Suh Min Kim

Cold ischemic time is critical in outcomes of expanded criteria donor renal transplantation

The outcomes of expanded criteria donor (ECD) kidneys have been reported to be inferior compared with standard criteria donor (SCD) kidneys. However, the graft survival rate of ECD is not so inferior to SCD in Korea. The purposes of this study were to compare the outcomes of ECD kidneys with SCD kidneys and identify the influencing factors. We retrospectively studied 143 deceased donor transplants from August 2006 to June 2010. The patients were divided into SCD (n = 117) and ECD (n = 26) by UNOS criteria. The one‐ and three‐yr graft survival rates of SCD and ECD (99.1% and 94.4% vs. 100% and 92.9%, respectively, p = 0.15) were not significantly different between groups. The mean cold ischemic time (CIT) was 3.8 ± 2.2 h. When compared the outcome of ECD kidneys with data reported by Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients (OPTN/SRTR) (one‐ and three‐yr graft survival rate: 86.7% and 73.2%), the graft survival rate of our center was superior. In OPTN/SRTR data, transplant with CIT shorter than 11 h was only 20%. The outcomes of ECD grafts are outstanding and comparable with SCD grafts in our center, and the only distinguishing factor is markedly short CIT. Finishing the allocation before organ recovery and immediate operations after recovery could shorten the CIT.

Reconstruction of portal vein and superior mesenteric vein after extensive resection for pancreatic cancer

Purpose Tumor invasion to the portal vein (PV) or superior mesenteric vein (SMV) can be encountered during the surgery for pancreatic cancer. Venous reconstruction is required, but the optimal surgical methods and conduits remain in controversies. Methods From January 2007 to July 2012, 16 venous reconstructions were performed during surgery for pancreatic cancer in 14 patients. We analyzed the methods, conduits, graft patency, and patient survival. Results The involved veins were 14 SMVs and 2 PVs. The operative methods included resection and end-to-end anastomosis in 7 patients, wedge resection with venoplasty in 2 patients, bovine patch repair in 3 patients, and interposition graft with bovine patch in 1 patient. In one patient with a failed interposition graft with great saphenous vein (GSV), the SMV was reconstructed with a prosthetic interposition graft, which was revised with a spiral graft of GSV. Vascular morbidity occurred in 4 cases; occlusion of an interposition graft with GSV or polytetrafluoroethylene, segmental thrombosis and stenosis of the SMV after end-to-end anastomosis. Patency was maintained in patients with bovine patch angioplasty and spiral vein grafts. With mean follow-up of 9.8 months, the 6- and 12-month death-censored graft survival rates were both 81.3%. Conclusion Many of the involved vein segments were repaired primarily. When tension-free anastomosis is impossible, the spiral grafts with GSV or bovine patch grafts are good options to overcome the size mismatch between autologous vein graft and portomesenteric veins. Further follow-up of these patients is needed to demonstrate long-term patency.

Conversion of Twice-Daily Tacrolimus to Once-Daily Tacrolimus Formulation in Stable Pediatric Kidney Transplant Recipients: Pharmacokinetics and Efficacy

The pharmacokinetics, efficacy and safety of once‐daily tacrolimus formulation (Tac‐OD) were assessed in 34 stable pediatric kidney transplant recipients. Enrolled patients received their dose of twice‐daily tacrolimus formulation (Tac‐BID) on study Days 0 through 7. On the morning of study Day 8, the total daily doses for patients were converted to Tac‐OD on a 1:1 basis and maintained on a once‐daily morning dosing regimen. Tacrolimus pharmacokinetic profiles were obtained on study Days 7, 14 and 28 (after dose adjustment). Although the mean C0 concentrations (4.10 ± 1.16–3.53 ± 1.10 ng/mL, p = 0.004), and AUC0–24 (151.8 ± 41.6–129.8 ± 39.3 ng h/mL, p < 0.001) were decreased significantly after a 1:1 based conversion, there was high interindividual variability. The dose of Tac‐OD was decreased in 26.5% and increased in 44.1% of patients. The resultant tacrolimus dose and pharmacokinetic profiles on study Day 28 were comparable to those on Day 7. There were no serious adverse events. In conclusion, Tac‐BID can be safely converted to Tac‐OD in stable pediatric kidney transplant patients with the heightened therapeutic drug monitoring. Effects of drug conversion on the cardiovascular risk factors, neurological side effects and adherence should be further evaluated.

Preconditioning with thyroid hormone (3,5,3-triiodothyronine) prevents renal ischemia-reperfusion injury in mice.

BACKGROUND 3,5,3-triiodothyronine (T3) was found to decrease ischemia-reperfusion (I/R) injury of liver and myocardium in animal models when preconditioned 48 hours in advance of the I/R injury. The purpose of this study was to evaluate the effects of T3 preconditioning on renal I/R injury with different time intervals and to determine the changes in antioxidants, apoptosis, and nitric oxide synthase (NOS) in each condition. METHODS In male C57BL/6 mice, renal I/R injury was induced by temporary ligation of the bilateral renal pedicles for 45 minutes followed by a reperfusion period for 24 hours. Preconditioning with intraperitoneal injection of T3 was performed 24 or 6 hours before or at the time of I/R injury. RESULTS From the histologic examination, tubular injury was decreased in mice preconditioned with T3 6 hours before I/R injury. The levels of proinflammatory cytokines were decreased with T3 preconditioning, either 6 hours or at the time of I/R injury. The levels of glutathione were increased in all treatment groups. Expressions of neuronal NOS were increased when preconditioned 6 hours before or at the time of I/R injury. The number of apoptotic tubular epithelial cell evaluated by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay was decreased when preconditioned immediately before I/R injury. CONCLUSION Preconditioning with T3 6 hours or immediately before I/R injury had a protective effect on renal I/R injury. The changes of NOS and antiapoptosis, other than well-known antioxidative properties, may play a role in the effect of short-term preconditioning.

Clinical significance of type I endoleak on completion angiography

Purpose Type I endoleak is known to be associated with sac enlargement and occasional rupture, therefore, the treatment of type I endoleak is recommended at the time of diagnosis. The aim of this study was to identify the significance of early type I endoleak found on completion angiography. Methods Between January 2000 and December 2012, a total of 86 patients underwent endovascular abdominal aortic aneurysm repair (EVAR) and 10 patients (11.6%) were diagnosed with type Ia endoleak on completion angiography. Clinical and radiologic data were reviewed retrospectively. Results Of the 10 patients, two underwent EVAR with custom-made stent-grafts in the initial stage and both of them needed immediate treatment: one case involved open repair while the other involved insertion of an additional stent-graft. In 8 patients, the amount of leakage decreased after repeated balloon molding. They were managed conservatively and followed up with computed tomography angiography within 2 weeks after EVAR. In 7 of the 8 cases, type Ia endoleaks disappeared. In one patient with a persistent endoleak and a folded posterior wall of the stent-graft, coil embolization was performed 1 week after EVAR. With a median follow-up of 12 months (range, 1-61 months), no patients showed recurrence of type I endoleak or sac expansion. Conclusion Type I endoleaks diagnosed on completion angiography sealed spontaneously in 7 of 10 patients (70.0%). In cases of decreased amounts of leakage after balloon molding, simple observation may be an alternative to repetitive procedures. The long-term follow-up of patients with self-sealed type I endoleaks is mandatory.

Successful thrombolysis, angioplasty, and stenting of delayed thrombosis in the vena cava following percutaneous vertebroplasty with polymethylmethacrylate cement

Percutaneous vertebroplasty is a widely used treatment for vertebral compression fracture. It is relatively safe, but it can be complicated by pulmonary or cerebral embolism caused by the cement injected during the procedure. Here, we present a case of a 69-year-old male with extensive deep vein thrombosis from the inferior vena cava to the right iliac and left femoral veins, which occurred 10 months after vertebroplasty. He was treated successfully by catheter-directed thrombolysis, angioplasty, and stenting. To the best of our knowledge, this is the first report of the successful treatment of delayed thrombosis caused by migrated cement inside the inferior vena cava.

Comparison of Costs of Endovascular Repair versus Open Surgical Repair for Abdominal Aortic Aneurysm in Korea

This study was designed to compare the hospital-related costs of elective abdominal aortic aneurysm (AAA) treatment and cost structure between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in Korean health care system. One hundred five primary elective AAA repairs (79 OSRs and 26 EVARs) performed in the Seoul National University Hospital from 2005 to 2009 were included. Patient characteristics were similar between two groups except for older age (P = 0.004) and more frequent history of malignancy (P = 0.031) in EVAR group. Thirty-day mortality rate was similar between two groups and there was no AAA-related mortality in both groups for 5 yr after repair. The total in-hospital costs for the index admission were significantly higher in EVAR patients (mean, KRW19,857,119) than OSR patients (mean KRW12,395,507) (P < 0.001). The reimbursement was also significantly higher in EVAR patients than OSR patients (mean, KRW14,071,081 vs KRW6,238,895, P < 0.001) while patients payments was comparable between two groups. EVAR patients showed higher follow-up cost up to 2 yr due to more frequent imaging studies and reinterventions for type II endoleaks (15.4%). In the perspective of cost-effectiveness, this study suggests that the determination of which method to be used in AAA treatment be more finely trimmed and be individualized.

Inhibition of intimal hyperplasia by local perivascular application of rapamycin and imatinib mesilate after carotid balloon injury.

Purpose Inhibition of the intimal hyperplasia after vascular surgery is an important issue. The purpose of this study is to define whether perivascular application of rapamycin, imatinib mesylate or cysteamine can reduce intimal hyperplasia in a carotid balloon injury model. Methods Each drug was mixed with 40% pluronic gel solution and was topically applied over the injured carotid artery evenly. Two or four weeks after injury, the arteries were harvested and morphometric analysis was done. Results The medial areas were not significantly different in each group and a thinning of the media as a toxic drug effect was not observed in any treatment group. The intimal area and intima-to-media (I/M) ratio were significantly reduced in rapamycin-treated group and imatinib-treated group (P < 0.05). But cysteamine-treated group showed a trend of decrease in I/M ratio in 2 weeks, but no difference in 4 weeks. Conclusion Perivascular delivery of imatinib or rapamycin with pluronic gel attenuated the development of intimal hyperplasia. But cysteamine did not. Further studies are needed to refine the optimal drug dosages in large animal models.

Chronic allograft injury by subclinical borderline change: evidence from serial protocol biopsies in kidney transplantation.

Purpose This study investigated the impact of subclinical borderline changes on the development of chronic allograft injury in patients using a modern immunosuppression protocol. Methods Seventy patients with stable renal allograft function and who underwent protocol biopsies at implantation, 10 days and 1 year after transplantation were included and classified based on biopsy findings at day 10. The no rejection (NR) group included 33 patients with no acute rejection. The treatment (Tx) group included 21 patients with borderline changes following steroid pulse therapy, and the nontreatment (NTx) group included 16 patients with borderline changes nontreated. Results The Banff Chronicity Score (BChS) and modified BChS (MBChS) were not different among the three groups at implantation (P = 0.48) or on day 10 (P = 0.96). Surprisingly, the NTx group had more prominent chronic scores at the 1-year biopsy, including BChS (3.07 ± 1.33, P = 0.005) and MBChS (3.14 ± 1.41, P = 0.008) than those in the Tx and NR group, and deterioration of BChS was more noticeable in the NTx group (P = 0.037), although renal function was stable (P = 0.66). No difference in chronic injury scores was observed between the Tx and NR groups at the 1-year biopsy. Conclusion Subclinical borderline changes can be a risk factor for chronic allograft injury and should be considered for antirejection therapy.