Influence of Donor’s Renal Function on the Outcome of Living Kidney Transplantation: 10-Year Follow-up

정현철,이성호,양대열,김성용,김하영,이삼열,김정원,이원기 대한비뇨의학회 2012 Investigative and Clinical Urology Vol.53 No.2

Purpose: With the improved surgical techniques and immunosuppression available today, conventional prognostic factors have taken on less significance. Accordingly, the native renal function of the donor is thought to be more important. Thus, we analyzed the prognostic significance of the donor’s renal function as assessed by 24-hour urine creatinine clearance on kidney graft survival for 10 years after living kidney transplantation. Materials and Methods: From January 1998 to July 2000, 71 living kidney transplantations were performed at a single institution. From among these, 68 recipients were followed for more than 6 months and were included in the present analysis. We analyzed kidney graft survival according to clinical parameters of the donor and the recipient. Results: Mean follow-up duration of recipients after living kidney transplantation was 115.0±39.4 months (range, 10 to 157 months), and 31 recipients (45.6%) experienced kidney graft loss during this time period. Estimated mean kidney graft survival time was 131.8±6.2 months, and 5-year and 10-year kidney graft survival rates were estimated as 88.2% and 61.0%, respectively. Donor’s mean 24-hour urine creatinine clearance (Ccr) before kidney transplantation was 122.8±21.2 ml/min/1.73 m2 (range, 70.1 to 186.6 ml/min/1.73 m2). The 10-year kidney graft survival rates for cases stratified by a donor’s Ccr lower and higher than 120 ml/min/1.73 m2 were 39.0% and 67.2%, respectively (p=0.005). In univariate and multivariate analysis, donor’s Ccr was retained as an independent prognostic factor of kidney graft survival (p=0.001 and 0.005, respectively). Conclusions: Donor’s 24-hour urine Ccr before living kidney transplantation was an independent prognostic factor of kidney graft survival. Therefore, it should be considered before living kidney transplantation. Purpose: With the improved surgical techniques and immunosuppression available today, conventional prognostic factors have taken on less significance. Accordingly, the native renal function of the donor is thought to be more important. Thus, we analyzed the prognostic significance of the donor’s renal function as assessed by 24-hour urine creatinine clearance on kidney graft survival for 10 years after living kidney transplantation. Materials and Methods: From January 1998 to July 2000, 71 living kidney transplantations were performed at a single institution. From among these, 68 recipients were followed for more than 6 months and were included in the present analysis. We analyzed kidney graft survival according to clinical parameters of the donor and the recipient. Results: Mean follow-up duration of recipients after living kidney transplantation was 115.0±39.4 months (range, 10 to 157 months), and 31 recipients (45.6%) experienced kidney graft loss during this time period. Estimated mean kidney graft survival time was 131.8±6.2 months, and 5-year and 10-year kidney graft survival rates were estimated as 88.2% and 61.0%, respectively. Donor’s mean 24-hour urine creatinine clearance (Ccr) before kidney transplantation was 122.8±21.2 ml/min/1.73 m2 (range, 70.1 to 186.6 ml/min/1.73 m2). The 10-year kidney graft survival rates for cases stratified by a donor’s Ccr lower and higher than 120 ml/min/1.73 m2 were 39.0% and 67.2%, respectively (p=0.005). In univariate and multivariate analysis, donor’s Ccr was retained as an independent prognostic factor of kidney graft survival (p=0.001 and 0.005, respectively). Conclusions: Donor’s 24-hour urine Ccr before living kidney transplantation was an independent prognostic factor of kidney graft survival. Therefore, it should be considered before living kidney transplantation.

Analysis of the Results of ABO-Incompatible Kidney Transplantation: In Comparison with ABO-Compatible Kidney Transplantation

전병주,김인곤,성열근,한보현 대한비뇨의학회 2010 Investigative and Clinical Urology Vol.51 No.12

Purpose: The number of patients waiting for kidney transplantation is incessantly increasing, but the number of cadaveric kidney transplantations or ABO-compatible donors is so insufficient that ABO-incompatible kidney transplantation is being performed as an alternative. There are overseas studies and research showing that the 5-year survival rate and 5-year graft survival rate of ABO-incompatible kidney transplantation are not much different from those of ABO-compatible kidney transplantation. However, domestic research on the subject is rare. Therefore, we report the results of 22 ABO-incompatible kidney transplantation cases performed in our hospital. Materials and Methods: This research was from 22 patients in our hospital who underwent ABO-incompatible kidney transplantation from 15 February 2007 to 20 May 2010. Results: As yet, there have been no donor graft losses and no deaths after transplantation. The results of the two groups were analyzed by analysis of covariance of the creatinine value of the recipients at 6 months after the operation, corrected for the preoperative value in order to statistically identify whether there were differences in renal function after the operation between ABO-compatible and ABO-incompatible kidney transplantation. The results of the analysis of covariance showed no statistical difference in renal function after the operation between the two groups. Conclusions: Even though there were not many cases, our initial results for ABO-incompatible kidney transplantation were positive. Considering the increasing number of patients waiting for kidney transplantation, longer-term domestic research studies of ABO-incompatible kidney transplantation are necessary.

이식신의 이식전후 사구체여과율의 변화에 관한 연구

정해혁(Hae Hyuk Jung),김경조(Kyung Jo Kim),장재원(Jae Won Jang),서장원(Jang Won Seo),김형호(Hyeong Ho Kim),양원석(Won Seok Yang),박정식(Jung Sik Park),한덕종(Duck Jong Han),문대혁(Dae Hyuk Moon) 대한내과학회 1996 대한내과학회지 Vol.50 No.4

N/A Objectives : The GFR of transplanted kidney has been studied in human, which has been reported to be around 50% to 70% of the donor total GFR before nephrectomy. The magnitude of hyperfiltration in the transplanted kidney is 0% to 40% on the assumption that each donor kidney functions 50% of the total GFR. These studies, however, did not take the relative function of the donated kidney into consideration. This study was performed to evaluate the magnitude of hyperfiltration in the transplanted kidney by measuring the GFR of the donated kidney before nephrectomy, and to determine factors that affect the GFR of the transplanted kidney. Methods The author measured GFR using 51Cr-EDTA clearance (CEDTA) and creatinine clearance (Ccr) in 70 donors of llving related renal transplantation performed in Asan Medical Center from December 1992 to January 1994. With relative kidney function measured by DMSA scan, the auther calculated the GFR of the donated kidney before nephrectomy(D'CEDTA and D'Ccr, respectively). When renal function was stable, usually 3 months after transplantation, the author repeated CEDTA and Ccr(R'CEDTA and R'Ccr, respectively) in 61 recipients. Nine patients were excluded because they did not maintain stable renal function within 2 months of transplantation. Results: The relative renal function of the donated kidney ranged 33 to 56% (mean 49%) The GFR of donated kidney before nephrectomy (D'CEDTA and DCcr) ranged 39 to 85m1/min(mean 59) and 26 to 80ml/min(mean 49), respectively. As expected, there was a close correlation between R'CEDTA and D'CEDTA with RCEDTA=0.72×D'CEDTA+26ml/min (r=0.59, p<0.01) and the geometric mean of R'CEDTA/DCEDTA was 115% (n=47). There was a significant correlation between R'Ccr and O'Ccr with R'Ccr=0.43×D'Ccr+48mVmin (r=0.44, p<0,01) and the mean of R'Ccr/D'Ccr was 140Fo(n=43). D'CEDTA (p<0.01) and the donor age(p=0.02) related independently with R'CEDTA on multiple regression analysis(n=47). Conclusion: With these results, we conclude that: 1) The relative function of the donated kidney was distributed in a wide range. 2) Transplanted kidney functions at 15 to 40N above the prenephrectomy level in about 3 months after transplantation. 3) The GFR of the donated kidney before nephrectomy and the donor age affect the GFR of the transplanted kidney.

소아 양측 신장과 방광벽을 이용한 성인 신장이식

송승환,이주한,한웅규,김유선,허규하 대한이식학회 2015 Korean Journal of Transplantation Vol.29 No.3

Kidney transplantation is a treatment of choice which improves survival and quality of life for patients with end-stage renal disease. Due to the growing waiting list for kidney transplantation, expansion of the donor pool to use of deceased pediatric kidneys is of critical importance. However, the use of pediatric kidneys has been limited due to concerns about early graft failure, hyperfiltration injury, and technical difficulties. Performing ureteroneocystostomy using small pediatric en bloc kidneys is sometimes difficult due to the small diameter and short length of the ureter in the adult kidney recipient. We hereby report on a partial bladder wall transplantation using pediatric en bloc kidneys. Pediatric en bloc kidneys and partial bladder wall from a 12-month-old female donor who weighed 9.13 kg was transplanted into a 49-year-old male recipient. The urinary tract was reconstructed with a partial bladder wall of the donor. At 12 months post-transplantation, Doppler ultrasonograpy and renogram showed stable graft renal function without urological complications. Pediatric en bloc kidney transplantation with a partial bladder wall can be a safe and feasible surgical technique to reduce urological complications. 신장이식은 말기신부전 환자의 생존율과 삶의 질을 향상시키는 치료 방법이다(1). 그러나 대부분의 환자가 적합한 신장 공여자가 없어, 뇌사자 신장공여를 대기하고 있는실정이다. Korean Network for Organ Sharing (KONOS)의통계에 따르면 2009년부터 최근 5년간 국내 신장이식 건수는 7,712예로 매년 증가 추세이며, 2013년 1,760건의 신장이식이 시행되었다. 그러나, 뇌사자 신장이식 대기자수는 14,181명(2013년 기준)으로 빠르게 증가하고 있다(2). 2013년 전체 뇌사 공여자중 17세 미만의 뇌사 공여자는18명으로, 전체 뇌사자 415명 중 4.3%에 해당한다. 공여자의 체중이 적을수록 불충분한 신장량(nephron dose, 수여자의 체중에 대한 공여자 신장 무게의 비)으로 인해, 과여과(hyperfiltration)와 이로 인한 신장손상이 일어날 수 있다(3-5). 따라서 KONOS에서는 기증자의 나이가 3세 이하인 경우, 체중이 15 kg 이하인 경우, 초음파검사상 신장 크기가 6 cm 이하인 경우에는 한쪽 신장이식(single kidney transplantation)이 아닌, 양측 신장이식(en bloc kidney transplantation)의 시행을 허용하고 있다. 하지만 체격이 작은 소아 뇌사공여자의 경우 작은 직경과 짧은 길이의 요관을 문합하여야 하므로 기술적으로 어려울 수 있다. Kato 등(6)은 이러한 어려움을 극복하고 방광의 용적을 늘리고자 소아 공여자의 방광벽 일부를 이용한 방광-방광 문합술을 최초로 시행하여 좋은 결과를 보여주었다. 국내에서는 이러한 증례가 드물고 아직 보고된 예가 없다. 저자들은 소아 뇌사공여자의 양측 신장과 방광벽을 이용하여 성공적으로 시행한 성인 신장이식 1예를 보고하고자 한다.

Impact of preoperative ultrasonography for predicting the prognosis of deceased donor kidney transplantation

Yun Sang Oh,Lee Kyo Won,Park Jae Berm,Min Jung Kim,박성윤,Park Boram 대한초음파의학회 2023 ULTRASONOGRAPHY Vol.42 No.2

Purpose: This study evaluated the role of donor kidney ultrasonography (US) for predicting functional kidney volume and identifying ideal kidney grafts in deceased donor kidney transplantation. Methods: In total, 272 patients who underwent deceased donor kidney transplantation from 2000 to 2020 at Samsung Medical Center were enrolled. Donor kidney information (i.e., right or left) was provided to the radiologist who performed US image re-analysis. To binarize each kidney’s ultrasound parameters, an optimal cutoff value for estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73 m2 within 1 year after kidney transplantation was selected using the receiver operating characteristic curve with a specificity >60%. Cox regression analysis was performed for an eGFR less than 30 mL/min/1.73 m2 within 1 year after kidney transplantation and graft failure within 2 years after kidney transplantation. Results: The product of renal length and cortical thickness was a statistically significant predictor of graft function. The odds ratios of an eGFR less than 30 mL/min/1.73 m2 within a year after kidney transplantation and the hazard ratio of graft failure within 2 years after kidney transplantation were 5.91 (P=0.003) and 5.76 (P=0.022), respectively. Conclusion: Preoperative US of the donor kidney can be used to evaluate donor kidney function and can predict short-term graft survival. An imaging modality such as US should be included in the donor selection criteria as an additional recommendation. However, the purpose of this study was not to narrow the expanded criteria but to avoid catastrophic consequences by identifying ideal donor kidneys using preoperative US.

중국에서 신 이식을 받고 돌아온 환자들의 폐렴

최수정,심광연,박무용,김나리,김태형,김진국,황승덕 순천향대학교 순천향의학연구소 2008 Journal of Soonchunhyang Medical Science Vol.14 No.1

Purpose: The Number of patients expecting for kidney transplantation and transplantation in foreign countries is rapidly increasing. The infectious complication such as pneumonia has happened commonly during maintenance immunosupression after transplantation. However, there was a lack of information about clinical progresses and outcomes of kidney recipients, underwent cadaveric kidney transplantation in China. Methods: We included 27 patients underwent cadaveric kidney transplantation in China and have been managed at Soonchunhyang University Bucheon Hospital from January 2002 to december 2007. We performed retrospectively study based medical records and clinical analysis for patients with pneumonia. Results: Mean age of 27 patients underwent kidney transplantation was 42.4 10.9 years. One of them didn't experience dialysis before transplantation. Twenty-one and five patients has been treated with hemodialysis and peritoneal dialysis, respectively. The mean dialysis duration was 32.6 ± 23.7 months. Among the causes of end stage renal disease of them, Chronic glomerulonephritis was most common. Post-transplantation follow-up duration was 26.6 ± 10.5 months. During the period above, the number of post-transplantation complication was 19. Pneumonia was most common and next was acute rejection. Ten patients experienced pneumonia at mean 123.7 48.4 day after transplantation. Mean age of them was 44.5 ± 7.8 years, and male to female ratio was 9:1. They had fever and admitted for mean 5.8 ± 4.2, and 19.6 ± 10.9 days, respectively. Seven and 3 patients were diagnosed as Pneumocystis carinii, and cytomegaloviral pneumonia, respectively. Two patients needed mechanical ventilator. One patient with cytomegaloviral pneumonia was expired. Conclusion: We offer informations and problems about kidney transplantation in china, and should be aware of possible complications including pneumonia of recipients undergoing cadaveric kidney transplantation in china.

이식 신장의 부피와 무게가 이식 후 신장기능에 미치는 영향

어성호,이수형,원제환,오창권 대한이식학회 2015 Korean Journal of Transplantation Vol.29 No.4

Background: Low functional nephron mass and graft kidney-recipient body size mismatch can lead to poor graft function. To examine the impact of the ratios of the surrogates to recipient body surface area (BSA) and body weight on graft function within 5 years post-transplantation, we measured the graft kidney volume, using computed tomography with 3-dimensional reconstruction before transplantation, and measured the graft kidney weight during surgery in living donor kidney transplantation (LDKT). Methods: Between February 2004 and November 2013, 142 LDKT recipients without delayed graft function, acute rejection, or infection within 5 years of transplantation were included. The graft function and its relations with graft kidney volume and its weight were analyzed. Results: The graft kidney volume/recipient BSA ratio showed correlation with the estimated glomerular filtration rate (eGFR) of recipients after 3 years post-transplantation. We found a difference in the graft function between recipients with a graft kidney volume/recipient BSA ratio of ≥80.4 mL/m2 and those with a ratio of <80.4 mL/m2 (P<0.05). Multivariate analysis showed that the graft kidney volume/recipient BSA ratio, the graft kidney weight/recipient body weight ratio, donor age, donor eGFR, and donor/recipient BSA ratio are independent predictors of graft function at each period of transplantation (P<0.05). Conclusions: The graft kidney volume of living donors may predict graft function and during living donor and recipient matching, both the potential volume of the donated kidney and the body size of the recipient should be considered.

HLA 일배체 부적합 혈연관계 생체 신이식에서 공여자 연령이 이식신 및 환자 생존율에 미치는 영향

김준홍(Jun Hong Kim),김찬덕(Chan Duk Kim),김석재(Seog Jae Kim),백미영(Mi Young Baek),권태환(Tae Hwan Kwon),김용림(Yong Lim Kim),조동규(Dong Kyu Cho),김영욱(Young Wook Kim),권태균(Tae Gyun Kwon),장세국(Sae Kook Chang) 대한내과학회 1998 대한내과학회지 Vol.54 No.3

N/A Objectives: Renal transplantation has become the therapy of choice for patients suffering from end-stage renal disease. But because of progressive disparity between the number of patients in needs of a transplant and the number of ideal kidneys available for transplantation, increasing numbers of kidneys are recovered for transplantation from donors that are not considered ideal, especially from donors over the age of 55. In country such as Korea, the number of cadaveric transplants is limited due to cultural and religious prejudices of the population, poor legal definition and deficient organization of cadaveric donor work-up. Therefore the main source is living related donors(LRD), especially the parent. But in Korea, there is few reports about the influence of donor age on outcome in living related kidney transplantation. Thus we performed this study to estimate the influence of donor age in itself on the outcome of the one HLA-haplotype mismatched living related kidney transplantation. Methods: The effect of donor age on the outcome of One HLA-haplotype mismatched living related kidney transplantation was studied in 71 recipients who under- went kidney transplantation from January 1981 to March 1995. The outcomes of 25 recipients from the older age group(?55 years: Group A) and 46 recipients from the younger age group(<55 years: Group B) were retrospectively reviewed. Patient death with a functioning graft was considered graft loss. Results: Demographic characteristics between 2 groups were similar, The 1-year and 3-year patient survival rates in recipients(group A and B) were similar regardless of donor age(96.0% and 90.8% vs.97.4% and 90.3%, respectively). The 1-year and 3-year graft survival rates in recipients(group A and B) were not significantly different (91.4% and 63.9% vs 92.7% and 79.3%, respectively). The mean levels of serum creatinine at discharge were significantly higher in group A. Short-term and intermediate-term renal function, as assessed by serum creatinine, was inferior in the group A throughout the follow-up periods of 3 years. The causes of graft loss in the first 3 years after transplantation were irreversible rejection(71%) and the patient death with functioning graft(29%) in group A, while the causes of graft loss in group B were irreversible rejection(50%), patient death with a functioning graft(40%) and technical reason(10%). Conclusion: These results of our analysis suggest that similar outcome can be achieved after living related renal transplantation from older donor. Therefore the kidneys may be used from donors over 55 years old on condition that the donors undergo complete and exhaustive work-up.

혈액형 부적합 신장이식의 현재와 과제

이신아,강덕희 이화여자대학교 의과학연구소 2015 EMJ (Ewha medical journal) Vol.38 No.1

Kidney transplantation is the best treatment for end-stage renal disease patients. However, the relative shortage of organs for transplantation has led to ABO-incompatible kidney transplantation as an accepted method to expand the pool of kidney donors. Recent advances in immunosuppression and antibody removal methods have made ABO-incompatible kidney transplantation more feasible, and have increased the opportunities for patients to receive kidney transplantation, as well as for special patients with ABO-compatible donor. Indeed, the outcome of ABO-incompatible kidney transplantation has shown remarkable developments and is now comparable to that of ABO-compatible kidney transplantation during last decade. However, there are still some uncertain issues to be addressed in ABO-incompatible kidney transplantation. In this article, we reviewed the current status and protocol of ABOincompatible kidney transplantation and listed the concerns to be addressed in near future.

Renal Cell Carcinoma in Kidney Transplant Recipients and Dialysis Patients

이형호,최경화,양승철,한웅규 대한비뇨의학회 2012 Investigative and Clinical Urology Vol.53 No.4

Purpose: In a group of surgery patients diagnosed with renal cell cancer, those who underwent dialysis were compared with those who received a kidney transplant. Materials and Methods: The 43 subjects included in this study were patients who had been undergoing dialysis because of end-stage renal disease or had undergone kidney transplantation. The patients were diagnosed with renal cell carcinoma (RCC) during follow-up and underwent radical nephrectomy from May 1996 to December 2010. Their medical records were retrospectively analyzed as part of the study. Results: In the transplantation group, the renal replacement therapy period averaged 54 months, and the period from transplantation to RCC averaged 119 months (range, 0 to 264 months). In the dialysis group, RCC was observed after an average of 124 months (range, 2 to 228 months) of dialysis, and nephrectomy was then conducted. Acquired cystic kidney disease (ACKD) was found more frequently in the dialysis group, and it had a statistically relevant effect on the occurrence of RCC by comparison with the transplantation group (p<0.01). Conclusions: Although the incidence rate of ACKD was significantly higher in the dialysis group among patients undergoing surgery for RCC, cancer was found even without ACKD development in some transplant recipients. Considering that the transplant recipients also underwent dialysis, an informative prospective study will be necessary to determine whether other immunosuppressive agents besides ACKD may function as a cancer risk factor. Purpose: In a group of surgery patients diagnosed with renal cell cancer, those who underwent dialysis were compared with those who received a kidney transplant. Materials and Methods: The 43 subjects included in this study were patients who had been undergoing dialysis because of end-stage renal disease or had undergone kidney transplantation. The patients were diagnosed with renal cell carcinoma (RCC) during follow-up and underwent radical nephrectomy from May 1996 to December 2010. Their medical records were retrospectively analyzed as part of the study. Results: In the transplantation group, the renal replacement therapy period averaged 54 months, and the period from transplantation to RCC averaged 119 months (range, 0 to 264 months). In the dialysis group, RCC was observed after an average of 124 months (range, 2 to 228 months) of dialysis, and nephrectomy was then conducted. Acquired cystic kidney disease (ACKD) was found more frequently in the dialysis group, and it had a statistically relevant effect on the occurrence of RCC by comparison with the transplantation group (p<0.01). Conclusions: Although the incidence rate of ACKD was significantly higher in the dialysis group among patients undergoing surgery for RCC, cancer was found even without ACKD development in some transplant recipients. Considering that the transplant recipients also underwent dialysis, an informative prospective study will be necessary to determine whether other immunosuppressive agents besides ACKD may function as a cancer risk factor.