You Sung Kim

Effectiveness of Rituximab and Intravenous Immunoglobulin Therapy in Renal Transplant Recipients with Chronic Active Antibody-Mediated Rejection

BACKGROUND Chronic active antibody-mediated rejection (CAMR) is an important cause of chronic kidney allograft dysfunction, but there has been no effective treatment protocol established for it. METHODS Six renal transplant recipients who showed progressive deterioration in graft function and CAMR as diagnosed by biopsy were enrolled. We administered a single dose of rituximab (375 mg/m(2)), followed by intravenous immunoglobulin (IVIg, 0.4 g/kg) for 4 days. The efficacy of this protocol was assessed on the basis of the improvement in allograft function, the amount of proteinuria, and the change in donor-specific antibodies (DSAs). We categorized the patients into 2 groups, responders and nonresponders, according to their response to the treatment. RESULTS All of the patients showed progressive deterioration of graft function before the diagnosis of CAMR. Luminex solid-phase assays showed that 3 patients had DSAs. After the treatment, allograft function improved or stabilized in 3 patients in the responder group, but still showed a deteriorating pattern in the nonresponder group. In the responder group, the amount of proteinuria also decreased after the treatment, but it increased in the nonresponder group. On diagnosis of CAMR, the nonresponders showed a longer posttransplantation period, a higher degree of transplant glomerulopathy, more severely deteriorated allograft function, and higher proteinuria compared with the responders. CONCLUSIONS The combination of rituximab and IVIg was effective in early-stage CAMR, but the effect was limited in the advanced stage.

The Long-Term Outcomes of Transplantation of Kidneys With Multiple Renal Arteries

Kidneys with multiple renal arteries are increasingly procured for transplantation. To compare the outcomes of kidney transplantation using allografts with multiple arteries, we studied long-term graft function and survival according to their number of arterial anastomoses during an 18-year period from July 1, 1990, through December 31, 2008, in which only the recipients external iliac artery or internal iliac artery was used for anastomosis (n = 1186). The recipients were divided into four groups: group I, single renal artery with single anastomosis (n = 890, 75.0%); group Il, multiple renal arteries, single anastomosis (n = 26, 2.2%); group Ill, multiple renal arteries, multiple anastomoses (n = 236, 19.9%); and group IV, polar artery ligation (n = 34, 2.9%). We compared the following variables patient and graft survivals; mean creatinine levels at 1 and 6 months, as well as 1-, 3-, and 5-years posttransplant; the number of acute rejection episodes, and the rates of vascular and urologic complications. The creatinine values and incidences of acute rejection episodes did not differ significantly (P = 0.399 and P = 0.990, respectively). There were no significant differences among the four groups in graft survival (P = 0.951), patient survival (P = 0.751), incidence of vascular (P = 0.999) or urologic complications (P = 0.371). The four groups were subdivided according to the recipient arterial anastomosis to the main graft renal artery. The subdivided groups showed no significant differences in graft or patient survival, or complications rates. The results indicated that multiplicity of renal arteries in kidney transplantation did not adversely affect allograft or patient survival compared with single renal artery transplantation. Moreover, the type of the arterial anastomosis (main renal artery end-to-end anastomosed to internal iliac artery or end-to-side anastomosed to external iliac artery appeared to not affect graft or patient survival or the incidence of vascular or urologic complications.

Combined use of rituximab and plasmapheresis pre‐transplant increases post‐transplant infections in renal transplant recipients with basiliximab induction therapy

We investigated the effect of combined use of rituximab (RTX) and plasmapheresis (PP) pre‐transplant on post‐transplant infection.

Imaging Findings of Intrahepatic Bile Duct Adenoma (Peribiliary Gland Hamartoma): a Case Report and Literature Review

Intrahepatic bile duct adenoma is a rare benign epithelial hepatic tumor derived from bile duct cells. We report the imaging findings of a patient with bile duct adenoma, which appeared as a small heterogeneously enhancing mass with focal small cystic change on CT and MRI. Follow-up images at seven months showed a slight increase in tumor size, which could be partly explained by intratumoral hemorrhage on pathologic examination. Although rare, bile duct adenoma should be considered as a differential diagnosis of a small hypervascular tumor located in the periphery of liver. Focal cystic change and intratumoral hemorrhage may occur.

Giant aneurysm of the common hepatic artery: US and CT imaging findings

Giant hepatic artery aneurysm is a very rare vascular lesion, but can be detected incidentally during abdominal imaging. We report the sonographic and computed tomography (CT) features of a giant hepatic artery aneurysm in a 52-year-old woman presenting with vague abdominal discomfort. This report illustrates that a giant hepatic artery aneurysm can manifest as an incidental large mass in the porta hepatis, and we discuss the role of sonography and CT in the diagnosis of the lesion and review the natural history and clinical presentation of hepatic artery aneurysm.

Delayed graft function in living-donor renal transplantation: 10-year experience.

BACKGROUND Delayed graft function (DGF), a dialysis requirement within a week after transplantation, can occur in deceased-donor renal transplantation. DGF is rare, in living-donor renal transplantation (LDRT) and its incidence and risk factors have not been established. METHODS We investigated the incidence and clinical characteristics of DGF in LDRT over 10 years. We compared HLA mismatches, panel reactive antibody status, frequency of nonrelated donors, donor age, sex match, recipient-donor body weight ratio, total ischemia time, and transplanted kidney weight between DGF and non-DGF patients. RESULTS The incidence of DGF in LDRT was 1.6%, which differed from earlier reports. HLA mismatch, female recipient frequency, and nonrelated donors were higher among the DGF group, but no risk factor for DGF was significant after multivariate logistic regression analysis. Biopsy findings showed 2 cases to be associated with rejection, 1 with acute pyelonephritis and 1 with acute tubular necrosis. The cases with rejection resulted in graft failure within 3 years after transplantation, but the other cases were followed with favorable graft function. CONCLUSIONS The incidence of DGF among LDRT was lower than that reported earlier studies, and the factors previously reported to cause DGF were not associated with DGF herein. Because DGF with rejection responses has a poor prognosis, strenuous strategies, including biopsy, should be performed in cases of DGF after LDRT.

The role of kidney biopsy to determine donation from prospective kidney donors with asymptomatic urinary abnormalities.

BACKGROUND There are no definite guidelines about donation among prospective donors with asymptomatic urinary abnormalities. We evaluated the pathology of prospective kidney donors with asymptomatic urinary abnormalities and assessed the clinical outcomes of their organs. METHODS We reviewed the medical records of 15 prospective kidney donors who underwent kidney biopsy. We evaluated the role of kidney biopsy in terms of graft function, protocol biopsy, and follow-up biopsy. We further assessed the clinical outcomes of donors and recipients. RESULTS Thin basement membrane nephropathy (TBMN) is the most common cause of the persistent microscopic hematuria (n = 7; 50%), followed by nonspecific findings (n = 4; 29%), IgA nephropathy (n = 2; 14%), and focal segmental glomerulosclerosis (n = 1; 7%). Of the 14 candidate donors with persistent microscopic hematuria, 9 were accepted as kidney donors: 5 with TBMN, 3 with mild mesangiopathy, and 1 with nonspecific interstitial changes. The function of the 9 grafts was relatively stable (mean serum creatinine level 2.38 mg/dL) over a mean follow-up of 57 months. Graft failure that developed in 2 grafts was not associated with biopsy findings: acute rejection and patient death with a functioning graft. Interestingly, basement membrane thickness in 2 allografts from donors with TBMN appeared normal by electron microscopy follow-up biopsy; the allografts did not show hematuria. Moreover, the clinical outcomes of donors were favorable (mean serum creatinine 0.94 ± 0.32 mg/dL) during the mean follow-up period of 34.7 ± 42.5 months. We did not observe new-onset hypertension or proteinuria in donors. CONCLUSIONS Kidney biopsy in prospective kidney donors with urinary abnormalities is a safe and effective diagnostic procedure to stratify candidates. Therefore, kidney biopsy should be actively performed to improve the prognosis of both donors and recipients.

Clinical Usefulness of 3-Dimensional Computerized Tomographic Renal Angiography to Detect Transplant Renal Artery Stenosis

OBJECTIVE The aim of this study was to evaluate whether 3-dimensional computerized tomographic angiography (3D-CTA) is useful to detect transplant renal artery stenosis (TRAS). METHODS Fourteen patients with clinically suspected TRAS underwent color Doppler ultrasonography (CDU) and 3D-CTA before renal angiography. We compared 3D-CTA and CDU for accuracy based on the results of renal angiography. The safety of 3D-CTA was investigated by measuring the estimated glomerular filtration rate (eGFR) before and after the 3D-CTA examination. RESULTS The 10 men and 4 women who participated in this study showed a mean eGFR of 75 mL/min/1.73 m(2) (range 60-94). Of these, 9 patients were diagnosed with TRAS. 3D-CTA detected stenoses in all 9 patients, but CDU failed to detect it in 3, including, 2 with end-to-side arterial anastomoses, which may be more challenging to detect compared with end-to-end anastomoses. The stenotic area in 3D-CTA was similar to that detected by renal angiography (70 ± 12 vs 68 ± 11). The eGFR did not differ significantly before versus after the 3D-CTA examination; 72 ± 13 vs 69 ± 14 mL/min/1.73 m(2). CONCLUSIONS 3D-CTA was an effective safe method to detect renal artery stenosis among transplant recipients with an eGFR >60 mL/min/1.73 m(2).

CT and MR Imaging Findings of Lymphangioleiomyomatosis Involving the Uterus and Pelvic Cavity

Lymphangioleiomyomatosis (LAM) is a rare idiopathic disease and this is characterized by a proliferation of abnormal smooth muscle cells in the lungs and in the lymphatic system of the thorax and retroperitoneum. The female genital tract is rarely affected by LAM. We report here on the CT and MR imaging findings of extensive LAM involving the uterus and pelvic cavity, and this was seen as multiple cystic uterine and parauterine masses with internal hemorrhage in a young female with tuberous sclerosis complex.