지역별 사회간접자본(SOC) 스톡 추계 연구(II)(Estimation of regional social overhead capital stock)

노트 : 이 연구보고서의 내용은 국토연구원의 자체 연구물로서 정부의 정책이나 견해와는 상관없습니다

사회간접자본(SOC) 스톡 추계 연구(Estimation of social overhead capital stock)

노트 : 이 연구보고서의 내용은 국토연구원의 자체 연구물로서 정부의 정책이나 견해와는 상관없습니다

국내 장기기증 활성화를 위한 방안: Organ Allocation 연구회 보고서

Organ shortage is a serious problem in the field of solid organ transplantation. Increasing number of death on the waiting list, transplant tourism, black market for organ selling are all caused by organ shortage and these eventually causing poor quality of life for patient and family, and may give rise to a serious confusion in domestic transplant system. Since the KONOS launched in the year 2000, some portion of the illegal side of organ supply were corrected but the number of organ donor was hardly to increase. In order to search any solution for this problem, organ allocation study group under the Korean society for organ transplantation was actively worked from August 2008 through February 2009, and got some solution. Among them, amendment of the transplantation law including brain death committee, reporting system of suspected brain dead patients, and set up an independent organ procurement organization system for an effective organ procurement. Organ donation and increasing the number of donor is not a task only for transplant society, but is closely related with quality of life for peoples. This also can change the execution of budget of national medical health insurance. To give a correct understanding about this and activate the nationwide organ donation, the transplant society should have a key role with various medical and nursing society, hospital association, government, national assembly and every voluntary groups.ope

Clinical Application of Mammalian Target of Rapamycin Inhibitor in Kidney Transplantation

Mammalian target of rapamycin inhibitors (mTOR-I)* is a novel immunosuppressive agent that has the variable action mode, such as anti-fibroblastic, anti-tumor and anti-atherosclerotic effect, but doesn`t have a nephrotoxicity. Since March 2006, two types of mTOR-I, sirolimus and everolimus, are clinically available in Korea. In this article, we summarize the pharmacologic characteristics of mTOR-I and review the clinical application of mTOR-I as the component of immunosuppressive regimen after kidney transplantation. Sirolimus and everolimus share the same action mode resulting in an arrest of cell cycle (G1 to S phase arrest). Despite the similarities of chemical structure between sirolimus and everolimus, there are remarkable pharmacokinetic differences between the two molecules. In summary, the half-life and time to reach steady state of everolimus is shorter than those of sirolimus. Therefore, there are significant difference in administration interval and mode. Four types of clinical application of mTOR-I were tried in de Novo renal transplant recipients; (1) for replacement of calcineurin inhibitor (CNI), (2) for replacement of antimetabolites, (3) in combination CNI with low dose mTOR-I versus high dose mTOR-I, (4) standard dose CNI plus low dose mTOR-I versus low dose CNI plus high dose mTOR-I. Generally, mTOR-I shows superior results in graft survival rate, acute rejection free rate and graft renal function (eGFR), but shows inferior results in maintenance rate of regimen and occurrence of side effect (such as proteinuria, wound healing problem and dyslipidemia). Conversion from CNI to mTOR-I was tried in recipients with de Novo post-transplant malignancy or chronic allograft dysfunction. These clinical trial data suggest that mTOR-I may be useful in management of selective type of post-transplant malignancy (such as non-melanoma skin cancer, Kaposi`s sarcoma and post-transplant lymphoproliferative disease) or chronic allograft dysfunction with CNI nephrotoxicity. Clinical application of mTOR-I makes variable combination of immunosuppressive agent possible. Therefore, it is possible to make the selective or tailored immunosuppressive regimen that yields the best outcome with minimal adverse effect.ope

건설산업 지식기반 구축방안 연구(A study on strategies for establishment of knowledge-based construction industry)

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Long-term Effect of Steroid-free Immunosuppressive Protocol in Kidney Transplantation

Purpose: Early experience of steroid-free immunosuppressive protocol for kidney transplant recipient was unsatisfactory due to a remarkable incidence of acute rejection. We also attempted steroid-free protocol in 1990, and experienced painful early result. Therefore, steroid-free protocol have not been tried since 1990. Now, we retrospectively reviewed our experience of steroid-free protocol which was performed in 1990, and verified the long-term effect of steroid-free protocol. Methods: Among 149 recipients who underwent living donor kidney transplantation in 1990, 48 recipients with stable graft function were enrolled in this study. Cyclosporine and steroid were administrated as a maintenance immunosuppressive regimen without induction immunosuppression such as anti-lymphocyte antibodies. Steroid was gradually reduced for 6~8 weeks at 2~3 month after transplantation. If acute rejection or graft dysfunction was developed during tapering period or after cessation, steroid was restarted. And such tapering failure and restart group were defined as steroid-free failure group. We compared the clinical outcomes of steroid-free trial group compared with non-trial (control) group. Results: 17 (35.4%) of 48 recipients failed in steroid-free protocol finally. Acute rejection was the most common cause of steroid-free failure by 11 (64.7%) recipients, and most failure (12 recipients, 70.6%) occurred within 1 year after transplantation. Therefore failure group showed significant inferior graft survival rate than steroid-free group (35.3% versus 80.7%, P=0.001). The overall steroid-free trial group showed similar graft survival rate compared with control group. But the steroid-free group showed superior graft survival rate than control without statistical significance (80.7% versus 60.4%, P=0.383). And also showed lower incidence of post-transplant diabetes, hypertension, hyperlipidemia and bone disease without or with significance. Conclusion: The steroid-free protocol without addition of other immunosuppressive agent causes high incidence of acute rejection and poor graft survival. Hwoever, success group to steroid-free protocol shows beneficial effect in graft survival rate and post-transplant complications.ope

Risk Factors Affecting Long-Term Outcome in Kidney Re-Transplantation Recipients

Purpose: The aims of this study were to review the result of kidney re-transplantation in comparison with first kidney transplantation, and to identify the prognostic factors affecting long-term outcome at a single center. Methods: Between April 1979 and January 2006, the total number of renal allografts was 2,495. Among these, 159 cases received second (155 cases) or third (4 cases) transplantation. Demographic characteristics and clinical outcomes of both groups were compared. And we examined the risk factors affecting long-term outcome in re-transplantation recipients. Results: The mean duration of previous graft survival in re-transplantation group was 86.1±51.4 (0~215) months. Major cause of the previous graft failure was chronic rejection (n=88, 55.3%). One-, 5-, and 10-year graft survivals of the re-transplantation group and the first transplantation group were 94.1%, 88.9%, 76.0% and 96.0%, 84.8%, 69.1%, respectively without significant difference (P=0.2203). In uni-variate survival analysis, acute rejection experienced group, elderly recipient more than 50 years old, and female gender group showed significant inferior graft survival rate compared to control group. Previous graft survival duration didn`t cause significant graft survival difference. Multivariate survival analysis also confirmed that the episodes of acute rejection within 12 months after transplantation (P=0.035, Odd ratio=2.514), elderly recipient more than 50 years old (P=0.002, odd ratio=3.734), and female gender (P=0.005, Odd ratio=3.692) were statistically significant independent risk factors affecting graft survival in kidney re-transplantation. Conclusion: Long-term outcomes after kidney re-transplantation were not different from that of first kidney transplantation. Therefore, renal re-transplantation could be the treatment of choice even in recipients with previous failed renal allograft.ope

T-tube Related Complication in Overseas Liver Transplantation Recipients

Biliary decompression by T-tube in liver transplantation can reduce the stenosis of biliary anastomosis site, but increase the biliary leakage. Therefore, policy of T-tube insertion is different in each transplantation center. Recently the overseas liver transplantations, especially from China, are increasing, and most of these recipients are transferred with T-tube insertion status. Due to limited operative information, T-tube related complications are frequently occurred. We report four cases of T-tube related biliary complication according to the diagnosis timing after T-tube removal, who underwent liver transplantation in China. The symptoms and treatment was variable from conservative management to open laparotomy. The 3 of 4 cases was the bile leakage after T-tube removal. In early diagnosed case after T-tube removal, the bile leakage was easily controlled by non invasive procedures. If the diagnosis was delayed, not only invasive procedures but also open laparotomy was required for control of bile leakage.ope

Clinical Outcome of Renal Transplantation in Patients with Positive Pretransplant Hepatitis B Surface Antigen

Purpose: The natural history of renal transplant recipients with positive HBs Ag is still unclear and unpredictable. Liver-related morbidity and mortality after long-term immunosuppression need clinical challenges. We retrospectively investigated the clinical outcome of pre-transplant HBs Ag positive renal recipients in a single transplant center located in endemic area. Methods: After excluding post-transplant de novo HBV infected, and peri-transplant anti-hepatitis C virus positive recipients, the clinical outcome of 1,816 recipients was examined by the nature of pre-transplant HBs Ag positivity. Results: Pre-transplant HBs Ag positivity was documented in 61 recipients (M/F=47/14). During mean follow up of 71.61±54.14 months, 24 recipients died (6 by infection, 12 by hepatic failure, 2 by hepatocellular carcinoma, 2 by other malignancies, 1 by suicide, 1 by gastrointestinal bleeding). In 14 recipients (58.3%), death was related to liver-associated reasons. The 10-year patient survival rates in HBs Ag negative and positive groups were 90.0% and 62.6%, respectively (P＜0.0001). The 10-year graft survival rates in HBs Ag negative and positive groups were 82.0% and 55.6%, respectively (P＜0.0001). When pre-transplant HBV DNA viral load by PCR was positive or when the level of post-transplant HBV-DNA viral load flared up, we started lamivudine therapy since 1997. Seventeen recipients received daily 100 mg lamivudine. The mean duration of patients survival with (n=17) and without (n=44) lamivudine therapy was 104.3±45.6 and 59.0±51.2 months, respectively (P=0.003). The 10-year patient survival rates in patients with and without lamivudine therapy were 80.7% and 55.4%, respectively (P=0.0698). Conclusion: Overall patient and graft survival in patients with positive pre-transplant HBs Ag was lower than negative recipients. Although, statistically not significant, lamivudine therapy showed a marginally positive impact on the survival of patients with pre-transplant positive HBs Ag.ope