De novo glomerulitis associated with graft-versus-host disease after allogeneic hematopoietic stem cell transplantation: A single-center experience

BACKGROUND: Nephrotic syndrome (NS) and proteinuria are uncommon, often unrecognized manifestations of graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT). Only a few isolated case reports and case series involving smaller number of patients who developed NS after HSCT have been published. METHODS: We reviewed the renal histopathological examination findings and clinical records of 15 patients who developed proteinuria after HSCT at Seoul and Yeouido St. Mary's Hospital (Seoul, Korea). We also measured the anti-PLA2 Rantibodies (M-type phospholipase A2 receptor) in the serum samples from the seven patients at the time of renal biopsy. RESULTS: All patients had GVHD. The most common indication for biopsy was proteinuria ( > 1 g/day), with nine patients having nephrotic range proteinuria. The most common histopathological finding was membranous nephropathy (MN; n = 12).Other findings were membranoproliferative glomerulonephritis, C1q nephropathy, and diabetic nephropathy. Eleven patients were treated with immunosuppressive agents, and three patients were treated only with angiotensin II receptor blocker. The overall response rate, including complete remission (urinary protein level < 0.3 g/day) and partial remission (urinary protein level = 0.31-3.4 g/day), was 73%. The mean follow-up period was 26 months, and none of the patients developed end-stage renal disease. All of the seven patients with MN had negative findings for anti-PLA2R antibodies, measured using an enzyme-linked immunosorbent assay kit. CONCLUSION: In this study the findings of 15 renal biopsies were analyzed and to our knowledge this is the largest clinicopathological study of GVHD-related biopsy-proven nephropathy. Approximately 80% of the patients were MN and 73% responded either partially or completely to immunosuppressive treatment. Currently, there is an increase in the incidence of GVHD-mediated renal disease, and therefore, renal biopsy is essential for diagnosing the nephropathy and preventing the progression of renal disease.

Clinical usefulness of kidney biopsy in liver transplant recipients with renal impairment

BACKGROUND: Chronic kidney disease is a common complication after liver transplantation. In this study, we analyzed the results of kidney biopsy in liver transplantation recipients with renal impairment. METHODS: Between 1999 and 2012, 544 liver transplants were performed at our hospital. We retrospectively analyzed the clinical and histological data of 10 liver transplantation recipients referred for kidney biopsy. RESULTS: The biopsies were performed at a median of 24.5 months (range, 3-73 months) after liver transplantation. The serum creatinine level was 1.81+/-0.5mg/dL at the time of kidney biopsy. There were no immediate complications. The most common diagnosis was glomerulonephritis (GN), such as immunoglobulin A nephropathy (n=4), mesangial proliferative GN(n=1), focal proliferative GN (n=1), and membranous GN (n=1). Typical calcineurin inhibitor (CNI)-induced nephrotoxicity was detected in three cases (30%).Chronic tissue changes such as glomerulosclerosis, interstitial fibrosis, and tubular atrophy were present in 90%, 80%,and 80% of cases, respectively, and mesangial proliferation was detected in 40%of cases. We began treatment for renal impairment based on the result of kidney biopsy; for example, angiotensin-receptor blockers or steroids were prescribed for GN, and the CNI dose was reduced for CNI nephrotoxicity. As a result, eight of 10 patients showed improvement in glomerular filtration rate, but two progressed to end-stage renal disease. CONCLUSION: Kidney biopsy is a safe and effective method for determining the cause of renal impairment after liver transplantation. Management of patients based on the result of kidney biopsy may improve renal outcomes.

A Case Report of Kidney Graft Failure after Duodenal Bypass Surgery / 대한내과학회지

The calcineurin inhibitor-immunosuppressant tacrolimus is widely used in patients undergoing kidney transplantation. Although tacrolimus is absorbed from the entire gastrointestinal tract, the duodenum is the primary site of its absorption and metabolism. Therefore, duodenal bypass surgery in a renal transplant recipient can significantly disrupt tacrolimus absorption and metabolism. Here, we report a case of allograft failure that developed after duodenal bypass surgery. The patient was a 41-year-old woman who received a deceased donor kidney transplantation. She underwent a gastrojejunostomy due to a duodenal perforation and pancreatitis after endoscopic retrograde cholangiopancreatography. After the surgery, her blood tacrolimus level decreased gradually, and remained lower than therapeutic target levels, even after the tacrolimus dose was increased from 5 to 12 mg/day. Repetitive rejection developed and the patient suffered allograft failure 3 months after bypass surgery. This case raises the importance of drug absorption in renal transplant recipients undergoing duodenal bypass surgery.

A Case of Chronic Arthritis Due to Mycobacterium intracellulare after Trauma / 결핵및호흡기질환

While nontuberculous mycobacterium (NTM) infections are recently on the rise, arthritis caused by NTM is hardly reported in Korea. NTM arthritis has no distinctive clinical characteristics from chronic arthritis. Tuberculosis of the joint specifically produces similar clinical and pathologic presentations to NTM arthritis, so it is not easy to distinguish between them. We report a case of Mycobacterium intracellulare in an arthritis patient after trauma and surgical repair of the injury. At the beginning, the patient was diagnosed as tuberculous tenosynovitis through pathology without microbiologic evidence. The final diagnosis was made after subsequent recurrences for several years. The misdiagnosis and delayed diagnosis led to irreversible joint destruction and functional impairment. NTM infection must be included in the differential diagnosis of chronic arthritis at the outset.

Stent Fracture at the Proximal Shaft of the Left Main Stem

Stent fracture is likely to be caused due to mechanical stress at the hinge point or kinking movement at the point of aneurysm formation with stent malapposition. To our knowledge, this is the first published report of stent fracture at the proximal shaft of the left main stem in a patient with acute myocardial infarction.

Knee Pain as an Initial Symptom of Colon Cancer / 대한내과학회지

Knee pain is rarely an initial symptom of colon cancer, because most bone metastases develop in the late stage of cancer. Therefore, patients with colorectal cancer usually present with gastrointestinal symptoms. Recently, we experienced a 46-year-old female with rectal cancer that presented as knee pain due to tibial metastasis without other organ metastasis. She was evaluated for knee pain and diagnosed with a rectal cancer after biopsies of the tibial and rectal masses. We report the first such case in Korea with a review of the literature.

A Case of Visual and Auditory Hallucinations during Intravenous Voriconazole Therapy

Voriconazole is a triazole with broad spectrum antifungal activity, and it is currently considered to be the first-line agent for the treatment of invasive aspergillosis. We report here on a case of visual and auditory hallucinations during intravenous treatment with voriconazole in association with a high trough level. A 28-year-old man with acute myelogenous leukemia was admitted for re-induction remission chemotherapy. During the persistent neutropenic fever, intravenous voriconazole was administered for the suspected invasive fungal pneumonia. He began to have visual hallucinations on the 1st day and auditory hallucinations on the 3rd day of voriconazole therapy. The plasma peak and trough concentration levels of voriconazole were 9.9 and 7.4 microg/ml, respectively, on the 3rd day. The hallucinations resolved after changing to amphotericin B deoxycholate, and the plasma concentration of voriconazole dropped to less than 0.5 microg/ml. The genotype of the CYP2C19 alleles was classified as a heterozygous extensive metabolizer. We suggest that therapeutic drug monitoring of voriconazole is indicated for a case that is suspicious for a voriconazole-related adverse event.

The Korean collaborative study on 11,000 prenatal genetic amniocentesis

Since amniocentesis made prenatal diagnosis feasible in 1967, the method has been remarkably instrumental in obstetrical practice. A recent study conducted between 1980 and 1997 collected 11,000 amniocentesis procedures done at 10 university hospitals and tertiary centers in Korea. The study indicated that the use of amniocentesis on patients has increased steadily since 1980; however, the number has increased sharply for patients in the mid 1990's. In the 1980's, amniocentesis had been used primarily for patients in advanced maternal age groups (at least 35 years or older). In 1995, amniocentesis had been implemented for the detection of abnormal serum markers (37.6%), and by 1997, amniocentesis was involved in such diagnosis even more frequently (44.8%). Of the total number of uses, 270 (2.5%) involved the detection of chromosomal anomaly. In autosomal disorders, 96 Down syndrome, 33 Edward syndrome, and 6 Patau syndrome were diagnosed. In sex chromosomal anomaly, 10 Turner syndrome, and 10 Klinefelter syndrome were diagnosed. Added to that, 83 translocations, and 15 mosaicisms were diagnosed. Of the 322 cases with abnormal ultrasonographic findings, 21 (6.5%) resulted in chromosomal anomaly. The use of genetic amniocentesis as a prenatal diagnostic test for Korean women has risen 10-fold between 1988 and 1998. As stated earlier, amniocentesis had earlier been used primarily for those in advanced maternal age groups. Today, maternal serum markers and highly sensitive ultrasonic technology can detect many fetal anomalies which eventually necessitate amniocentesis.

Prenatal Diagnosis with Genetic Amniocentesis / 대한주산의학회잡지

OBJECTIVE: Amniocentesis for the diagnosis of prenatal genetic abnormalities is now the standard care for women who are at special risk. because the application of population-based maternal serum screening to prenatal diagnosis is now widespread, we can estimate the trend change of amniocentesis indications. METHODS: Four hundred twenty eight women who were attending the antenaltal clinic of Hanyang University Hospital had a amniocentesis between January 1992 and June 1997. The result were analyzed in reference to indication of amniocentesis, gestational age, pregnancy outcome and karyotype. RESULT: The major indications were abnormal maternal serum marker(53.3%), advanced maternal age(23.8%), previous fetal chromosomal anomaly(7.9%) and the most common age distribution at amniocentesis was 25-29 years(37.9%). The pregnancy outcome was full-term delivery(84.2%), preterm delivery(13.7%), spontaneous abortion(1.4%) and termination of pregnancy(0.7%). Among the 33 cases(7.7%) of abnormal karyotype, structural aberration was 21 cases(4.9%) and numerical aberration was 12 cases(2.8%). Among the numerical aberration, six cases of trisomy 21, five cases of Klinefelter syndrome, and one case of Turner syndrome were found. Among the structural aberration, insertion was most common(nine cases), and seven cases of inversion, four cases of translocation and one case of deletion were found. CONCLUSION: This is a report of genetic amniocentesis, with analysis of the indication, gestational age, karyotype results and complication.

Prenatal Diagnosis with Genetic Amniocentesis / 대한주산의학회잡지

OBJECTIVE: Amniocentesis for the diagnosis of prenatal genetic abnormalities is now the standard care for women who are at special risk. because the application of population-based maternal serum screening to prenatal diagnosis is now widespread, we can estimate the trend change of amniocentesis indications. METHODS: Four hundred twenty eight women who were attending the antenaltal clinic of Hanyang University Hospital had a amniocentesis between January 1992 and June 1997. The result were analyzed in reference to indication of amniocentesis, gestational age, pregnancy outcome and karyotype. RESULT: The major indications were abnormal maternal serum marker(53.3%), advanced maternal age(23.8%), previous fetal chromosomal anomaly(7.9%) and the most common age distribution at amniocentesis was 25-29 years(37.9%). The pregnancy outcome was full-term delivery(84.2%), preterm delivery(13.7%), spontaneous abortion(1.4%) and termination of pregnancy(0.7%). Among the 33 cases(7.7%) of abnormal karyotype, structural aberration was 21 cases(4.9%) and numerical aberration was 12 cases(2.8%). Among the numerical aberration, six cases of trisomy 21, five cases of Klinefelter syndrome, and one case of Turner syndrome were found. Among the structural aberration, insertion was most common(nine cases), and seven cases of inversion, four cases of translocation and one case of deletion were found. CONCLUSION: This is a report of genetic amniocentesis, with analysis of the indication, gestational age, karyotype results and complication.

A Case of Partial Trisomy 5q

No abstract available.