2% were male. Graft loss occurred in 329 patients (41.9%), and the most common cause of graft loss was chronic allograft nephropathy (CAN, 52.0%), followed by patient death (17.6%), post-transplant glomerulonephritis (12.8%), and non compliance (7.9%). During the three time periods, 129, 172, and 28 patients lost their grafts, respectively. Five-year graft survival was 61.5%, 78.4%, and 90.8%, respectively, and increased significantly (P<0.000). CAN, as a cause of graft loss, fell from 65.1% (period I) to 32.1% (period III, P<0.000), but patient death increased from 12.4% to 32.1% (P=0.034). A multivariate analysis revealed that significant risk factors for graft loss included an older donor, transplantation at period I, and dual immunosuppression. Use of tacrolimus and mycophenolate mofetil was associated with a significantly reduced risk of graft loss. CONCLUSIONS: Graft survival has increased over the last three decades whereas the proportion of CAN, the most common cause of graft loss, has decreased. Attention to the main causes of graft loss, CAN, and patient death will offer potential improvement in graft survival.

Clinical outcomes of Asymptomatic Urinary Abnormalities in Adults / 대한신장학회지

PURPOSE: Urinalysis is one of the best methods for early detection of renal disease and recent wide- spread use of mass screening led to increasing prevalence of asymptomatic urinary abnormalities. Usually, primary chronic glomerulonephritis first presents with asymptomatic urinary abnormalities and chronic glomerulonephritis commonly causes end-stage renal disease. However, clinical outcome of asymptomatic urinary abnormalities in adults is not well known. METHODS: Between Jan 1995 to Aug 2009, 333 patients with asymptomatic urinary abnormalities who underwent percutaneous renal biopsy were enrolled. A retrospective study was performed to clarify the prognostic factors and the long-term renal outcome of this disease. RESULTS: According to clinical manifestation, there were 79 (23.7%) of isolated microscopic hematuria, 30 (9.0%) of isolated proteinuria and 224 (67.3%) of mixed hematuria and proteinuria. The patients were significantly younger in case with microscopic hematuria. Group with microscopic hematuria had significantly shorter follow up period (p=0.013). In pathologic diagnosis, IgA nephropathy was most common with 244 patients (73.3%). The proteinuria group and mixed group showed significantly higher rate of progression to chronic renal failure than the microscopic hematuria group (p=0.015). The group that 24-hour proteinuria was more than 0.5 g/day showed significantly higher progression rate to chronic renal failure (p<0.000). Using univariate regression analysis, 3 risk factors for progression to chronic renal failure were identified: age, serum creatinine, 24-hour total urine protein. In multivariate regression analysis, only 24-hour proteinuria was the independent prognostic factor for progression to chronic renal failure. CONCLUSION: IgA nephropathy is the most common cause of asymptomatic urinary abnormalities in adults. The group of proteinuria has higher progression rate to chronic renal failure than other groups. Over 0.5 gm of 24-hour proteinuria is a significant risk factor for progression to chronic renal failure in multivariate regression analysis.

Late Spontaneous Subcapsular Hematoma in an Allograft Kidney / 대한이식학회지

A spontaneous subcapsular hematoma in an allograft kidney is a rare condition with only a few cases reported in the literature. Common causes of subcapsular hematoma of an allograft include trauma, post-biopsy status, occult malignancy, vascular diseases, and infection. Chronic allograft dysfunction related to spontaneous subcapsular hematoma is extremely rare. We report a case of spontaneous subcapsular hematoma in a patient who underwent a renal transplant 14 years ago in which we could not find an associated condition.

Efficacy of Mycophenolate Mofetil in the Treatment of Refractory Membranous Nephropathy and Focal Segmental Glomerulosclerosis / 대한신장학회지

PURPOSE: This study was planned to determine the efficacy and safety of mycophenolate mofetil (MMF) as a rescue treatment in patients with membranous nephropathy (MN) and focal segmental glomerulosclerosis (FSGS) who were not responsive to standard therapy with steroid and immunosuppressive regimen. METHODS: We planned a prospective, non-randomized study from Oct. 2002 to Aug. 2009, including biopsy-proven MN or FSGS patients in Keimyung university Dongsan hospital. MMF was initiated at 0.5-0.75 g twice daily, and advanced as appropriate or as tolerated to 0.75-1 g twice daily. RESULTS: 14 cases with MN and 5 cases with FSGS was enrolled. The mean age of patients was 51.7+/-12.3 years, and mean treatment duration was 14.4+/-6.5 months. Five patients (26.4%) went into complete remission and the seven (36.8%) into partial remission. The mean value of 24hr total urine protein over the follow-up 6 months' period declined significantly from 7.6+/-6.2 g in pre-treatment, to 4.1+/-3.2 g in 3 months, and 3.1+/-2.1 g in 6 months (p=0.011). The mean 24hr total urine protein decreased from 7.5+/-6.3 g in pre-MMF to 1.9+/-1.8 g in post-MMF (p=0.001). The mean serum albumin rose from 3.2+/-0.8 g/dL in pre-MMF to 3.9+/-0.5 g/dL in post-MMF (p=0.001). There were no significant changes in mean value for WBC, hemoglobin, serum creatinine, and total cholesterol. Side effects of MMF were infrequent and generally mild. CONCLUSION: MMF appears effective in 63% of patients with MN and FSGS who are resistant to other forms of treatment. Studies with more cases and multicenter controlled trials are required to establish the role and standards of MMF in these disorders.

Risk Factors of Catheter Loss Following Peritonitis in Patients on Continuous Ambulatory Peritoneal Dialysis / 대한신장학회지

PURPOSE: Peritoneal dialysis (PD) catheter removal is regarded as an important index of patient morbidity. The aim of this study was to evaluate factors influencing catheter loss following peritonitis in PD patients. METHODS: We retrospectively reviewed 917 episodes of peritonitis in 621 new CAPD patients from Jan 2001 to Feb. 2009 in Dongsan Medical center. Episodes requiring PD catheter removal were compared by both univariate and multivariate analyses with those in which PD catheters were preserved. RESULTS: When peritonitis episodes requiring PD catheter removal (n=80) were compared to catheter preserved peritonitis episodes (n=837), the incidence of PD catheter loss increased as the duration on PD preceding the peritonitis were longer (p<0.000). Also, PD catheter removal was more likely to occur after peritonitis episodes with low serum albumin level (p=0.009) and high serum CRP level (p<0.000), those with long duration of PD effluent leukocyte count remaining above 100/mm3 (p<0.000), those with concomitant exit site/tunnel infection (p=0.043), and those with presence of abdominal pathology (p<0.000). The microbiological determinants of PD catheter loss included two or more bacteria cultured (p=0.002) and fungi (p<0.000). In multivariate analysis, the duration of PD effluent leukocyte count remaining above 100/mL and the number of organism cultured were independent risk factors of PD catheter removal in peritonitis episodes. CONCLUSION: Duration of PD effluent leukocyte count remaining above 100/mm3, and the number of organisms cultured were independent risk factors for catheter removal following peritonitis.

Effect of Perioperative Management on 1 Year Patency of Internal Arteriovenous Fistula

PURPOSE: Early arteriovenous fistula (AVF) failure especially during the first several months after fistula creation makes the patient, physician and surgeon frustrated. To evaluate the patency rate of arteriovenous fistulas which were made for hemodialysis, we analyzed three different protocols pre- and peri-operatively in our hospital. METHOD: From January 1983 through December 1998, total 2,078 cases of AVF were done in 1,711 patients. During the first period (from 1983 to 1988, n=280), all of the AVFs were performed with naked eyes but during the second period (from 1989 to 1993, n=770), we used surgical loupe and microvascular anastomosing technique. During the third period (from 1994 to 1998, n=1,028), besides using surgical loupe, patients were treated peri-operatively with certain volumes of fluid to maintain the systolic blood pressure above 100 mmHg, venogram and duplex sonogram to identify an available vein before AVF creation, aggressive salvage procedures and use of aspirin after fistula creation. RESULT: There were no differences between each periods in their age distribution, sex ratio, serum creatinine level, associated diabetes mellitus and hemoglobin level except significantly low incidence of hypotension at the time of operation in period 3. The early fistula failure rate at 3 months decreased in period 2, 3 than period 1 (6.9%, 6.7% vs 12.7%) and showed statistical significance (p<0.05). The rate of fistulas that is patent more than 3 months and continued at the end of 12 months were no difference between the periods. Frequency of re-AVF within 3 months in period 1 was significantly higher than period 2, 3 which suggested improved early patency in later periods. The center ability to manage the created AVF checked by rate of re-AVF showed significant difference between our hospital and other local dialysis centers. The patency of primary AVF in each period was 69.7%, 75.2%, 77.5% at one year but that of re-AVF were 77.7%, 86.3% and 80.2%. CONCLLUSION: Microsurgical technic under surgical loupe improved primary AVF patency and decreased early failure rate. Also a protocoled perioperative management, improved management skill and experiences of dialysis center might decrease the re-AVF rate.

Cadaveric Donor Renal Transplantation; Review of 39 Cases / 대한이식학회지

To improve the graft survival in cadaveric donor renal transplantation, various factors that affect the results of allograft function has been analysed and reported. From January 1994 through December 1998, 39 cases of renal transplantation were performed using 20 cadaver donor. Thirty five of them were from brain dead donor and four from cardiac arrest donor. The most frequent cause of brain death was head injury by traffic accident, mostly autobicycle accident. Male donor ratio was 85.0% and their mean age were 29.3 years old. Mean cold ischemic time was 347.5 minutes and warm ischemic time of 4 cardiac arrest cases were 55-60 minutes. The number of HLA mismatch more than 4 were 64.1%. There were 8 cases of multiple renal arteries and 4 cases of double ureter. Donor hypotension during and before kidney procurement and warm ischemic time were factors that cause the delayed graft function in our cases. The number of HLA mismatch and use of Cellcept as immunosuppressant were two factors that affected the development of acute rejection during 6 months after renal allograft. Among the 39 kidneys of 20 donors, 12 paired kidneys showed different graft result in each recipient. Recipient age, number of HLA mismatch, cold ischemic time, duration of hemodialysis before transplantation, and level of hemoglobin were factors that cause the diffrerent result in paired kidney. One and two year graft survival rate were 89.6% and 76.5% respectively. In summary, the early results of our cadaver donor renal transplantation was comparable to living donor transplantation. Adequate donor management and HLA matching between donor and recipient are factors that can improve the graft result.

Cadaveric Donor Renal Transplantation; Review of 39 Cases / 대한이식학회지

To improve the graft survival in cadaveric donor renal transplantation, various factors that affect the results of allograft function has been analysed and reported. From January 1994 through December 1998, 39 cases of renal transplantation were performed using 20 cadaver donor. Thirty five of them were from brain dead donor and four from cardiac arrest donor. The most frequent cause of brain death was head injury by traffic accident, mostly autobicycle accident. Male donor ratio was 85.0% and their mean age were 29.3 years old. Mean cold ischemic time was 347.5 minutes and warm ischemic time of 4 cardiac arrest cases were 55-60 minutes. The number of HLA mismatch more than 4 were 64.1%. There were 8 cases of multiple renal arteries and 4 cases of double ureter. Donor hypotension during and before kidney procurement and warm ischemic time were factors that cause the delayed graft function in our cases. The number of HLA mismatch and use of Cellcept as immunosuppressant were two factors that affected the development of acute rejection during 6 months after renal allograft. Among the 39 kidneys of 20 donors, 12 paired kidneys showed different graft result in each recipient. Recipient age, number of HLA mismatch, cold ischemic time, duration of hemodialysis before transplantation, and level of hemoglobin were factors that cause the diffrerent result in paired kidney. One and two year graft survival rate were 89.6% and 76.5% respectively. In summary, the early results of our cadaver donor renal transplantation was comparable to living donor transplantation. Adequate donor management and HLA matching between donor and recipient are factors that can improve the graft result.