Optimizing venous anastomosis for forearm loop arteriovenous grafts: A comparative analysis of elbow veins and upper arm basilic veins in end-stage kidney disease patients.

INTRODUCTION: Optimizing vascular access for hemodialysis in end-stage kidney disease is crucial. While arteriovenous fistulas (AVFs) are preferred for better patency and fewer complications, many patients require alternatives options like arteriovenous grafts (AVGs) due to anatomical constraints. This study compares outcomes between elbow and upper arm (UA) basilic veins for forearm loop AVGs, highlighting the potential benefits of the UA basilic vein to improve patency and feasibility in patients with poor elbow veins through retrospective analysis. METHODS: This retrospective study analyzed 59 limbs of patients who underwent forearm loop AVG formation from January 2018 to June 2022. Elbow veins (basilic, median cubital, brachial) and UA basilic veins were evaluated for suitability using duplex ultrasonography. AVG decisions were based on patient age, health, and vein diameter (⩾2.3 mm). Statistical analyses compared baseline characteristics and evaluated primary and secondary patency rates at 12 and 18 months using Pearson's chi-square, Student's t-test, Kaplan-Meier survival analysis, and the Log-rank test. RESULTS: Thirty-six patients had elbow anastomosis, while 23 had UA anastomosis for forearm loop AVG. The elbow group had a higher male proportion (72.7% vs 34.7% in UA, p = 0.005) and larger elbow vein diameters (2.52 ± 0.19 mm vs 2.16 ± 0.21 mm in UA, p < 0.001). Primary patency rates at 12 months were 72.7% for elbow and 56.2% for UA; at 18 months, 59.4% and 25.5%, respectively (p = 0.376). Secondary patency rates at 12 months were 75.7% for elbow and 62.2% for UA; at 18 months, 67.8% and 33.9%, respectively (p = 0.238). CONCLUSION: The primary and secondary patency rates of forearm loop AVG with UA basilic vein anastomosis were not inferior to those with elbow veins anastomosis. UA basilic vein can be a feasible alternative for creating forearm loop AVG when elbow veins are not suitable.

Multicenter, prospective, observational study for urinary exosomal biomarkers of kidney allograft fibrosis.

Severity of deceased donor kidney fibrosis impacts graft survival in deceased-donor kidney transplantation. Our aim was to identify potential miRNA biomarkers in urinary exosomes that mirror interstitial fibrosis and tubular atrophy (IFTA) severity. Among 109 urine samples from deceased donors, 34 displayed no IFTA in the zero-day biopsy (No IFTA group), while the remaining 75 deceased donor kidneys exhibited an IFTA score ≥ 1 (IFTA group). After analyzing previous reports and electronic databases, six miRNAs (miR-19, miR-21, miR-29c, miR-150, miR-200b, and miR-205) were selected as potential IFTA biomarker candidates. MiR-21, miR-29c, miR-150, and miR-205 levels were significantly higher, while miR-19 expression was significantly lower in the IFTA group. MiR-21 (AUC = 0.762; P < 0.001) and miR-29c (AUC = 0.795; P < 0.001) showed good predictive accuracy for IFTA. In the No IFTA group, the eGFR level at 1 week after transplantation was significantly higher compared to the IFTA group (41.34 mL/min/1.73m2 vs. 28.65 mL/min/1.73m2, P = 0.012). These findings signify the potential of urinary exosomal miRNAs as valuable biomarker candidates for evaluating the severity of IFTA in deceased donor kidneys before they undergo recovery.

Nationwide analysis of EVAR explantation outcomes in Korea: A comprehensive dataset study.

OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) is the primary treatment for abdominal aortic aneurysms, constituting 70%-80% of interventions. Despite initial benefits, long-term studies show increased mortality. Using nationwide data, this study assesses outcomes of EVAR, open aortic repair (OAR), and EVAR explantation (EE) in Korea, while exploring characteristics of late open conversion, including the rising EE incidence. METHODS: Employing the National Health Insurance Service database, covering health-related data for nearly 50 million Koreans, the study spanned from 2002 to 2020. Patients with AAA diagnoses (I71.3 or I71.4) were categorized into OAR, EVAR, and EE groups based on procedural codes. Statistical analyses, including t-tests, Fisher's exact tests, Cox proportional hazard models, and multivariate Cox regression, assessed baseline characteristics, mortality risks, and factors within the EE group. RESULTS: The analysis encompassed 26,195 patients, with 66.19% in the EVAR group, 31.87% in the OAR group, and 1.94% in the EE group. EVAR cases steadily increased from 2002 to 2018. Survival rates favored EVAR, followed by OAR and EE. 30-day survival was lower in EE than EVAR. Multivariate analysis for EE revealed no risk factors for 30-days survival but identified age, chronic kidney disease, high Charlson Comorbidity Index scores, and less than 6 months since EVAR as risk factors for overall mortality. CONCLUSION: Rising EE trends with increased EVAR adoption, particularly evident in the Korean dataset, underscore inferior outcomes. This highlights the critical need for strategic initial treatment decisions and timely interventions to enhance overall results and mitigate the unfavorable EE incidence.

Optimal Timing of Serum Creatinine Measurement for KDPI Scoring to Predict Postoperative Renal Function in Deceased Donor Kidney Transplantation.

INTRODUCTION: The widely employed Kidney Donor Profile Index (KDPI) scoring system, designed for assessing deceased donors (DD), plays a pivotal role in predicting graft function post kidney transplantation (KT). Given the dynamic nature of renal function, including serum creatinine (sCr), in managing DDs, it remains uncertain optimal timing to use KDPI for assessing postoperative graft function. METHODS: In this retrospective review, we assessed 246 DDs who were managed within a donor management program from January 2010 to December 2021. We collected sCr values for KDPI scoring at admission, peak, and last measurements before KT. Recipient data included occurrence of slow graft function (SGF), delayed graft function (DGF), and glomerular filtration rate (GFR) at one-year post-transplantation (1 Y). Using Receiver Operating Characteristic (ROC) and Pearson correlation analyses, we explored correlations of KDPI score (admission, peak, last) with graft function (SGF, DGF, GFR 1 Y). RESULTS: The average age of DDs and recipients was 49.78 ± 13.37 and 52.54 ± 10.49 years, respectively, with mean KDPI values at admission, peak, and last measurements of 62.36 ± 25.44, 66.94 ± 24.73, and 63.75 ± 25.80. After transplantation, SGF was observed in 81 recipients (32.9%) and DGF in 32 (13.0%). For SGF, the Area Under the Curve (AUC) from ROC analysis were 0.684 (95% CI, 0.615-0.753; P < .001) at admission, 0.691 (0.623-0.759; P < .001) at peak, and 0.697 (0.630-0.765; P < .001) at the last measurement. In predicting DGF, the corresponding AUC values were 0.746 (0.661-0.831; P < .001) at admission, 0.724 (0.637-0.810; P < .001) at peak, and 0.721 (0.643-0.809; P < .001) at the last. Moreover, KDPI scores at all time points-admission, peak, and last-moderately correlated with GFR 1 Y (R = -0.426, -0.423, -0.417). CONCLUSION: KDPI measurements at all time points, particularly admission, would be more effective in predicting DGF in DDKT.

Transjugular approach in aspiration thrombectomy and angioplasty of a thrombosed straight arteriovenous graft compared to the direct hemodialysis access approach.

PURPOSE: To evaluate the efficacy and outcome of the transjugular approach in endovascular recanalization of a thrombosed straight arteriovenous graft (AVG) compared to those of the direct hemodialysis access approach (conventional approach). MATERIALS AND METHODS: We retrospectively assessed patients who underwent aspiration thrombectomy and percutaneous transluminal angioplasty for thrombosed straight AVG performed at a single institution between October 2006 and October 2021. A total of 138 thrombosed AVGs in 83 patients (39 male and 44 females) were divided into the transjugular approach group (Group A) and the conventional approach group (Group B). Technical and clinical success, postintervention primary patency, cumulative patency, and periprocedural complications were compared. RESULTS: There was no statistical difference in demographic data between groups A and B. The technical success rate of group A and B was 96.4% (80/83) and 98.2% 54/55, respectively (p > 0.05). The mean procedure time was 61.4 min (Group A) and 70.5 min (Group B) (p > 0.05). There was no statistically significant difference between the two groups in postintervention primary patency. The cumulative patency of Groups A and B was 911.9 days (range 122-6277) and 1062.3 days (range 72-2302 days), respectively (p > 0.05). One patient in Group B experienced a major graft rupture. Pseudoaneurysm formation at the sheath insertion site occurred in two patients in Group B. No cases of stenosis or thrombosis of the IJV or hematoma at the puncture site were observed in Group A. CONCLUSION: The transjugular approach is as safe and effective as the conventional approach for aspiration thrombectomy and percutaneous transluminal angioplasty of thrombosed straight AVGs.

Evaluating anti-thymocyte globulin induction doses for better allograft and patient survival in Asian kidney transplant recipients.

Anti-thymocyte globulin (ATG) is currently the most widely prescribed induction regimen for preventing acute rejection after solid organ transplantation. However, the optimal dose of ATG induction regimen in Asian kidney recipients is unclear. Using the Korean Organ Transplantation Registry, we performed a retrospective cohort study of 4579 adult patients who received renal transplantation in South Korea and divided them into three groups according to the induction regimen: basiliximab group (n = 3655), low-dose ATG group (≤ 4.5 mg/kg; n = 467), and high-dose ATG group (> 4.5 mg/kg; n = 457). We applied the Toolkit for Weighting and Analysis of Nonequivalent Groups (TWANG) package to generate high-quality propensity score weights for intergroup comparisons. During four-year follow-ups, the high-dose ATG group had the highest biopsy-proven acute rejection rate (basiliximab 20.8% vs. low-dose ATG 22.4% vs. high-dose ATG 25.6%; P < 0.001). However, the rates of overall graft failure (4.0% vs. 5.0% vs. 2.6%; P < 0.001) and mortality (1.7% vs. 2.8% vs. 1.0%; P < 0.001) were the lowest in the high-dose ATG group. Our results show that high-dose ATG induction (> 4.5 mg/kg) was superior to basiliximab and low-dose ATG induction in terms of graft and patient survival in Asian patients undergoing kidney transplant.

Time-Varying Risk Factors for Incident Fractures in Kidney Transplant Recipients: A Nationwide Cohort Study in South Korea.

Little is known about the time-varying risk factors for fractures in kidney transplant recipients (KTRs). Using the Korea Organ Transplantation Registry, a nationwide cohort study of KTRs, the incidence, locations, and time-varying predictors of fractures were analyzed, including at baseline and post-transplant 6-month variables in KTRs who underwent KT between January 2014 and June 2019. Among 4134 KTRs, with a median follow-up of 2.94 years (12,441.04 person-years), 63 patients developed fractures. The cumulative 5-year incidence was 2.10%. The most frequent locations were leg (25.40%) and foot/ankle (22.22%). In multivariable analysis, older recipient age at baseline (hazard ratio [HR], 1.035; 95% confidence interval [CI], 1.007-1.064; p = 0.013) and higher tacrolimus trough level (HR, 1.112; 95% CI, 1.029-1.202; p = 0.029) were associated with higher risks for fractures. Pretransplant diabetes mellitus had a time-dependent impact on fractures, with increasing risk as time elapses (HR for diabetes mellitus 1.115; 95% CI, 0.439-2.832; HR for diabetes mellitus × time, 1.049; 95% CI, 1.007-1.094; p = 0.022). In conclusion, KTRs had a high risk of peripheral skeletal fractures in the first 5 years. At baseline recipient age, pretransplant diabetes mellitus and tacrolimus trough level after KT were responsible for the fractures in KTRs.

Characteristics from the 100 most influential articles on carotid stenosis.

BACKGROUND: There are three main competing treatment modalities for carotid artery stenosis (CS), i.e., carotid endarterectomy (CEA), carotid artery angioplasty/stenting (CAS), and medical treatment. In this study, we analyzed the performance and trends of CS research through bibliometric analysis. METHODS: We searched the Thomson Reuters Web of Science citation indexing database. The key words used in the search were "carotid artery" and "carotid stenosis". The top 100 most cited manuscripts (T100) were analyzed based on title, author, institution, country of origin, year of publication, and topic. RESULTS: The T100 were published between 1990 and 2016. The Stroke published the most manuscripts (n=22) and the New England Journal of Medicine was the most cited (n=15,113). The United States had the greatest number of publications (n=43), and the University of Oxford was the institution with the most publications (n=7). Peter M. Rothwell was the corresponding author with the most publications (n=10). The main topics were in the following categories: CEA (n=22), medication (n=11), CAS (n=9), diagnosis (n=44), and CEA vs. CAS (n=14). CONCLUSIONS: This bibliometric analysis of CS research provides insight into publication trends and perspective on the treatment of CS.

The most influential articles on kidney transplantation: A PRISMA-compliant bibliometric and visualized analysis.

BACKGROUND: Kidney transplantation (KT) has become common in the treatment of end-stage renal disease. However, to date, there have been no bibliometric analyses of KT research to identify the most influential articles. The purpose of this research is to identify and characterize the 100 most cited articles that focus on KT and to clarify the trends in the accomplishments in this field. METHODS: We searched the Thomson Reuters Web of Science citation indexing database and used keyword mapping of VOSviewer. The top 100 most cited manuscripts were analyzed based on their titles, authors, institutions, countries of origin, years of publication, and topics. RESULTS: The New England Journal of Medicine has published the most manuscripts on kidney transplantation (n = 26) and is the most cited journal (n = 15,642). The United States has the highest number of publications (n = 61). Kashika is the corresponding author with the most published papers (n = 5; 2892 citations). The most common topics of publication are immunosuppressant (n = 34), clinical outcome (n = 26), and pathology (n = 22). Keywords related to immunosuppressant are the most common in keyword mapping with VOSviewer. CONCLUSIONS: This bibliometric analysis of KT research provides the research characteristics and publication trends of this topic. In KT research, immunosuppressants and post-transplant clinical outcomes have been important topics.

Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study.

PURPOSE: Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. METHODS: A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. RESULTS: A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. CONCLUSION: There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.

Eculizumab as rescue therapy in a kidney transplant recipient with atypical hemolytic uremic syndrome: a case report.

A 61-year-old female patient with chronic kidney disease due to diabetes mellitus and hypertension-induced nephropathy received a deceased donor kidney transplant in March 2020. In July 2020, she was transferred from a local hospital due to the exacerbation of general weakness and diarrhea. Upon her arrival, we noticed a high level of serum creatinine (sCr) of 1.5 mg/dL and a decrease in urine output. Her laboratory results indicated significant hemolysis, with a hemoglobin level of 7.0 g/dL, platelet count of 20 ×103/µL, and a lactate dehydrogenase level of 3,207 IU/L. Kidney biopsy showed severe thrombotic microangiopathy without any evidence of acute rejection. Under the impression of atypical hemolytic uremic syndrome (aHUS), we immediately started plasmapheresis and hemodialysis for anuria. Eculizumab was considered as a kidney graft rescue therapy since her sCr level was not effectively decreased, and her anuria continued despite hemodialysis and plasmapheresis. Eculizumab (900 mg) was administered weekly for 4 weeks. An additional 600 mg of eculizumab was administered on the day of plasmapheresis. Since the patient's laboratory data gradually improved, hemodialysis and plasmapheresis were ceased on admission day 37. After that, eculizumab was administered biweekly (1,200 mg) two more times. The patient's sCr and platelet count normalized after 2 months of eculizumab treatment. Based on our experience, a shorter interval between the clinical diagnosis of aHUS and administration of eculizumab increases the likelihood of rescuing the kidney.

Analysis of trauma scoring system for patients with abdominal trauma.

BACKGROUND: This study investigated the correlations between several trauma scoring systems, including the injury severity score (ISS), clinical abdominal scoring system (CASS), new injury severity score (NISS), and clinical outcomes, including laparotomy, in-hospital mortality (IHM), and long hospital stay (LS) in patients with abdominal trauma. METHODS: Data of 749 patients with abdominal trauma between January 2009 and December 2019 were reviewed retrospectively. Data from medical records included age, sex, initial vital signs, type and mechanism of trauma, hospital stay, laparotomy, and IHM. Injured organs and grades were collected using computed tomography. Correlations between the scoring system and clinical outcomes were analyzed using the area under Curves (AUC) of the receiver operating characteristic (ROC) curve. RESULTS: The mean age of the patients was 40.14±19.47 years. Blunt trauma was the most common type of trauma in 704 patients (94.0%), and traffic accident was the most common mechanism in 475 (63.4%). Injured organs included liver (45.1%) and spleen (25.1%). A total of 179 patients (23.9%) underwent laparotomy and IHM was reported in 35 (4.6%). The AUC of ROC for ISS, NISS, and CASS was significantly associated with laparotomy (0.682; p=0.001, 0.713; p=0.001; 0.845; p=0.001). The AUCs showed significant for IHM (0.606; p=0.034, 0.626; p=0.012, 0.701; p=0.001). The AUCs for LS were 0.554 (p=0.041), 0.549 (p=0.062), and 0.581 (p=0.002). CONCLUSION: The CASS is excellent for predicting laparotomy, IHM, and LS in patients with abdominal trauma. The NISS is more appropriate than the ISS for predicting laparotomy and IHM.

Could the Injury Severity Score be a new indicator for surgical treatment in patients with traumatic splenic injury?

Purpose: The purpose of this study was to determine whether a higher Injury Severity Score (ISS) could serve as an indicator of splenectomy in patients with traumatic splenic lacerations. Methods: A total of 256 cases of splenic laceration were collected from January 1, 2005 to December 31, 2018. After the application of exclusion criteria, 105 were eligible for this study. Charts were reviewed for demographic characteristics, initial vital signs upon presentation to the emergency room, Glasgow Coma Scale, computed tomography findings, ISS, and treatment strategies. The cases were then divided into nonsplenectomy and splenectomy groups for analysis. Results: When analyzed with the chi-square test and t-test, splenectomy was associated with a systolic blood pressure lower than 90 mmHg, a Glasgow Coma Scale score lower than 13, active bleeding found on computed tomography, a splenic laceration grade greater than or equal to 4, and an ISS greater than 15 at presentation. However, in multivariate logistic regression analysis, only active bleeding on computed tomography showed a statistically significant relationship (P=0.014). Conclusions: Although ISS failed to show a statistically significant independent relationship with splenectomy, it may still play a supplementary role in traumatic splenic injury management.

Mesenteric and myocardial ischemia revealing lower limb sarcoma.

INTRODUCTION AND IMPORTANCE: Although most of the causes of acute superior mesenteric artery (SMA) embolism with a poor clinical course originate from the heart, we report a case of SMA embolism secondary to advanced sarcoma of the lower extremities. CASE PRESENTATION: A 66-year-old man presented with chest and epigastric discomfort that lasted for 1 day. Coronary angioplasty was performed, followed by laparotomy with an embolectomy of the SMA, small bowel resection, and ileostomy. After surgery, leiomyosarcoma was diagnosed on a biopsy performed in the left thigh, and lung metastasis was confirmed. He had recurrent peritonitis for 2 months and died of multiple organ failure. CLINICAL DISCUSSION: The common etiologies of SMA embolism include cardioembolic sources with atrial fibrillation and recent myocardial infarction. Rare etiologies include atherosclerotic plaque, mural thrombus of the aneurysm, and cardiac sarcoma. CONCLUSION: Efforts are required for the systemic evaluation of various etiologies in patients with SMA embolism who require rapid diagnosis and intervention.

Pulse Pressure Variation is a Valuable Marker for Predicting Fluid Responsiveness in Brain-Dead Donors.

PURPOSE: Hemodynamic management in brain-dead donors (BDDs) is challenging due to hemodynamic instabilities. We compared functional parameters with traditional parameters for hemodynamic monitoring in BDDs. MATERIALS AND METHODS: Seventeen BDDs with a positive balance of >500 mL for 8 hours were included. Functional hemodynamic monitoring, including pulse pressure variation (PPV), stroke volume variation (SVV), cardiac output, and systemic vascular resistance index (SVRI) was performed in the setting of tidal volume of 6 mL/kg to 8 mL/kg and minimal positive end-expiratory pressure of 5 cm to 8 cm H2O. Responders were defined by a cardiac output increase of >15% after fluid therapy. RESULTS: Among the 17 BDDs (mean age, 46.80±13.91 years), 15 were male. Seven responders out of 17 (41.1%) had a significantly higher PPV (22.8±8.4 vs 13.4±5.9%, P = .038) and serum albumin level (3.2±0.6 vs 2.6±0.5 g/L, P = .040) at baseline than nonresponders. However, other hemodynamic markers such as SVV and SVRI were similar between groups. Traditional markers of volume status, such as heart rate, central venous pressure, hemoglobin, and serum uric acid level were also similar between the 2 groups. Hemodynamic markers including PPV, SVV, and SVRI were significantly reduced in responders. CONCLUSIONS: PPV was the most valuable hemodynamic marker for predicting volume responsiveness in BDDs.

Outcomes of kidney transplantation from elderly deceased donors of a Korean registry.

To overcome organ shortage, expanded criteria donors, including elderly deceased donors (DDs), should be considered. We analyzed outcomes of kidney transplantation (KT) from elderly DDs in a nationwide study. In total, data of 1049 KTs from DDs using the database of Korean Organ Transplantation Registry (KOTRY) were retrospectively analyzed based on the age of DDs: age ≥60 years vs. <60 years. Clinical information, graft status, and adverse events were reviewed in DDs and recipients. The mean age of the 1006 DDs was 51.04±10.54 years, and 21.5% of donors were aged ≥60 years. Elderly DDs had a significantly higher prevalence of diabetes and hypertension and higher Kidney Donor Risk Index (KDRI) and Kidney Donor Profile Index (KDPI). The mean age of the recipients was 47.45±14.87 years. Patients who received KT from elderly DDs were significantly older (53.12±15.14 vs. 45.88±14.41, P<0.001) and had a higher rate of diabetes (41.9 vs. 24.4%, P<0.001). Graft outcomes were not significantly different. Renal function was similar between the groups at the time of discharge and at 6 months, 1 year, and 2 years after KT. The rate of delayed graft function (DGF) was not significantly different. Risk factors of DGF were significantly different in DDs aged ≥60 years and <60 years. In the multivariable model, male sex (odds ratio: 3.99, 95% confidence interval: 1.42-11.22; P = 0.009) and KDRI (12.17, 2.23-66.34; P = 0.004) were significant risk factors for DGF in DDs aged ≥60 years. In DDs aged <60 years, thymoglobulin induction (2.62, 1.53-4.48; P<0.001) and continuous renal replacement therapy (3.47, 1.52-7.96; P = 0.003) were significant factors. Our data indicated that graft outcomes, including renal function and DGF, were similar for elderly DDs and DDs aged <60 years. Elderly DDs might be considered tolerable donors for KT, with active preoperative surveillance.

Kidney Donor Risk Index Score Is More Reliable Than Kidney Donor Profile Index in Kidney Transplantation From Elderly Deceased Donors.

BACKGROUND: It is unclear whether both Kidney Donor Profile Index (KDPI) and Kidney Donor Risk Index (KDRI) scores can be applied to elderly deceased donors (DDs). This study aimed to compare the predictive values of KDRI and KDPI for the occurrence of delayed graft function (DGF) in kidney transplantation (KT) from elderly DDs. METHODS: The data for 1049 DD KTs from the database of the Korean Organ Transplant Registry were reviewed retrospectively. RESULTS: The mean age of the 1049 DDs was 50.94 ± 10.57 years. A total of 224 DDs were ≥60 years old (21.35%). The mean KDRI and KDPI were 1.24 ± 0.40 and 63.58 ± 25.16, respectively. Ninety (8.6%) recipients had DGF postoperatively. The right-skewed distributions of KDRI in both elderly and nonelderly DDs were similar. However, the KDPI curve showed a sharp increase from a KDPI score of 60 in DDs aged ≥60 years. The areas under the curve (AUCs) of receiver operator characteristics (ROC) for KDPI and KDRI were different. In DDs aged <60 years, the estimated AUCs of ROC showed significant values for KDPI (0.577, 95% confidence interval, 0.503-0.637; P = .048) and KDRI (0.576, 0.505-0.639; P = .043). However, in DDs aged ≥60 years, KDRI score, not KDPI, was a significant value: KDRI, 0.633 (0.498-0.767; P = .034); KDPI, 0.530 (0.476-0.643; P = .138). CONCLUSION: KDRI was more reliable in predicting graft outcome than KDPI in KT from elderly DDs. A longer follow-up period is needed to assess predictors for postoperative renal functions.

The Management of Retained Rectal Foreign Body.

PURPOSE: Because insertion of a foreign body (FB) into the anus is considered a taboo practice, patients with a retained rectal FB may hesitate to obtain medical care, and attending surgeons may lack experience with removing these FBs. We performed this study to evaluate the clinical characteristics of Korean patients with a retained rectal FB and propose management guideline for such cases based on our experience. METHODS: We retrospectively investigated 14 patients between January 2006 and December 2018. We assessed demographic features, mechanism of FB insertion, clinical course between diagnosis and management, and outcomes. RESULTS: All patients were male (mean age, 43 years) and presented with low abdominal pain (n = 2), anal bleeding (n = 2), or concern about a retained rectal FB without symptoms (n = 10). FB insertion was most commonly associated with sexual gratification or anal eroticism (n = 11, 78.6%). All patients underwent general anesthesia for anal sphincter relaxation with the exception of 2 who underwent FB removal in the emergency department. FBs were retrieved transanally using a clamp (n = 2), myoma screw (n = 1), clamp application following abdominal wall compression (n = 2), or laparotomy followed by rectosigmoid colon milking (n = 2). Colotomy and primary repair were performed in four patients, and Hartmann operation was performed in one patient with fecal peritonitis. No morbidity or mortality was reported. All patients refused postextraction anorectal functional and anatomical evaluation and psychological counseling. CONCLUSION: Retained rectal FB is rare; however, colorectal surgeons should be aware of the various methods that can be used for FB retrieval and the therapeutic algorithm applicable in such cases.

A case of successful late steroid withdrawal after ABO-incompatible kidney transplantation.

Few data exist regarding steroid withdrawal in ABO-incompatible (ABO-i) kidney transplantation (KT). Here, we report a case of steroid withdrawal after ABO-i KT. A 46-year-old man diagnosed with Henoch-Schonlein purpura received ABO-i KT from his 42-year-old sister. The recipient and donor blood types were O and AB, respectively. His preoperative ABO antibody titers were anti-A of 1:16 and anti-B of 1:8 in isoagglutinin test. HLA mismatch was 0 and he received a single 325 mg/m2 dose of intravenous (IV) rituximab 4 weeks before KT. Three sessions of plasma exchange were undertaken before KT and low-dose IV immunoglobulin of 0.1 g/kg was administered after plasma exchange. On the day of the operation, ABO antibody titer decreased to anti-A of 1:4 and anti-B of 1:2. Renal function remained stable after KT. The patient wished to stop steroid treatment despite the risk of rejection after withdrawal. Steroid tapering was initiated at 20 months and accomplished at 26 months after KT. At that time, serum creatinine level was 1.13 mg/dL, and anti-A and anti-B titers were 1:8 and 1:2, respectively. No issues were observed after steroid withdrawal. At 48 months after KT, serum creatinine level was 1.21 mg/dL, and anti-A and anti-B antibody titers were 1:32 and 1:2, respectively. Steroid withdrawal in ABO-i KT might be considered in immunologically low-risk patients.