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Background: Carbapenemase-producing Enterobacteriaceae (CPE) can lead to life-threatening outcomes with rapid spread of the carbapenemase gene in solid organ transplantation (SOT) recipients because of limitations of available antibiotics. We examined the characteristics and importance of CPE acquisition in SOT recipients with large numbers of CPE isolates., Methods: Between November 2015 and October 2016, 584 CPE isolates were found in 37 recipients and verified by carbapenemase gene multiplex polymerase chain reaction (PCR). One hundred recipients with at least 2 negative results in carbapenemase PCR for stool surveillance and no CPE isolates in clinical samples were retrospectively included., Results: Most CPE isolates were Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (546, 93.5%). The most frequent transplantation organ was lung (43.3%), and the most common sample with CPE isolates other than stool was respiratory tract (22.6%). The median time between SOT and first CPE acquisition was 7 days. All-cause mortality was significantly higher in recipients with CPE than in those without CPE (24.3% vs 10.0%; P = .03). In multivariate regression analysis, stool colonization of vancomycin-resistant Enterococci and/or Clostridium difficile during 30 days before SOT (odds ratio [OR], 3.28; 95% CI, 1.24-8.68; P = .02), lung transplantation (OR, 4.50; 95% CI, 1.19-17.03; P = .03), and intensive care unit stay ≥2 weeks (OR, 6.21; 95% CI, 1.72-22.45; P = .005) were associated with acquisition of CPE., Conclusions: Early posttransplantation CPE acquisition may affect the clinical outcome of SOT recipients. Careful screening for CPE during the early posttransplantation period would be meaningful in recipients with risk factors., (Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The shortage of donor organs has been a major challenge in transplantation. In an effort to reduce the donor shortage, kidney transplantation (KT) using expanded criteria donors (ECD) was encouraged. In Korea, transplantation centers used the Korea Network for Organ Sharing (KONOS) ECD criteria, which is different from the United Network for Organ Sharing (UNOS) criteria. The aim of this study is to evaluate the predictive power of KONOS criteria on delayed graft function (DGF) in comparison to UNOS criteria., Methods: A total of 376 recipients who underwent deceased donor kidney transplantation between January 2005 and December 2014 at Severance Hospital were retrospectively reviewed. Of these, 130 cases satisfied KONOS ECD, while the others followed KONOS standard criteria donor (SCD)., Results: Donor age and history of hypertension was significantly higher with KONOS ECD than with KONOS SCD. In KONOS subgroup analysis, donor characteristics were different than with UNOS criteria. The incidence of DGF was higher in the KONOS ECD group than in the KONOS SCD group. However, UNOS ECD showed a high incidence of DGF compared to UNOS SCD with the same KONOS criteria. UNOS ECD was an independent risk factor for DGF in multivariate analysis. However, KONOS ECD was not a risk factor for DGF. Although glomerular filtration rate was inferior in the KONOS ECD group compared to the KONOS SCD group, the UNOS SCD group within the KONOS ECD group showed similar graft function compared to the KONOS SCD group., Conclusion: KONOS criteria have a lower predictive power for DGF than UNOS criteria., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Acinetobacter baumannii has become an increasingly important nosocomial pathogen. Carbapenem is the preferred drug of choice for treatment of multidrug-resistant gram-negative bacilli, but carbapenem-resistant A baumannii (CRAB) has now emerged. The aim of this study was to determine the incidence, outcomes, and risk factors for CRAB bacteremia in liver transplant recipients., Methods: The medical records of 393 subjects who underwent living donor liver transplant at Seoul St. Mary's Hospital from January 2008 to April 2015 were reviewed., Results: A total of 92 (23.4%) bacteremic patients, comprising 156 episodes, were identified. Fourteen patients, totaling 18 episodes, had CRAB bacteremia. The median time of emergence of CRAB bacteremia was 55.5 (range, 2-829) days after transplantation, and 72.2% of episodes (n = 13) occurred within 6 months of transplant. The presumed sources of infection were intra-abdominal (n = 11, 61.1%), biliary tract (n = 3, 16.7%), lung (n = 2, 11.1%), catheter (n = 1, 5.6%), and wound (n = 1, 5.6%). By multivariate analysis, length of post-transplant intensive care unit (ICU) stay (odds ratio [OR], 1.1, 95% confidence interval [CI], 1.11-1.15; P = .04) was associated with CRAB bacteremia. Overall mortality in 14 recipients with CRAB bacteremia was 50% (n = 7), but only 10% (30 of 301) in non-bacteremic patients and 20.5% (16 of 78) in other bacteremic patients excluding CRAB (P < .001)., Conclusion: In our study, patients with CRAB bacteremia after liver transplant showed an unfavorable outcome and, recently, CRAB has become an increasingly major pathogen at our center. Reducing the length of ICU stay could be a solution for preventing CRAB bacteremia., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Uncontrolled infections are known to be an absolute contraindication for liver transplantation; however, the posttransplant prognosis of recipients treated for pretransplant infection is unclear. The aim of this study was to analyze pretransplant infections among liver transplant recipients and to determine their impact on posttransplant clinical outcomes., Methods: This study retrospectively analyzed 357 subjects who had undergone living-donor liver transplantation between January 2008 and May 2014., Results: Among 357 recipients, 71 patients (19.8%) had 74 episodes of infectious complications before liver transplantation. These complications consisted of pneumonia (n = 13), spontaneous bacterial peritonitis (n = 12), catheter-related infection (n = 10), urinary tract infection (n = 12), biliary tract infection (n = 6), and skin and soft-tissue infection (n = 3). Twenty-six patients experienced 29 episodes of bacteremia, and the most common pathogens were coagulase-negative staphylococci (n = 8), followed by Klebsiella pneumoniae (n = 7), Staphylococcus aureus (n = 4), and Streptococcus species (n = 3). Twenty-one bacteremic episodes (70%) occurred within 1 month before transplantation (n = 4). Recipients with pretransplant infections had significantly more frequent posttransplant infections (71.8% [51 of 71] vs 47.2% [35 of 286]; P = .0001), posttransplant bacteremia (33.8% [24 of 71] vs 20.3% [58 of 286]; P = .015), and longer posttransplant intensive care unit stays (11.2 ± 10.7 days vs 7.3 ± 4.2 days; P = .0004) than those without pretransplant infections. However, episodes of rejection (P = .36), length of hospitalization (P = .10), 28-day mortality (P = .31), and 1-year mortality (P = .61) after transplantation were not significantly different between the 2 groups., Conclusions: Pretransplant infection had an impact on posttransplant morbidity, although not on rejection and mortality. Alertness for posttransplant infection and proper management (including effective antimicrobial coverage) would improve patient morbidity., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Smoking is known to result in a decline in renal allograft function and survival of recipients; however, the effect of smoking on living kidney donors remains unknown. In this study we evaluated the impact of cigarette smoking on renal function of kidney donors., Methods: Among 1056 donors who underwent nephrectomy, 612 completed the 6-month follow-up protocol and were enrolled in the study. The association of smoking status, including pack-years smoking history, and postoperative renal function was evaluated., Results: Among donors, 68.1% had never smoked, 8% were former smokers, and 23.9% were current smokers. Donors who never smoked were older than former and current smokers (42.3 ± 11.8, 41.9 ± 11.1, and 38.3 ± 10.9 years, respectively; P < .001). There was no difference in preoperative renal function between groups; however, postoperative estimated glomerular filtration rate (eGFR) was lower in former and current smokers than in those who never smoked (64.6 ± 13.8, 64.7 ± 12.3, and 67.8 ± 13.1 mL/min/1.73 m 2 , respectively; P = .023). In former and current smokers, pack-years smoking history was negatively associated with pre- and postoperative eGFR (r = -0.305 and -0.435, P < .001), and correlated with postoperative percent eGFR decline (r = 0.248, P < .001). Smoking history was associated with postoperative development of chronic kidney disease (CKD). Especially in former smokers, a smoking history of more than 12 pack-years was strongly associated with development of CKD (odds ratio = 7.5, P = .003)., Conclusion: Even if they no longer smoke, donors with a smoking history require close observation due to increased risk of CKD development after kidney donation. A detailed pack-years smoking history should be obtained, and smoking cessation strategies should be implemented in kidney donors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The significance of proinflammatory M1 (classically activated) and profibrotic M2 (alternatively activated) macrophages in antibody-mediated rejection (ABMR) after kidney transplantation has not been investigated., Methods: Fifty-five biopsy-confirmed ABMR samples were stained with MRP 8/14 (a marker of M1 macrophages) and CD163 (a marker of M2 macrophages), and positive cells were counted in glomeruli and the tubulointerstitium, respectively. Patients were classified into M1 and M2 polarization groups according to the glomerular and tubulointerstitial M1:M2 ratio, and the results were compared with Banff scores, serum creatinine level, estimated glomerular filtration rate (eGFR), and graft survival., Results: The glomerular M2 polarization group showed significantly higher chronic glomerulopathy scores, serum creatinine levels, and lower eGFR at the time of biopsy (P = .019 and P = .015, respectively) and 3-month postbiopsy (P = .016 and P = .032, respectively) than the M1 polarization group. The tubulointerstitial M2 polarization group had significantly lower glomerulitis, arteritis, peritubular capillaritis, and glomerulitis + peritubular capillaritis scores than the M1 polarization group, but there was no significant difference in renal function. Long-term graft survival was not associated with macrophage polarization., Conclusion: Glomerular M2 polarization in ABMR biopsy samples is associated with chronic glomerular injury and poorer graft function, but without graft survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Plasma neutrophil gelatinase-associated lipocalin (pNGAL) is known to increase in proportion to the degree and period of renal damage. This study aimed to evaluate the clinical relevance of pNGAL and body adipose tissue to remaining renal function in living kidney donors., Methods: Between July 2013 and February 2015, 75 live kidney donors were enrolled. Visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and VAT/SAT ratio were measured in preoperative CT scan which performed before surgery. We analyzed the correlation among the variables (VAT, SAT, and VAT/SAT ratio), eGFR and pNGAL. ΔpNGAL-max(=Maximum pNGAL-measures), ΔpNGAL-min(=Minimum pNGAL-measures), ΔeGFR-max(=Maximum eGFR-measures) and ΔeGFR-min(=Minimum eGFR-measures) were also analyzed., Results: The highest value of pNGAL (207.46 ± 76 ng/mL) was observed on postoperative day 7, and the lowest value of eGFR (57.52 ± 11.20 mL/min/1.73 m 2 ) was also measured on postoperative day 7. A significant correlation was found between ΔpNGAL, VAT, and VAT-to-SAT ratio. Moreover, a significant correlation between ΔpNGALmin and ΔeGFRmin was revealed. Also, VAT-to-SAT ratio was correlated with ΔeGFRmin during the all of the follow-up periods, and it was also correlated with ΔpNGALmin until postoperative day 3., Conclusion: There was a correlation between the elevation of pNGAL until postoperative day 5 and the decrease of eGFR after living donor nephrectomy. VAT-to-SAT ratio had a significant correlation with both ΔpNGALmin and eGFRmin. Given the metabolism of pNGAL, the increase of pNGAL seemed to be affected as a consequence of body adipose tissue., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Diethylenetriamine pentaacetic acid (DTPA) and multi-detector computed tomography (MDCT) can predict postoperative estimated glomerular filtration rate (eGFR) in a live kidney donor. Accordingly, we compared predicted eGFR measured by use of DTPA and MDCT., Methods: From January 2013 to May 2015, 264 live kidney donors were enrolled. All donors underwent preoperative DTPA and MDCT, and bilateral renal cortex volume was measured by use of MDCT. We estimated DTPA-eGFR [remaining split renal function (%) × preoperative eGFR] and Vol-eGFR [remaining renal volume/total renal volume (%) × preoperative eGFR] and analyzed DTPA-eGFR, Vol-eGFR, and Modification of Diet in Renal Disease (MDRD)-eGFR during week 1 and in months 1, 3, and 6. Additionally, we compared DTPA-eGFR and Vol-eGFR by use of the formula ΔeGFR (maximum eGFR minus minimum eGFR during 6 months)., Results: The mean DTPA-eGFR and Vol-eGFR values (mL/min/1.73 m 2 ) were 52.97 ± 10.32 and 51.26 ± 10.26, respectively. Predictions of the dominant side did not agree in 113 of 303 (37.3%) cases. Postoperative MDRD-eGFR exhibited a statistically significant correlation with total renal volume, DTPA-eGFR, and Vol-eGFR (P < .0001). A significant correlation was found between ΔeGFR and total renal volume, DTPA-eGFR, and Vol-eGFR (P < .0001). Receiver operating characteristic curves were generated to predict the possibility of eGFR <60 mL/min/1.73 m 2 at 6 months, using DTPA-eGFR and Vol-eGFR, which indicated that DTPA-eGFR (area under the curve = 0.858; P < .0001) and Vol-eGFR (area under the curve = 0.878; P < .0001) could predict chronic kidney disease class III at 6 months., Conclusions: MDRD-eGFR, Vol-eGFR, and DTPA-eGFR were significantly correlated. Moreover, Vol-eGFR and DTPA-eGFR exhibited high predictive value for chronic kidney disease class III at 6 months, whereas Vol-eGFR was a good predictor of renal function recovery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: It was reported that a metabolic syndrome affected the remaining renal function after living donor nephrectomy. However, the measurement of waist circumference is unclear because it cannot distinguish between visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). We investigate the clinical correlation between body adipose tissue and renal function recovery after living donor nephrectomy., Methods: From July 2013 to February 2015, 75 living kidney donors were enrolled. The VAT and SAT were measured by preoperative computed tomography (CT) scan. Body mass index (BMI), VAT, SAT, and VAT-to-SAT ratio were analyzed according to a postoperative renal function recovery. Receiver operating characteristic (ROC) was performed to predict estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m 2 at postoperative 6 months for BMI, VAT, SAT, and VAT-to-SAT ratio., Results: The lowest value of eGFR (57.52 ± 11.20 mL/min/1.73 m 2 ) was measured at postoperative day 7. There was no statistically significant difference in eGFR between 1 month and 3 months. BMI, VAT, SAT, and VAT-to-SAT ratio showed a statistically significant correlation with each other (Pearson correlation, P < .05). Also, the recovery time of eGFR was correlated with VAT-to-SAT ratio; it was significant at postoperative 1, 3, and 6 months. VAT-to-SAT ratio (0.654, 95% confidence interval 0.525-0.783, P = .024) had higher predictive value in ROC., Conclusion: We developed a new variable to predict the value of lower eGFR (less than 60 mL/min/1.73 m 2 ) at a postoperative 6 months in living kidney donor. According to a CT scan, VAT-to-SAT ratio can predict renal function recovery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Donor organ quality from deceased donors affects graft survival after kidney transplantation. This study was performed to identify clinico-histological factors that affect early graft outcome, using time-zero biopsies of deceased donors., Methods: Between December 2006 and July 2011, 135 recipients of deceased donor kidneys were included, and data concerning donor and recipient-related clinical characteristics and histological findings of time-zero biopsies categorized by use of the Banff 07 scoring system were included in the analysis. Mean donor age was 44.3 ± 12.3 years. Mean terminal serum creatinine level and cold ischemic time were 1.50 ± 0.96 mg/dL and 349 ± 166 minutes. Mean follow-up time after transplantation was 37 ± 16 months, and all recipients were followed for at least 1 year., Results: Global glomerulosclerosis (38.5%), tubular atrophy (37.8%), arteriolar hyaline thickening (25.9%), interstitial fibrosis (23%), vascular fibrous intimal thickening (21.5%), and interstitial inflammation (20%) were the major pathologic findings of time-zero biopsies. The majority of pathologic scores were of mild degree. Among histological findings, arteriolar hyaline thickening and interstitial fibrosis were only significantly associated with early post-transplant renal function in multivariate analyses., Conclusions: Considerations of clinico-histological findings were found to be valuable for predicting early graft outcome after deceased donor kidney transplantation., (Copyright © 2016. Published by Elsevier Inc.)

The effects of pretransplantation dialysis modality on graft function are key issues in end-stage renal disease patients. The aim of this study was to evaluate post-transplantation outcomes according to pretransplantation renal replacement therapy modality in deceased-donor kidney transplantation. Among 444 deceased-donor kidney transplant recipients in Severance Hospital between April 1993 and Dec 2014, 275 who maintained a unique dialysis modality (hemodialysis [HD; n = 178] or peritoneal dialysis [PD; n = 97]) until transplantation were enrolled. There were no significant differences in sex, age, human leukocyte antigen mismatch, cold ischemic time, or duration of dialysis between groups. There was also no difference in 5-year graft survival between HD and PD groups (87.7% vs. 82.3%, respectively; P = .148). On multivariate Cox regression for risk factors affecting graft survival, renal replacement therapy modality was not found to be a risk factor. However, the rate of delayed graft function was higher in the HD group than in the PD group (32.0% vs. 19.6%, respectively; P = .028). In addition, graft function at 1 week after transplantation in the PD group was superior to that in the HD group. The pretransplantation dialysis modality was found to affect both delayed graft function and early graft function, although not graft survival., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The prevalence of post-transplantation immunoglobulin A nephropathy (PTIgAN) and diabetes mellitus (PTDM) increases with time after transplantation, and recognition and management of these conditions is becoming more important in renal allograft recipients as graft survival increases., Methods: We explored the influence of concurrent PTDM on renal allograft histology and function in 111 cases with PTIgAN diagnosed from 2000 to 2010 at our institution., Results: Sixteen patients (14.4%) had PTDM at the time of diagnosis of PTIgAN, which increased to 28 patients (25.2%) at the last follow-up (10.4 years after transplantation). Donor ages were younger in PTIgAN patients with concurrent PTDM. However, other clinical and demographic data were not significantly different between PTIgAN patients with and without PTDM. Histologically, Banff "mm" scores were higher and "M1" of the Oxford classification was more frequent in PTIgAN patients with concurrent PTDM than in patients without PTDM, but the difference did not reach statistical significance. Serum creatinine levels and proteinuria at the time of biopsy and overall graft survival did not vary according to the presence of PTDM both at biopsy and at the last follow-up., Conclusions: Concurrent PTDM does not significantly influence graft function or outcome for 10 years after transplantation in PTIgAN patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A retrospective review of intestinal transplantation (ITx) at Seoul St. Mary's Hospital was made by collecting clinical data over the past 10 years. Fifteen consecutive cases from 2004 were analyzed. Five children and 10 adults (6 months to 69 years of age) were included. Primary diseases in adults included 4 mesenteric vessel thromboses, 2 strangulations, and 1 each of visceral myopathy, malignant gastrointestinal stromal tumor (GIST), mesenteric lymphangiectasis, and injury. Pediatric cases involved 2 Hirschsprung disease, 2 visceral myopathy, and 1 necrotizing enterocolitis. Three of 7 stomas were closed using a serial transverse enteroplasty procedure before transplantation. The ITx were performed using 3 living-donor Itx, 12 deceased-donor ITx, 14 isolated Itx, and 1 modified multivisceral transplantation. Daclizumab, basiliximab, alemtusumab, or basiliximab with rabbit antithymocyte globulin (rATG) was used for the induction; tacrolimus monotherapy was used as the basic maintenance immunosuppressant; and m-TOR inhibitor was used for renal dysfunction patients. Seven cases of acute cellular rejection were treated with rATG. Three cases of antibody-mediated rejection were treated with rituximab alone or with rituximab and bortezomib combination. There were 4 cases of early mortality within 6 months after Itx. Causes of death were declamping shock, cardiac tamponade with acute cellular rejection, dysmotility, and sepsis. Surgical complications consisted of 1 feeding jejunostomy displacement, and a minor leakage at a colo-colostomy site. One-year survival of the patient and graft was 73.33% (Kaplan-Meier survival curve). Although the total number of ITx is small, its social impact has been remarkable in changing the related laws and reimbursement policy in Korea., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Because of the development of various desensitization strategies, ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has become a feasible option for patients with end-stage liver disease. However, there has been no united desensitization protocol for ABOi LDLT. We analyzed the outcomes after establishment of simplified protocol without splenectomy, intravenous immunoglobulin, and local infusion therapy., Methods: We analyzed 19 ABOi LDLT cases that had been performed between January 2012 and December 2013, without splenectomy and local infusion. We used a single dose of rituximab (375 mg/m(2)) 10 days before transplantation and several series of plasma exchange according to the recipients' iso-agglutinin titer-to-target titer ratio of 1:32., Results: Nineteen recipients received ABOi LTs from living donors. The mean initial immunoglobulin (Ig) M and IgG anti-ABO titers were 76.63 ± 78.81 (range, 8∼256) and 162.53 ± 464.1 (0∼2048). We performed preoperative plasma exchange to 16 recipients (mean number of sessions, 3.58; range, 1-10). After surgery, 9 patients received plasma exchange (mean, 1.84; range 1∼14). One death occurred as the result of pneumonia (5.3%). There were 4 cases of acute rejections (21.1%), and all of them were treated successfully with steroid pulse or thymoglobulin. Antibody-mediated rejection and graft failure did not occur. Six cases of postoperative complications (31.6%) occurred, including 3 cases of infections. There were 2 cases of biliary anastomotic stricture (10.5%) and 1 case of portal vein stenosis (5.3%)., Conclusions: ABOi LDLT with the use of simplified protocol can be safely performed without increased risk of antibody-mediated rejection and other complications., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Routine microbiologic surveillance is a method of infection control, but its clinical significance in transplant recipients is not known. We analyzed microbiologic data to evaluate the influence of cultured microorganisms between the point of surveillance and infectious episodes in liver transplant recipients., Methods: We performed surveillance culture for sputum and peritoneal fluid in liver transplant recipients from January 2009 to December 2011, at the time of transplantation (T1), 5 days (T2), and 10 days (T3) postoperatively., Results: Of the 179 recipients, 32.9% had a positive sputum culture result and 37.4% had a positive peritoneal culture result during surveillance. In the culture surveillance of sputum, 37 organisms were isolated from 35 recipients at T1, and the most common organism was Staphylococcus aureus (n = 13). At T2, 45 organisms were isolated from 39 recipients, including Klebsiella pneumoniae (n = 10), S aureus (n = 8), and Acinetobacter baumannii (n = 6). At T3, 18 organisms were isolated from 15 patients, including Stenotrophomonas maltophilia (n = 5) and K pneumonia (n = 4). In the peritoneal fluid, 11 organisms were isolated from 10 recipients at T1, including Pseudomonas aeruginosa (n = 2) and Enterococcus species (n = 2). At T2, 39 organisms were isolated from 36 recipients, including coagulase-negative Staphylococcus species (CNS; n = 8) and Enterococcus species (n = 7). At T3, 54 organisms were isolated from 51 recipients, including CNS (n = 17) and Candida species (n = 8). Among the 59 patients with positive culture results for sputum surveillance, 16.9% developed pneumonia caused by the same organisms. Among the 67 patients with positive peritoneal fluid culture, 16.4% developed an intra-abdominal infection caused by the same organisms cultured. The recipients with positive surveillance culture had a higher risk of pneumonia (20.3% [12/59] vs 1.6% [2/120]; P < .001) and intra-abdominal infection (31.3% [21/67] vs 18.7% [21/112]; P = .05)., Conclusions: Periodic microbiologic surveillance may be useful in the prediction of post-transplantation pneumonia and intra-abdominal infection and could offer a potential target for empirical antimicrobial therapy in cases of infection., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Living kidney donation has become an important source for renal transplantation. Thus, renal function after donation is an important issue. In this study, we examined histological abnormalities in implantation biopsy specimens from living kidney donors and analyzed the renal function of the remaining kidney., Methods: Using the 2007 Banff classification system, we analyzed 121 kidneys from living donors who underwent implantation biopsies (IBs) between 2010 and 2011. Donor characteristics, intraoperative factors, and perioperative renal functions, such as serum creatinine and glomerular filtration rate (GFR), were evaluated. Univariate and multivariate regression analyses were performed to identify the factors related to each histological abnormality and postoperative 1-year donor renal function., Results: Most histological abnormalities in healthy living donors were scored as 1 on the Banff scale. Univariate and multivariate analyses revealed that donor age was the only preoperative factor related to tubular atrophy (odds ratio [OR] = 1.104; P = .012) and glomerular sclerosis (OR = 1.050; P = .019). Intraoperative factors were not related to histological parameters. And histological abnormalities did not affect postoperative 1-year renal function. In contrast, donor age, preoperative GFR, and estimated blood loss were significantly related to 1-year postoperative GFR., Conclusion: Most histological abnormalities in healthy living donors were minor. The incidence of abnormalities correlated with donor age. However, postoperative renal functions in living donors were not affected by histological abnormalities. Larger-scale investigations with long-term follow-up analysis will be needed., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Donor and recipient age in kidney transplantation are known to affect graft and patient survival. To address the question of whether the age difference between donor and recipient impacts on graft survival and death-censored graft survival after transplantation, we examined the impact of age matching (less than 10-year age difference) on the survivals after living donor kidney transplantation., Methods: Two hundred one cases of the primary living donor kidney transplantation were performed and were divided into two groups, age-matched (n = 123) versus age-discrepant (n = 78). Variables included in this study were age, gender, body weight, height, kidney disease, type and duration of dialysis before transplantation, degree of human leukocyte antigen mismatch, ischemic time, graft weight, episode of rejection, type of immunosuppression, recipient serum creatinine after transplantation, and causes of patient death and graft loss., Results: We observed the disparities of graft survival (P = .008) and death-censored graft survival (P = .003) between the groups. One-, 3-, and 5-year death-censored graft survival was 100%, 100%, and 97% in the age-matched group, respectively; and 97%, 90%, and 88% in the age-discrepant group, respectively. By Cox regression multivariate analysis, the variable of age-matching was an independent predictor for both graft survival (ß = 1.325, P = .017) and death-censored graft survival (ß = 2.217, P = .021)., Conclusion: During living donor and recipient matching, age difference between donor and recipient should be minimized., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Acute renal failure (ARF) after liver transplantation requiring continuous renal replacement therapy (CRRT) adversely affects patient survival. We suggested that postoperative renal failure can be predicted if a clinically simple nomogram can be developed, thus selecting potential risk factors for preventive strategy., Methods: We retrospectively reviewed the medical records of 153 liver transplant recipients from January 2008 to December 2011 at Severance Hospital, Yonsei University Health System, in Seoul, Korea. There were 42 patients treated with CRRT (20 and 22 patients received transplants from living and deceased donors, respectively) and 115 were not. Univariate and stepwise logistic multivariate analyses were performed. A clinical nomogram to predict postoperative CRRT application was constructed and validated internally., Results: Hepatic encephalopathy (HEP; odds ratio OR, 5.47), deceased donor liver donations (OR, 3.47), Model for End-Stage Liver Disease (MELD) score (OR, 1.09), intraoperative blood loss (L; OR, 1.16), and tumor (hepatocellular carcinoma) as the indication for liver transplantation (OR, 0.11) were identified as independent predictive factors for postoperative CRRT on multivariate analysis. A clinical prediction model constructed for calculating the probability of CRRT post-transplantation was 1.7000 × HEP + [-4.5427 + 1.2440 × (deceased donor) + 0.0830 × (MELD score) + 0.000149 × the amount of intraoperative bleeding (L) - 2.1785 × tumor]. The validation set discriminated well with an area under the curve (AUC) of 0.90 (95% confidence interval, 0.85-0.95). The predicted and the actual probabilities were calibrated with the clinical nomogram., Conclusions: We developed a predictive model of postoperative CRRT in liver transplantation patients. Perioperative strategies to modify these factors are needed., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: This study was undertaken to investigate risk factors of mortality in patients with fulminant hepatic failure (FHF)., Methods: Fifty-three patients with FHF treated from January 2006 to April 2011 were allocated to a spontaneous survival group (group 1), a death without liver transplantation (LT) group (group 2), and an LT group (group 3). To analyze risk factors associated with mortality in FHF, we excluded group 3 patients. Clinical features, Model for End-Stage Liver Disease (MELD) scores, and King's College Hospital criteria at the time of hepatic encephalopathy in group 2 were compared with those of group 1., Results: The causes of FHF were acute viral infection (n = 29, hepatitis A:B, 28:1), drugs (n = 18; including 4 acetaminophen and 14 herbal medication), autoimmune (n = 4), and miscellaneous (n = 2). Of the 53 patients, 19 were allocated to group 1, 18 to group 2, and 16 to group 3. According to univariate analysis, risk factors for mortality in group 2 were acute renal failure requiring renal replacement therapy and a MELD score ≥30 at the time of hepatic encephalopathy. However, by multivariate analysis, a MELD score ≥30 was the only independent risk factor for mortality in group 2 (P = .042; hazard ratio, 4.500)., Conclusions: A MELD score ≥30 was found to be the only independent risk factor of mortality in FHF patients without LT. Therefore, the findings of this study suggest that these patients may need emergent LT for survival., (Copyright © 2013. Published by Elsevier Inc.)

Introduction: Liver stiffness measurements (LSMs) using transient elastography (TE) provide a noninvasive means to assess liver fibrosis that correlate with hepatic cholestasis. However, few studies have examined the correlation of TE to obtain LSMs with perioperative clinical and laboratory parameters in living donor liver transplantation (LDLT)., Patients and Methods: We retrospectively reviewed forty-eight subjects who underwent LDLT between November 2010 and October 2012. All donors and recipients underwent TE, abdominal computed tomography (CT), and biochemical tests within 1 month before and at 1 week after transplantation. Using a cut-off LSM of 7.5 kPa, which we arbitrarily assigned to be indicative of significant fibrosis, we divided our study population into ≤7.5 kPa (group L; n = 15, 31.3%) versus >7.5 kPa; (group H; n = 33, 68.8%)., Results: Pretransplantation serum total bilirubin, international normalized ratio, and Model for End-stage Liver Disease scores of recipients were significantly higher in group H than group L. Regarding the pretransplantation donor characteristics, the graft-recipient weight ratio was significantly smaller among those in group H (P = .039). In addition, the post-transplantation 1-week serum total bilirubin level was significantly higher in group H (2.3 mg/dL versus 1.2 mg/dL, P = .015), although neither biliary complications norhepatic congestion was identified by abdominal CT. Among the 1-week post-transplantation laboratory findings, only total bilirubin positively correlated with LSM (P = .044)., Conclusions: This pilot study suggested that a high LSM after LDLT suggests intrahepatic cholestasis and portal hypercirculation in the graft, irrespective of liver fibrosis, outflow obstruction, or biliary obstruction., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Infectious complications are major factors for morbidity and mortality in liver transplant recipients. To establish a proper strategy to reduce infectious complications, we analyzed epidemiologic and risk factors for post-transplant infections., Methods: We analyzed the medical records of 231 consecutive liver transplant recipients from December 2007 to November 2011, including at least 1-year follow up, for comparison with those from 1996 to 2005., Results: Among 231 patients, 126 (54.5%) experienced 244 infectious episodes, a rate of 1.05 per patient. Among overall mortality of 9.9% (23/231), infections were more prevalent (P = .04). Predominant infections were postoperative intra-abdominal problems (36.1%), peritonitis (15.2%), pneumonia (13.5%), bacteremia (4.1%), wound complications (1.6%), viral etiologies (18.0%), and other causes (11.5%). Causative organisms were bacterial (68.9%), viral (14.7%), fungal (7.0%), and unproven ones (9.4%). Multivariate analysis of risks for infection showed significant impacts of Model for End-stage Liver Disease score [P = .027; odds ratio (OR), 1.04], post-transplant biliary complications (P < .001; OR, 3.50), and rejection episodes (P = .023; OR, 3.39). Mortality was related to retransplantation (P = .003), post-transplant dialysis (P = .006), and infection (P = .056) upon univariate analysis, none of which were significant in multivariate analysis. Compared with data from the previous period, overall and infection-related mortality decreased from 24.5% to 9.9% and 52.9% to 26.1%, respectively. There were no significant changes in the types of infection or rate of drug-resistant bacteria, but candidal infections and cytomegalovirus reactivations were more prevalent., Conclusion: Our data showed current perioperative antimicrobial regimens need not be changed: however, new strategies are needed to reduce infectious complications after liver transplantation, to reduce biliary complications and to properly manage rejection episodes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: The use of new selective immunosuppressants as well as the emergence of new antimicrobial resistances raise the use of prophylactic antibiotics as a matter of controversy. The purpose of this study was to retrospectively analyze the clinical significance of prophylactic antibiotics in kidney transplantation., Methods: This retrospective study included 174 renal allograft recipients who were divided into two groups: group A including patients who received perioperative prophylactic antibiotics and group B, who did not receive them. We analyzed who the incidence of infectious complications as well as the causative micro-organisms and their antimicrobial resistance within 1 month after kidney transplantation., Results: Overall bacterial infections were observed during the first postoperative month in 13 cases (7.4%): 6 (3.4%) surgical site 4 (2.3%) urinary tract, 2 (1.1%) bacteremic, and 1 (0.6%) central catheter infections. There was no respiratory infection. The incidence of bacterial infection was not significantly different between the two groups. The major micro-organisms isolated after kidney transplantation, were Staphylococcus aureus and Escherichia coli; both of which had already shown multidrug resistance at the initial time of infection., Conclusion: Not only did use of prophylactic antibiotics have little impact to prevent bacterial infections after kidney transplantation, but also it may induce antimicrobial resistance against the antibiotics used for prophylaxis. Moreover, the increased antibiotic resistance prior to kidney transplantation hampers the effectiveness of prophylactic antimicrobial agents. Guidelines for perioperative antibiotic prophylaxis should be therefore revised., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Laparoscopic fenestration (LF) and percutaneous catheter drainage (PCD) are widely accepted treatments for symptomatic lymphoceles. The aim of this study was to review the results and compare the outcomes of LF with those of PCD., Patients and Methods: Among 1363 patients who underwent kidney transplantation at our institute between 1999 and 2011, 35 (2.5%) developed symptomatic lymphoceles. Among them, 7 were treated by LF after PCD; 10, LF only, and 18 PCD only. The patients were divided into 2 groups based upon the treatment method: LF (n = 17) and PCD-only groups (n = 18)., Results: No intergroup differences in age, gender, diabetes prevalence, retransplant rate, delayed graft function, or serum creatinine was observed at 7 days after the treatment. However, acute rejection episodes and sirolimus use were more frequent among the LF group (P = .028). Furthermore, median drainage on the first day was significantly greater in the LF versus PCD group. After catheter insertion, the PCD group showed a significant decrease in drainage on the following day, but no decrease was observed in the LF group., Conclusions: LF is a safe treatment for symptomatic lymphocele. LF should be held in reserve for treatment failures after PCD. LF seems to be a more reasonable first-line treatment for symptomatic lymphoceles in patients at high risk for graft dysfunction., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Few studies have evaluated the long-term effects of kidney donation on the donors themselves. This study investigated postoperative renal function stabilization in kidney donors after living-donor transplantation to determine the optimal follow-up period., Methods: Between March 2006 and July 2010, 203 patients in our hospital underwent live donor nephrectomy. Renal function recovery patterns were analyzed by calculating the postoperative rate of change of their Modification of Diet in Renal Disease study equation estimating glomerular filtration rate (MDRD-GFR) versus their preoperative level (%MDRD). We divided normal (n = 121) versus chronic kidney disease subjects (CKD; MDRD-GFR < 60 mL/min/1.73 m(2) at 6 months postoperatively, n = 82) for 1 year follow-up to compare time to renal function stabilization using the repeated measured data method., Results: When all donors were considered together at 1 month after transplantation, MDRD-GFRs were significantly increased compared with earlier follow-up times (for postoperative days 1, 4, and 7), P values were < .001, .006, and .002, respectively). Among all donors, there was no significant difference between MDRD-GFRs at 1 versus 3, 6, and 12 months posttransplantation (P < .05 in all three comparisons), indicating renal function stabilization. Importantly the %MDRD was significantly higher among the normal than the CKD group at postoperative months 1, 3, and 6 (P < .05 for all comparisons), although after 12 months there was no significant difference between the groups (69.06 ± 9.28% versus 70.14 ± 8.38%, P = .442)., Conclusion: After live donor kidney transplantation, renal function began to stabilize at 1 month postoperatively. Poor renal functional recovery and CKD later were predicted by inferior stabilization at 1 month postnephrectomy. These data suggested that even patients with normal GFRs should be followed beyond 1 year postoperatively to determine their ultimate renal functional outcomes., (Copyright © 2012 Elsevier Inc. All rights reserved.)

An 8-year-old girl was admitted for severe electrolyte imbalance and for hyponatremic seizure. In July 2005, at 3 years of age, she underwent isolated small-bowel transplantation of 100 cm ileum from her father. Her own bowel was only 50 cm of proximal jejunum which had been directly connected to the anus due to extended total aganglionosis. The graft was placed into the middle of her remaining bowel, using the splenic artery and vein as feeding vessels with saving of the spleen. Daclizumab induction and tacrolimus monotherapy were applied for immunosuppression. Two acute cellular rejection episodes, E on day 10 and 4 years after transplantation, were successfully treated with OKT-3 and recombinant antithymocyte globulin, respectively. However, because of intermittent bowel dysfunction, she was hospitalized several times for hydration and metabolic care. On admission, her abdomen was moderately distended, and a simple abdominal film showed a fixed dilated loop. Colonoscopy could not pass the narrowed lumen, with stiffness at the anastomosis between the graft and the distal bowel. Endoscopic biopsy at the entrance to the stricture showed a nonspecific inflammatory reaction with fibrosis. Similar findings on a gastrograffin enema suggested chronic rejection (CR). On laparotomy, an irregularly narrowed fibrotic loop was noticed at the distal part of the graft, proximal to the anastomosis. We performed a 20-cm segmental resection with an end-to-end anastomosis. Histopathologic findings showed CR with fibrosis and hyalinization of the entire bowel wall and vessel walls with mild cellular infiltrations. She recovered in 10 days. The graft may have been saved, but intermittent requirement of hydration over the following months suggested progressive graft dysfunction. A case of segmental involvement of CR with subsequent successful graft salvage by partial resection is rare in the literature., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Membranous nephropathy (MN) may develop as recurrence or de novo after transplantation. Recently, autoimmune or alloimmune responses to unspecified glomerular antigens have been considered as a pathogenetic mechanism. To explore the relationship between antibody-mediated injury and posttransplantation MN, we tested C4d positivity using polyclonal antibody in renal allograft biopsy samples diagnosed as posttransplantation MN. A total of 19 cases (16 males and 3 females), including 2 recurrent and 7 de novo forms, were the subject of the study. On light microscopy, stage II was the most common (n = 9). In addition to glomerular capillary immunoglobulin (Ig)G deposits, all but 2 cases having only sclerotic glomeruli were C4d-positive in glomerular capillary walls. Twelve cases were also positive in cortical peritubular capillaries (PTCs): diffuse in 8 cases and focal in 4 cases. Two of 3 cases associated with acute rejection and 3 of 4 cases associated with chronic rejection were PTC C4d-positive. The frequency of C4d positivity in PTCs was significantly higher than that of posttransplantation IgA nephropathy (P = .028). In conclusion, a higher frequency of PTC C4d positivity suggests an involvement of chronic antibody-mediated injury in the evolution of posttransplantation MN., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Cytomegalovirus (CMV), the most significant viral infection in liver transplant recipients, is addressed by 2 methods: Preemptive therapy (PT) or universal prophylaxis (UP)., Methods: We analyzed medical records including at least 1 year follow-up of patients who underwent liver transplantation from 2006 to 2009 in 3 tertiary hospitals. PT was used in 2 hospitals (PT group), whereas UP with valganciclovir for 3 months was adopted in the other hospital (UP group). The 2 groups were matched using propensity scoring by perioperative variables. We performed a 1:1 comparison of the efficacy of UP and PT., Results: We analyzed 634 liver transplant patients, including 562 matched subjects. Baseline characteristics and underlying liver status were comparable. CMV immunoglobulin G of recipients was positive in 98.9% of the PT group and 99.3% of the UP group. CMV viremia episodes that required administration of an antiviral agent occurred in 26 (9.3%) PT and 37 (13.2%) UP subjects (P = .18). CMV-related mortalities were similar (0.7% vs 1.8%; P = .45), but all-cause mortality was higher in the PT group (18.5% vs 13.2%; P = .08)., Conclusion: The efficacy of PT was similar to UP to prevent CMV disease and related mortality among a group at moderate risk for CMV infection., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: We sought to evaluate total and segmental liver regeneration by comparing preoperative computed tomographic (CT) volumetry and CT volumetry on postoperative day (POD) 7 after a right hepatectomy, in patients with various status and surgical indications., Method: We included 36 patients who underwent right lobectomy for living donor liver transplantation (healthy group), and 29 for hepatocellular carcinoma treatment (disease group). All of the disease group patients were Child-Turcotte-Pugh (CTP) class A. The regeneration of lateral, medial segment and total remnant liver volumes were assessed on POD 7 using a CT-based program. Total volumes and segmental volumes were measured for total liver, future liver remnant (FLR), and liver remnant. We calculated total and segmental early regeneration indexes, defined as [(VLR-VFLR)/VFLR]×100, where VLR is volume of the liver remnant and VFLR is volume of the FLR., Result: The VLR at POD 7 showed a 72.9% increase in volume among the healthy versus 55% in the disease group, (P=.012) In the disease group, segmental volume and regeneration indexes were also significantly lower than among the healthy group: 59.0% versus 46.9% in the medial and 86.8% versus 57.7% in the lateral segment (P=.023 and P<.001) respectively., Conclusion: The volume regeneration potential in diseased livers is significantly lower than that of a normal, healthy liver. So, we must consider a patient's liver status and volume profile before an extensive liver., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: The role of lymphocyte cross-matches (LCM) remains controversial in the liver transplant field. The aim of this study was to correlate the risk for acute rejection episodes and graft survival in liver transplantation with pretransplant LCM results., Patients and Methods: We enrolled 184 adult liver transplantation patients, excluding pediatric and second grafts. The 129 living donor and 55 deceased donor liver transplantations were divided into 2 groups: LCM (+); (n=20) and LCM (-); (n=164)., Results: There were no differences in the demographic features, such as gender and recipient age, original disease, Model for End-Stage Liver Disease score, donor type, number of human leukocyte antigen mismatches, and cold ischemia times. There were no hyperacute rejection episodes in the LCM (+) group. Also, posttransplant complications such as acute rejection episode, biliary complication, or hepatic artery thrombosis were not different. Acute rejection episodes occurred in 5.0% of the LCM (+) group and 15.2% of the LCM (-) group (P=.317). Bile duct complications after transplantation arose in 20.0% of the LCM (+) group and in 32.9% of the LCM (-) group (P=.312). The 2 groups showed no difference in graft survival rate analyzed by the Kaplan-Meier method according to LCM results., Conclusion: Pretransplant LCM results were not associated with overall graft survival or acute rejection episodes in this study., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: Sirolimus is a potent immunosuppressive agent used with increasing frequency in kidney transplantation. However, sirolimus can increase the rate of unexplained interstitial pneumonitis. The aim of this study was to evaluate the clinical characteristics of sirolimus-induced pneumonitis and the therapeutic results in renal transplant recipients., Patients and Methods: Seventy-two patients received sirolimus, conversion or de novo regimen, at our center between January 2007 and April 2011. Twelve of the 72 patients (16.7%) developed interstitial pneumonitis. The patients were divided into three groups according to the following indications of sirolimus use: de novo, early conversion, and late conversion groups., Results: The mean duration of follow-up was 11.0 ± 11.5 months. The mean blood level of sirolimus measured by microparticulate enzyme immunoassay was 16.5 ± 7.4 ng/mL at the time of diagnosis. The mean time from the start of sirolimus to pneumonitis onset was 14.7 ± 8.0 months. The clinical presentation included fever, cough, dyspnea, general weakness, and periorbital edema. In most cases, radiological imaging tests revealed bilateral lower-lobe involvement. Bronchoalveolar lavage was performed in three patients and two patients showed lymphocytic alveolitis. Sirolimus was discontinued or reduced for the treatment of pneumonitis. All cases of pneumonitis were resolved within 2 to 4 weeks., Conclusion: Sirolimus blood level should be monitored tightly and early intervention is important when sirolimus-induced pneumonitis is suspected., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Recently, the impact of human leukocyte antigen (HLA) mismatch (MM) on graft outcome has diminished since the introduction of potent immunosuppressive agents, whereas previous reports support the notion that greater numbers of HLA matches are beneficial. This study was undertaken to evaluate outcomes after five or six HLA-mismatched living donor kidney transplantations (LDKT)., Methods: The authors retrospectively reviewed graft function after 2687 LDKTs performed between June 1984 and February 2010. A database of 1364 living related and 1063 living-unrelated donor (LURD) kidney transplantations was used for this study. LURD kidney transplantations were classified into three groups; (1) zero to one HLA MM (n = 158); (2) two to four HLA MM (n = 851); and (3) five to six MM (n = 54). An acute rejection episode was diagnosed based on clinical deterioration of graft function or biopsy findings. Graft survival was calculated using the Kaplan-Meier method., Results: Graft survivals in the zero to one HLA MM, two to four HLA MM, five to six HLA MM, and one-haplo MM LDKT were not significantly different. The rates of acute rejection episodes within 1 year after transplantation were similar irrespective of the HLA MM; (1) zero to one HLA MM (37.3%), (2) two to four HLA MM (35.3%), (3) five to six HLA MM (33.3%; P = .832)., Conclusions: Survival of five or six HLA-mismatched LDKTs was comparable to that of one-haplo MM and relatively well-matched LDKT. The study showed that the presence of five or six HLA MM was not a risk factor for graft survival after LDKT., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: Video-assisted minilaparotomy surgical (VAMS) nephrectomy is believed to provide better cosmetic outcomes than open-donor nephrectomy in healthy donors. However, the results of a few studies have influenced the opinion of donors on their physical appearance. This study investigated the satisfaction of donors after a VAMS living donor nephrectomy., Methods: Donors who underwent VAMS living donor nephrectomy between 2009 and 2011 were requested to fill out a body image questionnaire. This questionnaire consisted of three subscales: body image scale (BS), confidence in surgery scale (CS), and hospital experience scale (HS). A total of 20 VAMS living nephrectomy donors completed the questionnaire., Results: The study included 3 male and 17 female donors of overall mean age of 38.7 ± 12.4 years. Eight donors were unmarried (40.0%), 11 were married (55.0%), and 1 was divorced. The mean follow-up was 7.9 ± 4.5 months. The mean BS, CS, and HS scores were 41.6 ± 5.3, 21.85 ± 8.3, and 13.9 ± 2.2, corresponding to perfect scores of 50, 30, and 20, respectively., Conclusion: The results of this study showed that VAMS nephrectomy donors tended to be pleased with their body image, operation, and hospital experiences., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: This study examined the current state of information on renal replacement therapy and the educational demands of kidney transplant recipients., Methods: The study was conducted through a survey. The questionnaire of this study was developed by researchers and was completed by 72 kidney recipients., Results: The recipients were most frequently informed of hemodialysis (87.5%), followed by kidney transplantation (69.4%) or peritoneal dialysis (48.6%) as a modality of renal replacement therapy at the time of diagnosis of chronic renal failure. Information about kidney transplantation was provided when they were diagnosed with end-stage renal disease (ESRD; 33.3%) or right after initiation of dialysis (15.3%) or a few years thereafter (9.7%). They were informed about kidney transplantation mostly by transplantation surgeons (mean degree score = 3.1 ± 1.3; range, 1-4), followed in order by transplant coordinators, nephrologists, family members, other patients, artificial kidney unit nurses, and mass media or internet. Regarding the influence of the information on their decision to receive a transplant, the mean score was 3.2 ± 1.2 (range, 1-5). Also, kidney transplantation was evaluated as the best renal replacement therapy for work, pregnancy/delivery, traveling, and diet., Conclusion: Patients diagnosed with ESRD are not fully informed of transplantation as a primary optimal renal replacement therapy for their quality of life., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Acinetobacter species have become increasingly important nosocomial pathogens worldwide and can result in a wide range of infections, including bacteremia, pneumonia, urinary tract infection, peritonitis, among others. The aim of this study was to investigate clinical characteristics, mortality, and outcomes among liver transplant recipients with Acinetobacter species infections., Methods: We retrospectively analyzed 451 subjects who had undergone living donor liver transplantations between January 2001 and May 2010. Pandrug-resistant (PDR) Acinetobacter species were defined as resistant to all commercially available antibiotics except colistin., Results: Infectious complications due to Acinetobacter species appeared in 26 patients (5.8%) with a total of 37 episodes. Of the species identified, 34 were Acinetobacter baumannii and 3 Acinetobacter Iwoffiii. The presumed sources of infection were the biliary tract (n = 21, 56.8%), lung (n = 7, 18.9%), intra-abdomen (n = 6, 16.2%), catheter (n = 2, 5.4%), and urinary tract (n = 1, 3.6%). Among the 37 Acinetobacter species, 75.7% (28/37) were PDR species. Age, duration of intensive care unit stay, Child-Pugh score, and Model for End-stage Liver Disease score were not significant risk factors for Acinetobacter species infection. However, the overall mortality among patients with Acinetobacter species infections was 50% (13/26), which was significantly higher than that among those free of infection (50% vs 11.5%, P < .05). Multivariate analysis using a Cox regression model showed that inappropriate antimicrobial treatment was a significant independent risk factor for mortality among patients with Acinetobacter species infections (hazard Ratio = 4.19, 95% confidence interval 1.1-18.7; P = .06)., Conclusion: Patients with Acinetobacter species infections after liver transplantation show a significantly worse prognosis. PDR Acinetobacter species have been a major problem in our center., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Biliary complications remain a major cause of morbidity after liver transplantation, especially in living donor liver transplantation (LDLT). Maintaining adequate blood supply to the bile duct is important for the prevention of biliary complications. The objective of this study was to analyze the effects of different techniques for bile duct anastomosis on posttransplantation biliary complications. From August 2005 to August 2008, 121 liver transplantations were performed at our center. Among the total 121 liver transplant recipients, 68 patients underwent a LDLT using a right lobe graft and were enrolled in this study. We used classic dissection for the first 38 recipients and the hilar plate looping technique for the next 30 patients. The hilar plate looping technique involves the looping of the complete hilar plate and Glissonian sheath around the hepatic duct after full dissection of the right hepatic artery and portal vein. Biliary complications were defined as bilomas or strictures that developed within 6 months after transplantation and required surgical or radiological intervention. There were no significant demographic differences between the 2 groups. The incidence of complications was 15 (39.5%) for classic dissection and 3 (18.8%) for hilar plate looping. Furthermore, there were no biliary strictures in the hilar plate looping group, and there was a significant difference in the complication rate between the 2 groups (P = .011). In conclusion, the hilar plate looping technique during LDLT significantly reduces recipient biliary complications., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: We compared the results of 2 immunoassay systems (affinity column-mediated immunoassay [ACMIA] and microparticle enzyme immunoassay [MEIA]), regarding hematologic and biochemical values at 2 weeks after liver transplantation., Methods: We obtained 256 blood samples from 35 patients, at 2 weeks after liver transplantation, excluding those from patients who were treated with interacting medications or renal replacement therapy. We also excluded the early mortality cases within 2 weeks of liver transplantation. A Dimension RxL HM with the tacrolimus Flex reagent cartilage was used for the ACMIA and the IMx tacrolimus II for the MEIA method., Results: The tacrolimus concentrations measured by the ACMIA method correlated closely with those measured by the MEIA method (r = 0.953). However, the weighted concordance correlation coefficient for the repeated-measurement design was 0.74 (95% confidence interval, 0.66-0.85). The discrepancies in the tacrolimus level between the 2 methods was large among samples with low tacrolimus concentrations especially <5 ng/mL. When the difference ratio of the 2 methods ([ACMIA - MEIA]/ACMIA) was analyzed with a linear mixed-effects model to identify significant laboratory findings, there were no significant differences based on hematocrit, renal function, or hepatic function. However, the serum potassium level correlated with the difference ratio of the 2 methods (estimated slope, 10.173; P = .02)., Conclusions: Both the ACMIA and the MEIA methods are precise; however, the ACMIA method has the advantage of fewer pretreatment procedures. In the early liver transplant period, however, there was a difference between the serum tacrolimus concentrations measured by the 2 methods, especially at a low drug concentrations., (Crown Copyright © 2010. Published by Elsevier Inc. All rights reserved.)

Proper maintenance of immunosuppression is required to achieve long-term graft survival. The aim of this study was to evaluate the effect of change or modulation of an immunosuppressive regimen (IR) on graft survival during the posttransplant period in patients undergoing kidney transplantation. A total of 1164 patients who underwent kidney transplantation between January 1997 and December 2008 at Yonsei University Health System were enrolled. All patients initially received calcineurin inhibitor (CNI)-based double or triple IR (DIR and TIR, respectively). The causes of IR changes or modulation were reviewed retrospectively. Graft survival rate was compared according to types of maintenance immunosuppression (DIR versus TIR). Initially, DIR and TIR were adopted in 201 (17.3%) and 963 (82.7%) recipients, respectively. In 77 DIR recipients (38.8%) and 271 TIR recipients (28.1%), IRs were changed. Among recipients of an initial DIR, the most frequent reasons for IR change were acute rejection (50%) within 6 months of transplantation and chronic allograft dysfunction (70%) after 6 months. In TIR recipients, the reasons for IR change included drug toxicity or drug-related side effects (34.3%) within 6 months of transplantation and complications related to overimmunosuppression (39.3%) after 6 months. The group in which the IR was changed from the initial DIR to the later TIR had a statistically superior graft survival rate compared to the group that did not have a change in the initial DIR (P = .032). In contrast, TIR recipients without change had better graft survival rate than recipients with initial TIR change to later DIR (P < .001). Change or modulation of immunosuppression from initial DIR to later TIR could affect long-term graft survival., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Right hepatectomy with the middle hepatic vein (MHV) affects venous return and function of the remaining liver. We compared the remnant liver volume in the donors of resection with or without the MHV on the remnant liver volume regeneration. Living donors who had undergone right hepatectomy without MHV (RH group; n = 36) and those with MHV (ERH group; n = 19) were reviewed. Volume regeneration of segments I-III, segment IV, and total remnant liver volume was assessed at postoperative day (POD) 7 and 30 using a computed tomography-based volumetry program. According to the measured volume data, we calculated the liver remnant volume and the rate of liver remnant volume increase. The regeneration rate of segment IV was significantly low in the ERH group compared with that in the RH group at POD 7 and POD 30 (160% vs 141%; P = .018 and 189% vs 154%; P = .007). In contrast, the regeneration rate of the total remnant liver volume was not significantly different between the 2 groups (173% vs 175%; P = .758 and 199% vs 198%; P = .880). In conclusion, extended right hepatectomy can be safely performed with careful preoperative evaluation without significant impairment of remnant liver regeneration., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Invasive pulmonary aspergillosis (IPA) is a serious and lethal complication among organ transplant recipients. This report described the clinical manifestations and treatment of IPA over a 28-year period. From January 1979 to December 2007, 3215 organ transplant patients (2954 kidney and 261 liver recipients) were enrolled in the study. Nine patients developed IPA (7 kidney and 2 liver recipients), yielding an incidence of 0.003% (9/3215). Five IPA patients (55.6%) were diagnosed by transbronchial lung biopsy or autopsy, and 3 (33.3%) by sputum culture study. One patient was diagnosed through clinical manifestations and observations of IPA characteristics on chest X ray. We used amphotericin B (n = 4; 44.4%), voriconazole (n = 2; 22.2%), or fluconazole (n = 1; 11.1%) as the primary antifungal agents, but 2 patients could not receive antifungal agents due to rapid disease progression and sequential mortality. This study showed a high mortality rate among IPA patients (55.6%; 5/9). Only patients who received early antifungal agent thereby after a prompt diagnosis recovered from IPA. This survival advantage warrants careful monitoring for invasive fungal infections after organ transplantation with immediate administration of antifungal agents or surgical intervention.

Background: Tacrolimus is a potent immunosuppressive drug used in organ transplantation. Because of its substantial toxic effects, narrow therapeutic index, and interindividual pharmacokinetic variability, therapeutic drug monitoring of whole-blood tacrolimus concentrations has been recommended. We investigated the comparability of the results of 2 immunoassay systems, affinity column-mediated immunoassay (ACMIA) and microparticle enzyme immunoassay (MEIA), comparing differences in the tacrolimus concentrations measured by the 2 methods in relation to the hematologic and biochemical values of hepatic and renal functions., Methods: A total of 154 samples from kidney or liver transplant recipients were subjected to Dimension RxL HM with a tacrolimus Flex reagent cartilage for the ACMIA method and IMx tacrolimus II for the MEIA method., Results: Tacrolimus concentrations measured by the ACMIA method (n = 154) closely correlated with those measured by the MEIA method (r = 0.84). The Bland-Altman plot using concentration differences between the 2 methods and the average of the 2 methods showed no specific trends. The tacrolimus levels determined by both the MEIA method and the ACMIA method were not influenced by hematocrit levels, but the difference between the 2 methods (ACMIA - MEIA) tended to be larger in low hematocrit samples (P < .001)., Conclusion: The ACMIA method used for a tacrolimus assay is precise and has advantages, including the lack of a required pretreatment procedure. Furthermore, it is only slightly influenced by the hematologic or biochemical status of the samples.

Serum creatinine (Scr) is the most frequently used test to estimate graft function after kidney transplantation. Our previous study demonstrated that the independent predictors of recipient posttransplantation Scr included the ratio of graft weight to recipient body weight, the ratio of graft weight to recipient body surface area (BSA), and the ratio of graft weight to recipient body mass index (BMI). A prospective analysis about the impact of the balance between metabolic demands and renal supply on posttransplantation Scr of recipients was previously reported. We plotted the scatter graph using the X-axis as the independent predictors of Scr by linear regression and the Y-axis as the recipient Scr. To generate the predictive formula of Scr, we calculated a fit of the line of plotted cases using a linear regression method with 2 regression lines for prediction of the upper and lower 95% confidence intervals. Each line was converted into a predictive formula: Scr = -0.0033* (Graft weight(g)/Recipient BSA(m2))+1.75. Under 95% confidence, the Scr ranges from -0.0033* (Graft weight(g)/Recipient BSA(m2))+1.07 to -0.0033* (Graft weight(g)/Recipient BSA (m2))+2.44. Scr = -0.1049* (Graft weight(g)/Recipient body weight(kg))+1.72, which ranges from -0.1049* (Graft weight(g)/Recipient body weight(kg))+1.06 to -0.1049* (Graft weight(g)/Recipient body weight(kg))+2.37. Scr = -0.0158* (Graft weight(g)/Recipient BMI(kg/m2))+1.56, which ranges from -0.0158* (Graft weight(g)/Recipient BMI(kg/m2))+0.75 to -0.0158* (Graft weight(g)/Recipient BMI(kg/m2))+2.26. Prediction of posttransplantation Scr may be achieved by measuring graft weight as well as recipient weight and height. When recipient Scr is significantly higher than that predicted by the formula, a clinician should suspect an underlying graft injury.

Using the pretransplant bone mineral density (BMD) data records of renal recipients, we retrospectively examined risk factors affecting posttransplant changes in BMD and the effect of antiosteoporosis management. For 294 kidney transplant recipients from January 1996 to September 2003, BMD values were expressed as spine and femur T-scores. Gender, age, pretransplant diabetes, blood type compatibility, mode and duration of dialysis, and previous transplantation were considered to be variables affecting BMD changes. T-test or ANOVA was used to compare risk factors. At the time of transplantation, mean spine T-scores were significantly lower among the retransplant group. Mean femur T-scores were significantly lower among the retransplant group, older patients (older than 45 years), and female recipients. Prolonged hemodialysis (>12 months) and retransplant were risk factors for BMD loss during the first year posttransplant. Early application of antiosteoporosis management was effective to ameliorate posttransplant BMD loss. However, antiosteoporosis management after 1 year posttransplant was relatively ineffective. Pretransplant evaluation of BMD and the possibility of significant BMD loss during the first posttransplant year should not be overlooked. Prophylaxis against bone loss and treatment should be started as soon as possible after transplantation for recipients with either normal or abnormal pretransplant BMD.

Background: To alleviate the organ shortage, the use of more living donors is strongly recommended world wide. A living donor exchange (swap) program was launched in Korea. After the success of a direct swap program between two families, we have developed the swap-around program to expand the donor pool by enrolling many kinds of unrelated donors. Herein, we report our results of a living donor exchange program., Methods: This retrospectively review of 978 recipients of kidney transplants from living donors, included analysis of donor-recipient relationships, mode of donor recruitment, episodes of acute rejection, and 5-year patient/graft survivals., Results: Transplantation was performed in 101 patients (10.3%) by way of the swap program. The proportion of swap patients among the number of unrelated donor renal transplants has been increasing from 4.2% to 46.6%. The incidence of acute rejection and 5-year patient/graft survival rates were comparable between the groups., Conclusions: We have achieved some success in reducing the organ shortage with a swap program in addition to our current unrelated living donor programs without jeopardizing graft survival. Potentially exchangeable donors should undergo strict medical evaluation by physicians and social evaluation by social workers and coordinators as a pre-requisite for kidney transplantation. Expanding the swap around program to a regional or national pool could be an option to reduce the organ donor shortage in the future.