BACKGROUND: We investigated the long-term effect of AST-120, which has been proposed as a therapeutic option against renal disease progression, in patients with advanced chronic kidney disease (CKD). METHODS: We performed post-hoc analysis with a per-protocol group of the K-STAR study (Kremezin study against renal disease progression in Korea) that randomized participants into an AST-120 and a control arm. Patients in the AST-120 arm were given 6 g of AST-120 in three divided doses, and those in both arms received standard conventional treatment. RESULTS: The two arms did not differ significantly in the occurrence of composite primary outcomes (log-rank P = 0.41). For AST-120 patients with higher compliance, there were fewer composite primary outcomes: intermediate tertile hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.38 to 1.01, P = 0.05; highest tertile HR 0.436, 95% CI 0.25 to 0.76, P = 0.003. The estimated glomerular filtration rate level was more stable in the AST-120 arm, especially in diabetic patients. At one year, the AST-120-induced decrease in the serum indoxyl sulfate concentration inversely correlated with the occurrence of composite primary outcomes: second tertile HR 1.59, 95% CI 0.82 to 3.07, P = 0.17; third tertile HR 2.11, 95% CI 1.07 to 4.17, P = 0.031. Furthermore, AST-120 showed a protective effect against the major cardiovascular adverse events (HR 0.51, 95% CI 0.26 to 0.99, P = 0.046). CONCLUSION: Long-term use of AST-120 has potential for renal protection, especially in diabetic patients, as well as cardiovascular benefits. Reduction of the serum indoxyl sulfate level may be used to identify patients who would benefit from AST-120 administration.
Arm ; Compliance ; Disease Progression* ; Glomerular Filtration Rate ; Humans ; Indican ; Korea* ; Renal Insufficiency, Chronic

BACKGROUND/AIMS: Sirolimus (SRL) is a promising immunosuppressant replacingcalcineurin inhibitors (CNIs). This study was performed to evaluate the safetyand immunologic benefits of conversion to SRL in stable kidney transplant (KT)recipients exposed to CNIs for long periods. METHODS: Fourteen CNI-treated KT recipients with stable renal function for morethan 10 years were included. Either 2 or 3 mg per day of SRL was administeredwhile CNIs were reduced by half starting on day 1, and then stopped 2 weeks afterSRL introduction. The safety of SRL conversion was assessed considering thegraft function, acute rejection, and graft loss. Immunologic alterations were measuredvia serial changes of T cell and B cell subsets after SRL conversion. Adverseeffects of SRL conversion were also evaluated. RESULTS: Conversion to SRL was successful in nine patients (64.2%). Conversionto SRL preserved graft function as compared to the baseline value (p = 0.115). Noacute rejection or allograft loss was observed during the follow-up period. Immunemonitoring of T and B cells revealed a regulatory T cells increase after SRL conversion (p = 0.028). Most adverse events developed within 6 weeks after SRLconversion, and oral mucositis was the main cause of SRL withdrawal. CONCLUSIONS: Conversion to SRL can be safe and has immunologic benefits in KTrecipients with long-term CNI exposure. Close monitoring of mucocutaneous adverseevents is, however, required in the early period after SRL conversion.
Allografts ; B-Lymphocyte Subsets ; B-Lymphocytes ; Calcineurin* ; Follow-Up Studies ; Humans ; Kidney Transplantation ; Kidney* ; Sirolimus* ; Stomatitis ; T-Lymphocytes, Regulatory ; Transplantation* ; Transplants

BACKGROUND: In this study, we assessed whether red blood cell distribution width (RDW) was associated with all-cause mortality in patients on peritoneal dialysis (PD) and evaluated its prognostic value. METHODS: This study included 136 patients who had RDW levels at PD initiation from January 2007 to January 2014 at the Presbyterian Medical Center and Seoul St. Mary's Hospital. We divided these patients into 2 groups (survivors vs. nonsurvivors), compared their clinical characteristics, and analyzed the predictors of survival. RESULTS: The study included 79 men and 57 women, with a mean age of 54 years (range, 15-85 years). The mean follow-up duration was 32 months (range, 1-80 months). Of 136 patients, 14 died during the follow-up period. When clinical characteristics of survivors (n = 122) and nonsurvivors (n = 14) were compared, no differences were identified, with the exception of serum albumin, total iron-binding capacity (TIBC), left ventricular ejection fraction, total leukocyte count, and RDW value. Survivors had higher serum albumin (3.4 ± 0.5 vs. 3.0 ± 0.5 g/dL, P < 0.001) and left ventricular ejection fraction (56.8 ± 9.8 vs. 48.7 ± 12.8, P = 0.040) and lower TIBC (213.4 ± 40.9 vs. 252.8 ± 65.6, P = 0.010), total leukocyte counts (6.9 × 103/μL vs. 8.6 × 103/μL, P = 0.009), and serum RDW values (13.9 ± 1.7 vs. 16.0 ± 1.8, P < 0.001). Patients with high RDW levels (≥ 14.8) showed significantly higher all-cause mortality than patients with low RDW levels (< 14.8, P < 0.001). In multivariate-adjusted Cox analysis, RDW and TIBC at the start of PD were independent risk predictors for all-cause mortality. CONCLUSION: RDW could be an additive predictor for all-cause mortality in patients on PD.
Erythrocyte Indices ; Erythrocytes* ; Female ; Follow-Up Studies ; Humans ; Leukocyte Count ; Male ; Mortality* ; Peritoneal Dialysis* ; Protestantism ; Seoul ; Serum Albumin ; Stroke Volume ; Survivors

BACKGROUND/AIMS: BK virus-associated nephropathy (BKVAN) is an important cause of allograft dysfunction in kidney transplant recipients. It has an unfavorable clinical course, and no definite treatment guidelines have yet been established. Here, we report our center's experience with biopsy-proven BKVAN and investigate factors associated with its progression. METHODS: From January 2004 to April 2013, 25 patients with BKVAN were diagnosed by biopsy at Seoul St. Mary's Hospital. Of the 25 patients, 10 were deceaseddonor transplant recipients and 15 were living-donor transplant recipients. Three of the patients underwent retransplantation. The primary immunosuppressant used was tacrolimus in 17 patients and cyclosporine in eight patients. RESULTS: BKVAN was observed at a mean duration of 22.8 ± 29.1 months after transplantation. The mean serum creatinine level at biopsy was 2.2 ± 0.7 mg/dL. BKVAN occurred with acute rejection in eight patients (28%). Immunosuppression modification was performed in 21 patients (84%). Additionally, leflunomide and intravenous immunoglobulin were administered to 13 patients (52%) and two (8%), respectively. Allograft loss occurred in five patients (27.8%) during the follow- up period at 0.7, 17.1, 21.8, 39.8, and 41.5 months after the BKVAN diagnosis. Advanced stages of BKVAN, increased creatinine levels, and accompanying acute rejection at the time of BKVAN diagnosis increased the risk of allograft failure. CONCLUSIONS: The clinical outcomes in patients with biopsy-proven BKVAN were unfavorable in the present study, especially in patients with advanced-stage BKVAN, poor renal function, and acute allograft rejection.
Adult ; Allografts ; Antiviral Agents/therapeutic use ; BK Virus/*pathogenicity ; Biomarkers/blood ; Biopsy ; Creatinine/blood ; Disease Progression ; Female ; Graft Rejection/diagnosis/drug therapy/immunology/*virology ; Graft Survival ; Humans ; Immunocompromised Host ; Immunosuppressive Agents/adverse effects ; Kaplan-Meier Estimate ; Kidney Transplantation/*adverse effects ; Male ; Middle Aged ; Opportunistic Infections/diagnosis/drug therapy/immunology/*virology ; Polyomavirus Infections/diagnosis/drug therapy/immunology/*virology ; Republic of Korea ; Retrospective Studies ; Risk Factors ; Time Factors ; Treatment Outcome ; Tumor Virus Infections/diagnosis/drug therapy/immunology/*virology

BACKGROUND/AIMS: Patients who undergo repeat kidney transplantations (KTs) are considered at high risk for experiencing immunologic and non-immunologic complications. In this study, we investigated the clinical outcomes, including medical and surgical complications, of patients who underwent a third KT at our center. METHODS: Between March 1969 and December 2012, a total of 2,110 KTs were performed at the Seoul St. Mary's Hospital. Of them, we examined 11 patients who underwent a third KT, and investigated the allograft outcomes and complication rates. RESULTS: The mean follow-up duration after KT was 72.4 ± 78.3 months. The mean age at KT was 38.2 ± 8.0 years, and seven patients (63.6%) were males. Nine patients (81.8%) underwent living-donor KT. A cross-match test yielded positive results in four of the nine patients, and all underwent pretransplant desensitization therapy. After KT, three patients (27.2%) showed delayed graft function. Acute rejection developed in four patients (36.4%), and surgical complications that required surgical correction occurred in three patients. Allograft failure developed due to acute rejection (n = 3) or chronic rejection (n = 1) in four patients. Allograft survival rates at 1, 5, and 10 years were 81.8%, 42.9%, and 42.9%, respectively; however, the allograft survival rate at 5 years was > 80% in patients who underwent KT only after results of the panel reactive antibody test became available. CONCLUSIONS: Thus, a third KT procedure may be acceptable, although aggressive pretransplant immune monitoring and patient selection may be required to reduce the risks of acute rejection and surgical complications.
Acute Disease ; Adult ; Allografts ; Chronic Disease ; Delayed Graft Function/diagnosis/*etiology/therapy ; Female ; Graft Rejection/diagnosis/*immunology/therapy ; Graft Survival ; *Histocompatibility ; Humans ; Immunosuppressive Agents/therapeutic use ; Kidney Transplantation/*adverse effects ; Male ; Middle Aged ; Patient Selection ; Reoperation ; Republic of Korea ; Risk Assessment ; Risk Factors ; Time Factors ; Treatment Outcome

PURPOSE: This study was to identify the effect of the experience of diabetes education on knowledge, self-care behavior and glycosylated hemoglobin (HbA1C). Further, this study was held to examine about patient's preferred methods of education and re-education frequency. METHODS: 166 type 2 diabetes patients from two hospitals in Incheon participated in this study. Data were analyzed by using descriptive analysis, t-test, ANOVA, Scheffe's test and multiple regression analysis. RESULTS: 72.3% patients needed re-education and the average interval of re-education was 8.53 months. Patients preferred education methods were lectures, practical training, and studying from pamphlet. Depending on the frequency of diabetes education, there were significant differences in the level of diabetes knowledge (F=10.88, p<.001) and self-care behaviors (F=4.59, p=.012), but there was not significant difference with HbA1C (F=1.53, p=.220). As to how much the diabetes education helped managing diabetes, there was a significant difference in the level of self-care behaviors (t=2.01, p=.049), but there were not significant differences in level of knowledge (t=1.10, p=.275) and HbA1C (t=-.33, p=.746). The experience of diabetes education was a significant factor which influenced patient's knowledge (t=3.93, p<.001) and self-care behaviors (t=2.21, p<.001). But HbA1C was not influenced by the experience of diabetes education (t=-1.68, p=.096). CONCLUSION: It is necessary to provide diabetes education with appropriate interval and methods and subjects that reflect the needs of patient through the study results.
Education* ; Hemoglobin A, Glycosylated* ; Humans ; Incheon ; Lectures ; Pamphlets ; Self Care*

This study aimed to investigate the effect of bortezomib in the desensitization and treatment of acute antibody mediated rejection (AAMR) in kidney transplantation. Nine patients who received bortezomib therapy for desensitization (DSZ group, n = 3) or treatment of AAMR (AAMR group, n = 6) were included in this study. In the DSZ group, 2 patients required DSZ owing to positive cross match and 1 owing to ABO mismatch with high baseline anti-ABO antibody titer (1:1,024). Bortezomib was used at 1, 3, 8, and 11 days from the start of the treatment. In the AAMR group, 3 patients showed full recovery of allograft function after bortezomib use and decrease in donor specific anti-HLA antibody (HLA-DSA). However, 3 patients did not respond to bortezomib and experienced allograft failure. In the DSZ group, negative conversion of T-CDC (complement-dependent cytotoxicity) was achieved, and HLA-DSA was decreased to lower than a weak level (median fluorescence intensity [MFI] < 5,000) in 2 patients. In the case of ABO mismatch kidney transplantation, the anti-A/B antibody titer decreased to below the target (< or = 1:16) after bortezomib therapy. Therefore, bortezomib could be an alternative therapeutic option for desensitization and treatment of AAMR that is unresponsive to conventional therapies.
Adult ; Boronic Acids/*therapeutic use ; Desensitization, Immunologic/*methods ; Female ; Graft Rejection/*drug therapy/*prevention & control ; HLA Antigens/immunology ; Humans ; Kidney/surgery ; Kidney Transplantation/*methods ; Male ; Middle Aged ; Pyrazines/*therapeutic use ; Treatment Outcome

BACKGROUND/AIMS: Recurrent focal segmental glomerulosclerosis (FSGS) following renal transplantation is relatively common. However, the risk factors and optimal pretransplant treatment preventing recurrence of FSGS remain controversial. METHODS: We retrospectively reviewed 27 adult renal transplant recipients with FSGS over a period of 10 years. We first compared possible risk factors for FSGS recurrence between the recurrence and nonrecurrence groups. Then we evaluated the effect of pretransplant plasmapheresis (PP; n = 4) and PP with rituximab (PP + RTX; n = 5) on recurrence of FSGS after transplantation compared to control patients that were not treated with these modalities. RESULTS: There were seven recurrences in 27 patients (25.9%), but there were no significant differences in possible risk factors for FSGS recurrence between the two groups. Recurrence rates between patients with pretransplant PP or PP + RTX and control patients were not significantly different (22.2% vs. 27.7%, p > 0.05). There was also no significant difference in recurrence between the pretransplant PP and PP + RTX groups (25% vs. 20%, p > 0.05). CONCLUSIONS: Pretransplant PP or PP + RTX do not significantly decrease the recurrence of FSGS in adult renal transplant candidates.
Adult ; Antibodies, Monoclonal, Murine-Derived/*administration & dosage ; Female ; Glomerulosclerosis, Focal Segmental/diagnosis/immunology/*surgery ; Humans ; Immunosuppressive Agents/*administration & dosage ; *Kidney Transplantation/adverse effects ; Male ; Middle Aged ; *Plasmapheresis ; Recurrence ; Retrospective Studies ; Risk Factors ; Treatment Outcome

In a prospective randomized controlled study, the efficacy and safety of a continuous ambulatory peritoneal dialysis (CAPD) technique has been evaluated using one icodextrin-containing and two glucose-containing dialysates a day. Eighty incident CAPD patients were randomized to two groups; GLU group continuously using four glucose-containing dialysates (n=39) and ICO group using one icodextrin-containing and two glucose-containing dialysates (n=41). Variables related to residual renal function (RRF), metabolic and fluid control, dialysis adequacy, and dialysate effluent cancer antigen 125 (CA125) and interleukin 6 (IL-6) levels were measured. The GLU group showed a significant decrease in mean renal urea and creatinine clearance (-Delta1.2+/-2.9 mL/min/1.73 m2, P=0.027) and urine volume (-Delta363.6+/-543.0 mL/day, P=0.001) during 12 months, but the ICO group did not (-Delta0.5+/-2.7 mL/min/1.73 m2, P=0.266; -Delta108.6+/-543.3 mL/day, P=0.246). Peritoneal glucose absorption and dialysate calorie load were significantly lower in the ICO group than the GLU group. The dialysate CA125 and IL-6 levels were significantly higher in the ICO group than the GLU group. Dialysis adequacy, beta2-microglobulin clearance and blood pressure did not differ between the two groups. The CAPD technique using one icodextrin-containing and two glucose-containing dialysates tends to better preserve RRF and is more biocompatible, with similar dialysis adequacy compared to that using four glucose-containing dialysates in incident CAPD patients. [Clincal Trial Registry, ISRCTN23727549]
Adult ; Aged ; CA-125 Antigen/analysis ; Creatinine/urine ; Dialysis Solutions/*therapeutic use ; Female ; Glomerular Filtration Rate ; Glucans/*therapeutic use ; Glucose/*therapeutic use ; Humans ; Interleukin-6/analysis ; Kidney/physiopathology ; Kidney Failure, Chronic/*therapy ; Male ; Membrane Proteins/analysis ; Middle Aged ; Peritoneal Dialysis ; Peritoneal Dialysis, Continuous Ambulatory ; Urea/urine

In a prospective randomized controlled study, the efficacy and safety of a continuous ambulatory peritoneal dialysis (CAPD) technique has been evaluated using one icodextrin-containing and two glucose-containing dialysates a day. Eighty incident CAPD patients were randomized to two groups; GLU group continuously using four glucose-containing dialysates (n=39) and ICO group using one icodextrin-containing and two glucose-containing dialysates (n=41). Variables related to residual renal function (RRF), metabolic and fluid control, dialysis adequacy, and dialysate effluent cancer antigen 125 (CA125) and interleukin 6 (IL-6) levels were measured. The GLU group showed a significant decrease in mean renal urea and creatinine clearance (-Delta1.2+/-2.9 mL/min/1.73 m2, P=0.027) and urine volume (-Delta363.6+/-543.0 mL/day, P=0.001) during 12 months, but the ICO group did not (-Delta0.5+/-2.7 mL/min/1.73 m2, P=0.266; -Delta108.6+/-543.3 mL/day, P=0.246). Peritoneal glucose absorption and dialysate calorie load were significantly lower in the ICO group than the GLU group. The dialysate CA125 and IL-6 levels were significantly higher in the ICO group than the GLU group. Dialysis adequacy, beta2-microglobulin clearance and blood pressure did not differ between the two groups. The CAPD technique using one icodextrin-containing and two glucose-containing dialysates tends to better preserve RRF and is more biocompatible, with similar dialysis adequacy compared to that using four glucose-containing dialysates in incident CAPD patients. [Clincal Trial Registry, ISRCTN23727549]
Adult ; Aged ; CA-125 Antigen/analysis ; Creatinine/urine ; Dialysis Solutions/*therapeutic use ; Female ; Glomerular Filtration Rate ; Glucans/*therapeutic use ; Glucose/*therapeutic use ; Humans ; Interleukin-6/analysis ; Kidney/physiopathology ; Kidney Failure, Chronic/*therapy ; Male ; Membrane Proteins/analysis ; Middle Aged ; Peritoneal Dialysis ; Peritoneal Dialysis, Continuous Ambulatory ; Urea/urine