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Background: Adequate kidney donor management after donation is increasingly emphasized due to concerns of renal function impairment after nephrectomy with increasing life expectancy. In this study, the clinical impact of a protocolized kidney donor follow-up system by nephrologists was evaluated., Methods: A total of 427 living kidney donors underwent nephrectomy from January 2010 to December 2014 and were followed for at least 2 years at the Samsung Medical Center. Donors were followed-up by nephrologists after the establishment of a donor clinic with systemized protocols in January 2013. The primary outcomes were incidence of post-donation low estimated glomerular filtration rate (eGFR) and renal function adaptability. Secondary outcomes were changes in compliance and incidence of hyperuricemia and microalbuminuria., Results: The patients were divided into 2 groups according to the time of nephrectomy: the pre-donor clinic period (n = 182) and the donor clinic period (n = 172). Preoperative eGFR in patients in the pre-donor clinic period was higher than that in patients in the donor clinic period. After donation, poor renal adaptation was less frequent in the donor clinic period compared to the pre-donor clinic period. Low eGFR tended to be less common during the donor clinic period. Shorter mean outpatient clinic visit intervals with more visits within 6 months after donation and earlier detection of de novo hyperuricemia were found during the donor clinic period., Conclusion: A protocolized donor clinic run by nephrologists may improve post-nephrectomy renal outcomes and compliance and facilitate better management of potential risk factors of chronic kidney disease in donors., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Despite compensatory hyperfiltration in remaining nephrons following donor nephrectomy, some donors show impaired renal adaptation and low estimated glomerular filtration rate (eGFR). We investigated the factors predicting early renal adaptation after nephrectomy and identified kidney donors at risk of inadequate renal adaptation., Methods: A total of 265 living kidney donors from 2010 to 2013 were retrospectively analyzed. Renal function was serially followed for 6 months after the operation. Regression analyses were performed to identify the independent predictors of low eGFR (eGFR <60 mL/min/1.73 m 2 ) and impaired renal adaptation (%Modification of Diet in Renal Disease [MDRD] <66% of baseline eGFR)., Results: A total of 148 donors belonged to the low eGFR group, and changes in eGFR (ΔeGFR) at postoperative (PO) 1 day and 1 month were identified as independent predictors of low eGFR. Impaired renal adaptation was related to age, ΔeGFR PO 2-3 days, and ΔeGFR PO 1 month. Early renal adaptation was associated with age, male gender, and residual kidney computerized tomography angiography (CTA) volume. The best sensitivity and specificity were obtained with a cutoff value of ΔeGFR 31 at PO 1 day and 1 month for predicting low eGFR and with a value of ΔeGFR 27 at PO 2-3 days and 1 month for predicting impaired renal adaptation., Conclusions: Our study showed that the degree of early renal adaptation determines subsequent renal function in kidney donors. Closer monitoring and management may be required in old or male donors with small residual CTA kidney volume as well as donors with persistent ΔeGFR >27 within 1 month of nephrectomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Living-donor liver transplantation (LDLT) has been accepted as feasible treatment for fulminant hepatic failure (FHF), although it has generated several debatable issues. In this study, we investigated the prognostic factors predicting fatal outcome after LDLT for FHF., Methods: From April 1999 to April 2011, 60 patients underwent LT for acute liver failure, including 42 patients for FHF at Samsung Medical Center, Seoul, Korea. Among 42 patients, 30 patients underwent LDLT for FHF, and the database of these patients was analyzed retrospectively to investigate the prognostic factors after LDLT for FHF., Results: Among 30 patients, 7 patients (23%) died during the in-hospital period within 6 months, and 23 patients (77%) survived until recently. In univariate analyses, donor age (>35 years), graft volume (GV)/standard liver volume (SLV) (<50%), cold ischemic time (>120 minutes), hepatic encephalopathy (grade IV), hepato-renal syndrome (HRS), and history of ventilator care were associated with fatal outcome after LDLT for FHF. In multivariate analyses, HRS, GV/SLV (<50%), and donor age (>35 years) were significantly associated with fatal outcome. Although the statistical significance was not shown in this analysis (P = .059), hepatic encephalopathy grade IV also appears to be a risk factor predicting fatal outcome., Conclusions: The survival of patients with FHF undergoing LDLT was comparable to that in published data. In this study, HRS, GV/SLV <50%, and donor age >35 years are the independent poor prognostic factors., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: The influence of human leukocyte antigen (HLA) mismatch on liver transplantation has been widely studied, but is still controversial. The aim of this large single-center study was to analyze the role of HLA compatibility between donor and recipient in the graft outcomes of living donor liver transplantation (LDLT)., Materials and Methods: A total of 925 recipients who had undergone LDLT between March 2001 and April 2012 were retrospectively analyzed. HLA typing was performed using a standard complement-dependent cytotoxicity technique. The degree and type of HLA-A, HLA-B, and HLA-DR mismatch were assessed. We also investigated the posttransplantation laboratory data, incidence of rejection, recurrence of hepatitis B virus (HBV), and graft survival as outcome parameters., Results: The type of HLA-A, HLA-B, and HLA-DR mismatch had no effect on rejection episodes, whereas the beneficial effect of a much lower degree (0-2) of HLA mismatch was notable. Recipients with 2 HLA-B mismatches or recipients with a higher degree of mismatch were associated with elevated bilirubin level, a higher recurrence rate of HBV, and inferior graft survival. A complete mismatch of 2 at the DR locus also decreased graft survival in LDLT recipients., Conclusions: This study confirmed that the degree of HLA mismatch, as well as the locus-specific type of HLA mismatch, namely B and DR, play a major role in graft outcomes after LDLT. To obtain an improved graft outcome, HLA compatibility should be considered in the setting of LDLT, which provides sufficient time to select a more favorable donor-recipient combination., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Antibody-mediated rejection (AMR) is one of the major causes of poor outcomes in ABO-incompatible kidney transplantation (ABOi KT). Studies investigating AMR risk factors found that anti-ABO titer is a major issue. However, the significance of antibody titer has been debated. This retrospective study analyzed AMR risk factors in 59 patients who underwent ABOi KT between August 2010 and January 2015. We also analyzed AMR risk factors in recipients with high anti-ABO baseline titers (≥1:64 on dithiothreitol at 37°C phase or ≥1:256 on antihuman globulin phase). The 2-year patient survival rate was 95.8%, and the 2-year graft survival rate was 94.9%. Nine patients (15.3%) experienced clinical (6 of 59 [10.2%]) or subclinical (3 of 59 [5.1%]) AMR. One patient experienced graft loss from hyperacute rejection. AMR risk factor analysis revealed that baseline antibody titer was associated with incidence of AMR. In patients with high baseline titers, low doses of rituximab (200-mg single-dose), an antibody against CD20, was predictive for AMR. Six patients who received pretransplant intravenous immunoglobulin did not experience AMR even when they had high baseline antibody titers. Our results indicate that a high baseline antibody titer affected the incidence of AMR. ABOi KT candidates with high baseline titers need to undergo an intensified preconditioning protocol, including high-dose rituximab (375 mg/m(2)) and intravenous immunoglobulin., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Biliary tract complications are the main concern associated with living-donor liver transplantation (LDLT). Many laboratory parameters have been studied for the early detection of post-LDLT complications, including various cytokines. To explore immunologic activation status and its clinical significance, the cytokine secretion patterns of LDLT patients who developed biliary complications were analyzed. Serum samples from LDLT recipients were collected 1 day before and 3, 7, 14, and 30 days after transplantation. Each sample was tested for interleukin (IL) 2, IL-4, IL-6, IL-8, IL-10, IL-12, interferon-α, and tumor necrosis factor α with the use of multiplex bead flow cytometry. Fifteen patients without any complications and 6 patients with biliary complications showed differential serum cytokine profiles. The biliary complication group (4 biliary stricture and 2 biliary obstruction patients) displayed significantly increased concentrations of IL-2 and IL-12 on post-transplantation days 3 and 7 and of IL-4 on post-transplantation day 7. Profiling cytokine secretion in the serum of patients in the first month of LDLT may be helpful for the prediction and diagnosis of biliary complications within 1 year., (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.)

A kidney stone in a person with a solitary kidney requires urgent attention, which may result in surgical and/or hospital attention. We conducted a matched retrospective cohort study to determine if living kidney donors compared to healthy nondonors have a higher risk of: (i) kidney stones with surgical intervention, and (ii) hospital encounters for kidney stones. We reviewed all predonation charts for living kidney donations from 1992 to 2009 at five major transplant centers in Ontario, Canada, and linked this information to healthcare databases. We selected nondonors from the healthiest segment of the general population and matched 10 nondonors to every donor. Of the 2019 donors and 20 190 nondonors, none had evidence of kidney stones prior to cohort entry. Median follow-up time was 8.4 years (maximum 19.7 years; loss to follow-up <7%). There was no difference in the rate of kidney stones with surgical intervention in donors compared to nondonors (8.3 vs. 9.7 events/10 000 person-years; rate ratio 0.85; 95% confidence interval [CI] 0.47-1.53). Similarly there was no difference in the rate of hospital encounters for kidney stones (12.1 vs. 16.1 events/10 000 person-years; rate ratio 0.75; 95% CI 0.45-1.24). These interim results are reassuring for the safety of living kidney donation., (© Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Purpose: Advanced donor age is a well-known risk factor for poor graft function after living donor liver transplantation (LDLT). In addition, advanced recipient age has a significant impact because of the high prevalence of comorbidities. We investigated the relationship between donor-recipient age gradient (DRAG) and the posttransplant outcomes in LDLT., Methods: We included 821 consecutive adult recipients who underwent LDLT from June 1997 to May 2011. According to the value of DRAG, they were divided into 2 groups: Negative years (the donor was younger than the recipient) and positive years (the donor was older than the recipient). These groups were further divided into subgroups (≤-21, -20 to -1, 0 to 20, and ≥21 years). We collected retrospectively patient characteristics, laboratory results, medical and surgical complications, and graft loss., Results: The positive DRAG group had higher level of posttransplant alkaline phosphatase, but a lower incidence of biliary complications. The negative DRAG group, particularly DRAG ≤ -21 years was associated with the superior 1-, 3-, 5-, and 10-year graft survivals. Recipients with DRAG ≥ 21 showed persistently inferior graft survival during the observation period. In cases of young donors, transplants utilizing lower DRAG seen between young donors and older recipients showed more favorable graft survival than that of young-to-young transplants., Conclusion: This study demonstrated that DRAG and a fixed donor age limit could be significant factors to predict graft survival after LDLT. Patients should carefully consider the worse graft survival if the donor is older than the recipient by ≥20., (Copyright © 2013. Published by Elsevier Inc.)

We investigated the effect of the donor kidney weight (Kw) to recipient body weight (Rw) ratio (Kw/Rw) on long-term graft function. To investigate the impact of the Kw/Rw ratio on the graft function, we retrospectively collected data from 213 kidney transplant recipients at least 5 years Post-transplantations. Renal function showed a positive correlation with the Kw/Rw ratio until 5 years after transplantation (at 60 months after transplantation, R = 0.158, P = .023); however, this ratio does not affect graft survival (P = .794). We used the mixed-effect model to identify the factors that affect the estimated glomerular filtration rate (eGFR) over time. In univariate analysis, donor age, BSA, kidney weight, and Kw/Rw ratio were associated with eGFR. To identify independent factors that affect to the eGFR, multivariate analysis using a mixed model was applied. Donor age (P < .001) and Kw/Rw ratio (P < .001) were independent factors that affected the eGFR. To identify the cutoff values of the Kw/Rw ratio and donor age that affect long-term graft function, multiple testing using a mixed model was applied. The cutoff value for the Kw/Rw ratio was 3.16 (P = .0104) and the cutoff value of donor age was 44 years (P = .0001). Based on our results, we conclude that the Kw/Rw ratio and donor age are important factors for the long-term function of graft., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Successful arterial reconstruction is essential for liver transplantation. In the case of inadequate arterial inflow, an arterial conduit from the aorta using artery graft or re-establishment of arterial flow through other arteries such as the splenic artery, gastroepiploic, or sigmoid artery is considered. Herein we report our experience of 27 cases of hepatic artery reconstruction using alternative methods. The most common cause of hepatic artery reconstruction requiring alternative methods was intimal dissection for which we usually used the gastroepiploic artery. Many patients had a previous operation or transarterial chemoembolization history. Among these cases, hepatic artery reconstruction using the jejunal artery was performed for 2 cases of living donor liver transplantation due to the absence of suitable alternatives. These patients have been followed up with patent hepatic arterial flow until now. Thus, the jejunal artery can be a useful option for arterial reconstruction in living donor liver transplantation when suitable arterial inflow is absent., (Copyright © 2013. Published by Elsevier Inc.)

Background: Many patients are diagnosed with hepatocellular carcinoma (HCC) within the Milan criteria. In Korea, these patients are preferentially treated with locoregional therapy (LRT) instead of living donor liver transplantation. We investigated the effectiveness of LRT in liver transplant recipients who met the Milan criteria at the time of HCC diagnosis and investigated risk factors for HCC recurrence., Methods: We retrospectively reviewed the medical records of patients diagnosed with HCC who met the Milan criteria between 2002 and 2008., Results: We performed 101 liver transplants for HCC during the study period. Seventy-one patients (70%) underwent pretransplant LRT. The disease-free survival rates at 1, 3, and 5 years in patients who received LRT were 96.6%, 93.1%, and 93.1%, and in those who did not receive LRT, 94.2%, 83.4%, and 83.4%, respectively. There were no differences between the 2 groups. Multivariate analysis showed that a low Model for End-Stage Liver Disease (MELD) score and microvascular invasion were independent predictors of HCC recurrence after transplantation. The MELD scores and rate of microvascular invasion were not statistically different in patients with or without previous LRT., Conclusion: Pretransplant LRT for patients with HCC who met the Milan criteria at the time of diagnosis did not provide a clear benefit with respect to HCC recurrence after transplantation. If patients have suitable living donors, those who meet the Milan criteria should undergo a liver transplantation as soon as possible., (Copyright © 2012. Published by Elsevier Inc.)

Introduction: Anatomic variants of the hepatic vasculature are common, so precise preoperative donor evaluation, including variations in the vasculature, is essential. We analyzed the anatomic similarity according to the donor-recipient relationship., Methods: Among the cases who underwent living donor liver transplantations from September 2008 to January 2011 we selected 104 cases with clearly defined hepatic artery and portal vein on preoperative computed tomography. They were classified according to Hiatt et al for the hepatic artery and Cheng for the portal vein. We categorized the 104 cases into three groups: parents-child (n=40), sibling (n=24) and no-relation (n=40), for analysis of the concordance of the hepatic artery and portal vein., Result: Anatomic variations were observed in 25% of donors and 23.1% of recipients in the hepatic artery and 6.7% of donors and 10.6% of recipients in the portal vein. There was no significant difference in the distribution of the type of hepatic vasculature. Identical anatomic variations between donors and recipients were observed in 62.5% of the parent-child; 66.7% of the sibling and 52.5% of no-related group (P=.493) in the hepatic artery and 92.5%, 100%, and 77.5% (P=.014) in the portal vein respectively., Conclusion: There was no similarity in the anatomic variations of the hepatic artery according to the donor-recipient relationship, but a similarity in portal venous anatomy according to the donor-recipient relationship., (Copyright © 2012. Published by Elsevier Inc.)

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.)

Older living kidney donors are regularly accepted. Better knowledge of recipient outcomes is needed to inform this practice. This retrospective cohort study observed kidney allograft recipients from Ontario, Canada between January 2000 and March 2008. Donors to these recipients were older living (≥ 60 years), younger living, or standard criteria deceased (SCD). Review of medical records and electronic healthcare data were used to perform survival analysis. Recipients received 73 older living, 1187 younger living and 1400 SCD kidneys. Recipients of older living kidneys were older than recipients of younger living kidneys. Baseline glomerular filtration rate (eGFR) of older kidneys was 13 mL/min per 1.73 m² lower than younger kidneys. Median follow-up time was 4 years. The primary outcome of total graft loss was not significantly different between older and younger living kidney recipients [adjusted hazard ratio, HR (95%CI): 1.56 (0.98-2.49)]. This hazard ratio was not proportional and increased with time. Associations were not modified by recipient age or donor eGFR. There was no significant difference in total graft loss comparing older living to SCD kidney recipients [HR: 1.29 (0.80-2.08)]. In light of an observed trend towards potential differences beyond 4 years, uncertainty remains, and extended follow-up of this and other cohorts is warranted., (©2011 The Authors Journal compilation©2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Introduction: The benefit of preemptive kidney transplantation (KTx) for graft survival compared with nonpreemptive KTx is controversial., Objective: To analyze the influence of preemptive KTx on graft survival., Patients and Methods: The study included 476 of 531 patients who had undergone living-donor KTx between January 2000 and June 2007. Pediatric patients and those who had previously undergone KTx were excluded. Recipients were divided into 2 groups; group 1 included 413 patients (86.8%) who received grafts after institution of maintenance dialysis, and group 2 included 63 patients (13.2%) who underwent preemptive KTx., Results: Donor type and HLA mismatch demonstrated significant differences between the 2 groups. Group 1 had more living donors and fewer HLA mismatches. Warm ischemia time in group 2 was significantly shorter than in group 1. The serum creatinine concentration in group 1 on postoperative day 7 was significantly higher than in group 2. Five- and 10-year graft survival in groups 1 and 2, respectively, were 95.3% and 81.3% vs 92.9% and 92.9%. Graft survival was not significant insofar as duration and method of dialysis. At our institution, independent risk factors for graft survival in living-donor KTx are primary end-stage renal disease, acute cellular rejection episodes, and recipient age., Conclusion: We observed no benefit on graft survival in recipients of living-donor KTx insofar as whether they had undergone previous dialysis., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Purpose: This study sought to define the pharmacokinetics of mycophenolic acid (MPA) in Korean living donor liver transplant recipients., Methods: Thirty-two liver transplant recipients (29 males, 3 females) were administered 750 mg mycophenolate mofetil (MMF) twice daily with concomitant tacrolimus. Plasma MPA concentrations were measured by liquid chromatography with tandem mass spectrometry detection assay from samples drawn before dosing (C0) and after dosing at 0.5 hours (C1/2) and 2 hours (C2), providing a total of 114 pharmacokinetic profiles at various periods from 3 days to 6 months posttransplantation (D3, D7, D14, M1, M3, and M6)., Results: The mean area-under-the-curve from 0 to 2 hours (AUC0-2) was 30.0+/-11.6 microg.h/mL (range, 7.8-60.7). Of 114 pharmacokinetic profiles, 40 (35%) AUC and 7 (6.1%) trough values were within the target value (30-60 microg.h/mL and 1.7-4.0 microg/mL, respectively). The C0, C1/2, and C2 concentrations showed large interindividual variability: C0 (0.01-4.46 microg/mL), C1/2 (0.14-36.86 microg/mL), and C2 (0.79-18.19 microg/mL). A positive correlation was observed between AUC and C0 (r=.6374; P<.0001), and C2 (r=.7460; P<.0001). When analyzed according to the date posttransplant, a positive correlation between AUC and C0 was shown on day 7, day 14, and at month 1. There was no difference in any pharmacokinetic parameter relative to age, weight, or albumin level., Conclusion: This study demonstrated that C0 values on day 7, day 14, and at month 1 provided valuable information for MPA monitoring. C0 was shown to be the most reliable monitoring time in relation to AUC. However, results from a larger randomized trial with more time intervals are eagerly awaited., (Copyright (c) 2010. Published by Elsevier Inc.)

Budd-Chiari syndrome (BCS), which is characterized by hepatic venous outflow obstruction due to occlusion of the major hepatic vein and/or the inferior vena cava (IVC), is rare. Traditionally, a caval resection is advocated for these patients; however, such a maneuver renders living donor liver transplantation (LDLT) impossible. We encountered BCS in 4/377 LDLT patients during a 5-year period (January 2003 to December 2007). This report examine the various surgical modifications in these 4 patients, who underwent to LDLT for BCS. Resection of right hepatic vein (RHV) with an adjacent fibrotic part of the IVC with direct anastomosis of the graft RHV to the IVC was performed in 2 patients. One patient underwent retrohepatic IVC excision and reconstruction with a cryopreserved autologous IVC graft. The fourth patient, with a preexisting mesoatrial shunt for BCS, underwent conversion of this to a RHV atrial shunt. Graft and patient survivals were 100%. There were few complications in either donors or recipients. LDLT for BCS can be performed safely with adequate venous drainage techniques and with anticoagulant therapy and good follow-up for early diagnosis and treatment of recurrence leading to excellent long-term results., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

In living donor kidney transplantation, initial function of the donor kidneys is split into the remnant kidney and the recipient's implanted kidney. We addressed the questions whether the donor's remnant kidney function increases or decreases after donation and whether the donor's donated kidney is greater or less than that of the recipient's implanted kidney after transplantation. We measured and calculated the functional ratio of each kidney using technetium-99m diethylenetriaminepentaacetic acid (99mTcDTPA) as well as serum creatinine (Scr; mg/dL) and creatinine clearance (Ccr; mL/min/1.73 m2) using 24-hour urines from 100 donors. The Ccr was also calculated using the Cockcroft-Gault formula (Ccr-CG; mL/min/1.73 m2). Within 7 days postnephrectomy, we measured Scr, Ccr, and Ccr-CG of the remnant kidney. For recipients, the Scr, Ccr, and Ccr-CG of the implanted kidney with 24-hour urine were obtained within 7 days posttransplantation. The average Scr, Ccr, and Ccr-CG of the donors were 0.85 +/- 0.17 mg/dL, 110.4 +/- 20.8 mL/min/1.73 m2, and 82.8 +/- 17.3 mL/min/1.73 m2, respectively. After donation, the Ccr and Ccr-CG of remnant kidney increased from 54.5 +/- 11.4 and 40.8 +/- 9.3 mL/min/1.73 m2 to 68.0 +/- 14.3 and 53.6 +/- 11.6 mL/min/1.73 m2, respectively. The recipient Ccr and Ccr-CG of donated kidney also increased from 55.9 +/- 11.8 and 42.0 +/- 9.9 mL/min/1.73 m2 to 78.4 +/- 18.0 and 53.4 +/- 16.4 mL/min/1.73 m2, respectively. Kidney transplantation from a living donor should be encouraged with total functional benefit for both donors and recipients.

Living donor liver transplantation (LDLT) is a widely accepted treatment for end-stage liver diseases. Renal dysfunction, a frequent complication after liver transplantation, has an unfavorable effect on the prognosis. Despite special characteristics of LDLT, such as small-for-size graft syndrome (SFS), the relations between graft size and postoperative renal dysfunction have not been evaluated. So we described the relevance of previously known risk factors with SFS (graft-recipient body weight ratio [GRWR] < 0.8%) and early postoperative renal dysfunction in LDLT. The study population consisted of adults who received LDLT from May 1996 to November 2005. The 284 patients who were followed to 3 months after LDLT were classified as group I (n = 201, creatinine < 1.5 mg/dL) versus group II (n = 83, creatinine > or = 1.5 mg/dL). Univariate analysis showed renal dysfunction in the early postoperative period was related to preoperative total bilirubin, blood urea nitrogen, creatinine, prothrombin time level, model for end-stage liver disease (MELD) score, GRWR, presence of preoperative renal dysfunction, transfusion of packed red blood cell, fresh frozen plasma, cryoprecipitate, reoperation, and the need for renal replacement therapy (RRT). Upon multivariate analysis, MELD score, GRWR, preoperative renal dysfunction, and need for RRT were related to early postoperative renal dysfunction. In conclusion, there was a significant relationship between SFS (GRWR < 0.8) and early postoperative renal dysfunction.

To prevent hyperfiltration of the renal allograft, it is important to initially provide adequate functioning nephrons to meet the metabolic demands of a recipient. During the preoperative evaluation of a potential kidney donor, it is necessary to estimate the renal function of donated kidney compared with the metabolic needs of the recipient. The functional ratio of each kidney was measured using technetium-99m diethylenetriaminepentaacetic acid. The serum creatinine (Scr, mg/dL) and estimated creatinine clearance (Ccr, mL/min/1.73 m(2)) using the Cockcroft-Gault formula were measured and calculated in 82 donors. We excluded recipients who had an episode of rejection, and followed all recipients for more than 6 months posttransplantation. The average functional proportion of the donated kidney was 50.5% +/- 4.7% of the total Ccr 83.4 +/- 18.3 of donors. The Scr of recipients at 1, 3, 6, and 9 months posttransplantation were significantly (P < .05) correlated with the fractional Ccr of the donated kidney; however, Scr at 1 year was not correlated (P = .307). Furthermore, the Ccr of the recipient at 1, 3, and 6 months posttransplantation were significantly (P < .05) correlated with the fractional Ccr of the donated kidney; however, the Ccr at 9 months and 1 year were not correlated (P = .094 and .141, respectively). The Scr and Ccr of recipients within 6 months after transplantation may depend on the functional mass of the donated kidney, which should be estimated prior to kidney donation and compared with the metabolic demands of the potential recipient.

Background: This study reviewed the impact of middle hepatic vein (MHV) reconstruction on right lobe graft with regard to functional recovery and graft regeneration at 1 week after transplantation., Materials and Methods: From January 1999 to September 2005. 211 adult living donor liver transplantations were performed using the right lobe. The reconstruction of hepatic venous tributaries from segment 5 or segment 8 or both was performed in every cases of sufficient size. The patency of graft vessels was evaluated with computed tomography (CT) angiography on postoperative day 7. We analyzed liver enzymes (aspartate transferase [AST], alanine transferase [ALT] and bilirubin) at 1 week postoperatively and evaluated regeneration activity by CT volumetry at 1 week postoperatively., Results: Among 211 cases, 182 (86.3%) were reconstructed with interpositional MHV grafts. Among them, 51 cases (51.9%) were patent at 1 week postoperatively. The levels of AST and ALT in patent cases of all patients and small-for-size grafts were lower than among the occlusion cases, albeit not significantly. The mean graft regeneration at 1 week postoperatively among patent cases was 1.75 +/- 0.39 versus 1.64 +/- 0.24 in the occluded cases (P = .111), but among small-for-size grafts, there was a significant difference in graft regeneration between patent versus occluded cases (2.05 +/- 0.50 vs 1.66 +/- 0.17, P = .037)., Conclusion: Functional recovery and graft regeneration in small-for-size grafts showed a beneficial effect in patent cases, compared with occluded cases. Our selection criteria for MHV reconstruction must include cases of small-for-size grafts not all cases.

Background: This article reviewed our experience with right lobe donor hepatectomy in living donor liver transplantations (LDLT), particularly in the context of preserving donor safety., Materials and Methods: From January 2000 to August 2005, we performed 206 adult LDLT operations using the right lobe. The donor characteristics, operative findings, postoperative results including the peak values of liver enzymes (aspartate transferase [AST], alanine transferase [ALT], and bilirubin) and regeneration volumes, as evaluated by computed tomography volumetry, were reviewed at 1 week, as well as 3 and 6 months after surgery. The effects of three risk factors on donor safety were analyzed: age (<55 years, > or =55 years): fatty change in the donor liver (<10%, > or =10%); and remnant volume (<35%, > or =35%)., Results: The liver enzymes and regeneration volumes showed no significant difference according to age, only ALT was significant increased associated with the severity of fatty change (P < .05). There were significant differences in postoperative AST, ALT, and regeneration volume between the group with <35% and the group with > or =35% remnant liver volume (P < .05). Upon further analysis with combinations of two out of three risk factors, the group according to remnant volume and fatty change was meaningful. Follow-up data on donor ALT showed a return normal levels and after postoperative 3 months there was regeneration of the remnant liver to more than 70% of the whole liver preoperatively. There was no donor mortality, but postoperative complications were observed in 39 patients (39/206, 18.9%). Biliary complications were encountered in 24 patients: one bile duct injury, 22 bile leakages, and one bile duct stricture. Other complications consisted of pleural effusion (n = 8), delayed gastric emptying (n = 6), atelectasis (n = 1), and hepatic encephalopathy (n = 1)., Conclusion: In cases of careful donor selection, a right lobectomy can be performed safely with minimal risks when the remnant liver volume exceeds 35% of the total liver volume and shows less than 10% fatty changes.

Unlabelled: In adult-to-adult living donor liver transplantation (LDLT), right lobe grafts without a middle hepatic vein can cause hepatic congestion and disturbance of venous drainage. To solve this problem, various types of interposition vein graft have been used., Objectives: We used various types of interposition vein grafts for drainage of the paramedian portion of the right lobe in living donor liver transplantation., Methods: From June 1996 to June 2003, 37 of 176 patients (128 adults, 48 pediatric) who underwent LDLT received vein grafts for drainage of segments V, VIII, or the inferior portion of the right lobe., Results: In 36 adult cases the reconstruction included the inferior mesenteric vein of the donor (n = 14); cadaveric iliac vein stored at cold (4 degrees C) temperature (n = 5); cryopreserved (-180 degrees C) cadaveric iliac vein (n = 10); cryopreserved cadaveric iliac artery (n = 1 case); donor ovarian vein (n = 1); recipient umbilical vein (n = 3); recipient saphenous vein (n = 1); recipient left portal vein (n = 1); recipient left hepatic vein (n = 1). In a pediatric case with malignant hemangioendothelioma that encased and compressed the inferior vena cava, we used an interposition vein graft to replace the inferior vena cava., Conclusion: Various types of interposition vein grafts can be used in living donor liver transplantation. Cryopreserved cadaveric iliac vein and artery are useful to solve these drainage problems.

Introduction: The Milan criteria, namely, tumors 5 cm or less in diameter in patients with single hepatocellular carcinoma (HCC), no more than 3 tumor nodules, and each 3 cm or less in diameter in patients with multiple tumors, are accepted for cadaveric liver allocation. However, in living donor liver transplantation (LDLT), graft donation may only depend on the donor's intention. The aim of this study was to elucidate the feasibility of Milan criteria in LDLT., Materials and Methods: From January 2001 to December 2002, 46 cases of liver transplantation (LT) for HCC included 5 hospital mortalities and 3 cadaveric transplantations, all of which were excluded. We classified the patients into Group I cases that met the Milan criteria and Group II cases that did not meet the Milan criteria. The analyses examined tumor-related risk factors affecting recurrence and survival, such as tumor size, number of tumor nodules, and presence of microvascular and macrovascular invasion., Results: Twenty-one cases belonged to Group I and 17 to Group II. There was no significant difference in the recurrence or survival rates between Groups I and II. The risk factors affecting recurrence were macrovascular invasion and tumor size (5 cm). The number of tumor nodules and microvascular invasion did not appear to affect recurrence. The risk factor affecting survival was macrovascular invasion., Conclusion: We suggest that in selected cases the Milan criteria could be extended to increase the number of tumor nodules as long as the HCC were small and did not macrovascular invasion.

Hepatitis B virus (HBV) prophylaxis is necessary to prevent de novo hepatitis B infection from HbcAb-positive donors. However, which protocol is more effective is somewhat controversial. Also, it is uncertain whether it is necessary to administer HBV prophylaxis for HbsAb-positive recipients. This study attempted to determine whether it is necessary to administer HBV prophylaxis for HbsAb-positive patients and to evaluate the efficacy of an HBIG monotherapy protocol. From May 1996 to July 2001, among 128 donors examined for HbcAb, 58 donors (45.3%) were HbcAb-positive. Eighteen HbcAb-positive grafts were transplanted to HbsAg-negative recipients. The 4 patients who died of unrelated causes were excluded from this study. Of 14 study cases, 12 recipients were HbsAb-positive, and 2 were HbsAb-naive. Prior to late 1998, we used HBV vaccination only for de novo infection prophylaxis. However, starting from December 1998, HBIG was administered from the time of the liver transplantation regardless of HBsAb positivity. The overall rate of de novo HBV infections from HbcAb-positive donors was 21.4% (3 of 14). All 3 recipients without HBIG prophylaxis presented with de novo HBV infections. Two were HbsAb-positive preoperatively. No de novo HBV infections occurred among recipients with HBIG prophylaxis. Therefore, it is essential to administer HBV prophylaxis even for vaccinated HbsAb-positive patients. HBIG monotherapy is effective to prevent de novo hepatitis B infections from HbcAb-positive donors in living donor liver transplantation.

Living donor liver transplantation (LDLT) has been considered as an alternative option to resolve the shortage of cadaveric donor organs, despite the ethical aspects of the donor procedure. The objective of this study was to analyze the risk factors affecting graft survival in LDLT. From June 1996 to December 2002, 141 patients who underwent LDLT were retrospectively analyzed. Graft survival rates were 82.5%, 80%, 77.3%, and 77.3% at 6 months, 1 year, 3 years, and 5 years, respectively. The factors influencing graft survival in univariate analysis were graft-to-recipient body weight ratio (GRWR) less than 0.8% (P = .0009), intraoperative transfusion of more than six packed RBC units in addition to the use of cell saver amounts (P = .0001), left lobe grafts in adults causing small-for-size situations (P = .0135), and donor age (P = .0472). The multivariate analysis demonstrated that GRWR less than 0.8% (P = .002) and intraoperative transfusion of more than six packed RBC units (P = .014) were independent factors that decreased graft survival rates. The graft selection of greater than 0.8% of GRWR and reduction of intraoperative RBC transfusion improve graft survival.

In the era of living donor liver transplantation (LDLT), graft size is related to recipient prognosis. This study was performed to compare the clinical outcomes according to the graft-to-recipient weight ratio (GRWR) in adult LDLT. Seventy-nine adult patients who had undergone LDLT between June 1997 and June 2002 were retrospectively analyzed. The patients were divided into two groups according to the GRWR (group I, GRWR < 0.8%, n = 11; group II, GRWR > or = 0.8%, n = 68). The mean follow-up period was 19.4 (range 1 to 48) months. The recipients were 62 men (78.5%) and 17 women (21.5%) of mean age 45.2 (range 18 to 63) years. The overall patient survival rates were 74.7% at 1 year and 70.7% at 2 years. The patient survival rate in group I was 54.6% at 1 year and 40.9% at 2 years, whereas that in group II was 77.9% at 1 year and 75.3% at 2 years, showing a significant difference (P = .03). There were no significant differences in postoperative total bilirubin, transaminase enzyme level, prothrombin time (INR), portal vein flow on Doppler sonography, amount of ascites through the drain, complications, or acute rejection rates between the two groups. In conclusion, the minimum acceptable graft size in an adult-to-adult LDLT is GRWR of 0.8%. This study suggests that careful postoperative management and/or technical modifications during surgery are necessary, because small-for-size grafts (GRWR < 0.8%) result in lower patient survival rates.

Long-term effects of donor and recipient gender on the outcome of living donor kidney transplantation have been examined but the impact on early graft function is less certain. In this study, we analyzed age, gender, body weight, height, body surface area (BSA), and lean body weight (LBW) of both donors and recipients. Preoperatively we collected 24-hour urine samples to measure creatinine excretion from donor and postoperatively we determined when the recipient serum creatinine (Scr) reached baseline levels. Variables included were ischemic times, kidney graft weight, duration of dialysis, cause of end-stage renal disease (ESRD), degree of HLA match, and mismatch, types of immunosuppression (cyclosporine or FK506, dual or triple), and episodes of acute rejection. The variables were analyzed by independent sample t tests and chi-square statistics using SPSS. Values of P < .05 were considered significant. Male patients of both donors and recipients were significantly taller and heavier (higher BSA and LBW) than female. Urinary 24-hour creatinine excretion was greater in male patients whether donors or recipients. There were no statistical differences in graft weight or creatinine clearance based on the gender of the donor or recipient. The creatinine of male donors or recipients was higher than that of females. The other variables were not significantly different. In conclusion, the effect of donor or recipient gender on early graft function depends on the metabolic demands, which are higher in male recipients.

Numerous studies have reported various prognostic factors that affect graft and patient survival in living and cadaveric donor kidney transplantation (KT). The purpose of this study was to evaluate the clinical outcomes and prognostic factors affecting graft and patient survivals in living and cadaveric donor KT. Between February 1995 and December 2001, 421 patients who had undergone cadaveric donor KT (group I: 216 cases, 51.3%) or living donor KT (group II: 205 cases, 48.7%), were retrospectively analyzed. Five-year overall graft survival rates in living was significantly better than that in cadaveric donor KT, respectively (P = .0234). There was no difference in patient survival rates between the two groups. Such factors as absence of rejection, female donor, female recipient, adult KT according to recipient age (>14 years), and donor serum creatinine level just before transplantation (< 2.5 mg/dL) were significantly associated with good graft survival among cadaveric donor KT, whereas two factors-absence of rejection and adult KT according to recipient age (>14 years)-influenced graft survival in living donor KT. In multivariate analysis, the only significant prognostic factor related to graft survival was the presence of rejection. In conclusion, we suggest that the presence of rejection is the only factor that impairs graft survival in both cadaveric and living donor KT, while other factors affected graft survival differently in the two groups.