Analysis of 1,500 Kidney Transplantations at Sungkyunkwan University / 대한이식학회지

BACKGROUND: The most effective treatment for end-stage renal disease is kidney transplantation, and the number of kidney transplantations has shown a rapid increase. The aim of this study was to determine graft survival and functional outcome of 1,500 kidney transplant cases in a single center. We also investigated the factors affecting graft failure after kidney transplantation. METHODS: We retrospectively reviewed the clinical data of 1,500 pairs of donors and subsequent recipients who underwent kidney transplantation in Samsung Medical Center, from February 1995 to January 2012. RESULTS: The mean follow-up period was 2,241.5+/-1,609.4 days. There were 851 (56.7%) male recipients; 62 (4.1%) recipients were younger than 19 years old. Eleven (0.7%) cases were ABO blood group incompatible kidney transplant. A total of 531 (35%) deceased and 969 (65%) living donors were included. Among them, 191 (12.7%) recipients were experienced in graft failure. The most common cause of graft loss was chronic allograft nephropathy. One-year, 5-year, 10-year, and 15-year graft survival were 97.3%, 92.8%, 81.6%, and 75.1% (85.2% for living, 75.4% for deceased donor), respectively. Higher incidence of graft failure was observed in recipients who received deceased donor kidneys or experienced a rejection episode. CONCLUSIONS: In our experience, overall 10-year graft survival after kidney transplantation was 81.6%. This report demonstrated that the type of donor (living or deceased) and history of allograft rejection are the only significant factors affecting graft survival.

Effect of early enteral nutrition after hepatectomy in hepatocellular carcinoma patients

BACKGROUNDS/AIMS: To evaluate the effect of early enteral nutrition after hepatectomy in hepatocellular carcinoma (HCC) patients on postoperative gastrointestinal motility recovery and admission days, liver function and nutrition recovery, and postoperative complication. METHODS: From August 2010 to July 2011, 102 patients with primary HCC underwent hepatectomy. Forty two patients took a sip of water (SOW) at postoperative day (POD)#1, soft blended diet (SBD) at POD#2 (early diet group, ED group), otherwise 60 patients took a SOW at POD#3, SBD at POD#4 (conventional diet group, CD group). Postoperative flatus-pass day, stool-pass day, nausea, vomiting, admission days, immediate postoperative (POD#0) and POD#1, 3, 5, 7 profiles of albumin, prothrombin time (PT) INR, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), white blood cell (WBC), and POD#1, 3, 5, 7 profiles of C-reactive protein (CRP), and postoperative complications cases were compared between ED group and CD group. All clinical data were compared retrospectively. RESULTS: Flatus-pass days (p<0.01), stool-pass days (p<0.01) and postoperative admission days (p=0.012) were shorter in ED group. Total bilirubin levels were higher at POD#0, 1, 3 but lower or similar at POD#5, 7 in ED group. AST, ALT levels were higher at POD#0 but lower at POD#1, 3, 5. There were no significant differences in albumin, PT INR, WBC, CRP and postoperative complication rates. CONCLUSIONS: ED group had no difference in nutritional recovery and postoperative complication rates compared to CD group but it has better gastrointestinal motility recovery, liver function recovery, and shorter postoperative admission days.

Graft-versus-host disease after kidney transplantation / 대한외과학회지

Graft-versus-host disease (GVHD) is a rare complication after kidney transplantation. We describe a 62-year-old female with end-stage renal disease due to hypertension. She received a kidney with 4 mismatched human leukocyte antigen (HLA) out of 6 HLA - A, B, DR from a deceased donor. After the procedure, the patient showed watery diarrhea on postoperative day (POD) 45. An endoscopic biopsy of the colon revealed some apoptotic cells consistent with GVHD. Thrombocytopenia was gradually developed on POD 54. She received steroid pulse therapy, and thrombocytopenia did not progress. However, pneumonia, renal failure, and cardiac failure occurred. She died due to multiple organ failure. We must consider GVHD in renal transplant recipients without homozygous or identical HLA, who had only watery diarrhea without other typical GVHD symptoms such as skin rash and fever, although GVHD is rare in renal transplant recipients.

Cardiac tamponade caused by tuberculosis pericarditis in renal transplant recipients / 대한외과학회지

A 50-year-old male, renal transplant recipient, was admitted with fever and chest discomfort. At admission, chest radiologic finding was negative and echocardiography showed minimal pericardial effusion. After 2 days of admission, chest pain worsened and blood pressure fell to 60/40 mmHg. Emergency echocardiography showed a large amount of pericardial effusion compressing the entire heart. Pericardiocentesis was performed immediately. Mycobacterium tuberculosis was isolated from pericardial fluid. Tuberculosis pericarditis should be considered as the cause of cardiac tamponade in renal transplant recipients, even with the absence of pericardial effusion in the initial study or suggestive history.

Paranasal Aspergillosis in Patients Prior to Liver Transplantation / 대한이식학회지

BACKGROUND: Aspergillosis infection is associated with high morbidity and mortality in liver transplant recipients. This study investigated the prognosis of liver transplant recipients with a pre-operative treatment for paranasal aspergillosis. METHODS: We collected data from 979 cases of patients who underwent liver transplants at the Samsung Medical Center from May 1996 to Feburary 2010. RESULTS: Eight patients were diagnosed with paranasal aspergillosis after functional endoscopic sinus surgery (FESS), before liver transplantation. In these 8 patients, 7 (87.5%) were male, with a mean age of 55 years. All patients had a hepatitis B virus infection, and 6 patients had hepatocellular carcinoma. The mean days from FESS to liver transplantation was 31 (range, 12~47 days) and anti-fungal agents were not used during these periods. All 8 patients were free from a recurrence of aspergillosis after liver transplantation. CONCLUSIONS: Surgical treatment for paranasal aspergillosis in patients prior to liver transplantation does not induce aspergillosis infection after transplantation.

Paranasal Aspergillosis in Patients Prior to Liver Transplantation / 대한이식학회지

BACKGROUND: Aspergillosis infection is associated with high morbidity and mortality in liver transplant recipients. This study investigated the prognosis of liver transplant recipients with a pre-operative treatment for paranasal aspergillosis. METHODS: We collected data from 979 cases of patients who underwent liver transplants at the Samsung Medical Center from May 1996 to Feburary 2010. RESULTS: Eight patients were diagnosed with paranasal aspergillosis after functional endoscopic sinus surgery (FESS), before liver transplantation. In these 8 patients, 7 (87.5%) were male, with a mean age of 55 years. All patients had a hepatitis B virus infection, and 6 patients had hepatocellular carcinoma. The mean days from FESS to liver transplantation was 31 (range, 12~47 days) and anti-fungal agents were not used during these periods. All 8 patients were free from a recurrence of aspergillosis after liver transplantation. CONCLUSIONS: Surgical treatment for paranasal aspergillosis in patients prior to liver transplantation does not induce aspergillosis infection after transplantation.

Aspergillosis in Liver Transplant Recipients: A Single Center Experience

PURPOSE: The aim of this study was to review the epidemiology, clinical features, diagnosis, and effect of treatments of aspergillosis infections in adult liver transplantation patients. METHODS: We retrospectively studied the cases of aspergillosis among 625 (164 deceased donor liver transplantation (DDLT), 461 living donor liver transplantation (LDLT)) adult liver transplantation recipients (> or =18 yrs old) operated between May 1996 to May 2008. RESULTS: Fourteen cases of aspergillosis infection were detected, which consisted of 9 cases of invasive aspergillosis, 5 cases of aspergilloma in maxillary sinuses which occurred before the transplantation. One patient with invasive aspergillosis, who had received liver transplantation overseas and had post-operation care in our center, was also included. Among the 8 cases (1.28%) of invasive aspergillosis (excluding one case operated overseas), 6 cases (3.7%) were DDLT and 2 cases (0.4%) LDLT (P-value<0.05). Among the 6 patients with early onset of invasive aspergillosis, 5 patients (1.8%) had fluconazole and only 1 patient (0.3%) had itraconazole as prophylactic antifungal agent (P-value<0.05). The three cases with localized lesions in the lung survived after lobectomy, but the disseminated and inoperable cases died. CONCLUSION: The incidence of invasive aspergillosis was lower in LDLT cases and prophylactic itraconazole might be more effective than fluconazole. Paranasal aspergilloma, detected before transplantation had no relation with posttransplant invasive aspergillosis infection. Patients who had localized lesion in the lung, and underwent surgery had better survival than who could not.

Investigation of the Effective Dose of Agonistic 4-1BB Monoclonal Antibody in a Murine Colon Cancer Metastasis Model

PURPOSE: The aim of this study was to find the dose of agonistic 4-1BB monoclonal antibody (mAb) that results in optimal T cell activation. METHODS: Cancer was induced in mice by an intrahepatic parenchymal injection of 1x10(5) cells of CT26 cells. Cancer-carrying mice (n=84) were divided into seven groups and treated with either rat IgG or agonistic 4-1BB monoclonal antibody (mAb) (5microgram, 10microgram, 20microgram, 100microgram, 200microgram, or 300microgram). All treatments were administered intraperitoneally on days 7, 9, and 11. Mice from each group were sacrificed on days 14, 28, and 42. Harvested livers were weighed and the numbers of T cells in the splenocytes were analyzed with a FACS Vantage flow cytometer. RESULTS: Liver weights increased when 5microgram of agonistic 4-1BB mAb was administered, but showed no additional weight increase for doses greater than 10microgram. The absolute numbers of CD4+ and CD8+ T cells increased in groups treated with low doses of agonistic 4-1BB mAb (5microgram, 10microgram, or 20microgram), but did not increase in the groups treated with high doses of mAb (100microgram, 200microgram, or 300microgram). The levels of CD4/annexin V and CD8/annexin V increased as the dose increased, and the absolute cell numbers of CD4/annexin V were greater than those of CD8/annexin V. CONCLUSION: Liver weight, including the cancer mass, failed to increase at agonistic 4-1BB mAb doses greater than 10microgram. A high dose (> or =100microgram) of agonistic 4-1BB mAb resulted in lower counts of absolute T cells. This study suggests that a low dose (20microgram) of agonistic 4-1BB mAb can be used for optimal T cell activation in combination with other anti-cancer treatments.

Re-anastomosis above a Preceding Anastomosis Made by a Low Anterior Resection

Periodic colonoscopic checkup is needed for patients suffering from colorectal cancer, based on the property that a colorectal neoplasm often recurs synchronously or metachronously. Surgical management appropriate to the occasion should be taken in recurrent colorectal cancer. Particularly, recurring colorectal cancer closely above the prior anastomosis for a low anterior resection should be eliminated by using an abdomino-perineal resection, including the preceding anastomotic site or a new anastomotic creation. Under the latter instance, ample possibility exists for postoperative anastomotic stenosis or leakage by reason of insufficient blood supply to the segment between the earlier anastomosis and the later one. The authors report two cases of re-anastomosis for colorectal cancer just above a previous anastomosis taken by a low anterior resection for rectal cancer. In a 52-year-old male with a history of neoadjuvant concomitant chemo-radiotherapy (CCRT) and low anterior resection for rectal cancer located at 6 cm from the anal verge, a new adenocarcinoma was detected 7 cm from the previous anastomotic site and 3 cm from the anal verge. Considering anal sphincter preservation, the re-anastomosis was made at the upper part of the preceding anastomosis. The patient experienced no surgical complications, such as anastomotic stenosis or leakage and functional defecation difficulty. In another patient, a 50-year-old male with a low anterior resection and adjuvant CCRT for rectal cancer 8 cm from anal verge, a new adenocarcinoma was detected in the colon. The new adenocarcinoma was located 10 cm from the anal verge and 8 cm from the previous anastomosis. The same surgical management was applied to this case, with the same postoperative result.

The Frequency of Occurrence and Clinical Significance of the Giacomini Vein

PURPOSE: The Giacomini vein (GV) is one of branches that arising from the short saphenous vein (SSV) which extends cephalad along the posterior thigh communicating to the great saphenous vein (GSV), GSV branch or deep venous system. Despite of its common occurrence, the clinical significance of this venous structure isunknown yet. We investigated the frequency and the anatomical feature of the GV and the frequency of superficial or deep venous reflux associated GV to clarify its clinical significance. METHOD: We conductednon-invasive vascular evaluations on both legs using duplex ultrasonography in 50 patients having leg varicosity or telangiectasis. RESULT: 16 patients (32%) of 50 patients[28 limbs (28%) of 100 limbs]revealed the GV in their lower extremities. Among the patient with GV, venous refluxes of GSV, SSV or perforating vein (PV) were noted in frequencies of 16 limbs (76%), 8 limbs (38%) and 9 limbs (42%) respectively. The SSV and PV reflux were more common in the legs with GV than the legs without GV (P<0.001 respectively, McNemar test) regardless the existence of GV reflux. CONCLUSION: The SSV or PV reflux was more commonly associated with GV.

The Frequency of Occurrence and Clinical Significance of the Giacomini Vein

PURPOSE: The Giacomini vein (GV) is one of branches that arising from the short saphenous vein (SSV) which extends cephalad along the posterior thigh communicating to the great saphenous vein (GSV), GSV branch or deep venous system. Despite of its common occurrence, the clinical significance of this venous structure isunknown yet. We investigated the frequency and the anatomical feature of the GV and the frequency of superficial or deep venous reflux associated GV to clarify its clinical significance. METHOD: We conductednon-invasive vascular evaluations on both legs using duplex ultrasonography in 50 patients having leg varicosity or telangiectasis. RESULT: 16 patients (32%) of 50 patients[28 limbs (28%) of 100 limbs]revealed the GV in their lower extremities. Among the patient with GV, venous refluxes of GSV, SSV or perforating vein (PV) were noted in frequencies of 16 limbs (76%), 8 limbs (38%) and 9 limbs (42%) respectively. The SSV and PV reflux were more common in the legs with GV than the legs without GV (P<0.001 respectively, McNemar test) regardless the existence of GV reflux. CONCLUSION: The SSV or PV reflux was more commonly associated with GV.