Increased depression risk in patients with abdominal aortic aneurysm: a nationwide cohort study

Purpose@#Abdominal aortic aneurysm (AAA) is a critical disease. Most studies of AAA consider reoperation rate, complications, or mortality, but do not consider a patient’s mental state. However, there is a possibility of interaction between AAA and depression in disease development and prognosis. We investigated the incidence and risk ratio of depression in patients with AAA using nationwide data. @*Methods@#We selected subjects from National Health Insurance System database who were diagnosed with AAA between 2009 and 2015 and survived at least 1 year after diagnosis or AAA surgery (n = 10,373). We determined the control group using propensity score matching by age and sex. The control group had about 3 times the number of subjects as the AAA cohort (n = 31,119). @*Results@#The incidence of depression was 1.4 times higher in the AAA group than the control group. We further analyzed the incidence of depression in the AAA group according to treatment modalities (nonsurgical vs. surgical or nonsurgical vs. open surgical aneurysm repair vs. endovascular aneurysm repair) but found no significant difference among them. The incidence of depression was significantly higher in patients aged <65 years than in patients aged ≥65 years (hazard ratio, 1.539 vs. 1.270; P < 0.001). @*Conclusion@#The incidence of depression was higher in the AAA group, with an especially high risk for depression in patients aged <65 years. The psychiatric status of patients with AAA should be carefully monitored for clinicians to intervene when appropriate.

Incidence and outcome of isolated distal deep vein thrombosis in kidney transplant recipients

Purpose@#Isolated distal deep vein thrombosis (IDDVT) is a localized lesion; nonetheless, the risk of proximal vein propagation makes it difficult to decide on the treatment protocol—that is, whether immediate anticoagulation after diagnosis or surveillance via serial imaging should be employed. This study aimed to investigate the appropriate treatment protocol for IDDVT in kidney transplant recipient (KTR). @*Methods@#Surveillance for venous thromboembolism (VTE) was performed using duplex ultrasonography (DUS) before transplant surgery and at 1 week, 2 weeks, 1 month, 3 months, 6 months, and 1 year after transplant surgery. Dual mechanical prophylaxis was administered to prevent VTE. @*Results@#In total, 60 out of 829 patients (7.2%) developed VTE, with 49 cases (81.6%) of IDDVT. Among IDDVT patients, 15 patients were treated using anticoagulation-first strategy, whereas the remaining 34 patients were treated using surveillance-first strategy. No patient in either group exhibited thrombus extension into the proximal vein or recurrence within 1 year from transplant surgery. @*Conclusion@#In Korean KTR, extension of IDDVT into the proximal vein could be prevented safely and effectively by serial DUS surveillance along with the maintenance of mechanical prophylaxis. However, the patients who have high thrombus burden or are difficult to get repeated DUS require the use of anticoagulation in early stages.

Incidence and outcome of isolated distal deep vein thrombosis in kidney transplant recipients

Purpose@#Isolated distal deep vein thrombosis (IDDVT) is a localized lesion; nonetheless, the risk of proximal vein propagation makes it difficult to decide on the treatment protocol—that is, whether immediate anticoagulation after diagnosis or surveillance via serial imaging should be employed. This study aimed to investigate the appropriate treatment protocol for IDDVT in kidney transplant recipient (KTR). @*Methods@#Surveillance for venous thromboembolism (VTE) was performed using duplex ultrasonography (DUS) before transplant surgery and at 1 week, 2 weeks, 1 month, 3 months, 6 months, and 1 year after transplant surgery. Dual mechanical prophylaxis was administered to prevent VTE. @*Results@#In total, 60 out of 829 patients (7.2%) developed VTE, with 49 cases (81.6%) of IDDVT. Among IDDVT patients, 15 patients were treated using anticoagulation-first strategy, whereas the remaining 34 patients were treated using surveillance-first strategy. No patient in either group exhibited thrombus extension into the proximal vein or recurrence within 1 year from transplant surgery. @*Conclusion@#In Korean KTR, extension of IDDVT into the proximal vein could be prevented safely and effectively by serial DUS surveillance along with the maintenance of mechanical prophylaxis. However, the patients who have high thrombus burden or are difficult to get repeated DUS require the use of anticoagulation in early stages.

Kidney transplantation using expanded criteria deceased donors with terminal acute kidney injury: a single center experience in Korea

PURPOSE: We investigated the clinical outcomes of deceased donor kidney transplantation (KT) using kidneys with terminal acute kidney injury (AKI). METHODS: Between February 2000 and December 2013, we performed 202 deceased donor renal transplants from 159 brain dead donors. According to the expanded criteria donor (ECD) and AKI network criteria, we divided 202 recipients into 4 groups: Group I: Non-AKI & standard criteria donor (SCD) (n = 97); group II: Non-AKI & ECD (n = 15); group III: AKI & SCD (n = 52); and group IV: AKI & ECD (n = 38). RESULTS: The incidence of delayed graft function (DFG) was significantly higher in patients with AKI than it was in the non-AKI group (P = 0.008). There were no significant differences among the 4 groups in graft survival (P = 0.074) or patient survival (P = 0.090). However, the long-term allograft survival rate was significantly lower in group IV than it was in other groups (P = 0.024). CONCLUSION: Allografts from deceased donors with terminal AKI had a higher incidence of DGF than did those from donors without AKI. However, there is no significant difference in graft and patient survival rates among the groups. So, the utilization of renal grafts from ECDs with terminal AKI is a feasible approach to address the critical organ shortage.

The Effect of Bortezomib on the Management of Immediate Postoperative Refractory Antibody-Mediated Rejection after Kidney Transplantation / 대한이식학회지

BACKGROUND: Bortezomib has been used to treat antibody-mediated rejection (AMR) that usually develops after kidney transplantation (KT). Although it has been used in various clinical situations, it is difficult to precisely define how the drug affects the clinical course. We used bortezomib to treat eight cases of AMR that developed immediately following KT in patients who were resistant to conventional treatment. METHODS: Eight cases of refractory AMR that developed immediately after KT were treated with bortezomib on days 1, 4, 8, and 11. RESULTS: The resolution rate was 75%, and the 2-year rejection-free survival rate was 83%. Six cases underwent immunologically high-risk KT. Six recovering patients exhibited clinical improvement within 2 weeks of the first dose of bortezomib and recovered completely within 2 months. The effects of bortezomib seemed to be prolonged; only one additional rejection episode was observed. The two failed patients never exhibited any clinical improvement and progressed aggressively to graft failure soon after transplantation. Their donor specific anti-human leukocyte antigen antibody were sustained at high levels. CONCLUSIONS: Bortezomib is an effective rescue therapy in patients with AMR that developed immediately after KT.

The optimal duration of ischemic preconditioning for renal ischemia-reperfusion injury in mice

PURPOSE: The aim of the present study was to investigate the protective effects of ischemic preconditioning for different periods of time and to elucidate the optimal safe ischemic preconditioning time for renal ischemia-reperfusion (I/R) injury in mice. METHODS: A total of 25 male C57BL/6 mice were randomly divided into 5 groups (sham, I/R, ischemic preconditioning [IP]-3, IP-5, and IP-7 groups), in which the kidney was preconditioned with IP of various durations and then subjected to I/R injury (the last 3 groups). To induce renal ischemia, the left renal pedicle was occluded with a nontraumatic microaneurysm clamp for 30 minutes followed by reperfusion for 24 hours. The effects of IP on renal I/R injury were evaluated in terms of renal function, tubular necrosis, apoptotic cell death and inflammatory cytokines. RESULTS: Results indicated that BUN and creatinine (Cr) levels increased significantly in the I/R group, but the elevations were significantly lower in IP groups, especially in the IP-5 group. Histological analysis revealed that kidney injury was markedly decreased in the IP-5 group compared with the I/R group, as evidenced by reduced renal necrosis/apoptosis. In addition, IP significantly inhibited gene expression of pro-inflammatory cytokines (TNF-α, IL-1β, and IL-6) and chemokines (monocyte chemoattractant protein-1). Western blot analysis indicated that the expression levels of Toll-like receptor 4 (TLR4) and nuclear factor-kappa B (NF-κB) were upregulated in the I/R group, while expression was inhibited in the IP groups. CONCLUSION: Five-minute IP had the greatest protective effect against I/R injury.

Novel method of laparoendoscopic single-site and natural orifice specimen extraction for live donor nephrectomy: single-port laparoscopic donor nephrectomy and transvaginal graft extraction

Laparoscopic live donor nephrectomy (DN) has been established as a useful alternative to the traditional open methods of procuring kidneys. To maximize the advantages of the laparoendoscopic single-site (LESS) method, we applied natural orifice specimen extraction to LESS-DN. A 46-year-old woman with no previous abdominal surgery history volunteered to donate her left kidney to her husband and underwent single-port laparoscopic DN with transvaginal extraction. The procedure was completed without intraoperative complications. The kidney functioned well immediately after transplantation, and the donor and recipient were respectively discharged 2 days and 2 weeks postoperatively. Single-port laparoscopic DN and transvaginal graft extraction is feasible and safe.

Risk factors and long-term outcomes of delayed graft function in deceased donor renal transplantation

PURPOSE: The purpose of this study was to analyze the risk factors for delayed graft function (DGF) and determine its impact on the outcomes of deceased donor (DD) kidney transplantation (KT). METHODS: Between January 2000 and December 2011, we performed 195 DD renal transplants. After the exclusion of primary nonfunctional grafts (n = 4), the study recipients were divided into two groups-group I, DGF (n = 31, 16.2%); group II, non-DGF (n = 160, 83.8%). The following variables were compared: donor and recipient characteristics, patient and graft survival, postoperative renal function, acute rejection (AR) episodes, and the rates of surgical and infectious complications. RESULTS: Donor-related variables that showed significant differences included hypertension (P = 0.042), diabetes (P = 0.025), and prerecovery serum creatinine levels (P 20%, P = 0.008). On multivariate analysis, only the prerecovery serum creatinine level (P < 0.001; hazard ratio [HR], 1.814) was an independent risk factor for the development of DGF. A Cox multivariate analysis of risk factors for graft survival identified these independent risk factors for graft survival: nephron mass (donor kidney weight to recipient body weight ratio) index (P = 0.026; HR, 2.328), CMV infection (P = 0.038; HR, 0.114), and AR episode (P = 0.038; HR, 0.166). CONCLUSION: In DD KT, an independent risk factor for DGF was the prerecovery serum creatinine level. Although there was a significant difference in graft survival between the DGF and non-DGF groups, DGF was not an independent risk factor for graft failure in this study.

Transumbilical pure single-port laparoscopic donor nephrectomy

Transumbilical single-port laparoscopic donor nephrectomy (SPLDN) is a novel, rapidly evolving, minimally invasive treatment modality for kidney transplantation. This method causes minimal parietal injury, has cosmetic advantages, and allows rapid recovery because of low postoperative pain and short hospital stay. Like other abdominal surgeries, when conducted by experienced laparoscopic surgeons, it can meet the same graft requirements as conventional laparoscopic surgery. Here, we report the first two cases of transumbilical SPLDN at Daejeon St. Mary's Hospital, The Catholic University of Korea. We used the umbilicus as a common path for laparoscopic procedures and as a route for specimen retrieval. The operating times were 230 and 265 minutes in cases 1 and 2, respectively. No intra- or postoperative complications were noted. In case 1, the wound length was 4 cm and duration of hospitalization was 2 days. In case 2, the wound length was only 2.5 cm, and the duration of hospitalization was only 1 day.

Low-Grade Endometrial Stromal Sarcoma with Inferior Vena Cava Extension: First Report in Korea

Low-grade endometrial stromal sarcoma (LGESS) with intravascular extension is very rare, with only 26 cases having been reported. We experienced a case of LGESS with inferior vena cava (IVC) extension. A 60-year-old female presented with left leg edema. She had a history of total hysterectomy, and was diagnosed of leiomyoma at that time. On imaging study, tumor masses were located around both common iliac veins (CIV), and within the CIV and IVC. The pelvic masses on both side and IVC mass were resected, and then the patient received adjuvant hormonal therapy and radiotherapy over the remnant pelvic masses. LGESS with IVC extension is difficult to distinguish from intravascular leiomyomatosis. LGESS is a malignant disease and commonly recurs, even in early stages. Accurate diagnosis, complete resection, proper adjuvant therapy and close follow-up are very important.

Mechanical thromboprophylaxis is sufficient to prevent the lower extremity deep vein thrombosis after kidney transplantation

PURPOSE: Deep vein thrombosis (DVT) is a severe and common complication that occurs after the major operation. Despite the commonality of DVT there is limited data on the incidence of DVT after kidney transplantation (KT). Furthermore, most studies have been retrospective in design and were conducted in western countries. The aim of this study was to evaluate the incidence of lower extremity DVT with mechanical thromboprophylaxis within 1 month of KT in Korea. METHODS: A total of 187 consecutive patients who underwent KT were included in this study. Patients used a graduated elastic stocking (n = 93) or an intermittent pneumatic compression device (n = 94) to prevent DVT. The frequency of DVT during the first month after KT was evaluated using serial color duplex ultrasound on postoperative days 7 +/- 2, 14 +/- 2, and 28 +/- 3. All patients were tested for eight thrombophilic factors before KT. RESULTS: DVT occurred in four patients (2.1%) during the first month after KT. All DVT developed in the graduated elastic stocking group. Interestingly, none of the patients had the factor V Leiden mutation or the prothrombin gene 20210A mutation. CONCLUSION: The incidence of DVT in this study was relatively lower than that of western populations. We did not encounter a factor V Leiden mutation or a prothrombin gene 20210A mutation in our study population. These findings suggest that inherited thrombophilic risk factors may be partially responsible for the difference in DVT incidence rates between different nationalities and/or ethnicities.

Predictors of Postoperative Mortality of Ruptured Abdominal Aortic Aneurysm: A Retrospective Clinical Study

PURPOSE: Despite significant improvements in surgery, anesthesia, and postoperative critical care, the postoperative mortality rate of ruptured abdominal aortic aneurysm (RAAA) has remained at 40% to 50% for several decades. Therefore, we evaluated factors associated with the postoperative mortality of RAAA. MATERIALS AND METHODS: From January 1999 to December 2008, a retrospective study was performed with 34 patients who underwent open repair of RAAA. The preoperative factors included age, sex, smoking, comorbidities, serum creatinine, hemoglobin, shock, pulse rate, and time from emergency room to operation room. The intraoperative factors included blood loss, transfusion, aortic clamping site and time, aneurysmal characteristics, rupture type, graft type, hourly urine output (HUO), and operative time. The postoperative factors included inotropic support, renal replacement therapy (RRT), reoperation, bowel ischemia, multiple organ failure (MOF), and intensive care unit stay. The 2-day and the 30-day mortality rates were analyzed separately. RESULTS: The 2-day and the 30-day mortality rates were 14.7% and 41.2%, respectively. On univariate analysis, shock, transfusion, HUO, inotropic support and MOF for the 2-day mortality and serum creatinine, transfusion, aortic clamping site, HUO, inotropic support, RRT and MOF for the 30-day mortality were statistically significant. On multivariate analysis, shock, inotropic support and MOF for the 2-day mortality and aortic clamping site, RRT and MOF for the 30-day mortality were statistically significant. CONCLUSION: To decrease the postoperative mortality rate of RAAA, prevention of massive hemorrhage and acute renal failure with infrarenal aortic clamping, as well as prompt operative control of bleeding and maintenance of systemic perfusion are important.

A Clinical Consideration of Abdominal Aortic Aneurysm Rupture / 대한혈관외과학회지

PURPOSE: With current advances in surgical technique, the prognosis for elective open repair of abdominal aortic aneurysm (AAA) has improved, but the mortality rate for ruptured AAA remains high. The aim of this study was to define the risk factors of AAA rupture. METHODS: We performed a retrospective analysis of 169 AAA patients who underwent open surgical repair between March 2000 and October 2010. According to the rupture, the patients were divided into 2 groups: 'ruptured' (n=41), 'non-ruptured' (n=128). To define the risk factor of ruptured AAA, we compared following variables between the 2 groups: clinical co-morbidities (hypertension, diabetes mellitus, ischemic heart disease, malignancies), diameter (maximal diameter of AAA), location of rupture, gender, and previous abdominal surgery history. RESULTS: Mean patient-age was 68.4+/-4.4 years (range: 32 to 86 years); the majority of patients were males, 135 (79.8%). Mean diameter of AAA was 6.67+/-2.0 cm (range: 4 to 15 cm); 'non-ruptured': 6.3+/-1.6 cm, 'ruptured': 7.8+/-2.6 cm. The risk of AAA rupture was statistically significantly increased with increased diameter of the AAA (P=0.007). On multivariateanalysis, the only statistically significant risk factor for AAA rupture was diameter of AAA (P=0.004). CONCLUSION: The only significant risk factor for AAA rupture found in this study is the diameter of AAA. To minimize the rupture rate of the AAA patients, we will have to closely monitor the size of AAA diameter.

Relationship of Serum Ferritin, Cholesterol, and Intimal Hyperplasia after Mechanical Injury to Carotid Artery in a Rat Model

PURPOSE: Iron plays an important role in the process of oxidizing Low Density Lipoprotein (LDL) in the arterial wall during the development of atherosclerosis, but the role of iron during the development of intimal hyperplasia has not been confirmed. Therefore, we evaluated the relationship of serum ferritin, serum cholesterol and intimal hyperplasia. METHODS: Forty rats were divided into four groups according to diet. Group I was the normocholesterol and normoferritin group, group II was the hypercholesterol and normoferritin group, group III was the hypercholesterol and hypoferritin group, and group IV was the hypercholesterol and hyperferritin group. At the sixth week, we induced clamping injury at the left common carotid artery of each rat. At the end of the eighth week, we obtained tissue of the left common carotid artery from each rat, and we performed staining. After that, we evaluated differences of the intima to media ratio (IMR) of arterial walls according to groups. RESULTS: The IMR of group II was higher than that of group I (P<0.001). Among hypercholesterol groups (group II~IV), the IMR of group III was lower than that of group II (P<0.001), and the IMR of group IV was higher than that of group II (P=0.007). CONCLUSION: We suggest the possibility that serum ferritin and serum cholesterol are proportionally related with intimal hyperplasia. But we think that large-volume experiments in animal models and prospective studies in humans are needed to confirm and expand on our results.

Free Floating Thrombus of the Aorta: An Unusual Cause of Peripheral Embolization

PURPOSE: Free-floating thrombus (FFT) of the aorta is very rare but has a high risk of distal embolization. While the necessity of treating such a condition is evident, the diagnostic and therapeutic modalities remain controversial. Thus, we reviewed seven cases of FFT of the aorta. METHODS: A retrospective study was performed usings even patients diagnosed with FFT of the aorta at the Catholic University of Korea between January 1999 and December 2008. We excluded those patients who had thrombi with concomitant atherosclerotic or aneurysmal aorta. RESULTS: The mean patient age was 59.6+/-13.6 years old. The male-to-female ratio was 3:4. Embolization to arteries of the extremities occurred in two patients and to visceral arteries in four patients. Of these seven patients, four were initially treated with anticoagulation, and two were initially treated with thrombectomy; one patient refused any kind of treatment. Of the four patients treated with anticoagulation, three experienced complete dissolution of the thrombi while anticoagulation proved ineffective in the remaining patient who subsequently underwent thrombectomy. In all of the three patients who had received thrombectomy, postoperative anticoagulation was employed. There was no recurrence of FFT of the aorta during the follow-up period. CONCLUSION: Were commend systemic anticoagulation with low molecular weight heparin (LMWH) as the first line of treatment for FFT of the aorta. If the thrombus persists or recurrent embolism occurs during anticoagulation therapy, surgery should be undertaken.

Short-term results of ABO-incompatible living donor kidney transplantation: comparison with ABO-compatible grafts / 대한외과학회지

PURPOSE: ABO incompatible (ABOi) kidney transplantation (KT) has been increasing to compensate for the shortage of organ donors. However, detailed comparative analyses of ABOi KT with ABO compatible (ABOc) KT are still rare. METHODS: This retrospective study compared 12 consecutive ABOi KTs to 50 ABOc KTs that employed the same maintenance immunosuppressive agents during the same period. Comparisons of patient survival, graft survival, graft function, and complications were made until post-transplant day 90. RESULTS: Baseline characteristics of the two groups were similar except for the positivity of panel reactive antibody (12% in the ABOc group vs. 42% in the ABOi group; P = 0.029). There were no significant differences in patient survival, graft survival, post-operative renal function, incidence of acute rejection, infections, or medical and surgical complications. However, bleeding complications were more common in the ABOi group (25%) than versus the ABOc group (6%) (P = 0.08). The preoperative and total hospital stay of the ABOi patients was significantly longer than the ABOc patients (P = 0.001). CONCLUSION: ABOi KT is a viable and safe option for patients whose only donor is blood incompatible, despite the longer preoperative hospital stay for preparation.

Symptomatic Lower Extremity Deep Vein Thrombosis after Kidney Transplantation: a 40-Year Single Center Experience in Korea / 대한이식학회지

BACKGROUND: It is well known that kidney transplant recipients in Western countries are at high risk for development of lower extremity (LE) deep vein thrombosis (DVT). The aim of this study was to establish the frequency of symptomatic LE DVT, the time until their occurrence, and to define risk factors for them following kidney transplantation (KT) in Korea. METHODS: We performed a retrospective analysis of LE DVT among 1695 patients who were kidney transplant recipients between 1969 and 2009. All patients were symptomatic with objective diagnostic modalities. Results were compared with those for a cohort of kidney transplant recipients from the same center without DVT. RESULTS: During follow-up, 21 symptomatic LE DVTs (1.2%) occurred in 18 patients (1.1%). The mean interval between transplantation and a first episode of DVT was 77.1+/-76.6 months. No DVT episode developed within one month after KT. There were no significant differences in body mass index, graft function, donor age and sex, recipient sex, type of preoperative renal replacement therapy, immunosuppressive agents, and malignancy between the two groups. Patients who developed LE DVT had a significantly different recipient age, presence of diabetes mellitus, presence of acute rejection episodes, and type of donor (P<0.05). CONCLUSIONS: Our retrospective study showed that the incidence of LE symptomatic DVT after KT is lower than after other surgeries performed in Korean hospitals and after KT performed in Western countries. There were no cases of symptomatic DVT within 1 month after KT. Our findings suggest that aggressive DVT prevention is not necessary for KT recipients in Korea.

Acute Necrotizing Pancreatitis after Kidney Transplantation: A Case Report / 대한이식학회지

Acute necrotizing pancreatitis after kidney transplantation is a rare, but serious complication. We report a case of patient who was developed acute pancreatitis after cadaveric kidney transplantation with several causative factors: viral infection (Cytomegalovirus, Varicella zoster virus), usage of immunosuppressant, gallbladder stones, and previous peritoneal dialysis history. Cytomegalovirus infection was suspected as major etiologic factor of this case, but other factors would have a complex effect on development of acute pancreatitis.

Kidney Transplantation after ex vivo Repair of an Aneurysm of the Donor Renal Artery / 대한이식학회지

Kidney transplantation, particularly from a living donor, is the treatment of choice for most patients with end-stage renal disease. The superior results achieved with kidney transplantation from living donor. We report a case of transplantation using a kidney with renal arterial aneurysm from a 49-year-old living donor to her 51-year-old brother. A preoperative CT angiogram in a donor candidate showed the right kidney with 6 mm sized saccular aneurysm involves the proximal portion of anterior segmental artery. The kidney was removed by a hand-assisted laparoscopic nephrectomy. After ex vivo aneurysmectomy, the graft was transplanted into the right iliac fossa. The total ischemic time was 62 minutes, and the urine flow was started immediately after declamping. If there are multiple donor candidates of same condition, donor with unilateral renal artery aneurysm should be chosen for transplant. The use of those grafts is safe for both recipients and donors.

The Anatomical Relationship of the Aortic Bifurcation and the Iliocaval Junction to the Lumbar Vertebrae in a Korean Population

PURPOSE: The objective of this study was to determine the anatomic significance and the level of the abdominal aortic bifurcation and the iliocaval junction in relation to the lumbar spine. METHOD: We conducted a retrospective study of 79 patients who underwent prosthetic replacement of an intervertebral disc by the anterior approach. The location of the aortic bifurcation and iliocaval junction and the size of the aorta and IVC were evaluated using CT angiography. The levels of the aortic bifurcation and iliocaval junction were recorded in relation to the upper or lower half of the adjacent vertebral body or intervertebral disc. RESULT: The aorta was bifurcated at the lower half of the L4 vertebral body in 35.4% of the cases. The iliocaval junction was between L4 and L5, and it was most often at the upper half of L5 (43.0%). CONCLUSION: The variability of the aortic bifurcation and iliocaval junction is high and an accurate description may be useful for using the various retroperitoneal approaches for not only aortic and venacaval surgery, but also for the anterior approach for spinal surgery.