Allograft dysfunction and parenchymal necrosis associated with renal artery stenosis and perigraft hematoma after kidney transplantation.

Transplant renal artery stenosis (TRAS) is one cause of allograft dysfunction. TRAS causes parenchymal necrosis and graft insufficiency. Herein, we report the case of a 40-year-old female with end-stage renal disease due to immunoglobulin A nephropathy, who underwent kidney transplantation with her elder sister. The surgery was successful and the allograft showed primary graft function. At postoperative day (POD) 2, urine output decreased sharply. We checked a non-enhanced abdominal computed tomography scan which showed subcapsular and pelvic cavity hematomas. She underwent hematoma removal surgery with renal upper polar capsulotomy. Bleeding control was successful, but her serum creatinine was 5.4 mg/dL. At POD 25, abdomen magnetic resonance angiography showed significant stenosis at the anastomosis site between the graft renal artery and the recipient's internal iliac artery. Then, percutaneous transluminal angioplasty was implemented. Significant stenosis (>80%) was detected at the anastomotic site and a 5-mm stent was inserted at stenotic lesion with post-stent balloon angioplasty using a 5-mm balloon catheter. The renal arterial diameter and blood flow were normalized. At postoperative 5 months, a 99mTc dimercaptosuccinic acid scan showed multiple focal radioisotope defects. At 54 months after renal transplantation, her serum creatinine level was 4.0 mg/dL and her glomerular filtration rate was 13 mL/min/1.73 m2. Hence, we report that TRAS can cause parenchymal necrosis and allograft dysfunction.

Long-term Survival Analysis of Kidney Transplant Recipients Receiving Mizoribine as a Maintenance Immunosuppressant: A Single-Center Study.

BACKGROUND: Mizoribine (MZR) has been developed as an immunosuppressant and is widely used in Asia. However, most studies on MZR have been performed in Japan, and there remains a lack of reports on long-term use in other countries. The purpose of this study is to evaluate the efficacy and safety of MZR's use in Korean kidney transplant recipients by observing their clinical courses and analyzing their long-term patent and graft survival rates. METHODS: We studied 129 subjects who had received MZR as a maintenance immunosuppressant since January 2000. Our analysis was based on the patients' medical records from January 2000 to December 2017. RESULTS: The overall survival rates of the kidney transplant recipients were 100% at 1 year, 99.1% at 5 years, 96.8% at 10 years, and 92.5% at 15 years. The graft survival rates were 100% at 1 year, 98.3% at 5 years, 93.2% at 10 years, and 82.2% at 15 years. There were differences in the recipient survival and graft survival rates according to the kidney donor and the use of renal replace therapy before transplant. There were no differences in the survival rates according to the MZR dose, the type of underlying disease, or other clinical factors. CONCLUSIONS: The use of low doses of MZR as a maintenance immunosuppressant could be an effective means of ensuring relatively good long-term patient and graft survival rates in cases of kidney transplant.

Efficacy and Safety of Ultra-Low-Dose Valganciclovir Chemoprophylaxis for Cytomegalovirus Infection in High-Risk Kidney Transplantation Patients.

INTRODUCTION: Valganciclovir (VGCV) prophylaxis of 900 mg twice daily for 6 months is recommended to prevent cytomegalovirus (CMV) infection, which is a major cause of decreased graft and patient survival in kidney transplant recipients. However, recent studies have shown the efficacy of 900 mg once daily for 3 to 6 months. Maintaining VGCV compliance is difficult because of high drug costs and side effects, such as thrombocytopenia and leukopenia. Therefore, we studied the efficacy of ultra-low dose, short-duration VGCV (450 mg every other day for 3 months) in preventing CMV infection in ABO-incompatible (ABOiKT) and deceased donor kidney transplant (DDKT) recipients. METHODS: We retrospectively reviewed the medical records of all kidney transplant patients > 18 years old treated at Bong Seng Memorial Hospital from June 2009 to July 2016 who received ultra-low-dose VGCV prophylaxis (450 mg every other day for 3 months). The review included 74 CMV seropositive donor/seropositive recipient (D+/R+) ABOiKT and 78 CMV D+/R+DDKT recipients. The primary outcome was occurrence of CMV infection. Secondary outcomes were graft and patient survival and hematologic side effects. RESULTS: Mean prophylaxis and follow-up were 3 and 98 months, respectively. CMV disease occurrence was significantly higher in DDKT than in ABOiKT (12 cases, 8.1%, vs 1 case, .7%, P < .01). There were no significant differences in patient survival rate, graft survival rate, or hematologic side effects between the groups. CONCLUSION: Ultra-low-dose VGCV prophylaxis to prevent CMV infection is effective in ABOiKT, but other treatment protocols are needed for DDKT patients.

Placement of tunneled cuffed catheter for hemodialysis: Micropuncture kit versus Angiocath IV catheter.

INTRODUCTION: Tunneled cuffed catheters provide stable, instantaneous, long-term intravenous access for hemodialysis. Because catheterization is often performed in emergency situations, speed and accuracy are emphasized. METHODS: We retrospectively compared the Micropuncture kit with the standard 18-gauge Angiocath IV catheter for tunneled cuffed catheter insertion in the right jugular vein. From June 2016 to May 2017, 31 tunneled cuffed catheters were successfully inserted via the Micropuncture kit and another 31 via the Angiocath IV catheter. All patients underwent the same ultrasound-guided procedure performed by a single experienced interventionalist. Procedure time was the time from draping of the patient to the completion of povidone dressing after the catheterization. In our center, the Angio Lab nurse maintains records, including procedure time and method for every procedure. All patient records were retrospectively tracked through electronic medical record review. The primary outcome was procedure time and the secondary outcomes were complications and cost-effectiveness. RESULTS: There were no significant differences in the patients' demographic data between the two groups. However, procedure time was significantly shorter in the Angiocath group than in the Micropuncture group (12.4 ± 3.5 vs 17.6 ± 6.9 min, p = 0.001); there were no serious complications, such as hemorrhage, pneumothorax, or hematoma, in both groups. Moreover, cost-effectiveness was better in the Angiocath group than in the Micropuncture group (0.34 vs 52 US$, p < 0.01). CONCLUSIONS: Using the Angiocath IV catheter can reduce procedure time and cost with no severe complications. Moreover, experienced practitioners can reduce the risk of complications when using Angiocath. There are several limitations to this study. First, it was retrospective; second, it was not randomized; and finally, it was conducted by only one experienced interventionalist.

Treatment of acute antibody-mediated rejection using bortezomib: a case report.

Here we report the successful treatment of acute antibody-mediated rejection (AMR) with bortezomib. Bortezomib rescue treatment was administered after a 42-year-old woman failed to respond to steroid pulse and plasmapheresis with intravenous immunoglobulin (IVIG). The patient underwent a second renal transplantation with a deceased donor kidney. She was treated pre-operatively with rituximab (200 mg/body) and underwent plasmapheresis twice (day-1 and operation day) because ELISA screening revealed that her pre-operative peak panel reactive antibody (PRA) composition was 100% class I and 100% class II and 15 times of cross-match positive history during the waiting period for transplantation. The patients received induction therapy with Simulect (an IL-2-blocking agent). A 1-hour protocol biopsy revealed C4d-positivity and mild peritubular capillary inflammation. This was suggestive of early AMR-associated changes. After transplantation, the patient underwent plasmaphereses (nine times) with low-dose IVIG (2 mg/kg). Despite this treatment regimen, serum creatinine levels increased to 3.4 mg/dL on post-transplant day 15. A second graft biopsy was performed, which showed overt AMR with glomerulitis, peritubular capillary inflammation and no C4d deposition. On post-operative day (POD) 22, treatment with four doses of bortezomib (1.3 mg/m(2) ) was initiated with the patient's consent. On POD 55, renal function had recovered and serum creatinine was 1.5 mg/dL. In summary, bortezomib was administered as a rescue treatment for a patient who developed AMR that was refractory to a combination of plasmaphereses with low-dose IVIG and preemptive administration of rituximab.

Graft rupture after high-dose intravenous immunoglobulin therapy in a renal transplant patient.

Cases of life-threatening thromboses in pulmonary, coronary, cerebral and peripheral vessels are associated with high-dose intravenous immunoglobulin (IVIg) therapy that is generally considered safe. We experienced a patient with a renal graft rupture that developed after high-dose IVIg was administered for desensitization. A needle biopsy performed 4 days prior to the rupture revealed the presence of glomerular thrombosis and mesangiolysis. The ruptured nephrectomy specimen contained renal infarction around the haemorrhagic segment and arterial wall thickening with intimal fibrosis. This might have contributed to rupturing associated with small arterial and glomerular arteriolar thrombi. This is the first case of a graft rupture as a complication of high-dose IVIg we have encountered.