Longterm renal allograft survival after sequential liver-kidney transplantation from a single living donor.

Combined liver-kidney transplantation (CLKT) is well established as a definitive therapy with the potential to provide complete recovery for certain liver-kidney diseases, although the results might be contingent on the cause of transplantation. The purposes of the present study were to review the longterm outcome of renal allografts in CLKT patients from single living donors and to investigate the beneficial factors, compared with solitary renal transplantation. Thirteen patients underwent sequential liver transplantation (LT) and kidney transplantation (KT) from single living donors. The indications for KT were oxaluria (n = 7), autosomal recessive polycystic disease (n = 3), and others (n = 3). The same immunosuppressive regimen used after LT was also used after KT. KT was performed between 1.7 and 47.0 months after the LT. The overall patient survival rate was 92.3% at 10 years. In 12 of the 13 surviving patients, the renal allografts were found to be functioning in 11 patients after a mean follow-up period of 103.6 months. The death-censored renal allograft survival rate at 10 years was 100%, which was better than that of KT alone (84.9%) in Japan. Immunological protection conferred by the preceding liver allograft may have contributed to the longterm outcomes of the renal allografts. In addition, the donation of double organs from a single living and related donor may have a favorable impact on the graft survival rate. In the future, investigations of factors affecting the longterm outcome of renal allografts, including details of the involvement of de novo donor-specific antibody, will be needed. Liver Transplantation 23 315-323 2017 AASLD.

Prevalence and factors associated with lateral epicondylitis among hospital healthcare workers.

Background: Hospital healthcare workers have been reported to have a high prevalence of musculoskeletal disorders, but their association with lateral epicondylitis (LE) is unknown. This study aimed to clarify the prevalence of LE and its associated factors among hospital healthcare workers. Methods: The present study included all staff members of a secondary emergency hospital who provided their consent to participate. Participants with a history of elbow joint trauma were excluded from this study. The diagnostic criteria for definite LE were: (1) pain in the elbow joint within 2 weeks of the study; (2) pain in the lateral epicondyle region on resisted extension of the wrist with the elbow extended; and (3) tenderness in the lateral epicondyle. The diagnosis of LE was defined by meeting all criteria. Age, height, weight, sex, dominant hand, occupation, years of employment, smoking history, drinking history, personal computer usage history, and smartphone usage history were investigated using a questionnaire. A physical examination, in addition to evaluation of pain in the lateral epicondyle, grip strength and wrist extension strength were measured. A statistical analysis was used to assess the prevalence of LE and its associated factors. All investigations, including the diagnosis of LE, were performed by a single orthopedic specialist. Results: We evaluated 544 individuals, corresponding to approximately 80% of all staff members. The median age was 39 years (interquartile range, 30-48). The study population included 154 males and 390 females. The occupations of the participants were as follows: nurses (n = 265), doctors (n = 47), clerks (n = 93), therapists (n = 27), certified care workers (n = 23), medical technologists (n = 22), pharmacists (n = 19), and others (n = 48). LE was diagnosed in 30 limbs/30 individuals with a prevalence of approximately 5.5%. There was no difference in the prevalence of LE among occupations (P = .85). A logistic regression analysis revealed that age (odds ratio, 1.05; 95% confidence interval 1.01-1.1; P = .01) and smoking history (odds ratio, 2.94; 95% confidence interval 1.01-8.56; P = .04) were independently associated with LE. Conclusion: This study was conducted to evaluate the prevalence of LE among hospital healthcare workers. The prevalence of LE was 5.5%, and LE was independently associated with age and smoking history.

Nine-yr experience of 700 hand-assisted laparoscopic donor nephrectomies in Japan.

OBJECTIVE: We reviewed the introduction of a new, minimally invasive, live kidney donation program in our department. METHODS: The operating times of 700 consecutive hand-assisted laparoscopic donor nephrectomies (HALDN) conducted from February 2001 to April 2010 were examined. The risk factors for prolonging operating times were analyzed and major surgical barriers in HALDN investigated. RESULTS: All procedures were successfully performed without the requirement for conversion to open surgery or blood transfusion. The overall prevalence of perioperative complications was 3.0%, with no mortality, in this non-obese donor population with mean body mass index (BMI) as low as 23.2 ± 3.2 kg/m(2) . After the initial learning curve, a second learning plateau was detected until around case 300. Multivariate analyses showed that the significant risk factors were male sex, graft weight, number of renal arteries, right nephrectomy, and previous epigastric surgery (p < 0.05). HALDN provided direct handling of the surgical field, secure vascular control, safe manipulation of adhesive tissues, and served to maintain surgical safety. Mean values of the BMI of donors had a significant positive correlation with the prevalence of complications between large studies (p = 0.042). CONCLUSIONS: Laparoscopic donor nephrectomy was safely introduced and established in a single institution with the help of the hand-assistance method.

Acute kidney injury as defined by the RIFLE criteria is a risk factor for kidney transplant graft failure.

Acute kidney injury (AKI) is not recognized as a major complication at the maintenance phase after kidney transplantation (KTx). Moreover, it is not clear whether the onset of AKI leads to graft failure. We examined the incidence of AKI that developed three months or later after KTx at our institute. We examined whether the incidence of AKI defined by the Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-stage kidney disease criteria associates with graft failure by matched-pair Cox regression analysis. A total of 289 patients were available for the final analysis. The overall incidence of AKI was 20.4%, and the common etiology of AKI was bacterial infectious diseases. The group that developed AKI had significantly lower graft survival than non-AKI group independently of acute rejection. AKI Risk represented a high risk for graft failure and AKI Injury/Failure represented a higher risk for graft failure. The analysis by the AKIN classification yielded the similar results. These results indicate that AKI is a relatively common complication of KTx and represents the major risk for graft failure. We should make every effort in the prevention and early detection to avoid the occurrence of AKI and the subsequent graft failure after KTx.

Kidney transplantation restored uncoupled bone turnover in end-stage renal disease.

BACKGROUND: While kidney transplantation (KTx) reverses many disorders associated with end-stage renal disease (ESRD), patients who have received KTx often have chronic kidney disease and bone and mineral disorder (CKD-MBD). However, it is unknown how bone metabolism changes by KTx. PATIENTS AND METHODS: Living donor-KTx recipients (n = 34) at Tokyo Women's Medical University were prospectively recruited and the levels of bone-specific alkaline phosphatase (BAP) and serum cross-linked N-telopeptides of Type 1 collagen (NTX) were measured before, 6 and 12 months after transplantation. RESULTS: Before KTx, serum BAP was within the reference range in more than half of patients while NTX was high in most patients. Serum NTX was higher in patients with longer dialysis durations compared to that with shorter durations before KTx. However, there was no difference in serum BAP between these patients. After KTx, BAP increased while NTX decreased along with the decline of PTH. In addition, the numbers of patients who showed high BAP and NTX were comparable after KTx. CONCLUSION: These results suggest that bone formation is suppressed and uncoupled with bone resorption in patients with ESRD and this uncoupling is restored by KTx. Further studies are necessary to clarify the mechanism of bone uncoupling in patients with ESRD.

The relative role of fibroblast growth factor 23 and parathyroid hormone in predicting future hypophosphatemia and hypercalcemia after living donor kidney transplantation: a 1-year prospective observational study.

BACKGROUND: Kidney transplantation (KTx) restores many of the disorders accompanying end-stage renal failure. However, hypercalcemia and hypophosphatemia are both common complications after renal transplantation. Prospective observation of these complications has not been well described and pre-transplant predictors also remain unknown. This prospective observational cohort study was carried out to clarify pre-transplant risk factors of persistent hypophosphatemia and/or hypercalcemia at 12 months after transplantation. METHODS: Consecutive living donor KTx recipients (n = 39) at Tokyo Women's Medical University were prospectively recruited. Parameters of bone and mineral metabolism including intact parathyroid hormone (iPTH) and full-length fibroblast growth factor (FGF) 23 were followed. RESULTS: FGF23 decreased to comparable levels for renal function while hyperparathyroidism persisted at 12 months after transplantation. Multivariate linear regression analysis revealed that pre-transplant iPTH correlated with hypercalcemia at 12 months and pre-transplant FGF23 was the best pre-transplant predictor of persistent hypophosphatemia at 12 months. CONCLUSIONS: It is intriguing that although FGF23 is not a causal factor for hypophosphatemia at 12 months post-transplantation, it is a significant predictor of this common complication.

Collagenase Clostridium histolyticum Injection Therapy Improves Health-related Quality of Life in Patients with Dupuytren's Disease.

OBJECTIVES: This study was conducted to investigate the changes in clinical and psychosocial outcomes in patients with Dupuytren's disease after initial treatment with collagenase Clostridium histolyticum (CCH) injection. METHODS: This study involved 14 patients with Dupuytren's disease who underwent treatment with CCH injection. The range of motion of each phalangeal joint was measured before treatment and at 6 months posttreatment. The following assessments were also carried out pre- and posttreatment: the Geriatric Depression Scale Short - Japanese version (GDS-J) to evaluate depressive status, Hand 10 to assess hand health status, and EuroQol-5-dimension-3-level Japanese version to evaluate health-related quality of life. RESULTS: Significant improvements were found in metacarpophalangeal joint extension and proximal interphalangeal joint extension. Significant differences were also found between values before the initiation of CCH injection and those at 6 months posttreatment for the EuroQol index score and the EuroQol Visual Analog Scale (VAS). Significant positive correlations were found between the pre- to posttreatment change in GDS-J scores and for the change in Hand 10 scores. Moreover, a significant negative correlation was found between the change in GDS-J scores and change in EuroQol index scores/EuroQol VAS scores before and at 6 months after CCH injection. CONCLUSIONS: For patients with Dupuytren's disease, CCH therapy directly improved the health-related quality of life. The degree of improvement of depressive status was associated with the degree of improvement of hand health status and health-related quality of life.

Successful Nonoperative Treatment of Osteochondritis Dissecans of the Humeral Capitellum in a Young Baseball Player with Advanced Skeletal Maturity.

BACKGROUND: Osteochondritis dissecans (OCD) of the humeral capitellum presents most typically in adolescent athletes who perform repetitive overhead activities. Earlier studies have demonstrated that conservative treatment of OCD is appropriate for patients with an open capitellar growth plate from the standpoint that spontaneous healing can be expected. CASE: A 12-year-old male baseball player with two years of experience with a local team participated in our medical check that included screening for capitellar OCD using ultrasonography. The subject experienced elbow pain when throwing, and ultrasonographic elbow examination indicated OCD of the capitellum, detected as irregularity of the subchondral bone of the capitellum. The initial radiograph, taken with the elbow at 45° of flexion, identified new bone formation in the lateral aspect of the OCD lesion; however the epiphyseal lines of the capitellum and lateral epicondyle were closed. We advised the patient to stop heavy use of the elbow, e.g., throwing and batting, and started conservative treatment in anticipation of spontaneous healing. Physiotherapy focusing on the shoulder girdle, core, and hip and lower limb stretches were performed to resolve general tightness. The OCD lesion had healed completely 12 months after the start of conservative treatment. DISCUSSION: Conservative treatment for young baseball players might be worth considering if lateral new bone formation within the OCD lesion is detected on radiographic findings, even if the epiphyseal lines of the capitellum and lateral epicondyle are closed.

Risk Factors for Throwing-Related Shoulder and Elbow Pain in Adolescent Baseball Players: A Prospective Study of Physical and Developmental Factors.

BACKGROUND: Throwing-related shoulder and elbow pain continues to be reported among adolescent baseball players. Few prospective studies have specifically examined the association between throwing-related shoulder and elbow pain and physical and developmental changes. PURPOSE: To evaluate the changes in physical and developmental characteristics during 1 year with respect to throwing-related shoulder and elbow pain in adolescent baseball players. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This 1-year prospective follow-up study investigated 164 baseball players aged 7 to 13 years. Player data (age, height, weight, field position, and pitch count), lower extremity muscle tightness, and range of motion (ROM) of the shoulder, elbow, and hip joints were assessed during the 2016 and 2017 preseason medical examinations. After the 2016 season, the participants completed questionnaires related to throwing-related shoulder and elbow pain, defined as an inability to play for ≥1 week because of elbow or shoulder difficulties. For study participants with and without throwing-related shoulder or elbow pain during the 2016 season, we conducted univariate and multivariate logistic regression analysis to identify risk factors for throwing-related shoulder or elbow pain. RESULTS: Overall, 21 players (12.8%) reported a shoulder pain episode, 56 players (34.1%) had an elbow pain episode, and 70 players (42.7%) reported having experienced shoulder and/or elbow pain during the 2016 season. In multivariate logistic regression analysis, (1) shoulder pain was associated with 2016 preseason height (odds ratio [OR], 1.06; 95% CI, 1.01-1.11; P = .01) and change in dominant-side elbow extension ROM from 2016 to 2017 (OR, 1.12; 95% CI, 1.02-1.24; P = .02); (2) elbow pain was associated with change in weight from 2016 to 2017 (OR, 1.21; 95% CI, 1.04-1.41; P = .014); and (3) throwing-related shoulder and/or elbow pain was associated with greater 2016 preseason height (OR, 1.04; 95% CI, 1.003-1.68; P = .03) and an increase in height from 2016 to 2017 (OR, 1.17; 95% CI, 1.01-1.35; P = .03). CONCLUSION: Our results indicated that adolescent baseball players who were taller in the preseason and those with an increase in height over the 1-year study period faced significant risks for developing throwing-related shoulder and/or elbow pain.

Very low but stable glomerular filtration rate after living kidney donation: is the concept of "chronic kidney disease" applicable to kidney donors?

BACKGROUND: Renal prognosis and outcome of Japanese kidney donors, who have lower preoperative glomerular filtration rate (GFR) and are generally older than their counterparts abroad, have scarcely been investigated. Here, the longitudinal changes in renal function of Japanese kidney donors were studied to clarify the prevalence and consequences of low GFR. METHODS: We reviewed charts of the living kidney donors and followed renal function by estimated GFR (eGFR, ml/min/1.73 m(2)) from the time of transplantation (n = 237), until 1 (n = 162) to 3 years after donation (n = 77). RESULTS: Median eGFR at the time of transplant was 78.7. GFR declined by approximately 40% at 1 year after donation, and as a result, most (85%) Japanese kidney donors developed chronic kidney disease (CKD) stage 3, with a median eGFR of only 48.0. The result, that the mean change in eGFR at 1-3 years after donation showed a steady increment of 0.97 ml/min/1.73 m(2) per year, was distinct from the generally accepted notion that GFR declines with age. This upward change was seen irrespective of the absolute values of eGFR at or 1 year after donation, even including a subgroup with the lowest postoperative eGFR of <40. CONCLUSION: Most Japanese donors developed CKD stage 3 after donation but without subsequent progression, at least for several years. Although CKD is in general regarded to confer a significant risk for progressive kidney disease, this notion might not apply to living kidney donors with low GFR but without the risk factors for progression.

Preoperative assessment system for hand-assisted laparoscopic donor nephrectomy by discriminant analysis.

We developed a preoperative assessment system to predict surgical workload in hand-assisted laparoscopic donor nephrectomy (HALDNx) using the normal-based linear discriminant rule (NLDR). A total of 128 cases of left HALDNx performed by a single operator were used as training data. Surgical workload was measured by operative time. The optimized model had 9 explanatory variables: age, total protein, total cholesterol, number of renal arteries (numberRA), 4 variables of perinephric fat (PNF), and thickness of subcutaneous fat. This model was validated using cross-validation and the .632 estimator to estimate discrimination rates with future test data. PNF and numberRA were the predominant factors affecting workload followed by the computed tomography value of PNF, body weight, and male sex. The estimated accuracy of the prediction system was 94.6%. The complication rate was 9.38% and did not correlate with surgical workload. We also made our program available online for constructing assessment functions from other cohort data. In conclusion, the surgical workload of HALDNx could be predicted with PNF and numberRA as the dominant risk factors.

Early Steroid Withdrawal Protocol With Basiliximab and Rituximab in ABO-Incompatible Kidney Transplant Recipients.

OBJECTIVES: Corticosteroids remain an important component of immunosuppressive regimens in high-risk kidney transplants. In this study, we investigated the efficacy of early steroid withdrawal with basiliximab and rituximab in ABO-blood type incompatible (ABO-i) recipients of kidney transplants. METHODS: Between 2008 and 2019, 15 patients underwent ABO-i kidney transplantation. Seven of the 15 patients were treated with a steroid maintenance protocol and the remaining 8 with an early steroid withdrawal protocol. The immunosuppressive protocol consisted of tacrolimus, mycophenolate mofetil, and methylprednisolone (MP), with basiliximab administered as induction therapy. Rituximab was administered as a single 200-mg dose 1 to 4 weeks before kidney transplantation. Two to 4 sessions of either double-filtration plasmapheresis or regular plasmapheresis or both were performed to remove anti-AB antibodies before transplantation. During surgery, MP was administered at a dose of 500 mg; thereafter, the dosage was tapered rapidly, and the drug was discontinued on day 14 post transplant. RESULTS: In the steroid maintenance group, 2 patients experienced acute antibody-mediated rejection (AMR). One patient with severe AMR had graft loss on postoperative day 4. Patient and graft survival rates in the steroid maintenance group were 100% and 86%, respectively. MP was successfully withdrawn in the steroid withdrawal group. In this group, there was no biopsy-proven rejection. Patient and graft survival rates were 100%, and when last measured, serum creatinine level ± SD was 1.6 ± 0.8 mg/dL. CONCLUSIONS: Our protocol successfully enabled the early withdrawal of steroids in recipients of ABO-i grafts; however, further follow-up is necessary to confirm our results.

A Clinical Trial With Adoptive Transfer of Ex Vivo-induced, Donor-specific Immune-regulatory Cells in Kidney Transplantation-A Second Report.

BACKGROUND: Although the outcome of kidney transplantation (KTx) has improved, various adverse effects of immunosuppressants and chronic rejection aggravate the long-term prognosis of patients. Therefore, the induction of immune tolerance may be an effective therapeutic strategy. METHODS: A clinical trial aiming at immune tolerance induction was conducted in kidney transplant recipients from HLA mismatched living donors by infusing autologous donor-specific regulatory T cells (Treg). To obtain Treg, recipient's peripheral blood mononuclear cells were cocultured with irradiated donor cells in the presence of anti-CD80/CD86 monoclonal antibody for 2 weeks. For preconditioning, splenectomy + cyclophosphamide (CP) was employed in the first series (group A; n = 9). In group B, splenectomy was substituted by preadministration of rituximab (group B; n = 3). In the latest cases, rituximab + rabbit antithymocyte globulin was administered instead of cyclophosphamide (group C; n = 4). Twelve days after KTx, the cultured cells were intravenously infused, and immunosuppressants were gradually tapered thereafter. RESULTS: Although mixed lymphocyte reaction was remarkably suppressed in a donor-specific fashion, 6 out of 9 patients from group A, 1 out of 3 from group B, and 1 out of 4 from group C developed acute rejection within 1 year after KTx. Complete cessation of immunosuppression was not achieved, and a small dose of immunosuppressants was continued. CONCLUSIONS: The adoptive transfer of autologous ex vivo-expanded Treg is 1 of the options to possibly induce alloimmune hyporesponsiveness. However, in the present study, further regimen optimization is still required and should be the focus of future investigations.

An experimental model of encapsulating peritoneal sclerosis.

In Japan, only about 3% of all patients with end-stage renal disease are maintained by continuous ambulatory peritoneal dialysis (CAPD). Although the reasons for the low proportion of patients receiving CAPD are multifactorial, encapsulating peritoneal sclerosis (EPS), a fatal complication of CAPD, is a major factor. In 1995 we developed a rat model of EPS, and in 2001 also developed an EPS model in mice. These rodent EPS models are reliable, reproducible, and inexpensive and have been used by other investigators. The renin-angiotensin system negatively regulates the transforming growth factor-beta signaling pathway, which plays a major role in tissue fibrosis. To investigate the anti-EPS effect of renin-angiotensin system inhibition, an angiotensin-converting enzyme inhibitor, quinapril, was administered to an EPS model in mice. Quinapril was found to inhibit EPS, both macro- and microscopically, in a dose-dependent manner. We report our experience of developing the experimental in vivo EPS model, and the inhibitory effect of this angiotensin-converting enzyme inhibitor on EPS.

The oral health of children in a rural area of the Lao People's Democratic Republic.

The lack of information on oral health in Laos makes it difficult to estimate the need and methods for preventing oral disease. This study identified problems concerning the oral health of Lao children. The study subjects were 59 school children who lived in Pakkading District. Dental caries, gingivitis malocclusions, temporomandibular joint (TMJ) disorders, dental plaque, and calculus were examined. We observed an average of 1.6 decayed, missing, and filled teeth (DMFT) and 4.1 decayed and filled deciduous teeth (dft) per child. 25.4% had gingivitis scores from 16 to 20 on the papillary, marginal, and attached (PMA) index; 29.6% had one or more occlusal abnormality; and 0% had signs of TMJ disorders. 93.5% of the children had at least one buccal or lingual tooth surface with plaque covering more than two thirds of the surface; 32.6% had dental calculus. Oral health promotion programs for children should prioritise prevention and treatment of caries. It is likely that the high rate of gingivitis in Lao children is due mainly to unsuccessful plaque control in daily life. In addition to descriptive epidemiological studies of dental diseases in other areas, the influence of sociological and behavioural factors on oral health should be analyzed epidemiologically to promote child health.

Primary Nonfunction on Kidney Transplant Recipients From Donation After Circulatory Death Donors.

BACKGROUND: The need for donor pool expansion remains an important task for kidney transplantation. The aim of this study is the evaluation of primary nonfunction (PNF) from donation after circulatory death (DCD) kidneys. METHODS: Between 1996 and 2017, 100 kidney transplants from DCD donors were conducted in our department. We retrospectively analyzed PNF of kidney transplant recipients from DCD donors in terms of donors' and recipients' epidemiologic characteristics. RESULTS: Of 100 grafts, 95 recipients (95.0%) had discontinued hemodialysis at the time of hospital discharge. Only 5 recipients (5.0%) developed PNF. All 5 PNF recipients received a single graft from an expanded criteria donor (ECD). The mean donor age in the PNF group was 65.0 (SD, 6.2) years. Significant differences between the PNF group and discontinued dialysis group were found for donor age (P < .01) and for the use of ECD kidneys (P < .02). Nevertheless, no significant difference was found between groups for several factors: a history of hypertension and cerebrovascular events, terminal creatinine levels, and graft weight. CONCLUSION: The incidence of PNF from DCD kidneys was very low. Although ECD kidneys in older donors might be a significant risk factor for PNF, these findings suggest that DCD kidneys should be used more frequently for donor expansion.

Trough Level of Mycophenolic Acid Did Not Affect De Novo DSA Development in Kidney Transplantation.

INTRODUCTION: Mycophenolate mofetil has improved long-term outcomes of kidney transplantation. However, the impact of mycophenolic acid (MPA) trough level on the development of de novo donor-specific anti-HLA antibody (DSA) is unclear. We examined the relation between MPA trough level and de novo DSA development. METHOD: We retrospectively studied 617 kidney recipients whose MPA trough level and de novo DSA data were available. All patients underwent primary kidney transplant from living donors from 2008 to 2014, and were chronically treated with a calcineurin inhibitor, mycophenolate mofetil, and +/- steroids. They were equally divided into 4 groups according to the mean trough level of MPA (mMPA) at 1 year post-transplantation: Group 1, mMPA < 2.14 ng/mL (n = 152); Group 2, mMPA 2.14-2.83 ng/mL (n = 157); Group 3, mMPA 2.83-3.57 ng/mL (n = 153); and Group 4, mMPA ≥ 3.57 ng/mL (n = 155). The groups were compared by incidence rate of de novo DSA, graft survival rate, and renal function. RESULTS: The incidence rates of de novo DSA were 33.3% in Group 1, 23.7% in Group 2, 22.9% in Group 3, and 30.3% in Group 4 (P = .158). Although there was no significant difference in graft survival rates, a significant difference of renal functions was noted: the higher the renal function, the lower the MPA trough level. CONCLUSION: The mMPA trough level at 1 year post-transplantation was not statistically associated with the incidence rate of de novo DSA after kidney transplantation.

Single fixed low-dose rituximab as induction therapy suppresses de novo donor-specific anti-HLA antibody production in ABO compatible living kidney transplant recipients.

This study was conducted to evaluate de novo donor-specific anti-human leukocyte antigen (HLA) antibody (dnDSA) production leading to antibody-mediated rejection (ABMR) after rituximab induction in non-sensitized ABO-compatible living kidney transplantation (ABO-CLKTx). During 2008-2015, 318 ABO-CLKTx were performed at the Department of Surgery III at Tokyo Women's Medical University Hospital. To reduce confounding factors, we adopted a propensity score analysis, which was applied with adjustment for age, gender, duration of pretransplant dialysis, HLA mismatch count, preformed DSA, non-insulin-dependent diabetes mellitus, immunosuppressive treatment, and estimated glomerular filtration rate (eGFR) on postoperative day 7. Using a propensity score matching model (1:1, 115 pairs), we analyzed the long-term outcomes of 230 ABO-CLKTx recipients retrospectively. Recipients were classified into a rituximab-treated (RTX-KTx, N = 115) group and a control group not treated with rituximab (C-KTx, N = 115). During five years, adverse events, survival rates for grafts and patients, and incidence of biopsy-proven acute rejection (BPAR) and dnDSA production for the two groups were monitored and compared. All recipients in the RTX-KTx group received rituximab induction on preoperative day 4 at a single fixed low dose of 100 mg; the CD19+ B cells were eliminated completely before surgery. Of those recipients, 13 (11.3%) developed BPAR; 1 (0.8%) experienced graft loss. By contrast, of C-KTx group recipients, 25 (21.7%) developed BPAR; 3 (2.6%) experienced graft loss. The RTX-KTx group exhibited a significantly lower incidence of BPAR (P = .041) and dnDSA production (13.9% in the RTX-KTx group vs. 26.9% in the C-RTx group, P = .005). Furthermore, lower incidence of CMV infection was detected in the RTX-KTx group than in the C-KTx group (13.9% in the RTX-KTx group vs. 27.0% in the C-KTx group, P = .014). No significant difference was found between groups for several other factors: renal function (P = .384), graft and patient survival (P = .458 and P = .119, respectively), and the respective incidences of BK virus infection (P = .722) and leukopenia (P = .207). During five-year follow-up, single fixed low-dose rituximab therapy is sufficient for ensuring safety, reducing rejection, and suppressing dnDSA production for immunological low-risk non-sensitized ABO-CLKTx.

Analysis of the full-length genome of hepatitis B virus in the serum and cerebrospinal fluid of a patient with acute hepatitis B and transverse myelitis.

Although many extrahepatic manifestations have been described in patients with acute or chronic hepatitis B, there are few reports about neurological disorders. We describe a 55-year-old man who contracted acute hepatitis B virus (HBV) infection and transverse myelitis. His neurological findings were gradually reduced along with the recovery from hepatitis. The cerebrospinal fluid (CSF) was revealed to be positive for HBsAg and HBV DNA. Full-length sequences of HBV in his serum and CSF were determined, and it was revealed that these two isolates had mutations at nucleotide (nt) 1762/1764 in the core promoter region and nt 1896 in the precore region. They were identical to each other except for two ambiguous codes at nt 2020 and 2631 in the CSF isolate. After cloning of the amplicons, substitutions at nt 2020 and 2631 were found in 6 (38%) of the 16 CSF clones. One clone of the 6 CSF clones had an additional substitution at nt 2119. These substitutions were not found in 16 serum clones. The presence of HBV clones unique to CSF suggests that HBV was a possible causative agent of the myelitis.

Preoperative Low-Density Lipoprotein Apheresis for Preventing Recurrence of Focal Segmental Glomerulosclerosis after Kidney Transplantation.

BACKGROUND: Focal segmental glomerulosclerosis (FSGS) often develops rapidly and frequently progresses to renal failure, while the recurrence rate after kidney transplantation is 20-50%. We performed low-density lipoprotein (LDL) apheresis before kidney transplantation in FSGS patients to prevent recurrence. METHODS: Five adult patients with chronic renal failure due to FSGS undergoing living related donor kidney transplantation were investigated retrospectively. LDL apheresis was done 1-2 times before transplantation. Postoperative renal function and recurrence of FSGS were assessed. RESULTS: The patients were two men and three women aged 24 to 41 years. The observation period ranged from 60 days to 22 months. Preoperative LDL apheresis was performed once in one patient and twice in four patients. Blood LDL cholesterol levels were normal before LDL apheresis and remained normal both after LDL apheresis and after kidney transplantation. Additional LDL apheresis was performed once in one patient with mild proteinuria after transplantation. The renal graft survived in all patients and there was no evidence of recurrent FSGS. CONCLUSIONS: Although the observation period was short, FSGS did not recur in all 5 patients receiving preoperative LDL apheresis. These results suggest that LDL apheresis can be effective in preventing recurrence of FSGS after kidney transplantation.