Chung Jye Hung

All chronic rejection failures of kidney transplants were preceded by the development of HLA antibodies

Background. Recent studies show that almost all patients who have rejected a kidney transplant had human leukocyte antigen (HLA) antibodies. In this study, we sought to determine whether patients develop HLA antibodies before chronic rejection. Methods. For the past 8 years, 139 patients who had undergone kidney transplantation were systematically examined, using an enzyme-linked immunosorbent assay–based method, for the development of class-I and class-II HLA antibodies 3 months, 6 months, and yearly after transplantation. Chronic rejection was diagnosed by biopsy. Results. Among 29 patients with chronic rejection, 100% of the patients had HLA antibodies before rejection. Of these patients, 14 patients developed antibodies de novo. In contrast, among 110 patients with stable function, 27% of the patients developed HLA antibodies posttransplant (P <0.001). Conclusions. HLA antibodies were found in 29 consecutive cases of chronic rejection failures as much as one year before the loss of grafts. We conclude that HLA antibodies may be a prerequisite for chronic immunologic rejection.

Reappraisal of HLA Antibody Analysis and Crossmatching in Kidney Transplantation

Enzyme-linked immunosorbent assay (ELISA) and flow cytometric techniques have been introduced to overcome the limited sensitivity and specificity of the CDC assay. This retrospective study used lambda antigen tray-mixed screening and Luminex HLA class I and II specificity assays to re-examine: (1) the accuracy with which detection of HLA antibody and specificity by ELISA predicts pretransplantation National Institutes of Health (NIH)/Centers for Disease Control and Prevention (CDC) crossmatch; and (2) a comparison of Luminex and ELISA methods to detect HLA antibodies. Sera from 481 patients awaiting kidney transplantation were tested using the ELISA method lambda antigen tray-mixed and using NIH-CDC to determine how well HLA antibodies detected using ELISA predicted crossmatches using CDC. Pretransplantation sera from 48 patients with follow-up data were retested using both ELISA lambda antigen tray-mixed and Luminex to compare the efficacy of the 2 methods.

Aggressive resection of the airway invaded by thyroid carcinoma

The aim of this study was to investigate the hypothesis that outcome following concomitant airway resection is superior to that after shaving of the tumour in patients with airway invasion of thyroid carcinoma.

A Simple, Secure and Universal Pancreaticojejunostomy following Pancreaticoduodenectomy

Although the operative mortality of pancreaticoduodenal resection has decreased recently, the operative morbidity resulting from a leaking pancreatic anastomosis remains high. We described our experience in 50 consecutive cases with a simple, secure end to side pancreaticojejunostomy. We used a paediatric nasogastric tube in the pancreatic remnant duct as a temporary external pancreatic drain. There were 29 men and 21 women ranging from 12 to 84 years with a median age of 61 years. Forty-two patients underwent a standard Whipple procedure and eight a pylorus preserving pancreaticoduodenectomy. Average operating time was 270 minutes with a range of 170 to 480 minutes. The pancreaticojejunostomy could be constructed in a mean of 8 minutes. Intraoperative blood loss ranged from 150 to 3500 mL with a mean of 910mL. Twenty-five patients (50 %) received no blood transfusion. The consistency of the pancreatic remnant was hard in 12 patients (24 %) and normal in 38 patients (76 %). The pancreatic duct was dilated (>4mm) in 15 patients (30 %). There was no operative mortality and only three (6.0 %) minor leaks from the pancreatic anastomosis which healed spontaneously. It was difficult to determine if the leaks were related to the consistency of the pancreatic remnant, the size of the pancreatic duct, the amount of intraoperative blood loss, operating time, sex of the patient or experience of the surgeon, as there were only three leaks. We concluded that our technique for pancreaticojejunal anastomosis following pancreaticoduodenectomy was safe and applicable to, standard Whipple or pylorus preserving pancreaticoduodenectomy, small or dilated pancreatic ducts, normal or fibrotic pancreas.

Role of right hepatic lobectomy in the treatment of isolated right-sided hepatolithiasis

BACKGROUND The role of right hepatic lobectomy is evaluated in the treatment of selected patients with isolated right-sided hepatolithiasis. METHODS During the past 7 years right hepatic lobectomy was performed in five patients who had isolated right-sided hepatolithiasis. The rationale and indications of this procedure are discussed. The efficacy of preoperative evaluations, the operative findings, and the operative results are analyzed. RESULTS All the patients were female with a mean age of 49.2 years (range, 33 to 63 years). The main symptoms were upper abdominal pain (n = 5), fever (n = 4), and jaundice (n = 2). The mean operative time was 166.4 minutes, and the mean blood loss was 880 ml. The complete stone clearance rate was 100%. No operative deaths occurred. Right subphrenic abscess with reactive pleural effusion developed in two patients. Echo-guided percutaneous drainage was applied to one patient, and no surgical intervention was needed. The mean follow-up period from the treatment was 13.4 months (range, 6 to 18 months). During the follow-up period no stone recurrence was found. CONCLUSIONS Right hepatic lobectomy is indicated in patients who have localized right-sided hepatolithiasis with irreversible biliary stricture involving the right hepatic duct, an atrophied right lobe of the liver, multiple cholangitic abscesses, or possible presence of cholangiocarcinoma. Preoperative evaluations, including cholangiography, abdominal ultrasonography, and computed tomography, are important for the accurate selection of patients and successful treatment.

High concentrations of circulating macrophage migration inhibitory factor in patients with severe blunt trauma: Is serum macrophage migration inhibitory factor concentration a valuable prognostic factor?

ObjectiveTo determine serum concentrations of macrophage migration inhibitory factor and other cytokines in severe blunt trauma patients in critical settings and to evaluate their association with patient outcome. DesignProspective, observational study. SettingEmergency department and surgical intensive care unit of a university hospital. PatientsFifty-four severe blunt trauma patients with systemic inflammatory response syndrome requiring intensive care, emergency surgical intervention, or both were enrolled in the study. Forty-four patients with minor injuries were the controls. InterventionsSerum macrophage migration inhibitory factor concentrations were measured in the emergency department <4 hrs postinjury (day 1) and the surgical intensive care unit 24 hrs later (day 2). Blood samples for determination of tumor necrosis factor-&agr;, interleukin-6, interleukin-8, and interleukin-10 were measured both in patients with severe blunt trauma and in controls. The Acute Physiology and Chronic Health Evaluation II, Injury Severity Score, Revised Trauma Score, and Trauma Revised Injury Severity Score were used for clinical evaluation of trauma severity. Measurements and Main ResultsSerum macrophage migration inhibitory factor concentrations were higher in severe blunt trauma patients than in controls; were significantly correlated with Acute Physiology and Chronic Health Evaluation II, Revised Trauma Score, and Trauma Revised Injury Severity Score scores in severe blunt trauma patients but not in controls; and were higher in nonsurvivors than in survivors. ConclusionsOur data suggest that the serum macrophage migration inhibitory factor concentration is higher in severe blunt trauma and that it reflects the severity of trauma. The serum macrophage migration inhibitory factor concentration might be a valuable predictor for the outcome of severe blunt trauma.

Does Immunosuppressive Pharmacotherapy Affect Isoagglutinin Titers

OBJECTIVE Preoperative reduction of isoagglutinins leads to successful ABO-incompatible (ABOi) renal transplantation. The strategy includes pretransplantation plasmapheresis, more potent immunosuppressive drugs, splenectomy, and anti-CD20 antibody. It has been reported that low isoagglutinin antibody titers posttransplant were observed among ABOi renal transplants with favorable outcome. The isoagglutinin titers may increase slightly when plasmapheresis is discontinued; however, it never returns to the pretreatment level under immunosuppressive therapy. This raises the question of what occurs to the isoagglutinin titer in ABO-compatible renal transplants under maintenance immunosuppressive pharmacotherapy. METHODS We analyzed 10 renal transplant recipients, including seven living and three cadaveric donors. Patients were treated with basiliximab (20 mg) intravenously on day 0 and day 4. Maintenance immunosuppressive therapy involved a calcineurin inhibitor, mycophenolate mofetil, and steroid. Anti-human globulin isoagglutinin titers were routinely examined 1 day before and day 0 and 1, 2, 3, 4, 8, 12, and 24 weeks posttransplant. No ALG or intravenous immunoglobulin or plasmapheresis treatment was provided in the follow-up period. RESULTS Our preliminary data showed nearly no influence on isoagglutinin titer levels in 6-month follow-up under maintenance immunosuppressive therapy. In addition, no significant difference in isoagglutinin titer was observed between tacrolimus and cyclosporine groups. CONCLUSION Maintenance immunosuppressive pharmacotherapy did not affect isoagglutinin titer levels in ABO-compatible kidney transplants. Further study is needed to investigate the mechanisms of persistent low-level isoagglutinin titers among successful ABOi renal transplantation patients.

A role for chronic parvovirus B19 infection in liver dysfunction in renal transplant recipients

Background. Clinically, liver dysfunction in renal transplant recipients is related to hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. The contribution of parvovirus B19 (B19) to liver disease in renal transplant recipients has not been studied. Here we present the association of liver dysfunction with or without the coinfection of B19, HBV, and HCV after renal transplantation. Methods. We used enzyme-linked immunosorbent assay to identify B19, HBV, and HCV infections in serum samples taken from 144 renal transplant recipients before transplantation and at 12 and 24 months after transplantation. After each patient had fasted for 12 hr, blood was taken for measurement of aspartate aminotransferase and alanine aminotransferase monthly for at least 6 months. Results. Liver dysfunction developed at the significantly higher incidence of 47% in the anti-HCV(+) patients compared with 6% in the noninfected group (P <0.0001). HBV infection had no impact on the incidence of liver dysfunction in renal transplant recipients. A higher incidence of liver dysfunction was found in 42% of B19 IgG(+)IgM(−) group patients compared with 13% of the B19 IgG(+)IgM(+) group (P =0.0051) and 9.5% of the B19 IgG(−)IgM(−) group (P =0.0003). A B19 polymerase chain reaction (PCR) assay revealed significantly higher liver dysfunction in 29% of B19 PCR(+) group patients compared with 13.6% of B19 PCR(−) patients (P =0.0419). Patients who were anti-HCV(+) and B19 PCR(+) had a significantly higher incidence of liver dysfunction than B19 PCR(−) patients (P =0.002). Conclusions. Chronic B19 infection and HCV infection, both separately and in combination, increase the incidence of liver dysfunction in renal transplant recipients. HBV infection does not seem to be independently or synergistically associated with liver dysfunction.

Virtual teams: cultural adaptation, communication quality, and interpersonal trust

Virtual teams are commonly formed in all industries and in a variety of areas. How the members adapt to the team culture when participating in a virtual team and how the adaptation affects communication quality and facilitates interpersonal trust within the team are important issues of coordination among the diverse members of a team. Thus, this study proposed a model using human- and technology-related factors to explain the phenomenon. Both qualitative and quantitative methods were employed. After the case study approach, academic and practical perspectives were both taken into consideration. The results of quantitative analysis revealed that both cultural adaptation and interpersonal trust have positive effects on the performance of virtual teams. A significantly negative effect was found between communication quality and performance of virtual teams, which is inconsistent with the viewpoint of traditional teams. Finally, academic and practical implications were also provided.

Kidney grafts with multiple renal arteries is no longer a relative contraindication with advance in surgical techniques of laparoscopic donor nephrectomy

OBJECTIVES Kidney grafts with multiple renal arteries were considered as a relative contraindication. We retrospectively reviewed our experience of kidney grafts with multiple renal arteries to clarify the usefulness of these grafts. METHODS Between September 2002 and June 2011, 100 laparoscopic donor nephrectomies (LDNs) were performed consecutively. Three-dimensional computed tomographic angiography was routinely performed preoperatively. Donor demographics, operative characteristics, donor and recipients perioperative complications, and donor and recipient outcomes were reviewed retrospectively. RESULTS Eighty-nine donors had single (group A1) and 11 donors had multiple renal arteries (group B1). Multiple arteries caused by application of the vascular stapler were found in another six donors. Overall, 17 kidney grafts required bench arterial reconstruction (group B2). The other 83 donors with single renal artery did not require further arterial reconstruction (group A2). There was a significant increase of warm ischemic time in the group of multiple renal arteries. There were no significant difference between groups A1 and B1 in regard to donor demographics, operative characteristics, and donor outcome. Kidney grafts requiring vascular reconstruction experienced equal immediate and long-term allograft outcomes with those of group A2. The actuarial 1-, 3-, and 5-year allograft survival rates were also comparable in both groups (95.4%, 92.6%, 92.6% in group A2 and 100%, 100%, 100% in group B2). CONCLUSION LDN in the presence of multiple renal arteries is feasible and safe. Both immediate and long-term allograft outcomes are comparable between kidney grafts with and without vascular reconstruction. Kidney grafts with multiple renal arteries are no longer a relative contraindication with advanced LDN surgical techniques.