Thrombotic microangiopathy (TMA) is a serious complication of solid organ transplantation. Drug-induced TMA is typically caused by immunosuppressants, particularly calcineurin inhibitors. Withdrawing the causative drug can be one of the treatments for TMA. However, the more immunosuppressants are reduced, the more risk of rejection increases. Even if TMA is successfully resolved, the outcomes of patient and graft survival would be worse than expected. Therefore, it is necessary to maintain efficient and safe immunosuppression therapy. We report on a case of de novo TMA after kidney transplantation triggered by tacrolimus and reactivated by sirolimus. Belatacept, a novel CTLA4 Ig fusion protein, was administered for maintenance immunosuppressant with mycophenolate mofetil and prednisolon. The patient had excellent early graft outcome, and there have been no adverse events so far.
Abatacept ; Calcineurin ; Graft Survival ; Humans ; Immunosuppression* ; Immunosuppressive Agents ; Kidney Transplantation* ; Kidney* ; Organ Transplantation ; Sirolimus ; Tacrolimus ; Thrombotic Microangiopathies* ; Transplants

Kidney transplantation (KTP) lowers the mortality and morbidity of patients with end-stage renal disease. Post-transplantation infection and antibody mediated rejection (AMR) are the most common complications. Hepatitis B surface antigen (HBsAg) positive carrier donors and high anti A/B antibody titer ABO incompatible KTP could lead to recipient hepatitis B virus (HBV) infection and AMR. Here, we report a case of successful KTP in a 41-year-old male with a high titer of ABO incompatible and HBsAg positive donor. He underwent seven rounds of plasmapheresis, low dose intravenous immunoglobulin and rituximab treatment to inhibit antibody production and remove antibodies from the serum, after which he was administered anti-viral agent for HBV prophylaxis. The recipient maintained successful allograft function for 6 months after transplantation; therefore, we report that desensitization and anti-viral treatment achieved successful outcome in a 1:512 anti A/B antibody titer ABO incompatible and hepatitis B carrier donor KTP.
Adult ; Allografts ; Antibodies ; Antibody Formation ; Hepatitis B Surface Antigens ; Hepatitis B virus ; Hepatitis B* ; Hepatitis* ; Humans ; Immunoglobulins ; Kidney Failure, Chronic ; Kidney Transplantation* ; Kidney* ; Male ; Mortality ; Plasmapheresis ; Rituximab ; Tissue Donors

Transplant renal artery stenosis (TRAS) is an important cause of hypertension, allograft dysfunction, and graft loss. Patient and allograft survival rates are lower in patients with TRAS. Causes of TRAS include acute rejection, cytomegalovirus infection, calcineurin inhibitor toxicity, atherosclerosis of recipient, and/or donor. Technical problems due to surgery are a common cause of early TRAS. A 62-year-old male in end stage renal disease received kidney transplant surgery. There was 5/6 mismatch of human leukocyte antigen and the panel reactive antibody of patient was class I 0% and class II 0%. End to side anastomosis was done between the graft's renal artery and the patient's common iliac artery. His serum creatinine was measured at 6.4 mg/dL before transplantation but his serum creatinine level did not fall below 2.6 mg/dL at 5 days postoperative. His blood pressures was 160/90~180/100 mmHg. There was a significant TRAS (about 80% luminal narrowing) at the arterial anastomosis site on the renal magnetic resonance angiography. We performed percutaneous transluminal angioplasty (PTA) for the stenotic lesion. The balloon angioplasty was done with a 5 mm balloon and low pressure (8 mmHg, nominal pressure was 10 mmHg) at the stenotic lesion. The arterial pressure gradient was 8 mmHg (recipient's common iliac arterial pressure, 147/73 mmHg; poststenotic segmental renal arterial pressure, 139/70 mmHg) just before the balloon angioplasty. After PTA, the arterial pressure gradient became 3 mmHg (recipient's common iliac arterial pressure, 157/66 mmHg; poststenotic segmental renal arterial pressure, 154/65 mmHg). The arterial size and blood flow recovered to within normal range and serum creatinine level was normal after PTA. PTA using low pressure and a small balloon was safe and effective modality in treating early TRAS.
Allografts ; Angioplasty ; Angioplasty, Balloon* ; Arterial Pressure ; Atherosclerosis ; Calcineurin ; Creatinine ; Cytomegalovirus Infections ; Humans ; Hypertension ; Iliac Artery ; Kidney ; Kidney Failure, Chronic ; Kidney Transplantation ; Leukocytes ; Magnetic Resonance Angiography ; Male ; Middle Aged ; Phenobarbital ; Reference Values ; Renal Artery Obstruction* ; Renal Artery* ; Survival Rate ; Tissue Donors ; Transplants

Transplant renal artery stenosis (TRAS) is a common surgical complication after kidney transplantation (KTP) and is the cause of allograft dysfunction. TRAS is a potentially curable cause of refractory hypertension and allograft dysfunction which accounts for approximately 1% to 5% of cases of post-transplant hypertension. Acute cellular rejection (ACR) is also common after KTP, which is the main cause of allograft dysfunction. Although the incidence of ACR has declined with the advent of new immunosuppressive drugs, it is still around 15% worldwide. Although each disease is frequently seen individually, seeing both together is rare. A 42-year-old man with end stage renal disease underwent KTP, and the donor was his younger brother. Four months after KTP, his serum creatinine was increased to 2.1 mg/dL, and renal biopsy showed interstitial lymphocytic infiltration and tubulitis. With the diagnosis of acute T-cell mediated rejection, steroid pulsing therapy was started, but it was resisted. Therefore thymoglobulin 60 mg (1 mg/kg/day) was administered for 6 days, but serum creatinine was 1.8 mg/dL. Abdomen magnetic resonance angiography showed TRAS, stenosis at the anastomosis site and lobar artery in the lower pole. Percutaneous transluminal angiography was performed successfully. After balloon angioplasty, the stenotic lesion showed a normal size and blood flow. The patient's renal function returned to normal levels and he is currently being followed up for 9 months.
Abdomen ; Adult ; Allografts ; Angiography ; Angioplasty, Balloon ; Arteries ; Biopsy ; Constriction, Pathologic ; Creatinine ; Diagnosis ; Humans ; Hypertension ; Incidence ; Kidney Failure, Chronic ; Kidney Transplantation ; Magnetic Resonance Angiography ; Renal Artery Obstruction* ; Renal Artery* ; Siblings ; T-Lymphocytes ; Tissue Donors ; Transplantation*

Tuberous sclerosis complex (TSC) is a neurocutaneous disease characterized by the formation of hamartomas in multiple organs. TSC can show lesions including facial angiofibroma, shagreen patch on the skin, cortical tuber, subependymal nodule, astrocytoma in the brain, cardiac rhabdomyoma, and renal angiomyolipoma. In particular, renal angiomyolipoma may be a cause of end-stage renal disease (ESRD). On the other hand, sirolimus has regulatory effects on cellular growth and proliferation via its inhibitory effect on a protein, mammalian target of rapamycin. We report on a case of an 18-year-old male who underwent renal transplantation due to ESRD induced by TSC. Sirolimus played a role in successful treatment of TSC and effective immunosuppression for transplantation.
Adolescent ; Angiofibroma ; Angiomyolipoma ; Astrocytoma ; Brain ; Hamartoma ; Hand ; Humans ; Immunosuppression ; Kidney Failure, Chronic* ; Kidney Transplantation ; Male ; Rhabdomyoma ; Sirolimus* ; Skin ; Tuberous Sclerosis*

Acute antibody-mediated rejection is the major cause of graft failure in the early stage of kidney transplantation. Preoperative treatment and early diagnosis of acute rejection is very important to prevent graft loss in sensitized patients. High panel reactive antibody (PRA) means a likelihood of acute rejection, and the recipient of high PRA needs adequate pretreatment for kidney transplantation. However, there is not sufficient time and chances for desensitization in deceased kidney transplants. We report a successful renal transplant outcome in a 47-year-old-woman with high PRA levels (Class I 97.5%, Class II 36.7%). The cross match was negative on the CDC (ELISA) and flowcytometric methods. Plasma exchange was performed on the recipient before transplantation (fresh frozen plasma replacement, 1.3 plasma volume) and immediately after plasma exchange she was given 200 mg of rituximab. She received basiliximab and methyl prednisolone induction therapy and was maintained on steroids, mycophenolate mofetil, and tacrolimus. Graft function was normal immediately after transplantation, but decreased urinary output and elevated serum creatinine was noted on POD 5. On POD 6, a graft biopsy revealed acute cellular rejection (Type IIa) and antibody-mediated rejection (Type II). On 9~13 days after transplantation, additional plasma exchange was performed every other day, and steroid pulse therapy was performed 3 times. After normalization of urinary output and serum creatinine, the patient was discharged and is being followed up on. In conclusion, immunologically careful preparation and pretransplant treatment may be needed on the negative cross match in cadaveric kidney recipients with high levels of PRA.
Antibodies, Monoclonal ; Antibodies, Monoclonal, Murine-Derived ; Biopsy ; Cadaver ; Centers for Disease Control and Prevention (U.S.) ; Creatinine ; Early Diagnosis ; Graft Rejection ; Humans ; Immunization ; Kidney ; Kidney Transplantation ; Mycophenolic Acid ; Plasma ; Plasma Exchange ; Prednisolone ; Recombinant Fusion Proteins ; Rejection (Psychology) ; Rituximab ; Steroids ; Tacrolimus ; Tissue Donors ; Transplants

Renal biopsy is an essential diagnostic tool for detecting acute and chronic kidney rejection as well as recurrent and de novo nephropathies in renal allograft recipients. However, a well-known complication of percutaneous renal biopsy is arteriovenous fistula (AVF). Most post-biopsy AVFs are asymptomatic and regress spontaneously but some AVFs result in hypertension, hematuria, and renal insufficiency. Whether post-biopsy AVF superimposed on transplant renal artery stenosis (TRAS) also regresses spontaneously is unknown. We present a case of acute renal insufficiency in a 51-year-old female renal allograft recipient with post-biopsy AVF and TRAS. Percutaneous angioplasty with stent implantation was performed for the TRAS and transcatheter arterial coil embolization therapy applied for AVF. The patient's renal function returned to baseline levels and is currently being followed up for 6 months.
Acute Kidney Injury ; Angioplasty ; Arteriovenous Fistula ; Biopsy ; Female ; Hematuria ; Humans ; Hypertension ; Kidney ; Rejection (Psychology) ; Renal Artery ; Renal Artery Obstruction ; Renal Insufficiency ; Stents ; Transplantation, Homologous ; Transplants

BACKGROUND/AIMS: Heart rate variability (HRV) is a method for evaluation of autonomic nervous system activity by expressing the balance of sympathetic and parasympathetic tones. Some studies of HRV in patients with end-stage renal disease (ESRD) have been performed in Korea. However, few have examined kidney transplantation (KT) patients. Therefore, we investigated autonomic nervous system activity by means of HRV in patients with KT due to ESRD. METHODS: We compared the pattern of cardiac sympathetic and parasympathetic activity by time- and frequency-domain analysis of HRV with 24-h Holter monitoring of 23 KT and 56 dialysis patients. Patients underwent KT between January, 2008 and June, 2011. RESULTS: The mean ages of KT and dialysis patients were 54.2 +/- 12.3 and 53.7 +/- 12.6 years, respectively. The KT group showed increased time- and frequency-domain HRV (including HRV index), very low frequency (VLF), means and standard deviations of all normal R-R intervals for all 5-min segments of the entire recording (SDNNi), low frequency (LF), LF in normalized units (LF norm), and LF to high-frequency power ratio, compared with the dialysis group. CONCLUSIONS: Autonomic tone in patients with KT is higher than that in patients with ESRD on dialysis.
Autonomic Nervous System ; Dialysis ; Electrocardiography ; Electrocardiography, Ambulatory ; Heart ; Heart Rate ; Humans ; Kidney ; Kidney Failure, Chronic ; Kidney Transplantation ; Korea

PURPOSE: Quantification of the dialysis dose is an essential element in the management of hemodialysis. The author investigates the reliability of hemodialysis adequacy measured by ionic dialysance (Online clearance monitoring(R), OCM). Because OCM is a non-invasive and instantly accessible method, it could be replaced Kt/V derived from single-pool variable volume urea kinetic model (UKM). METHODS: Kt/V using UKM and OCM were measured simultaneously in 51 patients who have received hemodialysis therapy via arteriovenous fistula. The analysis of the data collected from 186 hemodialysis sessions were performed. RESULTS: Kt/V of conventional hemodialysis, high efficiency hemodialysis and hemodiafiltration measured by UKM were 1.39+/-0.24, 1.41+/-0.23 and 1.53+/-0.17, and by OCM were 1.24+/-0.17, 1.26+/-0.19 and 1.39+/-0.19, respectively. The data of UKM were significantly higher than those of OCM (p=0.00). Also, there were strong positive correlations between UKM and OCM in hemodialysis (r=0.80, p=0.00), high efficiency hemodialysis (r=0.65, p=0.00) and hemodiafiltration (r=0.67, p=0.00). CONCLUSION: The Kt/V using OCM measured by ionic dialysance provided slightly lower data than that of UKM derived from single-pool variable volume urea kinetic model, but it may be a reliable test to evaluate dialysis adequacy in conventional hemodialysis, high efficiency hemodialysis and hemodiafiltration.
Arteriovenous Fistula ; Dialysis ; Hemodiafiltration ; Humans ; Renal Dialysis ; Urea

Peritonitis is a major cause of morbidity in continuous ambulatory peritoneal dialysis (CAPD) patients. Achromobacter xylosoxidans is a rarely reported cause of peritonitis in CAPD patients. In this report, a peritonitis case due to Achromobacter xylosoxidans in a 60-year-old male patient with end-stage renal failure receiving CAPD for 7 years, has been reported. White blood cell (WBC) count in peritoneal fluid was 3,160/mm3 with 95% neutrophil. Gram staining of the peritoneal fluid yielded gram negative rod. Empirical antibiotic therapy with ceftriaxone was initiated intraperitoneally. But drug sensitivity test revealed these regimens were resistant. On fourth hospital day, Achromobacter xylosoxidans was cultured from peritoneal effluent, the antibiotic regimen was switched to piperacillin/tazobactam intraperitoneally. The patient rapidly recovered and the WBC count of the peritoneal effluent decreased. The therapy was continued for 14 days and then the patient was discharged. The peritoneal catheter was not removed.
Achromobacter ; Achromobacter denitrificans ; Ascitic Fluid ; Catheters ; Ceftriaxone ; Humans ; Kidney Failure, Chronic ; Leukocytes ; Male ; Middle Aged ; Neutrophils ; Peritoneal Dialysis, Continuous Ambulatory ; Peritonitis