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Background This study aimed to investigate whether high body mass index (BMI) and presensitization to human leukocyte antigen (HLA) in kidney transplant recipients (KTRs) affected allograft outcomes. Methods From January 2010 to December 2018, 1,290 kidney transplantations (KTs) were performed at the Seoul St Mary's Hospital. Of these, 682 cases of ABO-compatible living donor KT patients were enrolled. They were divided into four groups (low BMI-non-sensitized, high BMI-non-sensitized, low BMI-sensitized, and high BMI-sensitized) according to the median BMI value (22.7 kg/m2) and HLA presensitization status (anti-HLA antibody mean fluorescence intensity > 3,000). Short-term and long-term allograft outcomes were compared between groups. Results In the high BMI-sensitized group, the decline in allograft function was higher than that in the other three groups. Death-censored graft loss (DCGL) rates were highest in the high BMI-sensitized group (4 of 21 [19.0%], p = 0.04). In the multivariable Cox regression hazard regression model analysis, the hazard ratio (HR) for DCGL was intensified when high BMI and presensitization statuses were combined (HR, 3.75; p = 0.03); these statuses significantly interacted with each other (p-value for interaction = 0.008). Conclusion Our results suggest that presensitization to HLA and high BMI might have an interactive adverse impact on allograft outcomes in KTRs.

Tacrolimus is a key drug in kidney transplantation (KT) with a narrow therapeutic index. The association between the tacrolimus metabolism rate and KT outcomes have not been investigated in large-scale multi-center studies. The Korean Organ Transplantation Registry (KOTRY) datasets were used. A total of 3456 KT recipients were analyzed. The tacrolimus metabolism rate was defined as blood trough concentration of tacrolimus (C0 ) divided by the daily dose (D). The patients were grouped into fast, intermediate, or slow metabolizers by the C0 /D measured 6 months after transplantation. The slow metabolism group was associated with a 2.7 ml/min/1.73 m2 higher adjusted estimated glomerular filtration rate (eGFR) at 6 months [95% confidence interval (C.I.) 1.2-4.3, P = 0.001], less acute rejection (AR) within 6 months [Odds ratio (OR) 0.744, 95% C.I. 0.585-0.947, P = 0.016], and less interstitial fibrosis and tubular atrophy [OR 0.606, 95% C.I. 0.390-0.940, P = 0.025]. Fast tacrolimus metabolism affected the 6-month post-KT eGFR through mediation of AR [natural indirect effect (NIE) -0.434, 95% C.I. -0.856 to -0.012, P = 0.044) and delayed graft function (DGF; NIE -0.119, 95% C.I. -0.231 to -0.007, P = 0.038). Slow tacrolimus metabolism was associated with better post-KT eGFR. AR and DGF were found to be significant mediators.

We investigated the impact of acute kidney injury (AKI) in elderly deceased-donors (DDs) vs. AKI in young DDs on post-transplant clinical outcomes. A total of 709 kidney transplant recipients (KTRs) from 602 DDs at four transplant centers were enrolled. KTRs were divided into young-DDKT and elderly-DDKT groups according to the age of DD of 60 years. Both groups were subdivided into non-AKI-KT and AKI-KT subgroups according to AKI in DDs. We investigated short-term and long-term clinical outcomes of non-AKI-DDKT and AKI-DDKT subgroups within young-DDKT and elderly-DDKT groups. The incidence of DGF in the AKI-DDKT subgroup was higher and the allograft function within 12 months after KT in the AKI-DDKT subgroup was lower than those in the non-AKI-DDKT subgroup in both young-DDKT and elderly-DDKT groups. Death-censored allograft survival rate was significantly lower in the AKI-elderly-DDKT subgroup than that in the non-AKI-elderly-DDKT subgroup, but it did not differ between AKI-young-DDKT and non-AKI-young-DDKT subgroup. In multivariable analysis, AKI-elderly-DDKT was an independent risk factor for allograft failure (hazard ratio: 2.648, 95% CI: 1.170–5.994, p = 0.019) and a significant interaction between AKI and old age in DDs on allograft failure was observed (p = 0.001). AKI in elderly DDs, but not in young DDs, can significantly affect long-term allograft outcomes of KTRs.

Background The aim of this study was to investigate whether high body mass index (BMI) and pre-sensitization to human leukocyte antigen (HLA) in kidney transplant recipients (KTR) had a synergistic impact on the allograft outcomes.Methods From January 2010 to December 2018, 1,290 KTs were performed in Seoul St Mary's Hospital. Of these, 682 cases of ABO compatible KT were enrolled. They were divided into 4 groups (low BMI-non-sensitized, high BMI-non-sensitized, low BMI sensitized, high BMI-sensitized) according to the median BMI value (22.7 kg/m2) and HLA pre-sensitization status (HLA-DSA MFI >3,000). Short-term and long-term allograft outcomes were compared between the groups.Results The rate of late antibody mediated rejection tended to be the highest in the high BMI-sensitized group, and the decline in allograft function in the high BMI-sensitized group was higher than in the other 3 groups. Death-censored graft loss (DCGL) rates and the hazard ratio (HR) for DCGL were the highest in the high BMI-sensitized group (4/21 (19.0%), HR 4.648, P = 0.022) and a significant interaction was detected between high BMI and HLA pre-sensitization status (P value for interaction = 0.008). Conclusions Our results suggest that pre-sensitization to HLA and high BMI in KTRs might have a synergistic adverse impact on the allograft outcomes.

We investigated if clinical outcomes after kidney transplantation (KT) from deceased donors (DDs) with high Kidney Donor Profile Index (KDPI) can be different according to the age of KT recipients (KTRs). Six-hundred fifty-seven KTRs from 526 DDs were included from four transplant centers. We divided KTRs into elderly-KTR and young-KTR groups based on age 60 and each group was subdivided into high- or low-KDPI subgroup based on KDPI score of 65%. We compared short-term and long-term clinical outcomes among those four subgroups (low KDPI-young KTR, low KDPI-elderly-KTR, high KDPI-young-KTR, high KDPI-elderly-KTR). In short-term outcomes including acute rejection, BK virus and CMV infection, there was no significant difference among the four subgroups. In the long-term outcomes, the development of cardiovascular disease was higher in the high KDPI-elderly-KTR group than the other groups. In comparison of allograft survival rate, the high KDPI-young KTR subgroup showed highest risk for allograft failure and there was significant interaction between high-KDPI donors and young-KTR on allograft survival rate (P = 0.002). However, there was no significant difference in comparison of the patient survival rate. In conclusion, clinical impact of high-KDPI in DDs on post-transplant allograft survival may be less significant in elderly-KTR than in young-KTR.

Background Evidence of antibody-mediated injury in the absence of donor-specific HLA antibodies (HLA-DSA) has recently emerged, suggesting a role of antibodies in targeting non-HLA antigens expressed on renal allograft tissue. However, the clinical significance of pre-transplant non-HLA antibodies remains unclear. We compared the histological and clinical impact of pre-transplant HLA-DSA and non-HLA antibodies, especially angiotensin II type I receptor (anti-AT1R) and MHC class I-related chain A (anti-MICA), in kidney transplant patients. Methods Pre-transplant HLA-DSA, anti-AT1R, and anti-MICA were retrospectively examined in 359 kidney transplant patients to determine the effect of each antibody on allograft survival and clinical characteristics. Results Pre-transplant HLA-DSA, anti-AT1R, and anti-MICA were detected in 37 (10.3%), 174 (48.5%), and 50 patients (13.9%), respectively. Post-transplant antibody-mediated rejection was associated with a pre-transplant HLA-DSA (+) status only. The development of microvascular inflammation (MVI) was associated with pre-transplant HLA-DSA (P=0.001) and anti-AT1R (P=0.036). Anti-AT1R (+) patients had significantly lower allograft survival compared with anti-AT1R (-) patients (P=0.042). Only pre-transplant anti-AT1R positivity was an independent risk factor for allograft failure (hazard ratio 4.824, confidence interval 1.017-24.888; P=0.038). MVI was the most common histological feature of allograft failure in patients with pre-transplant anti-AT1R. Conclusions Pre-transplant anti-AT1R is an important risk factor for allograft failure, which may be mediated by MVI induction in the allograft tissue.

Background Favorable long-term and short-term graft survival and patient survival after kidney transplantation (KT) from deceased donors with acute kidney injury (AKI) have been reported. However, few studies have evaluated effects of donor AKI status on graft outcomes after KT in Asian population. Thus, the purpose of this study was to evaluate graft function after KTs from donors with AKI compared to matched KTs from donors without AKI using a multicenter cohort in Korea. Methods We analyzed a total of 1,466 KTs collected in Korean Organ Transplant Registry between April 2014 and December 2017. KTs from AKI donors (defined as donors with serum creatinine level ≥ 2 mg/dL) and non-AKI donors (275 cases for each group) were enrolled using a 1:1 propensity score matching. Graft outcomes including graft and patient survival, delayed graft function (DGF), rejection rate, and serially measured estimated glomerular filtration rate (eGFR) were evaluated. Results After propensity matching, KTs from AKI donors showed higher rate of DGF (44.7% vs. 24.0%, p < 0.001). However, the rejection rate was not significantly different between the two groups (KTs from AKI donors vs. KTs from non-AKI donors). eGFRs measured after 6 months, 1 year, 2 years and 3 years were not significantly different by donor AKI status. With median follow-up duration of 3.52 years, cox proportional hazards models revealed hazard ratio of 0.973 (95% confidence interval [CI], 0.584 to 1.621), 1.004 (95% CI, 0.491 to 2.054) and 0.808 (95% confidence interval [CI], 0.426 to 1.532) for overall graft failure, death-censored graft failure and patient mortality, respectively, in KTs from AKI donors compared to KTs from non-AKI donors as a reference. Conclusions KTs from AKI donors showed comparable outcomes to KTs from non-AKI donors, despite a higher incidence of DGF. Results of this study supports the validity of using kidneys from deceased AKI donors in Asian population.

IgA nephropathy (IgAN) is a globally well-known primary glomerular nephropathy. Hypertriglyceridemia (HTG) is one factor contributing to atherosclerosis and is a common complication of renal failure. HTG is a significant risk factor for decreased renal function in patients with IgAN. We evaluated the association of HTG with the histopathological features of IgAN patients. A total of 480 patients diagnosed with IgAN via kidney biopsy from eight university hospitals affiliated with the College of Medicine of the Catholic University of Korea were included in the final cohort. Pathological features were evaluated by eight expert pathologists with hospital consensus. HTG was defined as a serum triglyceride (TG) level of ≥150 mg/dL. In the study population analysis, the HTG group was older, with more males, higher body mass index (BMI), low-density lipoprotein cholesterol (LDL-C) and spot urine protein ratio, and lower estimated glomerular filtration rate (eGFR). In the lipid profile analysis, eGFR was negatively correlated with TGs/ high-density lipoprotein cholesterol (HDL) and triglyceride-glucose index (TyG). Proteinuria positively correlated with TGs/HDL, non-HDL/HDL, LDL/HDL, TyG, TGs and LDL. The percentages of global sclerosis (GS), segmental sclerosis (SS) and capsular adhesion (CA), and the scores for mesangial matrix expansion (MME) and mesangial cell proliferation (MCP), were more elevated in the HTG group compared to the normal TG group. Multivariable linear regression analysis showed that the percentages of global sclerosis, segmental sclerosis and capsular adhesion, as well as the scores for mesangial matrix expansion and mesangial cell proliferation, were positively associated with TG level. In binary logistic regression, the HTG group showed a higher risk for global sclerosis and segmental sclerosis. In conclusion, HTG is a significant risk factor for glomerulosclerosis in IgAN.

Background/Aims To investigate if BK virus (BKV)-specific T cell immunity measured by an interferon-γ enzyme-linked immunospot (ELISPOT) assay can predict the outcome of BK virus infection in kidney transplant recipients (KTRs). Methods We included 68 KTRs with different viremia status (no viremia [n = 17], BK viremia [n = 27], and cleared viremia [n = 24]) and 44 healthy controls (HCs). The BK viremia group was divided into controller (< 3 months) and noncontroller (> 3 months) according to sustained duration of BKV infection. We compared BKV-ELISPOT results against five BKV peptides (large tumor antigen [LT], St, VP1-3). Results BKV-ELISPOT results were higher in three KTRs groups with different BKV infection status than the HCs group (p < 0.05). In KTR groups, they were higher in cleared viremia group than no viremia or BK viremia group. Within the BK viremia group, controller group had higher LT-ELISPOT results compared to noncontroller group (p = 0.032). Also, KTRs without BK virus-associated nephropathy (BKVN) had higher LT, St, VP1, and VP2-ELISPOT results than those with BKVN (p < 0.05). Conclusions BKV-ELISPOT assay may be effective in predicting clinical outcomes of BKV infection in terms of clearance of BK virus and development of BKVN.

Spontaneous renal artery dissection is a rare disease and an uncommon cause of renal infarction. The patient was a man who presented to the emergency room with sudden-onset right flank pain. Computed tomography revealed right renal infarction; thus, anticoagulation was initiated. Renal angiography revealed luminal narrowing of the segmental artery to the superior pole of right kidney without a dissection flap or false lumen. We stopped anticoagulation due to a lack of evidence of thrombi or luminal narrowing of the dissected vessels. When patients present with acute flank pain, it is important to suspect renal infarction and to perform a correct diagnostic workup, even when the patient shows normal urinalysis results and a normal LDH value.

Hyperuricemia is a significant risk factor for cardiovascular morbidity and chronic kidney disease progression. IgA nephropathy (IgAN) is a well-known primary glomerular nephropathy. Hyperuricemia is associated with a poor prognosis in IgAN patients. We evaluated the association of hyperuricemia with the histopathological severity of IgAN in male and female patients, 658 patients diagnosed with IgAN via kidney biopsy were initially included. Baseline patient data were collected by eight university hospitals affiliated with the College of Medicine of the Catholic University of Korea. Pathological features were independently evaluated by eight expert pathologists working in the hospitals, and the consensus was reached. Of the initial 658 patients, 517 were finally included (253 males and 264 females). Hyperuricemia was defined as a serum uric acid (UA) level &gt, 7.0 mg/dL for males and &gt, 5.6 mg/dL for females, 108 (42.7%) males and 95 (35.9%) females exhibited hyperuricemia. Compared to the patients with normal UA levels, the global glomerulosclerosis, segmental sclerosis, mesangial matrix expansion (MME), endocapillary proliferation (ECP), interstitial fibrosis (IF), and tubular atrophy (TA) scores were higher in hyperuricemic males and females. In multivariable linear regression, the serum UA level correlated significantly with the MME, ECP, IF, and TA scores of female IgAN patients only.

Purpose We sought to assess the relationship between retinal nonperfusion area (NPA) on ultra-widefield fluorescein angiography (UWFA) and renal function in type 2 diabetes mellitus (DM) patients with diabetic retinopathy (DR) and nephropathy. Methods UWFA was performed in 248 eyes (124 patients) with DR, comprising 94 eyes from patients with chronic kidney disease (CKD) caused by diabetes and 154 eyes without CKD (non-CKD). Serum creatinine level (Cr), estimated glomerular filtration rate (eGFR), urine albumin/creatinine ratio (UACR), and urine protein/creatinine ratio (UPCR) were collected. On UWFA, retinal NPA was measured in an automated manner. The correlation between NPA and renal function was analyzed. Results The mean NPA value of the total eye was 33.11 ± 45.77-disc diameter (DA) in non-CKD and 100.57 ± 69.52 in CKD (P < 0.001). NPA of posterior pole was 1.21 ± 3.28 DA in non-CKD and 7.99 ± 6.75 in CKD group (P < 0.001). The NPA values of both the total eye and posterior pole were significantly correlated with Cr (r = 0.585 and 0.483), eGFR (r = −0.572 and −0.524), UACR (r = 0.541 and 0.482), and UPCR (r = 0.509 and 0.529, respectively) (all P ≤ 0.001). Linear modeling encompassing all clinical factors and relative clinical factors suggested eGFR as the most important predictor for NPAs of the total eye and posterior pole. Conclusions Larger retinal NPA on UWFA is associated with worse renal function in DM patients. Renal function can be used to predict retinal NPA in type 2 DM patients with nephropathy and DR.

Background: Human leukocyte antigen (HLA) analysis has been suggested as a predictive tool for alloimmune risk stratification in kidney transplantation (KT). We investigated whether the whole or single molecule HLA class II eplet mismatch was related to the de-novo donor-specific-antibody (dnDSA) development or antibody-mediated rejection (AMR). Methods: Total 300 kidney transplants performed at Seoul St. Mary’s Hospital between 2016 December and 2020 January with out preformed DSA have been analyzed. HLA class II eplet mismatches were determined by high resolution HLA DRB1/DQB1 typing results and HLA Matchmaker program. Results: During the 22.6 months (median) follow-up period, 24 recipients developed HLA class II dnDSA and 20 patients diag nosed as AMR. Using receiver operating characteristic analysis, we identified eplet mismatch thresholds associated with dnDSA development and stratified recipients into low-, intermediate-, and high-risk categories. In whole eplet mismatch analysis, risk categories were significantly correlated with dnDSA development (log-rank P-value 8 predicted dnDSA development with 75% sensitivity and 63.4% specificity. Risk categories by single molecular eplet mis match also had significant correlation with dnDSA development (log-rank P-value= 0.001) with significant difference between low (HLA-DR ≤7 and HLA-DQ ≤4) (n=78) and intermediate (HLA-DR ≥8 and HLA-DQ ≤6 or HLA-DR 0-7 and HLA-DQ 5-6) (n=95) group (P=0.026). High-risk group (HLA-DR 0-20 and HLA DQ 7-17) predicted dnDSA development with 75% sensitivity and 60.5% specificity. Both eplet mismatch risk categories were significantly associated with AMR, but no differences were found among risk groups. Conclusions: HLA class II eplet mismatches showed the possibility of being used as a clinically relevant parameter in alloim mune risk assessments of KT.

Background: Uremic pruritus is a common, but unpleasant, complication of end-stage renal disease. The uremic burden may differ between hemodialysis (HD) and peritoneal dialysis (PD) patients. This difference may also change the clinical characteristics of uremic pruritus between the 2 modalities. In this study, we investigated the uremic pruritus between patients on HD and PD. Methods: A total of 425 HD and 223 PD patients from the Clinical Research Center registry in Korea were included. Patients were assessed for pruritus intensity, scratching activity, pruritus distribution, and frequency of pruritus-related sleep disturbance using the visual analog scale and questionnaire. Results: The prevalence of uremic pruritus was higher in PD patients than that in HD patients (62.6% vs. 48.3%, P = 0.001). In the multivariable logistic analysis, PD treatment was significantly associated with the prevalence of uremic pruritus (odds ratio, 1.76; 95% confidence interval, 1.20-2.57, P = 0.004) after adjustment for clinical variables. The visual analog scale score, representing a subjective intensity of itchiness, was significantly higher in PD patients (PD 2.11 +/- 2.32 vs. HD 1.65 +/- 2.28, P = 0.013) compared with HD patients. The intensity of uremic pruritus was independently related with serum albumin levels (beta = -0.143, P = 0.006) in HD patients and total weekly Kt/V (beta = -0.176, P = 0.028) in PD patients. Conclusion: Our data demonstrate the difference in prevalence, intensity, and risk factors of uremic pruritus between HD and PD patients. These findings suggest that careful consideration for uremic pruritus might be needed in end-stage renal disease patients according to the dialysis modality. Copyright (C) 2016. The Korean Society of Nephrology. Published by Elsevier.

The increasing interest in healthcare and health screening events is revealing additional cases of asymptomatic isolated microscopic hematuria (IMH). However, a consensus of the evaluation and explanation of the IMH prognosis is controversial among physicians. Here, we present the natural course of IMH together with the pathological diagnosis and features to provide supportive data when approaching patients with IMH. We retrospectively evaluated 350 patients with IMH who underwent a renal biopsy between 2002 and 2011, and the pathological diagnosis and chronic histopathological features (glomerulosclerosis, interstitial fibrosis, and tubular atrophy) were reviewed. Deterioration of renal function was examined during follow up. The patients with IMH were evaluated for a mean of 86 months. IgA nephropathy was the most common diagnosis in 164 patients (46.9%). Chronic histopathological changes were observed in 166 (47.4%) but was not correlated with proteinuria or a decline in renal function. Ten patients developed proteinuria, and all of them had IgA nephropathy. Three patients progressed to chronic kidney disease with an estimated glomerular filtration rate < 60 mL/min/1.73 m(2) but none progressed to end stage renal disease. In conclusion, IMH had a generally benign course during 7-years of observation, although IgA nephropathy should be monitored if it progresses to proteinuria. Future prospective randomized studies may help conclude the long-term prognosis and lead to a consensus for managing IMH.

Eosinophils are bone-marrow–derived granulocytes present in peripheral blood and tissue that are primarily involved as effector cells in various conditions, including inflammatory diseases, allergic diseases, and parasitic infections [1,2]. Researchers have long thought that the main role of eosinophils was to act as effector cells in allergic reactions and helminth infections, but their role as antitumor effectors has recently been revealed [3-6]. Eosinophils function as antitumor effector cells in neoplastic lesions through a variety of eosinophil-derived mediators, including tumor necrosis factor alpha and granzyme-A [3,7]. Changes in the number of tissue eosinophils have been reported in several types of cancer and premalignant lesions from a wide range of organs, including the head and neck and the gastrointestinal tract [5,8-12]. Some studies have shown that the degree of tissue eosinophilia correlates with cancer prognosis because of its significant association with response to chemoradiation therapy, operability, and even lymph node metastasis [5,11,13-16]. These findings suggest that the degree of eosinophilia could be used as a prognostic marker. Among the studies on eosinophils and neoplastic conditions, both increasing and decreasing trends in the number of eosinophils in colorectal neoplasms have been reported with regards to tumor progression. A histopathological study on tissue eosinophilia in colorectal neoplasms has revealed that the degree of eosinophilia differs according to the malignant potential of the lesion; the number of tissue-infiltrating eosinophils increases in low-grade dysplasia, decreases in high-grade lesions, and decreases even more in cancer cases, showing significant and rapid change compared to the surrounding normal tissues [17-19]. As mentioned earlier, more prominent eosinophilia in colorectal cancer is associated with a better prognosis, including significant improvement in the 5-year survival rate. As the association between the infiltration of eosinophils and neoplasms is better understood, interest in how chemokines affect the differentiation and migration of eosinophils is increasing. Many kinds of chemokines are involved in the production, differentiation, and migration of eosinophils. Among the interleukins, interleukin (IL)-3 and IL-5 play major roles in the production and differentiation of eosinophils, and IL-4, IL-6, IL-11, and IL-12 are involved in their differentiation. A variety of C-C chemokines (named after the cysteine terminus residue near the C-terminus in the amino acid sequence), including C-C chemokine ligands-5 (CCL5, RANTES), CCL11 (eotaxin-1), CCL24 (eotaxin-2), and CCL26 (eotaxin-3), are involved in the differentiation and, in particular, the migration of eosinophils from the bone marrow to tissue stroma through enhancement and regulation of tethering, rolling, and endothelial adhesion of the eosinophils [1,2]. Expression of CCL11 and CCL24 in the human gastrointestinal tract is higher than in other tissues in the normal state, and increases during inflammatory disease, allergic reaction, and helminth infections, in which eosinophils function as effector cells [1,20-22]. The concentration of CCL24 is shown to be elevated in tumor tissue, and is also elevated in the stromal cells of colorectal tumors [23]. As mentioned earlier, a decrease in tissue eosinophils was observed in colorectal adenocarcinoma, but tissue levels of CCL11 were found to be elevated. Therefore, there is a discrepancy between decreased tissue eosinophilia and the tissue levels of chemokines such as CCL11 and CCL24, which enhance the recruitment of eosinophils. Serum chemokine levels appear to be elevated in prostate and colorectal adenocarcinoma, and they have been proposed as serum tumor markers [24-28]. In this study, we aimed to (1) evaluate the number of tissue-infiltrating eosinophils in colorectal tubular adenoma with low-grade dysplasia, tubular adenoma with high-grade dysplasia, and adenocarcinoma, and (2) evaluate the expression of CCL11 and CCL24 in colorectal neoplastic lesions by immunohistochemical staining to determine the correlation between the expression of cytokines, eosinophilia, and progression of neoplastic lesions. Even though much is known about the correlation between the prognosis and progression of colorectal neoplasms and eosinophilia, little is known about local expression of the chemokines associated with eosinophils. This study may provide insight into the relationship between tumor eosinophilia and local expression of chemokines, and thus explain the observed discrepancy between chemokine levels and tissue eosinophilia.

Background: BK virus-associated nephropathy (BKVAN) is a known risk factor for allograft dysfunction and graft failure in kidney transplant recipients. The mainstay of treatment for BKVAN is reduction of immunosuppression and this may increase risk for acute rejection. We proposed to observe the effects of acute rejection on patients with BKVAN. Methods: Using data from the Korean Organ Transplantation Registry, a nationwide organ transplantation database, we com pared graft function, and allograft survival in BKVAN patients with or without biopsy proven acute rejection (BPAR). Results: Among the 5,403 patients who received kidney transplantation between 2014 and June 2019, a total of 97 patients were diagnosed with BKVAN. Twenty-six patients (27%) developed BPAR within 6 months of BKVAN diagnosis, 71 patients did not. There were no differences in baseline characteristics, immunosuppression or BKVAN treatment methods between the BPAR and no BPAR groups. There was a significant decrease in allograft function in the BPAR group compared to the no BPAR group in both the 1-year (BPAR creatinine [Cr], 2.5±1.9 mg/dL vs. no BPAR Cr, 1.9±0.9 mg/dL; P=0.044) and 2-year follow-up period (BPAR Cr, 3.8±3.6 mg/dL vs. no BPAR Cr, 2.2±1.0 mg/dL; P=0.015). The BPAR group had lower allograft survival rates compared to the no BPAR group, although not statistically significant (P=0.474). On multivariate Cox regression analysis, MMF discontinuation was observed as a significant risk factor for rejection in BKVAN patients (hazard ratio, 4.000; 95% confidence interval [CI], 1.014- 15.775; P=0.048). Conclusions: Acute rejection with BKVAN is associated with poorer allograft function and survival. Also, discontinuation of MMF as treatment for BKVAN increases risk for acute rejection.

Several studies reported the effect of obesity on the progression of IgA nephropathy (IgAN). However, the impact of obesity on the clinicopathologic presentation of IgAN remains uncertain. This is a retrospective cross-sectional study from eight university hospitals in South Korea. Patients were categorized into three groups using the Asia-Pacific obesity classification based on body mass index (BMI). Clinical and histopathologic data at the time of renal biopsy were analyzed. Among 537 patients with IgAN, the obese group was more hypertensive and had lower estimated glomerular filtration rate and more proteinuria than other groups. The histologic scores for mesangial matrix expansion (MME), interstitial fibrosis, tubular atrophy, and mesangial C3 deposition differed significantly between the three groups. Among these histopathologic parameters, BMI was independently positively associated with MME score on multivariable linear regression analysis (p = 0.028). Using multivariable logistic regression analysis, the obese group was independently associated with higher MME scores compared to the normal weight/overweight group (p = 0.020). However, BMI was not independently associated with estimated glomerular filtration rate or proteinuria on multivariable analysis. Obesity was independently associated with severe MME in patients with IgAN. Obesity may play an important pathogenetic role in mesangial lesions seen in IgAN.

Background Many women with endometriosis have become pregnant through assisted reproductive technology (ART), and have often experienced placenta previa (PP) during pregnancy. The objective of this study was to assess the association between women with endometriosis, especially those who conceived with ART, and the risk of PP. Methods Two reviewers independently determined studies that were considered suitable for meta-analyses published in various medicine-related databases from March 1, 2004 through July 31, 2017 without language restrictions. Eight studies met the inclusion criteria, with a combined sample size of 21,930 women. Of these 21,930 pregnancies, 6,256 had endometriosis (endometriosis) and 15,674 had no endometriosis. Four of these studies included 8,161 women who conceived with ART, 1,640 of whom had endometriosis (endometriosis + ART), and 6,521 of whom did not have endometriosis. Meta-analyses were estimated with odds ratios (ORs) and 95% confidence intervals (CIs) using random effect analysis according to heterogeneity of studies. Results These meta-analyses showed women with endometriosis (endometriosis) have an increased risk of PP (OR, 4.038; 95% CI, 2.291–7.116; P = 0.000). These results showed women who conceived with ART (endometriosis + ART), have a substantially increased risk of PP (OR, 5.543; 95% CI, 1.659–18.523; P = 0.005). Conclusion These meta-analyses demonstrate women with endometriosis have an increased risk of PP., Graphical Abstract

Emphysematous pyelonephritis (EPN) is a life-threatening infection characterized by the formation of gas. Complications of EPN include septic shock, acute renal failure, and disseminated intravascular coagulation. Spontaneous subcapsular hematoma (SCH) has also been reported as a rare complication of EPN, although there have been no reports to date of this occurring prior to the presentation of EPN. We report a case of EPN that initially presented as spontaneous SCH. The patient was admitted for left flank pain, and initial computed tomography revealed SCH without any air shadows. Laboratory findings and clinical symptoms suggested the presence of urinary tract infection and the patient was started on antibiotics. Fever developed 24 hours after admission. On follow-up computed tomography 7 days later, EPN was newly observed, and a percutaneous drain was inserted. Blood, urine, and drainage fluid cultures all revealed growth of extended-spectrum β-lactamase-negative Escherichia coli.

Objective To assess positive culture rate and antimicrobial susceptibilities of Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) in symptomatic general population and pregnant women admitted with preterm labor and premature rupture of membranes. Methods We retrospectively reviewed medical records of patients who have undergone culture test and antimicrobial susceptibilities at our center from January 2017 to April 2018. Patients with positive culture for MH, UU, or both were included in this study. Results There were 200 patients who were eligible for enrollment. Of these patients, 34 (17%) were pregnant women and 166 (83%) were non-pregnant women. Of these 200 patients, positive culture results were as follows: MH only, n=10 (5%); UU only, n=58 (29%); and both MH and UU, n=36 (18%). Susceptibilities of MH only to doxycycline, erythromycin, ciprofloxacin, and azithromycin were 100%, 10%, 40%, and 0%, respectively. Susceptibilities of UU only to doxycycline, erythromycin, ciprofloxacin, and azithromycin were 94.8%, 87.9%, 5.2%, and 81%, respectively. Susceptibilities of both MH and UU to doxycycline, erythromycin, ciprofloxacin, and azithromycin were 97.2%, 5.6%, 11.1%, and 11.1%, respectively. Conclusion UU only was the leading causative pathogen for genitourinary infection in our study. MH only accounted for about one sixth of UU only infections. Doxycycline was still the best antibiotics as most patients with MH only, UU only, or both MH and UU positive culture showed susceptibility. For ciprofloxacin, less than 12% of those with UU only and both MH and UU culture positive results showed susceptibility.

The efficacy of second-line chemotherapy for relapsed primary peritoneal serous carcinoma has been numerously reported, but reports on durable response after second-line therapy have been rare. We report the case of a 66-year-old woman with relapsed primary peritoneal serous carcinoma who showed durable response after just one cycle of second-line belotecan-based therapy. The response might be a complete pathologic remission. Considering the fact that our patient suffered from neutropenic sepsis during her treatment, we concluded that belotecan-based chemotherapy could be a good option for second-line chemotherapy in some selected patients, so patient selection should be carefully performed due to the toxicity of belotecan.

Background: The aim of this study was to evaluate the value of preoperative plasma B-type natriuretic peptide (BNP) level in predicting postoperative in-hospital major adverse cardiac events (MACE, defined as atrial fibrillation, congestive heart failure, nonfatal myocardial infarction and cardiac death) in elderly patients undergoing orthopedic surgery. Methods: Between March 2010 and September 2011, data from 156 patients (aged 65 years or older) who underwent scheduled or emergent orthopedic surgery, were investigated. Screening for postoperative in-hospital MACE was performed using clinical criteria. Results: MACE occurred in 12 patients (7.7%). The BNP level was significantly higher in patients with MACE than in those without (median, 152.0; interquartile range [36.3 to 352.8] pg/mL vs. median, 36.8; interquartile range [15.5 to 98.1] pg/mL, p=0.005). The BNP level was positively correlated with the revised cardiac risk index score (r=0.300, p=0.001). In a receiver operating characteristic (ROC) analysis for MACE, the ROC for BNP was 0.746 (95% confidence interval, 0.602 to 0.891). At the optimal cut-off point (BNP=110 pg/mL), the sensitivity, specificity and positive and negative predictive values were 66.7, 81.2, 22.0% and 96.6%, respectively. On multivariate analysis, preoperative BNP was an independent predictor for MACE (odds ratio, 5.091; p=0.018) after adjusting for baseline confounding factors such as diabetes mellitus and history of cerebrovascular accident. Conclusion: The preoperative BNP level may be a useful tool in stratifying the risk for MACE in elderly patients undergoing orthopedic surgery.

Background/aims The true incidence of aristolochic acid nephropathy (AAN) is thought to be underestimated because numerous ingredients known or suspected to contain aristolochic acid (AA) are used in traditional medicine in Korea. Methods We collected data on cases of AAN since 1996 via a database in Korea. We evaluated the year of AAN development, route to obtaining AA-containing herbal medicine, gender, reason for taking AA-containing herbal medicine, clinical manifestations, histological findings, phytochemical analysis, and prognosis of patients with AAN. Results Data on 16 cases of AAN were collected. Thirteen cases developed AAN before and three cases after the prohibition of AA-containing herbal medicine by the Korea Food and Drug Administration. Patients were prescribed AA-containing herbal medicine from oriental clinics or had purchased it from traditional markets. AAN was distributed in all age groups. Young females were most commonly exposed to AA-containing herbal medicine for slimming purposes and postpartum health promotion, while older adults took AA-containing compounds for the treatment of chronic diseases. The most common symptoms presented at hospitalization were nausea and vomiting, and acute kidney injury was accompanied by Fanconi syndrome in almost half of the patients. Phytochemical analysis of AA in herbal medicine was available in six cases. Progression to end stage renal disease (ESRD) was observed in seven patients (43.8%), and five patients (31.3%) had progressed to ESRD within 6 months of diagnosis. Conclusion Our report shows that patients were still exposed to AA-containing herbal medicine and that there is a possibility of underdiagnosis of AAN in Korea. A stronger national supervision system of herbal ingredients and remedies in oriental medicine is needed to prevent AAN.

Supplemental Digital Content is available in the text, With the development of the single antigen beads assay, the role of donor specific alloantibody (DSA) against human leukocyte antigens in kidney transplantation (KT) has been highlighted. This study aimed to investigate the clinical significance of DQ-DSA detected at renal allograft biopsy. We evaluated 263 KT recipients who underwent allograft biopsy and DSA detection at the same time. Among them, 155 patients who were nonsensitized before transplantation were selected to investigate the role of de-novo DQ-DSA. Both the total and nonsensitized subgroup was categorized into 4 groups each according to DSA results as: DQ only, DQ + non-DQ, non-DQ, and no DSA. In the total patient group, post-KT DSA was positive in 79 (30.0%) patients and DQ-DSA was most prevalent (64.6%). In the nonsensitized subgroup, de-novo DSAs were detected in 45 (29.0%) patients and DQ-DSA was also most prevalent (73.3%). The DQ only group showed a significantly longer post-KT duration compared to the other groups (P

In order to review the recent technological progress and issues on the urban mine resources recycling in Japan and Korea, recycling process of the ELV(End of Life Vehicles) and E-waste(WEEE) were studied. Although technological level for processing of the ELV and E-waste is almost similar in both countries, the treatment of hazadous materials of ELV such as freon, air bag and ASR is unsufficient in Korea. In the E-waste recycling, the technological level is deeply different according to the enterprise size in Korea. Finally, the big R&D project on recycling of urban mine resources sponsored by government in both countries were discussed.

In order to review the technological modulus of the recycling of urban mine resources and non-ferrous smelting process in Korea, key point of recycling process, physical separation, non-ferrous smelting process, unit operation for the recycling technology, recycling process of LS-Nikko Copper and Korea Zinc were studied. Finally, metal recycling processes of the typical non-ferrous smelters in Japan such sa DOWA Holdings and JX Holdings were compared with those of LS-Nikko Copper and Korea Zinc.

In order to review the recycling status of urban mine resources in Korea, metal consumption, metal stock reserves and metal scraps and wastes such as iron scrap, end of life vehicles(ELV), E-waste were surveyed. In making up the list of the metal consumption, the statistical data from the Korea Non-Ferrous Association, the Korea Iron and Steel Association, the HS code of Korea Custom Service, the symposium and the related companies were collected. Finally, "Principle uses and recycling potential of metals in the periodic table" by T.E.Graedel was introduced. This paper suggested the key point for development of urban mine resources.

Waste electrical and electronic equipment(WEEE or E-waste) is one of the fastest growing waste stream in Korea. The proper management of such equipment has become of major concern for solid waste professionals because of the large growth of the waste stream and the presence of a myriad of toxic materials with in it. In this paper in order to review the recycling system and recycling industries of the E-waste in Korea, the main frame concerning recycling of "Act on the Resources Recycling of Waste Electrical Electronic Equipment(WEEE) and End-of-life vehicles", recycling system, current recycling status, estimation of the E-waste generation, material flow of the E-waste, economics of PCB and recycling industries of the E-waste were surveyed.

In order to review the recycling status of urban mine resources in China, recycling of ELV(End of Life Vehicles), E-waste(WEEE) and nonferrous metals were surveyed. Number of the sales volume of the new vehicles were over more than ten million and number of discharge vehicles are increasing now. However, recycling system has not been managed smoothly in China. Though usage of home appliances in urban is similar with advanced countries, there are significant differences in rural community. In the other hand, China is the country with the largest E-waste import in the world. Production and consumption of the nonferrous metals are increasing year by year in China, but recycling of metals is not enough.

DOWA group has been working on metal recycling applying the smelting and refining process of KOSAKA Smelter. DOWA has developed it`s metal recycling technologies through the treatment of black ore(complex sulfide ores) that contain many kinds of non-ferrous metals. In addition to these special technologies, DOWA has strengthened its hydrometallurgical process of precious metals and ability to deal with low-grade materials such as used electrical appliances or vehicles. On the other hand, JX Nippon Mining & Metals Corporation(JX-NMMC) carries out its metal recycling and industrial waste treatment businesses employing advanced separation, extraction and refining technologies developed through its extensive experience in the smelting of non-ferrous metals. JX-NMMC collects approximately 100,000t/y of copper and precious metal scraps from waste sources such as electronic parts, mobile phones, catalytic converters, print circuit boards and gold plated parts. These items are recycled through the smelting and refining operations of Saganoseki smelter and Hitachi Metal-recycling complex(HMC). In this like, metal recycling industries combined with environmental business service in Japan have been developed through excellent technologies for mineral processing and non-ferrous smelting. Also, both group, Dowa and JX-NMMC, were contributed to establish Japan`s recycling-oriented society as the typical leading company of non-ferrous smelting. Now. it is an important issue to set up the collection system for e-waste.

The Korea auto industry has developed remarkedly over the past 40 years and ranked up to 5th vehicles production nation in the world. In 2009 alone, Korea produced 3.5million vehicles and number of vehicles registered surpassed the seventeen million. On the other hand, 711 thousand ELV(End of Life Vehicles) were scrapped and used cars more than 265 thousand were exported. In the year 2009, 568 thousand tons of iron, 46 thousand tons of aluminum and 7 thousand tons of copper were recovered from ELV in Korea. Recycling ratio of ELV is approaching 95% by using ASR(Automobile Shredding Residue) as a fuel at cement kiln. Korea has enacted the automobile recycling law in 2007 and enforced it from January 2009, actually. However, the law has not been managed smoothly due to delays in the construction of infrastructure and the existence of a hostile monitoring system. In this regard, a revision and supplement program focused on recycling fee on the automobile recycling law is running under the ministry of environment now. Here, a recycling model for enhancing ELV recycling is suggested.

Rationale:Anaphylaxis is a very rare event in pregnancy, triggering maternal hypotension leading to intrapartum hypoxic-ischemic encephalopathy in infant. Furthermore, cesarean sections are performed at a high rate in anaphylactic pregnant women.Patient concerns:A 34-year-old pregnant woman

SummaryInterleukin (IL)-5 and eotaxin families regulate the development of eosinophilic inflammation of asthma in a co-operative manner. The exposure to airborne lipopolysaccharide (LPS) induces varying degrees of airflow obstruction and neutrophilic airway inflammation. Production of IL-5 and eotaxin subfamily chemokines was analysed in response to Dermatophagoides pteronyssinus allergen (D.p.) according to the presence of specific IgE to D.p., and investigated the mechanism underlying their LPS-mediated regulation of these cytokines in response to the specific allergen. Peripheral blood cells (PBCs) from asthmatics with (group 1) or without (group 2) specific IgE to D.p. and from non-asthmatics with (group 3) or without (group 4) were stimulated with D.p. or LPS. For LPS-mediated inhibition of IL-5 and eotaxin-2 production, LPS-induced cytokines were added to the D.p.-stimulated PBCs. IL-5 and eotaxin-2, but not eotaxin-1 and 3, were significantly increased by D.p.-stimulated-PBCs from group 1, while only eotaxin-2 was elevated in group 3. Eotaxin-2 production was found in monocytes and correlated with the level of specific IgE to D.p. LPS treatment resulted in the decrease in eotaxin-2 and IL-5 production by the D.p.-stimulated PBCs. LPS-induced IL-10 completely inhibited D.p.-stimulated production of eotaxin-2 and IL-5. The differential responses of the eotaxin family to specific antigens suggest that the predominant role of eotaxin-2 and LPS may attenuate eosinophilic inflammation by inhibiting IL-5 and eotaxin-2 synthesis through IL-10 production.

Portal vein thrombosis is an uncommon but an important cause of portal hypertension. The most common etiological factors of portal vein thrombosis are liver cirrhosis and malignancy. Albeit rare, portal vein thrombosis can also occur in the presence of local infection and inflammation such as pancreatitis or cholecystitis. A 52-year-old male was admitted because of general weakness and poor oral intake. He had an operation for colon cancer 18 months ago. However, colonic stent had to be inserted afterwards because stricture developed at anastomosis site. Computed tomography taken at admission revealed portal vein thrombosis and inflammation at colonic stent insertion site. Blood culture was positive for Escherichia coli. After antibiotic therapy, portal vein thrombosis resolved. Herein, we report a case of portal vein thrombosis with sepsis caused by inflammation at colonic stent insertion site which was successfully treated with antibiotics.

Eosinophilic infiltration of airway tissue is a central feature of aspirin-induced asthma (AIA). Eotaxins belong to the family of CC chemokines, which coordinate the recruitment of inflammatory cells bearing chemokine (C-C motif) receptor-3 to sites of allergic inflammation. In the present study, the levels of eotaxin-1, eotaxin-2, and eotaxin-3 following an oral aspirin provocation test (APT) were measured, and the relationship between the eotaxin level and clinical parameters in patients with asthma was evaluated.An APT was performed in patients with asthma. Twenty AIA patients and 23 aspirin-tolerant asthma (ATA) patients were identified. Plasma levels of eotaxin-1, eotaxin-2, and eotaxin-3 levels were measured by enzyme-linked immunosorbent assay in the 43 patients with asthma and in 39 control subjects.The proportion of blood eosinophils was significantly higher in asthmatic patients than in control subjects. Nasal polyps were more common in AIA patients than in ATA patients (p0.05). In addition, the eotaxin-1 level was higher in AIA and ATA patients than in control subjects (p0.01 for each). The eotaxin-2 level was higher in ATA patients than in either the AIA patients (p0.05) or control subjects (p0.01). Similarly, the eotaxin-3 level was higher in ATA patients than in control subjects. A trend toward higher plasma levels of eotaxin-1 and eotaxin-3 at baseline and at 4 h after APT administration in the ATA group was noted but was not significant. Eotaxin-2 was also higher in ATA patients than in AIA patients at baseline and at 4 h after the APT.This study shows that eotaxin-2 is differentially secreted in patients with asthma according to aspirin intolerance, and that secretion is not time-dependent in response to the APT in AIA and ATA patients. It therefore appears that eotaxin-2 may be up-regulated and may act differentially in patients with ATA.

Granular cell tumor (GCT) is a rare soft tissue tumor that derived from Schwann cells. Most are benign, less than 2% are malignant and, in the malignant cases, the prognosis of survival is poor. Most of these tumors are less than 3 cm in size, and they are more common in black women. The disease usually occurs in the 40s to the 60s and occurs after menopause, but there are few cases reported in adolescence. A 45-year-old woman visited the outpatient clinic with a solid mass that developed 2 years ago and present to date on the left side of the clitoris. After complete resection, pathologic examination proved to be a granular cell. The patient has been living without recurrence for one year. We report the first case of the GCT of the clitoris in postmenopausal woman in Korea with a brief review of the literature.