A Brain Tumor from a Posttransplant Lymphoproliferative Disorder in a Kidney Transplant Recipient / 대한이식학회지

Posttransplant lymphoproliferative disorder (PTLD) is a life-threatening complication from organ transplantation. PTLD usually manifests as a mass in the lymph node or an extranodal mass in solid organs, such as the liver, transplanted kidney, tonsil, bone marrow, or spleen. PTLD rarely involves the central nervous system (CNS); however, here we report a case of PTLD that manifested as a brain tumor after kidney transplantation. A 52-year-old man who started peritoneal dialysis due to autosomal dominant polycystic kidney disease, underwent kidney transplantation 4 years ago. After kidney transplantation, he took tacrolimus, mycophenolate mofetil, and steroids. He was admitted to our hospital, complaining of a severe headache. Brain magnetic resonance imaging showed a multifocal, irregular, and round enhancing mass in the left basal ganglia. He underwent a needle biopsy for the enhancing mass and the pathological diagnosis was diffuse large B cell lymphoma. After this mass was confirmed as PTLD by histologic diagnosis, the patient had a reduction in his immunosuppression regimen (including a change from tacrolimus to sirolimus) and was treated with chemotherapy for PTLD. After 20 days, the patient expired from sepsis. PTLD involving the CNS is a rare and serious complication associated with solid organ transplantation. PTLD should be included in the differential diagnosis of brain tumors in recipients of solid organ transplants.

Hospitalization in Peritoneal Dialysis Patients / 대한신장학회지

PURPOSE: Hospitalization as a measure of morbidity in peritoneal dialysis (PD) patients is mainly related to peritonitis. And the hospitalization rate is expected to decrease as the peritonitis rate has decreased substantially with development of connectology. Yet there is no internal study on hospitalization. We evaluated hospitalization rates, causes and duration of admission of PD patients, and their prognosis. METHODS: We retrospectively reviewed the medical records of 414 patients who started and followed up at least three months at the Keimyung University Dongsan Hospital from January 2003 to December 2008. RESULTS: There were 1,036 admissions in 328 patients during a mean follow-up of 29.9 months. The admission rate was 1.0 per patients-year and hospital days were 17.1 per patients-year. The number of patients admitted once was 102 (31.1%), and more than 5 was 71 (21.7%). The most common cause of hospital admission was peritonitis (36.5%), followed by volume imbalance (13.8%), gastrointestinal disease (6.9%), other infection (6.2%), neurologic disease (5.5%), surgery (5.4%) and cardiac disease (4.3%). Catheter-related problems, including catheter related infection (1.8%) and catheter dysfunction (1.4%) were uncommon. Duration of admission was longest in neurologic disease (18.0+/-19.0) and shortest in catheter-related problems (9.3+/-3). Duration of admission of peritonitis (16.1+/-8.0) was similar to mean duration. Hospitalization was significantly greater in patients with prior history of peritonitis (p<0.000), and longer duration on PD (p<0.000). There were no significant differences in one and five year patient and catheter survival between hospitalized and non-hospitalized PD patients. CONCLUSION: Peritonitis remains a major cause of hospitalization in PD patients. To decrease admissions of PD patients, patient education and attention needs to be focused on preventing peritonitis. Also we should pay more attention to prevent multiple admissions due to recurrent peritonitis.

The Risk Factors and Outcome of Acute Kidney Injury in the Intensive Care Units

BACKGROUND/AIMS: Acute kidney injury (AKI) is a common and serious complication in critically ill patients, especially in the intensive care unit (ICU). The present study was performed to evaluate the occurrence rate of AKI using the RIFLE (increasing severity classes risk, injury, and failure, and the two outcome classes loss and end-stage kidney disease) classification, to define factors associated with AKI and hospital mortality. METHODS: We performed a retrospective study of all ICU patients over a 6-month period at Keimyung University Dongsan Hospital, Daegu, Korea. AKI was evaluated according to the RIFLE classification. RESULTS: AKI occurred in 156 of the 378 patients (41.3%) during their ICU stay, with maximum RIFLE-R, I, and F in 13.8%, 12.4%, and 15.1%, respectively. In univariate analysis, the proportion of medical admission and maximum Sequential Organ Failure Assessment (SOFA) score (SOFAmax) were significantly higher in patients with AKI than in those without. However, these factors did not remain significant in a multivariate analysis. The overall mortality rate of ICU patients was 25.7%. In multivariate analysis, mean age, occurrence of AKI, SOFAmax score, pulmonary disease, and malignancy were independent risk factors for hospital mortality. CONCLUSIONS: In these ICU patients, AKI is associated with increased hospital mortality. The RIFLE classification is a simple and useful clinical tool to detect and stratify the severity of AKI, and may aid in the prediction of outcome.

Treatment of Lupus Nephritis: A 21 Year, Single Center Experience / 대한신장학회지

PURPOSE:Renal disease is the major cause of mortality and morbidity in systemic lupus erythematosus. The aim of this study was to examine the therapeutic outcome of patients with lupus nephritis (LN) for 21 years. METHODS:We conducted a retrospective study of 100 patients with biopsy proven LN who were admitted at Keimyung University Dongsan Hospital between 1985 and 2006, and were followed with a mean of 73 months. We diagnosed renal pathology according to WHO 1995 classification, and analyzed the therapeutic and long-term outcome of patients with LN treated with steroid alone or steroid with intravenous cyclophosphamide (CYC). RESULTS:The mean age at the time of renal biopsy was 28. 3 years and male to female ratio was 1:9.9. The initial therapy consisted of steroid alone in 69 patients and steroid with intravenous CYC in 31 patients. The proportion of diffuse proliferative LN and titer of anti ds-DNA were significantly higher in patients treated with steroid and CYC than in patients with steroid alone. The percentage of patients with clinical response was significantly higher in patients with steroid and CYC than in patients with steroid alone (p=0.018). The patients who experienced clinical response had an excellent long term outcome compared with those who had no clinical response. CONCLUSION:The clinical response was significantly higher in CYC combination regimen than steroid alone. The response to therapy in LN was an important factor for long-term prognosis. The early diagnosis and aggressive treatment with immunosupppressive agents are valuable for better outcome in patient with LN.

Continuous Renal Replacement Therapy (CRRT) in Intensive Care Unit (ICU) Patients with Acute Renal Failure / 대한신장학회지

PURPOSE: The mortality rate in critically ill patients with acute renal failure (ARF) remains unacceptably high, despite numerous advances in dialysis techniques and intensive care medicine. We evaluated clinical characteristics and prognostic factors in ICU patients with ARF requiring continuous renal replacement therapy (CRRT). METHODS: We retrospectively reviewed the medical records of all ICU patients who received CRRT at the Keimyung University Dongsan Hospital from September 2002 to October 2007. RESULTS: Total number of patients who required CRRT in ICU was 58. The mean age was 58.3+/-14.8 years. The treatment duration of CRRT was 63.5+/-40.7 hours. The mechanical ventilation rate was 82.8%, vasoactive drug 79.3%, sepsis 39.7%. APACHE II score was 25.2+/-7.9, SAPS II score 48.1+/-15.1, CCF score 9.3+/-3.6, the number of organ dysfunction 2.1+/-1.3. Overall mortality rate was 48%. When we compared sepsis group with non-sepsis group, the number of organ dysfunction and severity of illness were significantly higher in sepsis group than that of non-sepsis group. A mortality rate of sepsis group was significantly higher than non-sepsis group (82.6% vs 31.3%, p<0.001). In univariate analysis, significant risk factors for mortality were the number of organ dysfunction, severity of illness, MAP, platelet count, serum albumin level, and a type of hemofilter. Significances of all these factors were lost in multiple linear regression analysis. CONCLUSION: A large scaled, prospective randomized multi-center trials are needed to confirm the beneficial effect of CRRT in patient with ARF in ICU.