Outcome of Cadaveric Kidney Transplantation from Expanded Criteria Donors / 대한내과학회지

BACKGROUND/AIMS: The Korean Network for Organ Sharing (KONOS) was established in 2000, and the KONOS criteria for expanded-criteria donors (ECD) have since been applied to kidney allocation from deceased donors. The outcome of cadaveric kidney transplantation from ECD according to KONOS criteria has not been investigated. METHODS: Seventy-seven cadaveric kidney transplants from January 2003 to December 2009 were recruited retrospectively. Factors that influence the glomerular filtration rate (GFR) of graft kidneys up to 36 months after transplantation were evaluated. Postoperative renal function and allograft and patient survival in the ECD group (n = 28) were compared with those in the standard-criteria donor (SCD) group (n = 49). RESULTS: The GFR of graft kidneys was different according to donor GFR, age, hypertension history, and cause of brain death. In the ECD group, GFR was lower than that in the SCD group by KONOS criteria. No differences in allograft or patient survival were observed until 3 years after kidney transplantation. CONCLUSIONS: Cadaveric kidney transplantation using the ECD by KONOS criteria is acceptable in term of graft and 3-year patient survival, although the GFR was lower in the ECD than in the SCD group.

Sustained Low-Efficiency Dialysis as an Alternative Therapy to Continuous Renal Replacement Therapy in Critically Ill Patients with Acute Kidney Injury / 대한신장학회지

PURPOSE: Although continuous renal replacement therapy (CRRT) is commonly used as a renal replacement therapy in critically ill patients with acute kidney injury, it has some disadvantages such as inconvenience, intensive labor, expensiveness and high bleeding risk. Recent studies have shown that sustained-low efficiency dialysis (SLED) can overcome these shortages of CRRT and also has the advantages of CRRT. We prospectively compared the efficiency, safety, cost and convenience between SLED and CRRT, and evaluated whether SLED could be a complementary substitute to traditional CRRT. METHODS: Forty-six critically ill patients with acute kidney injury (AKI) from 2003 to 2005 were treated with SLED (n=25) and CRRT (n=21). The modality was tended to be selected randomly and based largely on availability of equipments and not on the clinical status of patients. Mann-Whitney rank-sum test, Fisher's exact test and chi-square test were used for statistics, and data were described as median value, range from 25th to 75th. RESULTS: The Acute Physiology and Chronic Health Evaluation (APACHE) II score at the point of ICU admission was 27 for SLED (range 17-32, 25-75th percentile) and 26 for CRRT group (range 19-31) (p=NS). There were no significant differences between the two groups in mean arterial blood pressure when measured pre-dialysis (83 for SLED vs. 85 for CRRT; p=NS), mid-dialysis (90 vs. 84; p=NS) and at the end of treatment (88 vs. 80; p=NS). Incidences of hypotension also did not differ between the two groups (p=NS). Ultrafiltration volume per treatment day was similar in two treatment modalities (2,000 mL for SLED vs. 2,400 mL for CRRT; p=NS). Heparin was used to thirty-one patients (SLED: 18 patients, CRRT: 13 patients). The dosage of heparin tended to be lower in SLED (2,900 unit per day for SLED vs. 6,000 unit per day for in CRRT, p=0.065). Total clotting number was 4 for SLED and 11 for CRRT (p=NS). There was also no significant difference in hospital mortality between the two groups (56% for SLED vs. 42.9% for CRRT; p=NS). SLED was superior to CRRT in the aspect of cost and convenience. CONCLUSION: Our data suggest that SLED can be used as a useful substitute to traditional CRRT in critically ill patients with AKI.

Clinical characteristics of p-ANCA (anti-neutrophil cytoplasmic antibody)-related nephritis: a single center experience / 대한내과학회지

BACKGROUND/AIMS: We evaluated the clinical characteristics and prognostic value of the clinical, laboratory, pathologic features, at time of diagnosis, and the renal survival of patients with ANCA (anti-neutrophil cytoplasmic antibody)-related nephritis. METHOD: We retrospectively analyzed 17 patients who were diagnosed with ANCA-related nephritis at a single center. The risks of progression to ESRD or death according to the clinical parameters, the ANCA pattern and the renal pathologic findings were evaluated. RESULTS: The major symptoms were hematuria (100%), proteinuria (100%), uremic symptoms (41.2%), edema (35.5%), upper respiratory symptoms (29.4%) and oliguria (23.5%), which were not correlated with renal survival. All the patients showed a p-ANCA pattern. The BUN level (p=0.032) and GFR (p=0.023) at the time of diagnosis were different between the improved and the progressed patients in terms of renal function. The pathology indices were not predictive factors of both renal and patient survival. Eight patients (47.1%) were treated with steroid IV pulse, 4 (23.5%) with steroid IV pulse and cyclophosphamide IV pulse, 2 (11.8%) with steroid IV pulse, cyclophosphamide IV pulse and plasma exchange, and 2 (11.8%) with steroid IV pulse and plasma exchange. Fourteen patients (82.4%) needed hemodialysis. There were 3 (17.6%) disease-related deaths, 13 patients (76.5%) reached ESRD and 4 (23.5%) showed recovery of renal function. The mean percent of patients who survived was 80.2% and the mean percent of renal survival was 33.3% at the 1st and 3rd year, respectively. CONCLUSIONS: Poor renal function at presentation was associated with a high risk for disease progression, but age, gender, the clinical patterns of presentation and the pathologic findings were not associated with the prognosis. Early diagnosis and treatment seems to be essential to improve the renal outcomes.

Effect of Peritoneal Dialysis Duration on the Outcome of Peritonitis in CAPD Patients / 대한신장학회잡지

BACKGROUND: The clinical manifestations of peritonitis in long-term PD patients may be more severe due to structural and functional alterations of the peritoneum caused by repeated exposure to the bioincompatible dialysate. However, the study in which outcome of peritonitis was compared to the duration of PD has been reported rarely. This study was performed to evaluate the effect of PD duration on the outcome of peritonitis. METHODS: Medical records of patients cared for in Kyungpook University Hospital between June 1998 and May 2001 were reviewed retrospectively. Patients were divided into three groups by PD duration: group 1, or =37 months. RESULTS: There were 303 episodes (156 patients) of peritonitis during the study periods: 77 episodes in group 1, 115 episodes in group 2 and 111 episodes in group 3. There was no difference in gram- positive, gram-negative or fungal rate of peritonitis among three groups. In group 3, 16.2% of the patients transferred to hemodialysis, while 3.9% and 7.0% of patients in group 1 and 2 transferred to hemodialysis (p<0.05). CONCLUSION: Patients maintained on PD for over three years are associated with higher rate of technique failure than patients maintained on PD for less than three years. PD duration may be considered as a factor for predicting prognosis of peritonitis. Peritonitis in patients on long-term PD needs special attention.

A Case of Spontaneous Renal Artery Dissection with Renal Infarction in a Healthy Man Without Hypertension / 대한신장학회잡지

It is usually known that arterial dissection is associated with malignant hypertension, severe atherosclerosis or trauma. Marfan syndrome or Ehlers- Danlos syndrome may also be rare causes. However, as in this case, spontaneous arterial dissection without aortic dissection in normotensive men is rarely reported. A 39-year-old man presented with acute onset right flank pain with microscopic hematuria. Physical examination was unremarkable and his blood pressure was normal. Clinical impression was urolithiasis because he experienced two episodes of urolithiasis previously. IVP was not completed due to adverse reaction during study. Right renal infarction was diagnosed by contrast-enhanced computed tomography. To search for possible cardiac embolic disease, the patient underwent surface echocardiography, which was normal and a detailed evaluation for a thrombotic tendency was unremarkable. A renal arteriogram showed dissection of the main right renal artery with extension to renal artery branches and a wedge-shape perfusion defect in the distal part of the occluded artery. He received aorto-renal bypass surgery using his great saphenous vein. The patient developed hypertension 3 months later. To summary, we report a case of spontaneous renal artery dissection with renal infarction in a healthy man without hypertension.

Significance of overnight D/P sodium test in continuous ambulatory peritoneal dialysis / 대한내과학회지

BACKGROUND: Standard PET (peritoneal equilibration test) is time consuming and it cannot reflect the water removal accurately because it measures solute transport by diffusion only. Thus, it is important to find parameters that can be used to predict both the diffusive permeability of peritoneal membrane and the peritoneal fluid removal. Sodium removal in CAPD is strongly related to the ultrafiltration and the recent study has suggested that dialysate sodium concentration at 240 minutes could reflect both peritoneal fluid removal and peritoneal transport characteristics. In this study, we investigated whether a single dialysate sodium test after overnight dwell could provide the same information as the standard PET and could reflect ultrafiltration failure. METHODS: A 9-hour overnight dwell study with 2L of 3.86% glucose dialysis solution was carried out in 48 clinically stable CAPD patients. All patients underwent a PET test with 2L of 2.27% glucose solution in the morning after an overnight dwell study. According to ultrafiltration (UF) failure (net UF<100 mL/4 hour on 2.27% glucose solution), patients were divided into two groups (group I, UF failure group; group II, non UF failure group). D/P(Na540) and D(Na540) at the end of the 9-hour dwell were compared between two groups RESULTS: D/P(Na540) was significantly correlated with D/Pcreatinine (r=0.551, p<0.001) and drained volume (r=-0.536, p<0.001) at 240 minutes on PET. There was also a significant correlation between D/P(Na540) and drained volume (r=-0.555, p<0.001) at 540 minutes after overnight dwell. D(Na540) was significantly correlated with D/Pcreatinine (r=0.448, p<0.01) at 240 minutes on PET and also weakly correlated with drain volume at 240 minutes (r=-0.37, p<0.01). There was a significant difference in D/P(Na540) between the group I and group II (p<0.05), but not in D(Na540). CONCLUSION: Overnight 9-hour dwell study with 3.86% glucose solution is a simple procedure and easy to perform on outpatient basis. D/P(Na540) is comparable with PET results and may discriminate the different transport groups. D/P(Na540) may also be used as an indicator of ultrafiltration failure.

Comparison of the Survival Rates of Spousal Kidney Transplantation and Parental Donor Kidney Transplantation / 대한이식학회지

PURPOSE: The continuing shortage of donors has escalated the waiting times for kidney transplantation in most nations. In instances where first-degree relatives of the patient are not appropriate, living unrelated transplantations are considered as the next possible choice. In this category, genetically unrelated but emotionally related spouses are always preferred for organ donation rather than both genetically and emotionally unrelated donors. The aim of this study was to compare the results of parental donor kidney transplantation with spousal kidney transplantation. METHODS: Patient and graft survival were assessed with the Kaplan- Meier curve and statistical significance was determined by log-rank comparisons. RESULTS: In the spousal group, 1-, 3-, and 5-year graft survival rate were 84.6%, 72.3%, and 66.3%, in the parental donor group, 89.2%, 75.4% and 62.3% respectively. 1-, 3-, and 5-year patient survival rate were 84.6%, 80.4%, and 71.5% in the spousal group and 97.3%, 94.3% and 90.6% respectively in the parental donor group. Survival rate of grafts from spouses was comparable to that of parental-donor grafts, despite the average of 4.1 HLA mismatches in the spousal group, as compared with one haplotype sharing in the latter group (P<0.001) and higher donor age in the parental donor group (P<0.001). The survival rates were similar in the wife-to-husband and the husband-to-wife groups. CONCLUSION: While providing the couple with a better quality of life, spousal kidney transplantation also enables the couple to share the joy of giving and receiving the "gift of life" from one another. We believe that transplantation from a healthy volunteer spouse is a good alternative resource to years of dialysis while waiting for another donor that may never appear, to increase the donor pool and reduce the increasing length of waiting lists.

Nutrition and Dialysis Adequacy of Korean Patients on Long-term CAPD / 대한신장학회잡지

CAPD may have many negative impacts on nutritional status. Protein and caloric malnutrition are highly prevalent in chronic CAPD patients. In order to evaluate the relationship between nutritional and dialysis adequacy of long-term CAPD patients, twenty patients treated for aver 5 years on CAPD, with a mean age of 50.5+/-12.2 years and dialysis duration of 82.6+/-19.5 months(range 60-116) were studied. Fourteen of the twenty patients(70%) had no residual renal function(RRF). In these twenty patients the mean weekly Kt/Vurea and Ccr were 1.85+/-0.24 and 58.110.8L/week/1.73m2 with the median body surface area(BSA) of 1.61m2. Female(n=7) patients had lower BSA(1A7 vs 1.69m2), TBW(27.7 vs 35.6L), and higher serum albumin (4.01 vs 3.41g/dL), weekly Kt/Vurea(2.02 vs 1.76) than male(n=13) patients. Six patients had nPCR0.9 and nPCR was negatively correlated with age(r=-0.53, p or =3.5g/dL) and 6 had hypoalbuminemia(2.0 and Kt/Vurea was negatively correlated with BSA(r=-0.61, p<0.001). In conclusion, for Korean patients on long-term CAPD, small body size is the key for adequate dialysis and nutrition. Low serum albumin levels may be related with high peritoneal transport.

Malignancy Following Renal Transplantation / 대한이식학회지

PURPOSE: Survival rate after renal transplantation has increased after intense immunosuppressive agents and sophisticated operative techniques were introduced, but incidences of malignancy increase with time after transplantation. METHODS: We reviewed our experiences about post-transplant malignancy in patients who received renal allografts in our hospital from January 1981 to December 1999. The incidences and types of malignancy were analysed in 241 renal allograft recipients, who were followed-up for 1265 patient-years. RESULTS: Seven malignancies were found in 241 patients (2.9%). The mean age of these patients at diagnosis of malignancy was 45.5 years and the average interval between transplantation and diagnosis of malignancy was 34.9 (9.8-71.6) months. The types of malignancy were non-Hodgkin's lymphoma (n=2; CNS and nasal cavity), colon cancer with metastasis (n=2), in situ carcinoma of uterine cervix (n=1), follicular carcinoma of thyroid (n=1) and transitional cell carcinoma of bladder (n=1). Surgical resection was performed in 5 patients and 2 of them developed distant metastasis during follow-up periods. Radiotherapy was performed in 2 patients with non-Hodgkin's lymphoma and 1 patient with cord compression due to vertebral metastasis. Four patients are now alive and 3 of them have functioning renal allografts. CONCLUSION: We reviewed the incidences and types of post-transplant malignancy in our center and concluded that regular screening for malignancy and meticulous diagnostic approach for suspected symptoms or signs are important to immunosuppressed renal allograft recipients.