Panas Chalermsanyakorn

Long-Term Outcome of Very Early Cyclosporine Minimization and De Novo Everolimus Therapy in Kidney Transplant Recipients: A Pharmacokinetic Guided Approach

BACKGROUND Cyclosporine (CsA) nephrotoxicity is an important cause of chronic allograft dysfunction. Clinical information concerning the impact of very early CsA dose reduction in kidney transplant recipients is limited. We have examined the long-term outcomes of very early CsA dose reduction. This is synchronized with de novo everolimus and steroid therapy. METHODS We enrolled 10 de novo kidney transplant recipients to receive CsA (target C(0) 250-350 ng/mL) and prednisolone as initial therapy. CsA dosage was reduced by 50% at posttransplant day 7. Everolimus (target trough level, 3-8 ng/mL) was concomitantly started at the day of CsA reduction. Full pharmacokinetic studies of everolimus and CsA were studied at the period of 4-8 weeks after CsA reduction. CsA was then gradually reduced to maintain a trough level of 50-100 ng/mL and/or C(max) <600 ng/mL. RESULTS The mean follow-up was 51.2 ± 3.45 months. The nadir serum creatinine was 1.03 ± 0.33 mg/dL. The mean initial estimated glomerular filtration rate (eGFR) was 97.97 ± 23.36 mL/min. The mean initial trough everolimus was 5.2 ± 1.5 ng/mL. The eGFR at 1 year, 3 years, and last follow-up was 82 ± 25, 80 ± 21, and 80 ± 25 mL/min, respectively. Patient and graft survival was 100%. CONCLUSION Very early CsA dose reduction synchronized with de novo everolimus therapy was associated with good long-term patient and graft survival in kidney transplant recipients. This intervention can lead to 75% CsA minimization and is associated with very good GFR by the modification of Diet in Renal Disease Formula at year 4.

Primary Renal Inflammatory Myofibroblastic Tumor

A case of primary renal inflammatory myofibroblastic tumor of the left kidney in a 51-year-old man clinically presenting bleeding from the gums with thrombocytopenia and left flank mass is reported. Pathological examination of the left renal tumor characterizes macroscopically by a cortical mass and histologically by spindle cells admixed with variable amounts of extracellular collagen, lymphocytes and plasma cells. Immunohistological stainings are positive vimentin and focal positive smooth muscle actin. Clinical and pathological features with a brief review of the relevant literature are discussed. This is the first reported description in the literature of primary renal inflammatory myofibroblastic tumor associated with thrombocytopenia.

Hand-assisted laparoscopic nephrectomy for xanthogranulomatous pyelonephritis with nephrocutaneous fistula after failed flank exploration.

Xanthogranulomatous pyelonephritis presenting with nephrocutaneous fistula is a rare condition, and its treatment of choice is nephrectomy. Laparoscopic management has been proved to be challenging in these inflammatory renal conditions. However, there was no previous report in the literature regarding laparoscopic treatment of nephrocutaneous fistula especially after previous operation. In this communication, we report the first case of hand-assisted laparoscopic nephrectomy for xanthogranulomatous pyelonephritis with nephrocutaneous fistula after previous failed flank exploration.

Laparoscopic management of a single system ectopic ureterocele with transitional cell carcinoma in the distal ureter

Abstract  Single system ectopic ureterocele associated with transitional cell carcinoma in the ureter has not been described previously. Only two cases of transitional cell carcinoma in a single ectopic ureter have been reported in the published literature. With the development of minimally invasive surgery, we report the first case of single system ectopic ureterocele with transitional cell carcinoma in the distal ureter that was successfully managed by laparoscopic surgery.

Elevated urinary neopterin: A clue of activated macrophage and cellular immune response in the pathogenesis of idiopathic nephrotic syndrome

Summary: A study of cell mediated immunity (CMI) activation in patients with idiopathic nephrotic syndrome (INS) in the tropics was undertaken. Cell mediated immunity activation was investigated by measuring urinary neopterin excretion. All 31 patients with idiopathic nephrotic syndrome due to either minimal change nephrotic syndrome (MCNS), and focal and segmental glomerulosclerosis (FSGS) had significant elevation of neopterin excretion (mean values 451, 544 μmol neopterin/mol creatinine) when compared with 222 normal subjects (mean value 130, P < 0.001). However, in 25 patients with non‐nephrotic IgA nephropathy and eight nephrotic membranous nephropathy the urinary neopterin was not raised (mean value 131 and 129). A further 10 patients with MCNS were restudied when in complete remission and their urinary neopterin was found to have decreased significantly (mean value 186); however, this level was still above the normal range. Our study suggests that CMI and macrophage activation takes place in the pathogenesis of idiopathic nephrosis.

Propylthiouracil-associated rapidly progressive crescentic glomerulonephritis with double positive anti-glomerular basement membrane and antineutrophil cytoplasmic antibody: the first case report

We report a case of propylthiouracil (PTU)-induced double antineutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane antibody (anti-GBM antibody) disease causing pulmonary-renal syndrome in a 35-year-old Thai woman with 10-year history of PTU treatment for thyrotoxicosis. She developed clinical symptoms of vasculitis upon receiving long-term PTU treatment. Prednisolone treatment and the switching from PTU to methimazole resulted to short-term clinical improvement. Nevertheless following termination of steroid treatment, she developed recurrent pulmonary hemorrhage and rapidly progressive glomerulonephritis. The kidney biopsy showed crescentic glomerulonephritis with linear IgG deposit on the glomerular basement membrane although transbronchial lung biopsy showed no immune deposit along the alveolar basement membrane. Serum testing for p-ANCA was positive and western blot showed positive antibody to the alpha-3 chain of collagen type IV. Both ANCA and anti-GBM antibody may play a role in the development of end organ damage. To facilitate early and specific intervention, clinicians should be aware of the propensity of PTU to cause lupus-like syndromes with renal involvement. In patients with PTU-induced ANCA-associated glomerulonephritis, serum anti-GBM antibody test may be useful in the early diagnosis of double positive antibodies disease and plasmapheresis should be performed without delay.