The Efficacy of the Affinity Column-mediated Immunoassay Method in Cyclosporine Concentration Assay Compared with the Microparticle Enzyme Immunoassay Method

Purpose: Cyclosporine is a potent immunosuppressive drug used in organ transplantation. Because of its substantial toxic effect, narrow therapeutic index, and the inter-individual variability of pharmacokinetics, therapeutic drug monitoring of the whole blood cyclosporine concentration has been recommended. We have investigated the comparability of the results of two immunoassay systems, the affinity column- mediated immunoassay (ACMIA) and the microparticle enzyme immunoassay (MEIA), and compared the differences in the cyclosporine concentrations between the two methods in relation to the hematologic and biochemical values. Methods: One hundred twenty-one blood samples from kidney recipients were used. We used Dimension(R) RxL HM with a CSA Flex(R) reagent cartilage for the ACMIA method and AXSYM(R) Cyclosporine for the MEIA method. Results: Cyclosporine concentrations measured by the ACMIA method (n=121) were closely correlated with those measured by the MEIA method (r=0.948, P＜0.0001). The Bland-Altman plot using concentration differences between the two methods and the average of the two methods also showed no specific trends (R2=0.02, P=0.125). Except hematocrit, other hematologic and biochemical value (albumin, total bilirubin) didn``t affect to both cyclosporine level by MEIA and ACMIC method. Both cyclosporine levels determined by the MEIA method and the ACMIA method were positively correlated with hematocrit (P＜0.05). Conclusion: The ACMIA method used for a cyclosporine assay is precise and has advantages, including the lack of a required pretreatment procedure, and shows same influence by hematocrit compared with the MEIA.ope

Effects of Inosine Monophosphate Dehydrogenase Inhibition on Platelet-derived Growth Factor- Induced Fibronectin Secretion and Cellular Reactive Oxygen Species in Mouse Mesangial Cells

Purpose: Mesangial cell extracellular matrix (ECM) synthesis plays an important role in various renal diseases. Mycophenolic acid (MPA), which is an inhibitor of inosine monophosphate dehydrogenase (IMPDH), inhibits mesangial cell proliferation and ECM synthesis. However, the exact mechanism of MPA has not been clearly elucidated in mesangial cells. To examine the relative importance of IMPDH on the inhibitory action of MPA, we compared the effects of MPA or IMPDH2 siRNA on platelet-derived growth factor (PDGF)-induced fibronectin secretion and cellular reactive oxygen species (ROS) in mouse mesangial cells (MMC). Methods: MMC were stimulated with PDGF 10 ng/ml with or without MPA 0.1∼10μM, IMPDH2 siRNA 10∼50 nM, or N-acetylcystein (NAC). IMPDH2 siRNA was transiently transfected by lipofectamine for 24 hours. MPA 0.1∼10μM, ribavirin 10∼100μM, and NAC 5 mM were administered 1 hour before the stimulation. Cell viability was measured by methylthiazoletetrazolium (MTT) assay, fibronectin secretion by Western blot analysis, and dichlorofluorescein (DCF)-sensitive cellular ROS by flow cytometry. Results: PDGF 10 ng/ml effectively increased fibronectin secretion and cellular ROS in MMC. MPA and NAC at concentration without affecting basal level of fibronectin and cellular ROS ameliorated PDGF-induced fibronectin secretion and cellular ROS. However, IMPDH2 siRNA only partially reduced PDGF- induced fibronectin secretion and cellular ROS in MMC. Conclusion: These results suggest that MPA may inhibit PDGF-induced fibronectin secretion partly through IMPDH2 or cellular ROS in MMC, and there may be other mechanisms on the inhibitory action of MPA in mesenchymal cells.ope

Pre-transplant Serum Soluble CD30 Level; Correlation with Panel Reactive Antibodies and Lymphocyte Cross Matching

Purpose: Serum level of soluble form CD30 (sCD30), a marker for T helper 2-type cytokine-producing T cells, is used as a marker of immunologic status of pre-transplant recipient that can predict graft rejection and graft survival. This study compared pre-transplant serum sCD30 levels with conventional pre-transplant immunologic parameter, such as panel-reactive antibodies (PRA) and lymphocyte cross matching (LCM). Methods: Adult seventy two patients were enrolled this study. The blood for tests was sampled simultaneously. Measurement of serum sCD30 level was performed using enzyme-linked immunosorbent assay kit (Bender MedSystems, Co. CA, USA). We tested PRA using a commercial ELISA kit (Lambda Cell Tray Lymphocytotoxicity assay)(One Lambda Inc. CA, USA). We established LCM tests for T cells by Modified NIH (National institute center of health)/Johnson`s Method/AHG (Anti human globulin), and for B cells by warm test. Results: Mean score of sCD30 was 90.3±46.4 U/mL, ranged from 12.2 to 244.4 U/mL. There was no significant correlation between patient`s age or sex and sCD30 level. The correlation between sCD30 and mode or duration of dialysis was not statistically 63 significant clinical situation. The result of LCM didn`t show significant correlation with sCD30 level (87.3±55.7 U/mL in LCM positive group versus 91.9±41.3 U/mL in LCM negative group, P=0.696). And sCD30 level equal to or more than 86 U/mL could not predict the positive result of LCM. The positive and negative predictive value of sCD30 to LCM was merely 27.8% and 58.3% (P=0.322). Also the correlation between sCD30 level and PRA was not significant (P=1.0). Conclucion: There was no significant correlation between serum sCD30 level and conventional immunologic parameter such as PRA or LCM. That means the pre-transplant monitoring of the sCD30 level can be used as an independent immunologic parameter.ope

Long-term Change of Renal Function after Donor Nephrectomy for Kidney Transplantation

Purpose: Occurrence of renal failure and its related complications such as hypertension are long-term problems after donor nephrectomy for living donor kidney transplantation. We retrospectively reviewed renal function of unilateral kidney donor. Methods: From 669 living donors for kidney transplantation from December 1998 to October 2006, laboratory data related to renal function are collected from hospital medical record retrospectively in 251 (37.5%) donors who were followed-up after discharge. The selection criteria of donors were: 1) pre-nephrectomy serum creatinine level below 1.5 mg/dL, 2) no radiologic abnormality in bilateral kidney. The donor nephrectomy was performed by conventional open nephrectomy or video assisted minilaparotomy surgery. The estimated glomerular filtration rate (e-GFR) by Modification of Diet in Renal Disease (MDRD) study was used as renal function monitoring parameter. Results: In immediate post-nephrectomy period, e-GFR was decreased to 67.8±14.6% of pre-nephrectomy level (93.8±19.9 mL/min/1.73 m2). The urinary protein excretion for 24 hours was increased to 255% of pre-nephrectomy level (76.4±44.6 mg/day), but cases with proteinuria more than 300 mg per day were only 4 cases (1.7%, 4/251). After 14.0±15.2 months follow-up (range: 1~80 months), two cases (0.8%, 2/251) of renal failure (chronic kidney disease stage 5) were found. Relative renal function (post-nephrectomy e-GFR ratio versus pre-nephrectomy e-GFR, %) was increased by post-nephrectomy duration. The mean scores of e-GFR ratio within post-nephrectomy 2 months, 3~11 months, 12~23 months and after 24 months were 64.8±10.4%, 66.4±9.7%, 69.5±10.9% and 75.8±17.6% respectively. The relative e-GFR ratio after 24 months was significantly different from those of within 24 months (P＜0.0001 by ANOVA). In linear regression analysis, mean increment of e-GFR ratio per post-nephrectomy year was 2.88%. Conclusion: In spite of possibility of renal failure, our study shows the long-term compensation of residual renal function after nephrectomy.ope

Risk Factors of Post-transplantation Diabetes Mellitus in Renal Transplant Recipients

Purpose: The aim of this study was to assess the incidence of post-transplantation diabetes mellitus (PTDM) in renal allograft recipients and investigate the risk factors contributing to the development and progression of PTDM and its underlying pathogenic mechanism(s). Methods: We analyzed the incidence and risk factors of PTDM after renal transplantation, retrospectively. A total of 913 renal transplant recipients with normal glucose tolerance (NGT) were enrolled. The recipient who needs medical treatment of hyperglycemia more than one month was considered as PTDM patient. We classified PTDM as early PTDM (within post-Tx 1 year) and late PTDM. Results: Two hundred seven cases of PTDM were developed (22.7%) out of 913 patients. The cumulative incidence of PTDM was 9.4%, 20.5% and 29.0% at post-transplantation 1-, 5- and 10 year respectively. In uni-variate and multivariate analysis of PTDM onset, elderly recipients, tacrolimus-based immunosuppressive group and hepatitis B virus carrier group showed significantly higher incidence of PTDM. Among 207 cases of PTDM, early and late PTDM were 85 cases and 122 cases respectively. The late PTDM developed persistently after post-transplant 5 years. In risk factor analysis of early and late PTDM, late PTDM showed different results compared to early PTDM. The clinical conditions that cause larger dose or high level of calcineurin inhibitor (CNI), such as double immunosuppressive regimen group, induction immunosuppressive therapy-free group and unrelated donor transplant group, were a significant independent risk factor of late PTDM. Conclusion: Our data showed clinical clues that persistent cumulative CNI exposure was correlated with onset of late PTDM. Careful selection of immunosuppressive regimen in high-risk recipients such as elderly patients and hepatitis B virus carrier may decrease the development of PTDM.ope

마이코 페놀산에 의한 췌도세포주 사멸의 기전

목적: Mycophenolic acid (MPA)는 췌장이식을 포함한 다양한 종류의 장기이식에 사용되는 면역억제제로 inosine monophosphate dehydrogenase (IMPDH)의 선택적이고 비경쟁적인 억제제이나 췌도세포주에서는 세포 사멸을 유도한다고 알려져 있다. 본 연구에서는 인슐린을 분비하는 췌도 세포주인 HIT-T15 세포를 사용하여, MPA가 세포 사멸을 일으키는 기전을 규명하고자 하였다. 방법: 세포주는 American Type Culture Collection에서 구입하였으며 10% fetal bovine serum이 포함된 RPMI-1640을 사용하여 배양하였다. 세포 활성은 methylthiazoletetrazolium (MTT) assay, 세포 사멸은 annexin V와 PI 염색법, mitogen-activated protein kinase (MAPK) 활성화와 caspase-3 분절은 Western blot 분석으로 측정하였다. 결과: MPA 1μM과 10μM을 처리하였을 때 MTT, caspase-3 분절 그리고 annexin V 염색이 24시간에 농도 의존적으로 증가하였으며, 이는 외부에서 함께 투여한 guanosine 500μM에 의하여 부분적으로 회복되었으나 adenosine 500μM 투여에서는 변화가 없었다. 또한 MPA는 extracellular-regulated protein kinase (ERK), p38 MAPK 그리고 c-jun N-terminal protein kinase (JNK)의 활성화를 8시간과 24시간에서 증가시켰고 guanosine 투여는 이를 부분적으로 회복시켰다. ERK의 억제제인 PD98059, p38 MAPK 억제제인 SB203580 그리고 JNK 억제제인 SP600125는 MPA와 함께 처리하였을 때 각 시간에 증가된 MAPK 활성을 감소시켰지만 MTT와 caspase-3 분절을 살펴본 결과 PD98059는 영향이 없었으며 SB203580은 세포사멸을 증가시켰고, SP600125만이 MPA가 일으킨 세포 사멸을 일부 환원시켰다. Pan-caspase 억제제인 Z-VAD-FMK 또한 세포 사멸을 환원시켰다. 결론: MPA는 MAPK 활성을 IMPDH 의존적으로 증가시키지만, ERKl와 p38 MAPK와는 상관없이, JNK 활성화를 통한 caspase-3 증가의 경로로 췌도 세포 사멸을 유도함을 알 수 있었다.ope

The Efficacy of Pre-transplant Radiologic Evaluation for Graft Volume and Anatomy in Living Donor Liver Transplantation

Purpose: For securing donor safety in living donor liver transplantation (LDLT), we must know the anatomy of hepatobiliary and vascular structures as well as donor-recipient hepatic volume profile. The purpose of this study was to ascertain the role of donor-recipient evaluation by using pre-operative radiologic studies. Methods: Prospective pre-operative analyses of 94 LDLT candidate pairs (74 recipients and 94 donors) were performed. Tomographic images were reconstructed by 3-dimensional images and used as a resource of calculation of liver volume profile and anatomic structure evaluation. Results: The percentage of anatomical variation in portal, hepatic vein, hepatic artery and bile duct were 20.2, 41.5, 21.3 and 33.0%, respectively. Among 94 cases, 52 (55.4%) potential donors were unacceptable for LDLT due to a various reasons. The leading cause of unacceptability of donor was anatomical variation (n=24, 25.5%) such as anatomical variation of middle hepatic vein drainage patterns (n=20, 21.3%). Too small residual volume of donor (n=17, 18.1%) and ``small-for-size`` (n=5, 5.3%) were also considered criticalcauses of unacceptable donor. Only 19 out of 94 cases underwent successful 128 living donor right hepatic lobe transplantation. Conclusion: Pre-transplant evaluations of liver volume and anatomic structure by using three-dimensional imaging study and computerized volume measurement system is useful for performing safe LDLT.ope

Feasibility of a Laparoscopic Approach for Generalized Peritonitis from Perforated Appendicitis in Children

PURPOSE: This study evaluated the feasibility of a laparoscopic approach in children with generalized peritonitis secondary to perforated appendicitis. MATERIALS AND METHODS: We retrospectively analyzed the medical records of patients who underwent laparoscopic appendectomy with drainage for generalized peritonitis secondary to perforated appendicitis at our hospital between September 2001 and April 2012. Laparoscopic outcomes were compared with outcomes of an open method for perforated appendicitis. RESULTS: Ninety-nine patients underwent laparoscopic appendectomy (LA) for generalized peritonitis from perforated appendicitis, and 87 patients underwent open appendectomy (OA) for perforated appendicitis. Wound infection was more common in the OA group (12.6%) than in the LA group (4.0%; p=0.032). The incidence of intestinal obstruction during long-term follow-up was significantly higher in the OA group (4.6% vs. 0.0% in the LA group; p=0.046). LA was possible in most patients for whom LA was attempted, with a conversion rate of 10.8%. Conversion to OA was affected by the preoperative duration of symptoms and the occurrence of intraoperative complications. CONCLUSION: LA is feasible for use in children with generalized peritonitis from perforated appendicitis, with reasonable open conversion and perioperative complication rates comparable to those of the OA group.ope

장기이식환자의 이식 후 관리를 위한 국가 데이터베이스 구축

장기등 이식에 관한 법률이 시행된 이후 연간 장기이식 건수는 점차 증가 추세에 있으며 이에 따라서 국내 장기 이식건수의 이식 후 관리에 관한 데이터베이스의 구축은 국내 장기이식의 현황 및 실제 장기이식 후 성적을 파악하기 위한 국가자료로서 기본적으로 시행되어야 하는 과제임에 분명하다. 본 연구에서는 이식 후 관리를 위한 국가 데이터베이스 개발에 필요한 이식관련 자료의 내용, 수집범위 및 수집방법과 이를 이용한 국내 장기이식 보고서의 내용, 양식 및 보고형식을 구체적으로 제시한다. 아울러 이러한 장기이식관련 데이터베이스의 기술적 활용방안을 제시함으로써 장기이식 관련 데이터베이스 개발의 기본골격 및 방향을 제시하고자 한다. 장기이식환자의 이식 후 관리를 위한 국가 데이터베이스는 전국에서 시행되고 있는 모든 장기이식건수에 대하여 이식 전, 장기이식 및 이식 후 정보를 수집함으로써 장기이식에 관한 국가자료 형성을 목적으로 한다. 장기이식에 관한 국가자료에는 장기이식의 현황, 이식정보 및 이식 후 결과를 포함한다. 장기별 데이터베이스의 항목 수는 신장이 102개, 췌장이 87개, 간장이 149개, 심장이 10개 및 폐장이 96개로, ① 이식정보, ② 수여자 정보, ③ 공여자 정보, ④ 면역억제제, ⑤ 이식 후 결과 - 생존율, 이식 후 장기기능정보, 급성거부반응, 합병증, 만성질환 등으로 구분하였다. 데이터베이스의 항목은 기존의 KONOS의 자료를 최대한 활용하면서 발생빈도를 우선적으로 감안하여 선정하되, 국가 데이터 베이스로서 활용도와 학술적인 요구정도를 감안하여 선정하였다. 장기이식 환자의 이식 후 관리를 위한 국가 데이터베이스는 전국단위의 장기이식 현황과 결과를 생성하여, 이식관련 국가자료로 장기이식에 관련된 현황자료, 이식 후 성적자료 및 분석자료을 제공한다. 본 연구과제의 결과물은 장기이식 후 환자 관리를 위한 국가 데이터베이스의 논리적 설계에 해당된다. 데이터베이스의 설계는 장기별 데이터베이스의 항목과 항목당 이름, 내용, 정의, KONOS자료와의 중복여부, 통계분석의 활용도가 규정되어 있다. 국가 데이터베이스의 구축에 있어서 ① 항목의 선정, ② 선정된 항목의 기존 KONOS 자료와의 중복 여부, ③ 항목의 내용 및 정의, ④ 항목의 성격 및 규정, ⑤ 항목의 응용, ⑥ 항목을 이용하여 생성이 가능한 통계의 내용 등을 반영하면 데이터베이스의 물리적 설계가 가능할 것으로 판단된다.ope

Second serial transverse enteroplasty procedure in an infant with extreme short bowel syndrome

The serial transverse enteroplasty (STEP) procedure is a novel technique to lengthen and taper the bowel in patients with short bowel syndrome. The advantages of STEP include not only technical ease and simplicity, but also the ability to repeat the procedure. Herein, we report a case of extreme short bowel syndrome that was successfully treated by the second STEP procedure. A 3-day old newborn girl underwent STEP because of jejunal atresia with the small bowel length of 15 cm, but her bowel elongation was not enough to escape from short bowel syndrome. At the age of 6 months, she underwent a second STEP procedure. The bowel lengthening by the second STEP made her tolerable to enteral feeding with body weight gain and rescued her from short bowel syndrome. This case showed that second STEP is very helpful in treatment of extreme short bowel syndrome.ope