Ji-Il Kim

Comparison of Clinical Outcome between High and Low Baseline Anti-ABO Antibody Titers in ABO-Incompatible Kidney Transplantation

High baseline anti-ABO antibody titer is still an important obstacle for successful ABO-incompatible kidney transplantation (ABO IKT). This study aims to investigate the clinical outcome of ABO IKT in patients with a high baseline titer in comparison with patients with a low baseline titer. Fourteen patients who received ABO IKT at our center were classified as the high-titer group (≥1:256, n = 8) or the low-titer group (≤1:128, n = 6). We used a protocol composed of rituximab, plasmapheresis, and intravenous immunoglobulin (RTX/PP/IVIG). We compared the intensity of preparation, complications, and clinical outcome between the two groups. The high-titer group required more sessions of pretransplant (10.5 ± 3.5 vs. 6.0 ± 1.3 times, p = 0.01) and posttransplant (1.6 ± 1.8 vs. 0 ± 0 times) PP/IVIG than the low-titer group did. All patients from both groups showed immediate recovery of graft function. The antibody titer and allograft function in the high-titer group were stable and did not differ significantly from those of the low-titer group up to 1 year after kidney transplantation. There was no antibody-mediated rejection in either group during follow-up, but three cases of acute cellular rejection developed in the high-titer group. The high-titer group showed two cases of opportunistic viral infection (herpes gingivitis and cytomegalovirus viremia) and one case of graft loss due to postoperative bleeding. ABO IKT can be safely performed even in patients with a high baseline anti-ABO antibody titer, but the risk for infection and bleeding should be considered before transplantation.

Malignancies after kidney transplantation: a 40-year single-center experience in Korea

Cancer is a well‐recognized complication of kidney transplantation (KT), but nearly almost all data have come from Western countries. The aim of this study was to determine the incidence, type, and risk factors of malignancy after KT in Korea. The 1695 patients who underwent KT between 1969 and 2009 were studied retrospectively. Results were compared with a cohort of patients without cancer from the same center. During the follow‐up period, 136 of 1695 patients developed 141 post‐transplant malignancies (PTM). The cumulative incidence of cancer at 1, 5, 10, 20, and 30 years was 0.64%, 2.42%, 7.89%, 21.49%, and 66.35% respectively. Stomach cancer was the most common PTM. Risk of Kaposi sarcoma, malignant lymphoma, skin cancer, cervical cancer, and renal cell carcinoma was more than 10‐times higher in KT recipients. Multivariate logistic regression analysis showed that cancers were clearly associated with recipients’ age, recipients’ gender, duration of graft function and follow‐up period. Our data suggest that most malignancies develop more frequently after KT, but the incidence of individual cancer is different from Western countries. A more vigorous cancer surveillance program should be adapted to risk associated with transplant recipients, especially older, female or long‐term follow‐up recipients or those with functioning grafts.

Clinical impact of the baseline donor‐specific anti‐human leukocyte antigen antibody measured by Luminex single antigen assay in living donor kidney transplant recipients after desensitization therapy

The aim of this study is to investigate the clinical impact of donor‐specific anti‐HLA‐antibody (HLA‐DSA) baseline levels, measured using the Luminex single antigen assay (LSA), in living donor kidney transplantation (LDKT). Total 129 cases of LDKT were divided into four groups according to baseline mean fluorescence intensity (MFI) HLA‐DSA values: Strong (n = 6), >10 000; Moderate (n = 8), 5 000–10 000; Weak (n = 11), 1 000–5 000, Negative (n = 104), <1 000. Pretransplant desensitization (DSZ) was performed to decrease the MFI to weak or negative values before KT. Clinical outcomes in the four groups were compared. After DSZ, HLA‐DSA decreased to weak or negative levels in all patients; Acute rejections developed more frequently in strong group [5/6 (83.3%)] compared with other three groups (P < 0.05), and especially acute antibody‐mediated rejection (AAMR) developed almost exclusively in strong group [4/6 (66.7%)]. Strong HLA‐DSA levels at baseline were more predictive of AAMR than either type of XM (complement‐dependent lymphocytotoxicity or flow cytometry) in ROC analysis. Allograft function in this group showed significant deterioration during follow‐up compared with the other groups. In conclusion, strong HLA‐DSA levels at baseline are associated with worse allograft outcome even after successful desensitization; therefore, strict monitoring and strong maintenance immunosuppression may be required in such patients.

Comparison of Estimating Equations for the Prediction of Glomerular Filtration Rate in Kidney Donors before and after Kidney Donation

The aim of this study is to investigate the usefulness of the GFR-estimating equations to predict renal function in kidney donors before and after transplantation. We compared the performance of 24-hour-urine–based creatinine clearance (24 hr urine-CrCl), the Cockcroft-Gault formula (eGFRCG), the Modification of Diet in Renal Disease equation (eGFRMDRD), and the Chronic Kidney Disease Epidemiology Collaboration equation (eGFRCKD-EPI) with technetium-diethylenetriaminepentaacetic acid (99mTc-DTPA) clearance (mGFR) in 207 potential kidney donors and 108 uninephric donors. Before donation, eGFRCKD-EPI showed minimal bias and did not show a significant difference from mGFR (P = 0.65, respectively) while 24 hr urine-CrCl and eGFRMDRD significantly underestimated mGFR (P<0.001 for each). Precision and accuracy was highest in eGFRCKD-EPI and this better performance was more dominant when renal function is higher than 90 mL·min−1·1.73 m−2. After kidney donation, eGFRMDRD was superior to other equations in precision and accuracy in contrast to before donation. Within individual analysis, eGFRMDRD showed better performance at post-donation compared to pre-donation, but eGFRCKD-EPI and eGFRCG showed inferior performance at post-donation. In conclusion, eGFRCKD-EPI showed better performance compared to other equations before donation. In a uninephric donor, however, eGFRMDRD is more appropriate for the estimation of renal function than eGFRCKD-EPI.

Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis

Kim S‐J, Kim D‐G, Park J‐H, Moon I‐S, Lee M‐D, Kim J‐I, Yoon Y‐C, Yoo Y‐K. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis.
Clin Transplant 2011: 25: 111–118.

Impact of the Baseline Anti-A/B Antibody Titer on the Clinical Outcome in ABO-Incompatible Kidney Transplantation

Background/AIMS: We investigated the impact of the baseline anti-A/B antibody titer on the clinical outcome in ABO-incompatible kidney transplantation (IKT). Methods: We included 183 patients who had undergone KT (40 ABO IKT and 143 ABO-compatible KT). Eight patients with a baseline titer of ≥1:512 were assigned to the high-titer group and 32 patients with a baseline titer of ≤1:256 were assigned to the low-titer group. Patients who underwent ABO-compatible KT were used as the control group. We compared the clinical outcomes of the three groups. Results: Before transplantation, the high-titer group displayed more frequent antibody rebound, as shown in a lower titer reduction rate, and more difficulty reaching the target titer (1:16) than the low-titer group. During the postoperative period and out-clinic follow-up, antibody rebound was more frequent, and the rate of acute rejection and infection were significantly higher and allograft function was lower in the high-titer group than in the low-titer and control groups. Multivariate analysis showed that high baseline antibody titer was an independent risk factor for acute rejection. Conclusion: ABO IKT in the high-titer group (baseline titer ≥1:512) required greater caution compared to the low-titer group because of the higher tendency of antibody rebound and the risk for acute rejection.

Clinical outcome of kidney transplantation from deceased donors with acute kidney injury by Acute Kidney Injury Network criteria

PURPOSE In this study, we investigated the outcome of kidney transplantation (KT) from deceased donors with acute kidney injury (AKI), as defined by the Acute Kidney Injury Network criteria. METHODS Of 156 deceased donors, kidneys from 43 donors (27.6%) with AKI were transplanted into 57 recipients (AKI group). Another 147 recipients received kidneys from donors without AKI (non-AKI group). We compared the incidence of delayed graft function, allograft function for 1 year after KT, and long-term (5 and 10 years) graft survival rate between the 2 groups. RESULTS Delayed graft function developed more frequently in the AKI group than in the non-AKI group (42.1% vs 12.2%; P<.05), and allograft function-assessed by the modification of diet in renal disease equation-showed a significantly deteriorating pattern at 2 weeks and 1, 3, and 6 months after KT compared with that in the non-AKI group (P<.05 for comparisons at each time point). However, allograft function at 12 months after KT and the long-term allograft and patient survival rates did not differ between the AKI and non-AKI groups. CONCLUSIONS In KT from deceased donors, the AKI group that received kidneys with AKI, as defined by the Acute Kidney Injury Network criteria, showed a higher delayed graft function rate and lower allograft function for 6 months after KT but no effect on allograft function 1 year after KT and on long-term allograft survival.

Changing Donor Source Pattern for Kidney Transplantation over 40 Years: A Single-Center Experience

Background/Aims Kidney transplantations at our center rely mainly on living donors. The purpose of this study was to suggest future donor supply directions by reviewing changing trends in donor type. Methods During the past 40 years, 1,690 kidney transplantations were performed at our center. We divided the follow-up period into four decades and the donor population into three groups: living related, living unrelated, and deceased. We analyzed changing trends in donors from each group for each decade. Patients receiving overseas transplantation were also included. Results The proportion of living related donors decreased from 84% (54/64) in the 1970s to 61% (281/458) in the 2000s. Living unrelated donors showed a sustained proportion of around 20% after 1990. However, among living unrelated donors, the proportion of spouse donors increased from 4.6% (17/369) in the 1980s to 8.5% (39/458) in the 2000s. Transplants from deceased donors were only 3.3% (12/369) in the 1980s. However the proportion of deceased donors increased gradually, reaching 13.2% (105/799) in the 1990s and 19.9% (91/458) after 2000. Overseas transplantations increased after 2000 and reached 20% of all cases treated in our center during the 2000s. Such transplantations peaked in 2006 and decreased markedly thereafter. Conclusions The proportion of each donor type has continuously changed, and the changes were associated with changes in the social structure and system. We expect that this study could be an important reference for other countries to estimate future changes of donor type.

Matched-pair analysis to compare the outcomes of a second salvage auto-SCT to systemic chemotherapy alone in patients with multiple myeloma who relapsed after front-line auto-SCT.

The aims of this study were to investigate the outcomes of second salvage auto-SCT and to identify the impacts of a second auto-SCT compared with systemic chemotherapy alone on disease outcome. Data from 48 patients who underwent second auto-SCT were matched to 144 patients (1:3) who received systemic chemotherapy alone from the Korean Myeloma Registry. Groups were matched for nine potential prognostic factors and compared for treatment outcomes. The median age of matching-pairs at relapse was 55.5 years. A total of 156 patients (81%) received vincristine, doxorubicin and dexamethasone induction therapy before the first auto-SCT. Thirty-five patients (73%) in the second auto-SCT group received novel agent-based therapies before the second auto-SCT, and similar proportion in both groups received novel therapies after relapse of front-line auto-SCT. With a median follow-up of 55.3 months, patients who underwent a second auto-SCT had significantly better median OS (55.5 vs 25.4 months, P=0.035). In multivariate analysis for OS, <18 months time to progression after first auto-SCT, International Staging System III and salvage chemotherapy alone were independent predictors for worse OS. The outcomes of second auto-SCT appear to be superior to those of systemic chemotherapy alone. A randomized trial comparing both treatment strategies is required.

Determination of Rituximab Dose According to Immunologic Risk in ABO-Incompatible Kidney Transplantation

The adequate rituximab (RTX) dosage in ABO-incompatible transplantation (ABO-IKT) remains undetermined. We used two kinds of RTX dosage groups [low RTX (100 mg/m2) and typical RTX (375 mg/m2) dosage groups] according to immunologic risks and investigated the change of B-cell, anti-ABO antibodies, and the clinical outcome in ABO-IKT according to the RTX dose. Fifteen patients with high immunologic risk [panel reactive antibody (PRA) > 50%, retransplant, AB to O transplant] were assigned to typical RTX group and 17 patients without risk were assigned to low RTX group. We compared the changes of B-cell, anti-ABO antibody titer, required number of plasmapheresis (PP), and the clinical outcome after transplantation between the two groups. After infusion of RTX, peripheral blood B-cell counts were successfully depleted to <1% in both groups. Before kidney transplantation (KT), the minimal number of PP to achieve the target titer (1:16) (2.6 ± 2.7 vs. 2.2 ± 2.5; p = 0.66) and the titer reduction rate of anti-ABO antibodies did not differ between the two groups (low RTX: 1.52 ± 1.21 vs. typical RTX: 1.53 ± 1.20, p = 0.94). After KT, anti-ABO antibody titer was suppressed less than 1:32 in both groups up to posttransplant 1 year. The allograft function and infectious complication did not differ between the two groups as well. In ABO-IKT, low RTX is comparable with typical RTX dosing with respect to B-cell depletion, antibody rebound suppression, the effect on clinical outcome in patients with low immunologic risk.