The Evolution of Lupus Activity among Patients with End-Stage Renal Disease Secondary to Lupus Nephritis

The aim of this study was to evaluate the evolution of lupus activity in end-stage renal disease (ESRD) patients due to lupus nephritis and to determine the long-term prognosis. We reviewed the clinical courses of 45 patients with ESRD due to systemic lupus erythematosus (SLE). We analyzed the course of SLE following the onset of ESRD, with special attention to the clinical and serological manifestations, survival time on dialysis, and renal transplantation outcome. Disease activity was measured using the SLE Disease Activity Index (SLEDAI). Of the 45 patients, 21 patients were being treated with hemodialysis (HD), 11 were undergoing peritoneal dialysis (PD), and 13 underwent transplantation. Duration of follow- up was 53 +/- 29 months. The SLEDAI score on commencement of renal replacement therapy was not significantly different among the 3 groups (HD: 4.2 +/- 4.2, PD: 4.3 +/- 2.3, Transplant: 3.2 +/- 1.9). However, disease activity scored by follow-up maximal SLEDAI during dialysis or transplantation showed a significant increase after peritoneal dialysis (HD: 5.0 +/- 3.6, PD: 7.4 +/- 3.7, Transplant: 2.2 +/- 1.7, p < 0.05). When the individual changes in the maximal SLEDAI score were considered, a significant increase was apparent after peritoneal dialysis (p < 0.05), but not after either hemodialysis or renal transplantation. There was no significant difference in cumulative survival rate, and also in technique or graft survival rates of the 3 groups. Among the variables tested, follow-up maximal SLEDAI score was the only significant factor associated with patient survival (odds ratio: 1.15, p < 0.05). The incidence (36% versus 19%) of high disease activity was greater, but not significantly, in the peritoneal dialysis group, as compared to the hemodialysis group. Clinical activity of SLE was apparent in 65% of patients in the first year of dialysis, but none showed any activity after the third year of dialysis. We found that although lupus disease activity declined after patients progressed to ESRD, lupus disease activity still affected patients' survival. An incremental increase in postdialysis lupus activity was not uncommon, especially during the first one year of dialysis. During the follow-up period, maximal SLEDAI score increased significantly after peritoneal dialysis. However, the long-term prognosis was not significantly different according to the treatment modality.

Gastric Adenocarcinoma after Renal Transplantation

PURPOSE: The incidence of malignancy in renal transplant recipients has been reported higher than in the general population. Despite gastric cancer being the most common malignancy in Korea, little is known about the incidence of gastric cancer after renal transplantation. This study was performed to find out the incidence and clinicopathological features of gastric cancer after renal transplantation in an endemic area for gastric adenocarcinoma. METHODS: Between April 1979 and March 2001, 11 gastric adenocarcinoma patients out of 2000 renal transplants at a single institute were reviewed retrospectively. RESULTS: In 5 male and 6 female patients with a mean age of 46.1 years (0.55% of kidney transplanted patients), stomach cancer occurred about 59 months after renal transplantation. Nine patients underwent a gastric resection with a curative intent while 2 with distant metastasis were treated symptomatically. None of the patients received any type of adjuvant therapy. There was no postoperative mortality although there were two postoperative complications, which were treated conservatively. Five patients survived without any evidence of recurrence, whereas 6 died due to recurrences or progression of gastric cancer. Three patients with early gastric cancers remain alive while all 4 stage IV patients died within 4 months of diagnosis. CONCLUSION: Renal transplant recipients are at an increased risk of a gastric adenocarcinoma, the most common malig nancy in Korea. With curative surgery, a favorable prognosis can be anticipated in patients with early gastric cancer after renal transplantation unless there is their diagnosis. Every effort for the early diagnosis should not be overlooked during the follow-up period. However, considering the worse prognoses and the more aggressive behaviors of advanced gastric cancer in renal transplant recipients, the value of adjuvant chemotherapy should be evaluated in the near future.

Comparative Study of Renal Replacement Therapy in Korean Diabetic End-Stage Renal Disease Patients: a Single Center Study

The number of diabetic ESRD patients has increased and death rates of diabetic patients on hemodialysis (HD), peritoneal dialysis (PD) and renal transplantation (RT) have remained higher than the death rate of non-diabetic patients. An attempt was made to compare the clinical characteristics, patients' cumulative survival, and technical survival among the three groups retrospectively according to the mode of renal replacement therapy (RRT), and to analyze the risk factors associated with mortality. A total of 229 diabetic ESRD patients diagnosed between 1986 and 1995 at the Severance Hospital who began dialysis or who underwent a kidney transplant were included and their medical charts were reviewed. Hypertension was the most common co-morbid disease in all study groups. The prevalence of cardiovascular disease was the only co-morbid condition that was significantly different among the three groups, which was highest in the PD group (24.4%) and lowest in the RT group (8%). In the analysis of a patient's cumulative survival rate not adjusted for age and sex, the RT group had the highest survival rate, and the cumulative survival rate of the HD and PD group were similar. The 5-year survival rate of the patients treated with HD, PD and RT was 28.8%, 19.8%, and 72.0%, respectively. No differences were observed in the patient's cumulative survival rate between the HD and PD patients even when it was adjusted for age. When adjusted for age, sex and risk factors, the relative death rate of the RT group was significantly lower in male patients younger than 60 years of age. With the exception of male patients younger than 60 years of age, the PD group showed a slightly lower relative death rate although it was not significant. The multiple Cox regression analysis of patient survival showed that age, serum albumin, BUN, mean hospital days, the presence of cardiovascular disease at the initiation of RRT were associated with mortality. The analysis of the technique survival rate revealed a better result in the HD group compared to PD group, but a limitation in being able to investigate the AVF function disturbed the accuracy of the analysis of technical survival rate. In conclusion, the survival rate between the PD and HD patients was not different and the RT group had the best survival rate. Therefore, kidney transplantation in diabetic ESRD patients should be considered positively if no other contraindicated condition for RT exit.

Coronary Angiographic Findings and Risk Factors for Coronary Artery Occlusive Disease in Renal Transplant Patients with Clinically Suspected Ischemic Heart Disease / 대한이식학회지

PURPOSE: Cardiovascular disease is a substantial health problem in renal transplant patients, and ischemic heart disease is a leading cause of death in these patients. Renal transplant patients have many conventional risk factors for atherosclerotic coronary artery diaese, including hypertension, hyperlipidemia, and posttransplant diabetes mellitus. This study were to evaluate the prevalence of angiographically-determined coronary artery occlusive disease (CAOD) in renal transplant patients, and to identify the risk factors for significant coronary artery disease. METHODS: The retrospective study were performed in 36 patients with renal transplantation who underwent coronary angiography to diagnose ischemic heart disease. RESULTS: A total of 36 recipients (27 males, 9 females) were studied and the mean age was 51.5 years. Significant CAOD was identified in 69% of patients (1-vessel: 19%, 2: 25, 3: 25). By univariate and multivariate logistic regression analysis, the association of clinical variables with CAOD was assessed. The interval between the diagnosis of end-stage renl disease and renaltransplantation was an independent risk factor (P<0.05). The variables such as old age, acute rejection episodes, cholesterol level, as well as the presence of obesity, and D.M,. were not associated. CONCLUSION: The prevalence of angiographically-determined CAOD in renal transplant recipients is 69%. The risk of CAOD seems to be increased in recipients with long duration of dialysis before transplantation. The early or preemptive transplantation could be recommended for preventing CAOD in renal transplantation candidates.

Effect of Mycophenolic Acid on Human Vascular Smooth Muscle Cell Proliferation and Its Signal Transduction

PURPOSE: Vascular smooth muscle cells (VSMCs) migration and proliferation play important roles in chronic allograft rejection. Mycophenolic acid (MPA) inhibits the proliferation of VSMCs, glomerular mesangial cells and fibroblasts as well as lymphocytes. Since reactive oxygen species (ROS) and mitogen-activated protein kinase (MAPK) play important roles in the proliferation of VSMCs, the present study examined the effects of MPA on intracellular ROS generation, activation of ERK and p38 MAPK, and the proliferation of VSMCs cultured under platelet derived growth factor (PDGF). METHODS: Human VSMCs obtained from ATCC were cultured with RPMI-1640 containing 10% fetal bovine serum. Near confluent VSMCs were incubated with serum-free media for 48 hours to arrest and synchronize the cell growth. MPA was administered 1 hour before the addition of PDGF. 5-(and-6)- chloromethyl-2',7'-dichlorodihydrofluorescein (DCF)-sensitive intracellular ROS was detected by FACS. Activations of ERK1/ERK2 and p38 MAPK were measured by Western blot analysis. Proliferation of VSMC was assessed by [(3)]. RESULTS: PDGF administered at 10 ng/ml, which induced human VSMCs proliferation, rapidly increased intracellular ROS by 1.6-fold (P<0.05), ERK1/ERK2 activation by 2.1-fold, (P<0.05) and p38 MAPK activation by 1.9-fold (P<0.05), respectively, as compared to the control. MPA 1 and 10nM effectively inhibited PDGF-induced human VSMCs proliferation. MPA also effectively inhibited PDGF-induced intracellular ROS generation as well as ERK1/ERK2 and p38 MAPK activation. CONCLUSION: The present study suggests that MPA inhibits PDGF-induced human VSMCs proliferation, possibly by inhibiting intracellular ROS generation and the phosphorylation of ERK1/ERK2 and p38 MAPK. H]-thymidine incorporation.

Diffuse Glomerular Basement Membrane Lamellation in Post-Transplant IgA Nephropathy

Diffuse glomerular basement membrane (GBM) lamellation, reminiscent of Alport's syndrome, has rarely, and exclusively, been reported in renal allografts from pediatric donors to adult recipients. We report on a similar lesion, identified in a 42-year-old male, who received a kidney from an unrelated 21-year-old living male donor. The disease of the recipient was unknown. Renal allograft biopsies were performed 3.5 and 4.8 years after the renal transplantation, due to massive proteinuria and serum creatinine elevation. The histological features of both biopsies were similar, but more advanced in the second biopsy. Glomerular mesangium was widened and had an IgA deposit in the first biopsy. In addition to the presence of mesangial electron dense deposits, the GBM showed diffuse lamellation and splintering on the subepithelial side, but no definite deposits. In the second biopsy, IgA deposits were extended to the peripheral capillary walls, but electron microscopic examination was not available. Two months after the second biopsy, the patient returned for hemodialysis.

Diffuse Glomerular Basement Membrane Lamellation in Post-Transplant IgA Nephropathy

Diffuse glomerular basement membrane (GBM) lamellation, reminiscent of Alport's syndrome, has rarely, and exclusively, been reported in renal allografts from pediatric donors to adult recipients. We report on a similar lesion, identified in a 42-year-old male, who received a kidney from an unrelated 21-year-old living male donor. The disease of the recipient was unknown. Renal allograft biopsies were performed 3.5 and 4.8 years after the renal transplantation, due to massive proteinuria and serum creatinine elevation. The histological features of both biopsies were similar, but more advanced in the second biopsy. Glomerular mesangium was widened and had an IgA deposit in the first biopsy. In addition to the presence of mesangial electron dense deposits, the GBM showed diffuse lamellation and splintering on the subepithelial side, but no definite deposits. In the second biopsy, IgA deposits were extended to the peripheral capillary walls, but electron microscopic examination was not available. Two months after the second biopsy, the patient returned for hemodialysis.

The Results of Renal Transplantation after Lymphocyte Cross-match Negative Conversion by Combination Therapy with Plasmapheresis, Intravenous Gamma Globulin and Potent Immunosuppresants in Patients with Positive LCM / 대한이식학회지

PURPOSE: It is well-known that kidney transplantation cannot be done if recipient has circulating antibodies showing positive lymphocyte cross-match (LCX) to organ donor. In the United States and European countries, the incidence of positive LCX to cadaveric donors in patients who are on the waiting list is up to 20~40%. Unfortunately, these patients also show high rate of positive LCX to live donors when they have donor candidates in their family members and have to be on dialysis until compatible donor comes up. Recently, Eugene J Schweitzer and his associates at the University of Maryland used the combination therapy with plasmapheresis, intravenous gamma globulin and potent immunosuppression to induce negative conversion of LCX in patients who were LCX positive to their living donors and reported the good results after the trial. We did the combination therapy in patients who had positive LCX to their living donors and reported the results. METHODS: Seven patients, four women and three men who showed positive LCX to their living donors, underwent the conversion trials between January 1 and July 31, 2002. The mean age of patients was 43.86 (35~60) and the duration of dialyses varies from 9 to 120 months. We used combination therapy with plasmapheresis, intravenous gamma globulin injection, tacrolimus, mycophenolate mofetil (MMF) and steroids. Plasmapheresis had been done on every other day up to 6 times to induce negative conversion of LCX. If patient continue to show positive LCX to donor after 6 times of plasmapheresis, we stopped the therapy. The numbers of plasmapheresis varies from two to six times. Kidney transplantations were preformed immediately after negative conversion of LCX as a semi-elective procedures. Five to ten day courses of ATG (or OKT3) were used as an induction immunosuppression after transplantation and tacrolimus, MMF, and steroids were used as a maintenance immunosuppression. RESULTS: We could achieve negative conversion of LCX in six out of seven patients, and kidney transplantations were performed in these 6 patients successfully. There was no hyperacute rejection during the operations, but three patients developed acute rejection episodes during their early postoperative periods. Steroid pulse therapies were used as a primary therapy to treat acute rejection and all three patients showed complete recovery of their graft function after the treatments. Baseline serum creatinine level varies from 1.0 mg/dl to 1.9 mg/dl with 3 to 6 months follow-up periods after transplantations. We could not induce negative conversion in one patient and he remained on hemodialysis. CONCLUSION: We did successful kidney transplantations in six patients who achieved negative conversion of LCX to their donors after the combination therapy with plasmapheresis and potent immunosuppression. All patients showed excellent graft function since their operations and did not have any significant complications except three reversible acute rejection episodes. According to the results, although it is preliminary, we recommend the use of the combination therapy in patient who has LCX positive living donor. Further long-term study with more numbers of patients is needed for the evaluation of the efficacy of this trial.

Kidney Transplantation in Diabetic Patients: Clinical Study in a Single Center / 대한이식학회지

PURPOSE: End stage renal disease caused by diabetic nephropathy is increasing throughout the world. In earlier years, the results of kidney transplantation in diabetics were not as good as those in non-diabetics and the presence of diabetes has been considered as contraindication at many centers. But the survival rate of diabetic patients treated with transplantation has improved in recent years. In this study we compared the results of kidney transplantation in diabetic patients group with those of non-diabetic patients group. METHODS: We reviewed our experience in a single center with 1,386 kidney transplantation patients in non-diabetic patients, compared with 31 kidney transplantation patients in diabetic patients. The clinical characteristics such as age, sex, duration of diabetes mellitus, serum albumin, blood urea nitrogen, hemoglobin, glycated hemoglobin, creatinine clearance, and morbidity were retrieved from medical charts. RESULTS: For diabetic transplantation patients one- and five year patient survival were 92.3% and 84%; for non-diabetic transplantation patients one- and five year patient survival were 98.7% and 93.4%. It showed statistically significant differences in patient survival between two groups. We analyzed graft survival in two ways. When all deaths were not censored, the graft survival rate of diabetic transplantation patients was significantly lower than that of non-diabetic transplantation patients: 80.6% vs 85.8% at 5 years and 27.3% vs 68.6% at 10 years (P=0.04). But the graft survival rate did not differ significantly between the diabetic and non-diabetic patients when deaths were censored: 95% vs 91.7% at 5years and 63.3% vs 79.5% at 10 years (P=0.96) In the analysis of risk factors affecting patient mortality, presence of DM and graft loss were associated with mortality and its odds ratios were 8.94 and 6.33 respectively. CONCLUSION: The overall patient survival and graft survival were significantly worse in the diabetic transplantation patient group than the non-diabetic transplantation patient group. But graft survival was not different between two groups when death was censored. This means that graft survival in diabetic transplantation group is not different actually with non- diabetic transplantation group when comorbidities are fully evaluated and treated before transplantation.

Validity of C2 Monitoring of Microemulsion Cyclosporine in Early Renal Transplant Period / 대한이식학회지

PURPOSE: Four-hour area under the concentration-time curve (AUC0-4) was considered to be superior rather than C0 in predicting the development of acute rejection, and was reported most well correlated with C2 in post-transplant period. The purpose of this study was to demonstrate the correlation between AUC0-4 and each C0,1,2,3,4, and to compare C2 with C0 in predicting acute rejection in de-novo kidney recipients. METHODS: Fifty- six adult living donor kidney transplants were followed up 3 months after transplantation. Cyclosporine A (CsA) dose was adjusted with C0. AUC0-4 was measured on 5th and 19th post-operative day, and C2 as well as C0 was measured on post-operative 5, 12, 19, 30, 60, 90 days. RESULTS: Fifteen patients (26.8%) experienced acute rejection 12.0+/-10.9 (5~48) days after transplantation. CsA absorption pharmacokinetics was different with data based on Caucasian recipients. In more than 60% of patients, peak concentration (Cmax) was reached 2 hours after oral intake of CsA regardless the occurrence of acute rejection and postoperative days. AUC0-4 was most critically correlated with C2 on 5th and 19th post-operative days (R2>0.800, respectively). Recipients having acute rejection between 5th and 7th post-operative day, had statistically lowered AUC0-4, C2, C3 (P<0.05) compared with patients without acute rejection. CONCLUSION: In early post-transplant days, AUC0-4 was powerfully correlated with C2. Monitoring of C2 rather than C0 could predict the occurrence of acute rejection in this period. Value of C2 monitoring in Koreans beyond 7th day awaits further study by adjusting CsA dose with C2 rather than C0.

BK Virus Induced Interstitial Nephritis in Renal Transplants: Diagnosis, Treatment and Prognosis / 대한이식학회지

PURPOSE: It is difficult to differentiate BKV nephritis (BKVN) from acute rejection. We diagnosed 8 cases of BKVN in renal transplantation recipients. Herein, we report the clinical nature of BKVN in terms of diagnosis, treatment and prognosis. METHODS: Between June 1998 and September 2002, 8 cases of BKVN were confirmed by H and E stain, immunohistochemical study against SV40, and electron microscopy in renal allograft biopsy samples. Additionally, between April and September 2002, we obtained urine sample for urine cytology from 49 potential donors, 40 end-stage renal failure patients awaiting renal transplantation, and 140 renal transplant recipients who were hospitalized with variable causes and 32 renal transplants as a routine follow-up. RESULTS: In 7 male and 1 female patients, BKVN was diagnosed mean of 20.4 months after transplantation. The kind of immunosuppression they had been on were mycophenolate mofetil (6/8), azathioprine (1/8), cyclosporin (4/8), tacrolimus (4/8). Range of whole blood levels of cyclosporine and tacrolimus at the time of diagnosis of BKVN were 187.5~252.5 ng/ml and 11~16.5 ng/ml, respectively. Four patients had treated acute rejection episode, and in 6 patients, pathologically proven acute rejection was found concomitantly with BKVN. After reduction of net immunosuppression (discontinuation of MMF and AZA, dose reduction of cyclosporine or tacrolimus, and switch from tacrolimus to cyclosporine), renal function of 3 patients was fully recovered. However, 4 patients with delayed diagnosis lost grafts. In urine cytologic examination, 15 patients (one in end-stage renal failure patient, 10 in renal transplant recipients with elevated serum creatinine, 2 in patients with other infection, and 2 in other situation) were found to secrete decoy cell through urine. CONCLUSION: BKVN should be considered in the differential diagnosis of renal allograft dysfunction. Early diagnosis of BKVN and reduction of net immunosuppression can rescue the grafts. Monitoring of decoy cell in the urine cytology is a simple diagnostic tool both for screening of graft with dysfunction and follow-up of grafts after diagnosis and treatment of BKVN.

Risk Factors Affecting Long-term Outcome of Alport syndrome

PURPOSE: Alport syndrome is a hereditary nephrotic disease characterized by progressive nephrotic symptom, sensorineural hearing loss, ophthalmic abnormality, typical microscopic findings, and familial occurrence. In this study, we tried to find the risk factors related with its prognosis by taking a close observation on clinical symptoms of children with Alport syndrome reviewing retrospectively. MATERIALS AND METHODS: We chose children diagnosed as Alport syndrome in renal biopsy during 20 years(from 1980, Jan. until 1999, Dec.) who could receive follow up studies in the department of pediatrics. They were divided into two groups by comparing renal function at the time of diagnosis and at current status. We compared several clinical aspects in them, and applied nonparametric test for statistical analysis. RESULTS: The sex ratio(male:female) of 24 children was 3:1. The most common clinical symptom presented at their first visit was gross hematuria. Among those 24 children, 11 cases(46%) of progressing into chronic renal failure(Group II) were observed. Hypertension, proteinuria and edema were seen much frequently in group II. The level of serum protein, albumin, and creatinine clearance were decreased while BUN, creatinine were relatively increased. All the results were statistically significant. CONCLUSION: Clinically significant risk factors related to prognosis in Alport syndrome were the presence of hypertension, edema, and proteinuria at the time of diagnosis. Also, the level of serum protein, albumin, BUN, creatinine, and glomerular filtration rate were proved to be important factors in predicting prognosis. We believe that studies on these possible risk factors would be of great help in treating and predicting prognosis of children suffering with Alport syndrome.

Analysis of Risk Factors Affecting the Pediatric Renal Allograft Survival in Cyclosporine Era: A Single Center Study Based on 113 Renal Transplants / 대한이식학회지

Renal transplantation is now a well established mode of optimal therapy for children with end-stage renal disease. A total of 119 pediatric renal transplantations were performed during last 20 years but 6 cases (early 3 cases treated with azathioprine and most recent 3 cases) were excluded for this study. A total of 113 pediatric renal transplants out of total 1,906 kidney transplantation recipients receiving cyclosporine A and low dose prednisone as the main immunosuppressive agent were the subjects of this study to find out the risk factors which might influence the pediatric renal allograft survival in a single center. When the potential donor was living related, at least the HLA 1-haplotype matched relative was selected, but, when unrelated, at least DR-1/2 or A+B 2/4 matching was required for selection. Living related donation from parent, brothers, sisters (n=82), and unrelated donation (n=31) through the swap program or from fully motivated healthy volunteers were the major source of kidney for allograft. The mean age of the recipient was 14.1 years ranging from ages 2.1 to 19.9. During a mean follow-up of 68.1 months, there were 21 cases of graft loss, and 3 recipient deaths. The major causes of graft loss were acute and/or chronic rejection, poor compliance and patients death. The 1-, 3- and 5-year graft survival were 94.6%, 88.9% and 79.2% respectively. There was no significant difference between children and adult in graft survival rate. No significant graft survival difference between the related and unrelated donors (73.3 vs 77.2% at 5-year, p>0.05) was found. The significant risk factors for the outcome were the ABO compatibility (p=0.0001) and development of more than 1 episode of acute rejection within 6 month (p=0.01) and 1 year (p=0.0016). Graft survival decreased with increasing number of rejection episode within 6 month (p=0.009) and 1 year (p=0.002). Other factors such as recipients age, original kidney diseases, type and duration of dialysis before transplantation, combined native kidney removals did not influence the outcome of graft. And because of presence of only 2 cadaveric donor in this analysis, we could not demonstrate any benefit of living donor transplantation. In conclusion, pediatric renal transplantation in at least older children (>5 years) is encouraging. The outcome of pre- emptive renal transplantation is also promising. More aggressive ABO matching and effort for reducing the rejection episode within 6 months and 1 year might be important factors for the successful outcome of pediatric renal transplantation. So development and application of more effective immunosuppressive agents such as mycophenolate mofetil or rapamycin to reduce the rejection episodes is to be needed in near future.

Mycobacterial Infection after Kidney Transplantation: Single Center Experience / 대한이식학회지

PURPOSE: Transplant recipients under maintenance immunosuppression are likely to be exposed to mycobacterial infection that is associated with increased morbidity and mortality. METHODS: This review is based on the clinical data of 103 post-transplant tuberculosis recipients from the 1863 renal allograft recipients database between 1984 and 1999. Kinds of immunosuppression, history of acute rejection, use of anti-lymphocyte antibody, age and sex of recipient, presence of diabetes, presence of hepatitis B antigen pre- transplant, and history of pre-transplant tuberculosis were considered as potential risk factors for the development of post-transplant method and Cox proportional hazard model were used for the analyses. RESULTS: During 80 months of mean follow-up period, a total of 103 recipients were found to have tuberculosis (80 males and 23 females, mean age was 39.95+/-11.85 years old). Mean time interval from transplant to diagnosis of tuberculosis was 46+/-34.3 months. Cumulative incidence of tuberculosis post-transplant 5 and 10 year was 4.73 and nd culture for AFB, AFB-PCR, adenosine deaminase test, bronchoalveolar 7.76%, respectively, which were higher than that of the overall Korean population (0.8% in 1995). We a lavage and tissue biopsy (closed or bron-choscopic), and pleural tapping with biopsy. The treatment protocol was not different with regimens for general population. Duration of treatment differed from the clinical improvement (mean duration was 10.5 months). The pulmonary infection (including pleural effusion) was most common form of infection (n=71, 68.9%). Extra-pulmonary infection (including miliary tuberculosis) was 31.1% (n=32), which was higher than that of tuberculosis in Korean population (25% in 1998). In Cox regression analysis, previous history of tuberculosis was the strongest risk factor affecting the development of tuberculosis. Use of azathioprine-steroids or use of anti-lymphocyte antibody was also found to be a significant risk factor, respectively. Ten-year patient/graft survival rate in recipients with extra- pulmonary infection was 60.4/48.9, which was significantly inferior compared with those among the tuberculosis-free recipients (84.7/69.4%), or patients with tuberculosis limited to lung and pleura (81.1% and 56.6%). These differences were statistically significant (P<0.05, respectively). CONCLUSION: Taking considering that the pre-transplant tuberculosis history was strongest risk factor of post-transplant tuberculosis, strategy on the prophylaxis for tuberculosis should be planned.

Retroperitoneoscopy-Assisted Living Donor Nephrectomy: Recipient's Outcome / 대한이식학회지

PURPOSE: Laparoscopic living donor nephrectomy has recently been emerged as a very attractive measure to the standard open surgical procedure for kidney transplantation (KTx) because of many advantages. But it also has some disadvantages such as technical difficulty, impaired early graft function and expensiveness. To overcome this shortcomings, we developed a new surgical method of retroperitoneoscopy assisted live donor nephrectomy. The method has been reported as an attractive surgical methods with many advantages to donor. But, recipient`s outcome is also equally important in living donor kidney transplantation. METHODS: We retrospectively studied recipient`s outcome between patients who received living donor kidneys from conventional open nephrectomies (Group I, n=247) and retroperitoneoscopy assisted nephrectomies (Group II, n=82) at our institution from March 1, 1997 and July 30, 2000. We compared postoperative complication, patient and graft survival and graft function between two groups for 12 months retrospectively. RESULTS: Demographic data such as age, sex, kidney weight/body weight ratio; ABO compatibility; degree of HLA matching and method of immunosuppression were not different between two groups (p>0.05). Complications, such as delayed graft function, acute rejection, ureter complication, graft failure, patients motality were not different. For the evaluation of graft function, we measured serum creatinine level for 12 months after trasplantation. There also was no difference of graft function between two groups. CONCLUSION: Recipient's outcome in patient received kidney by retroperitoneoscopy assisted live donor nephrectomy was similar to those of patient received kidney by conventional operation.

Kidney Transplantation Due to Familial Focal Segmental Glomerulosclerosis in 4 Children with Identical HLA-A24 from 2 Families / 대한이식학회지

Focal segmental glomerulosclerosis (FSGS) is a relatively common glomerular disease which is known to be the final pathway of glomerular injuries caused by variable etiologies. There are some renal diseases that are known to have a tendency of familial inheritance such as adult polycystic kidney disease, thin glomerular basement membrane disease, and Alport's syndrome, nephrotic syndrome with many other diseases. Fanconi et al. described the familial occurrence of the nephrotic syndrome first. Since then, a number of other reports have described the cases of nephrotic syndrome within families, though only a handful of families were confirmed as FSGS with histologic evidence. Recently, reports of familial occurrence of FSGS are increasing in number. These patients have been found to be steroid-resistant and unresponsive to immunosuppressive drugs, and most of them progressed to the end stage renal disease. The specific factors leading to glomerular change are not clearly known, but a genetic predisposition has been postulated. A number of reports pointed out the importance of HLA type as a genetic factor related to the pathogenesis of FSGS but the genetic and immunological linkages in FSGS have not been clearly defined yet. We report cases with 4 patients in two unrelated families with HLA-A24 recovered from FSGS after kidney transplantation.

Malakoplakia in a Renal Allograft: A case report / 대한이식학회지

Malakoplakia is a rare inflammatory disease which usually involves the lower urinary tracts, especially in immunocompromised patients. The characteristic feature is parenchymal infiltration by macrophages, known as von Hansemann cells, and intra- or extracytoplasmic Michaelis-Gutmann bodies. We report a case of renal malakoplakia in a renal allograft patient. Renal allograft biopsy was performed 1.5 years posttransplantation under the impression of chronic rejection. By light microscopy, inflammatory infiltrate composed of many macrophages and Michaelis-Gutmann bodies were present in the renal medulla and accompanied by moderate tubular atrophy and interstitial fibrosis. (J Korean Soc Transplant 2001;15:256-258)

Reactivities of Commercial Antisera for HLA Typing / 대한임상병리학회지

BACKGROUND: The most common problem in HLA typing is unsatisfactory quality of the antisera, or a lack of understanding of their reactivities. Therefore, commercial antisera must be verified under the conditions applied in a particular tissue typing laboratory. METHODS: We evaluated the antisera reactivities of a commercial HLA-yping tray, Lymphotype HLA-BC 72 oriental, the lot 7220999, 7230100 (Biotest, Germany), in about 300 samples from organ transplant recipients and healthy potential donors. RESULTS: The relatively weak antisera were those that defined A26, A33, Cw5, Cw14, B46, B58, B64 and B71 etc. Some of these antisera were not indicated as 'weak reaction' in the test result catalogue. The reactivities of each antisera indicated as 'extra reaction' or 'sometimes missing' were various. CONCLUSIONS: As for antisera reactivities, the data obtained by a laboratory itself are necessary in addition to those in the test result catalogue. These data will be helpful for the correct interpretation for laboratories using same commercial kits.

Reactivities of Commercial Antisera for HLA Typing / 대한임상병리학회지

BACKGROUND: The most common problem in HLA typing is unsatisfactory quality of the antisera, or a lack of understanding of their reactivities. Therefore, commercial antisera must be verified under the conditions applied in a particular tissue typing laboratory. METHODS: We evaluated the antisera reactivities of a commercial HLA-yping tray, Lymphotype HLA-BC 72 oriental, the lot 7220999, 7230100 (Biotest, Germany), in about 300 samples from organ transplant recipients and healthy potential donors. RESULTS: The relatively weak antisera were those that defined A26, A33, Cw5, Cw14, B46, B58, B64 and B71 etc. Some of these antisera were not indicated as 'weak reaction' in the test result catalogue. The reactivities of each antisera indicated as 'extra reaction' or 'sometimes missing' were various. CONCLUSIONS: As for antisera reactivities, the data obtained by a laboratory itself are necessary in addition to those in the test result catalogue. These data will be helpful for the correct interpretation for laboratories using same commercial kits.

Serum Neuron Specific Enolase as Early Prognostic Marker of Neurologic Outcome after Cardiac Arrest

BACKGROUND: The purpose of this study was to determine that the assessment of serum neuron specific enolase(NSE) could provide a reliable early predictor of neurologic outcome after cardiac arrest. METHODS: Prospective, observational study was performed from April 1996 to March 1998 at a university teaching hospital ED. Serum NSE concentrations were analysed twice at 24 and 48 hours after return of spontaneous circulation(ROSC). Neurologic outcome was categorized using cerebral performance category(CPC). RESULTS: Twenty-nine patients(16 were men) were enrolled during the study period. The mean age was 50.8 years. Nine(31%) of them showed good outcome defied as CPC 1-3, and 20(69%) patients showed bad outcome defied as CPC 4-5. In the good outcome group, the serum NSE was revealed 33.8+/-9.3 ng/ml at 24 hours, 34.0+/-4.73 ng/ml at 48 hours. While in the bad outcome group, it was 99.5+/-11.7 ng/ml and 114.6+/-15.8 ng/ml. The NSE at 48hr after ROSC was more prescise than that of 24hr. When the cutoff value of 50 ng/ml at 48 hr, the sensitivity was 82%, and specificity was 93%. CONCLUSION: This study suggest that the serum NSE may represent a valuable, noninvasive, and useful clinical tool for prediction of neurologic outcome after cardiac arrest.