Multiple myeloma derived from a kidney transplant donor who also developed myeloma after kidney donation.

Patients who undergo kidney transplantation are at increased risk of cancer due to the long-term use of immunosuppressive treatment. Postrenal transplant cancers usually originate from recipient cells, but donor-related cancers have been rarely reported. We report the case of 49-year-old woman who developed multiple myeloma of donor origin 7 years after kidney transplantation. The donor was the mother of the recipient and also developed multiple myeloma 1 year after kidney donation. The diagnosis of multiple myeloma was based on IgG lambda monoclonal protein and the infiltration of plasma cells in bone marrow. The renal biopsy did not reveal plasmacytoma in the transplanted kidney. Epstein-Barr virus DNA load was negative in peripheral blood. The patient responded to lenalidomide and dexamethasone, and subsequently received autologous stem cell transplantation. Donor chimerism was detected in the recipient marrow by short tandem repeat analysis; however, studies of Ig gene rearrangement were inconclusive due to insufficient DNA quality. The chromosomal abnormalities in the two myelomas were different. This case suggests that donor cells with myeloma-initiating potential can be transferred to a recipient via a renal graft and can lead to the development of donor-derived multiple myeloma in the recipient under immunosuppression.

Prevalence and characteristics of hepatitis E virus infection in kidney transplant recipients: A single-center experience in Japan.

BACKGROUND: Hepatitis E virus (HEV) infection can lead to chronic hepatitis in solid organ transplant recipients. To investigate whether HEV infection influences outcomes following kidney transplantation, we examined the prevalence of HEV infection and clinical characteristics of kidney transplant recipients in our hospital. METHODS: Our cross-sectional study included 184 kidney transplant recipients. Blood samples were obtained from all patients to detect anti-HEV immunoglobulin (Ig)A, IgM, and IgG by enzyme-linked immunosorbent assay and HEV RNA by reverse transcription polymerase chain reaction. Clinical data were collected from medical charts for all patients. RESULTS: The prevalence of anti-HEV IgG was 8/184 (4.3%). Anti-HEV IgA, anti-HEV IgM, and HEV RNA were not detected in any patients. Compared to their anti-HEV IgG-negative counterparts, anti-HEV IgG-positive patients were significantly older at the time of transplantation, and they were more likely to receive kidneys from deceased donors. No significant differences in other characteristics such as the prevalence of primary cause of end-stage renal disease, blood transfusion, and immunosuppressive therapy use; liver and renal function; and the frequencies of hepatitis B and hepatitis C virus infection were observed according to the patients' anti-HEV IgG status. CONCLUSION: HEV infection had no significant influence on the outcomes of kidney transplantation at our institution. However, HEV infection should be recognized in kidney transplant recipients similarly as hepatitis B and hepatitis C virus infection in cases of liver dysfunction.

Accelerated recovery from Candida peritonitis of enteric origin by early surgical drainage in a peritoneal dialysis patient.

A 62-year-old man on continuous ambulatory peritoneal dialysis was transferred to our hospital with recurrent abdominal pain and a cloudy peritoneal effluent. Three weeks before the transfer, his symptoms were successfully treated with broad-spectrum antibiotics. However, their effectiveness was lost for his recurrent symptoms. Fungal peritonitis was diagnosed because of an increased white blood cell count in the peritoneal fluid on admission and isolation of Candida albicans from a peritoneal fluid culture. Intravenous fos-fluconazole was immediately started, although it was ineffective for his deteriorating symptoms. The concomitant isolation of Candida albicans in a stool culture suggested that fungal peritonitis had an enteric origin. An emergency laparotomy revealed multiple diverticulosis and sigmoid colon diverticulitis. A surgical drainage was performed in addition to peritoneal catheter removal. Postoperatively, the patient's symptoms improved rapidly and there were no signs of recurrence with continuous administration of fos-fluconazole. Surgical drainage accelerated the recovery from fungal peritonitis. This patient is the first case showing the usefulness of stool culture in the diagnosis of fungal peritonitis secondary to prior bacterial peritonitis. This case also demonstrated the importance of laparotomy to confirm the enteric origin of the fungus, and the efficacy of early surgical drainage for the treatment.

Retroperitoneoscopic hand-assisted live-donor nephrectomy according to the basic principle of transplantation in donor kidney selection.

PURPOSE: We assessed the feasibility of retroperitoneoscopic hand-assisted live-donor nephrectomy according to the basic principle of transplantation in kidney selection, namely, leaving the better-functioning kidney in the donor. PATIENTS AND METHODS: Thirty consecutive live-donor nephrectomies, including 10 right-sided and 20 left-sided procedures, were evaluated. The surgery was started endoscopically using three ports, followed by hand assistance for dissecting the renal pedicles through the extended inner-port incision. A vascular Endostapler and polymer clips were used to transect the renal vessels. RESULTS: Two right-sided cases required open conversion because of multiple renal vessels and uncontrollable bleeding. The median operative time, warm ischemia time (WIT), blood loss, and renal vein length were 244 minutes (upper and lower quartile 215 and 274 minutes), 186 seconds (134, 239 seconds), 175 mL (45, 305 mL), and 22 mm (19, 26 mm), respectively. The operative time and WIT were longer, and the renal vein was shorter, in the right-sided than in the left-sided procedures (P < 0.05), but no difference was found in the other perioperative data for the two sides. No delayed graft function was observed, and the kidney function 1 month postoperatively was acceptable in all donors and all recipients. CONCLUSION: Our technical devices, such as the site and timing of hand assistance and control of the renal vessels, seem feasible. Although we could not draw a conclusion about the safety of the right-sided procedure, this alternative procedure should be applicable for laparoscopic donor nephrectomy uninfluenced by the side of the donor kidney provided the surgical team has sufficient expertise.

Long-term results of living kidney transplantation from HLA-identical sibling donors under calcineurin inhibitor immunosuppression.

BACKGROUND: Recently, it has been revealed that alloantigen-independent causes are important factors for late graft loss in kidney transplantation. We compared the results of living kidney transplantation from HLA-identical siblings with those from HLA-non-identical siblings to analyse the impact of alloantigen-independent factors on long-term graft survival. METHODS: Two hundred and sixty-six recipients who were grafted from their siblings between 1983 and 2002 were subdivided into those transplanted from HLA-identical donors (n=86) and those from HLA-non-identical donors (n=180). RESULTS: The incidence of acute rejection was significantly lower in the HLA-identical group than in the HLA-non-identical group (9.3% vs 53.9%, respectively; P<0.0001). Graft survival was significantly higher in the HLA-identical group than in the HLA-non-identical group (91.3% vs 79.2% at 5 years, 80.3% vs 66.8% at 10 years and 59.1% vs 51.7% at 15 years, respectively; P=0.0372). Although acute rejection was not seen as a cause of graft loss in the HLA-identical group, death with functioning graft, recurrence of the original disease or chronic allograft nephropathy were observed as the major causes of graft loss in the late period of the HLA-identical group. CONCLUSION: We concluded that alloantigen-independent causes constitute a crucial factor for graft loss in the late period of HLA-identical kidney transplantation.

Differences in humoral immunity between a non-rejection group and a rejection group after ABO-incompatible renal transplantation.

BACKGROUND: Renal transplantation across the blood barrier is a unique model for investigating the humoral response to different carbohydrate antigens. However, in such a renal transplantation, the characteristics of B cells as well as of the antibodies produced by B cells are less well defined. METHODS: In the present study we investigated B cell subsets (i.e., the CD5(+) B-1 and CD5- B-2 subsets) by flow cytometric analysis, and their subclasses of antibody, by ELISA, in patients who had undergone renal transplantation across the blood barrier. The subjects consisted of five recipients with good function (group 1) and five recipients with graft loss (group 2) accompanied by antibody-titer elevation after ABO-incompatible renal transplantation. RESULTS: The B-cell population analysis revealed that CD5(+) B-1 cells temporarily increased in all patients in both groups soon after transplantation, and that CD5- B-2 cells significantly increased 1 month after transplantation only in group 2. The antibody subclasses analysis showed mild elevation of immunoglobulin (Ig) G2 and IgM in group 1 as opposed to remarked elevation of IgG2, IgM and IgG1 in group 2. CONCLUSIONS: The results of this study suggested that CD5(+) B-1 cell T-independent activation usually occurs soon after ABO-incompatible renal transplantation, but that CD5- B-2 cell T-dependent activation occurs only in patients who experience graft rejection.

Lack of correlation between results of ABO-incompatible living kidney transplantation and anti-ABO blood type antibody titers under our current immunosuppression.

In this study, we examined the impact of preoperative anti-A/B antibody titers on the results of ABO-incompatible living kidney transplantation (LKT). In all, 167 recipients underwent ABO-incompatible LKT at our institution between 1989 and 2002. These patients were subdivided into those transplanted under cyclosporine with azathioprine or mizoribine (Group 1, n=78) and those transplanted under tacrolimus or mycophenolate mofetil (Group 2, n=89). Overall patient survival at 5 and 10 years was 93.8% and 88.0%, respectively. Overall graft survival at 5 and 10 years was 76.9% and 55.9%, respectively. Graft survival in the patients with anti-A/B IgG titers over 1:128 was significantly lower in group 1, whereas no significant correlation between the anti-A/B IgG titers and graft survival was found in group 2. In conclusion, no correlation between anti-A/B antibody titers and the results of ABO-incompatible LKT was seen after tacrolimus or mycophenolate mofetil application.

A case of acute humoral rejection with various depositions of C4d, IgG, IgM, and C3c in peritubular capillaries and/or glomerular capillaries.

A 41-year-old Japanese male patient with end-stage renal disease received ABO compatible living related kidney transplantation from his sister on April 2003. The kidney functioned immediately after kidney transplantation. Protocol allograft biopsy at 1 yr after kidney transplantation was performed on April 2004. His serological data was not particular and he did not suffer with chronic inflammation. The allograft biopsy specimen revealed moderate accumulations of polymorphonuclear leukocytes in peritubular capillaries (PTCs), dilatation of PTCs and moderate infiltrations of polymorphonuclear and/or mononuclear cell in glomeruli (Transplant glomerulitis, moderate). Immunofluorescent study (IF) of a frozen section of the allograft biopsy specimen showed a strong, diffusely distributed endothelial-staining pattern in PTCs for C4d. The C4d was also strongly detected in a linear glomerular basement membrane (GBM) pattern. And widespread moderate C3c deposits, weak IgM, and IgG deposits were also seen in PTCs. Immunofluorescent study also showed granularly peripheral and mesangial deposits of strong IgM, C1q, and moderate IgG in glomeruli, IgA and C3c were faintly positive. The panel reactive antibody, which had been negative before transplantation, was positive for both HLA classes I and II at that time. We diagnosed as acute humoral rejection (AHR) and he was treated with course of steroid pulses and 5 d of gusperimus (DSG); and a total of three times Plasma exchange (PE) treatment was added. The level of serum creatinine, once increased to 1.7 mg/dL, decreased gradually to 1.4 mg/dL. He has a stable graft function. This is the only case of various depositions of immunoglobulins and complements in PTC and/or glomerular capillaries during AHR.

The mechanism responsible for accommodation after living-related kidney transplantations across the blood barrier.

The mechanism responsible for accommodation in renal transplantations across the blood barrier remains unclear. We recently encountered two patients with accommodated status after living-related kidney transplantations across the blood barrier. Both developed elevations of anti-blood-group antibodies to titers over 128x after transplantation, despite excellent renal function. We investigated the serum samples after the establishment of accommodation bound to the erythrocyte membrane of the donors or the third party with the same blood group. After the establishment of accommodation, the serum samples from both accommodated patients demonstrated a significant decrease in binding to the donors' erythrocyte membrane, but did not show any decrease in binding to the erythrocyte membrane of the third party. By contrast, serum samples from patients with graft loss after unsuccessful accommodation showed high anti-blood-type antibody activity directed towards both the donor's and the third party's erythrocytes. The result of this study suggests the difference of quality in antibodies produced by accommodated and nonaccommodated recipients.

Retroperitoneoscopic live donor nephrectomy (RPLDN): establishment and initial experience of RPLDN at a single center.

We tried to establish the technique of retroperitoneoscopic live donor nephrectomy (RPLDN). Between July 2001 and March 2004, 135 renal transplant donors underwent RPLDN. Low (average: 7 mmHg) CO2 gas pressure was employed during the procedure. All procedures were performed through a three-port retroperitoneal approach without opening the peritoneal cavity. The hand-assisted technique was not used. One hundred and twenty-seven cases were of left and eight cases were of right nephrectomy. Donor nephrectomy was carried out successfully in all patients. In one donor, the procedure was changed to open donor nephrectomy because of severe adhesion around the renal vein due to previous surgery. No serious complications, such as massive bleeding or bowel injury were encountered. Return of bowel function took 0.7 days on average. Post-operative hospital stay was 4.9 days on average, and return to work was 12 days on average. Ureteral complications occurred in 2 patients and were treated with temporally retrograde ureteral stenting. Average serum creatinine levels were 1.5 mg/dL, 1.3 mg/dL and 1.3 mg/dL at 3, 7 and 14 days after transplantation, respectively. No patients required hemodialysis after transplantation due to acute tubular necrosis. RPLDN could be an option for laparoscopic live donor nephrectomy.

Retroperitoneoscopic adrenalectomy: lateral versus posterior approach.

PURPOSE: We used a lateral or posterior approach to perform retroperitoneoscopic adrenalectomy for adrenal tumors and compared the results to determine which approach is more advantageous. PATIENTS AND METHODS: We removed 42 adrenal tumors from 42 patients by retroperitoneoscopic surgery. We used the posterior approach in 17 cases and the lateral approach in 25 cases. We compared the operating time, complications, and surgical advantages for the two approaches. RESULTS: The mean operating time was significantly shorter with the lateral approach, 141 +/- 64 minutes v 225 +/- 88 minutes for the posterior approach (P = 0.0019), which we believe reflects the technical advantages of the lateral approach. Complications included one case of pneumothorax and an instance of pulmonary edema in a patient with chronic renal failure using the lateral approach and one occurrence each of pneumothorax and bleeding using the posterior approach. Retroperitoneoscopic adrenalectomy could not be performed in 1 of 25 cases (4.0%) using the lateral approach and in 3 of 17 cases (17.6%) using the posterior approach. CONCLUSION: Our series suggests that the lateral approach is preferable to the posterior approach for retroperitoneoscopic adrenalectomy.

Transurethral ethanol injection therapy for prostatic hyperplasia: 3-year results.

PURPOSE: We assessed the medium-term (3-year) efficacy of transurethral ethanol injection therapy of the prostate (EIP) for benign prostatic hyperplasia. MATERIALS AND METHODS: A total of 34 patients were followed for a median of 4.3 years after EIP. Mean age was 68.1 years and mean baseline prostate volume was 49.3 ml. With the patient under combined sacral and urethral anesthesia, dehydrated ethanol was injected into the prostate with endoscopic guidance. A urethral catheter was inserted postoperatively. RESULTS: Mean total ethanol dose was 6.4 ml and a catheter was required for a mean of 7.6 days postoperatively. Mean International Prostate Symptom Score was 21.8 points before EIP (in 34 patients), and decreased to 13.1 points after 3 years (in 17, p <0.01). Mean quality of life index decreased from 5.0 points before EIP to 2.8 points after 3 years (p <0.001). Mean peak urine flow rate was 8.3 ml per second before EIP and increased to 12.7 ml per second after 3 years (p <0.01). Mean residual urine volume decreased from 93 ml before EIP to 28 ml after 3 years (p <0.01). Mean prostate volume decreased from 49.3 ml before EIP to 45.7 ml after 1 year (p <0.001), but increased to 51.4 ml after 3 years. No major complications were experienced. By 3 years after surgery 59.0% of patients had not required further treatment. CONCLUSIONS: Transurethral EIP caused minimal complications while maintaining improvement of the prostate symptom score and an increased peak urine flow after 3 years.

Effect of post-transplant double filtration plasmapheresis on recurrent focal and segmental glomerulosclerosis in renal transplant recipients.

In the present study, we reviewed the effect of post-transplant double filtration plasmapheresis (DFPP) on recurrent focal segmental glomerulosclerosis (FSGS) in the transplanted kidney allograft. Sixteen patients with post-transplant recurrent FSGS were enrolled in this study. Out of 16 patients with recurrent FSGS after transplantation, five did not receive DFPP and lost their grafts, while 11 did receive DFPP and four of these patients lost their grafts. Seven patients were able to maintain normal renal function for an average observation period of 57.1 +/- 40.7 months (range 7-125 months). In five patients who had a significant reduction in urinary protein after DFPP, the urinary protein level decreased from 26.60 +/- 23.05 g/day (range 3.34-62.6 g/day) to 2.95 +/- 3.42 g/day (range 0.02-8.64 g/day) and renal function was maintained. The beneficial effects of DFPP on graft outcome were more likely to occur if the patients experienced a marked drop in urinary excretion. Thus, post-transplant DFPP appears to be effective for reducing urinary protein levels and improving long-term graft survival. With the small numbers in this trial, however, none of the findings were statistically significant. We recommend the use of post-transplant DFPP to prevent the progression of recurrent FSGS.

Histological features of renal allograft biopsies in ABO minor-mismatched kidney transplantation.

We examined histological features of allograft biopsies in ABO minor-mismatched kidney transplantation. Forty-five patients who underwent ABO minor-mismatched kidney transplantation between September 1999 and December 2001 at our institute. The mean age was 32.6 years, with 28 males and 17 females. We divided them into five groups based on the donor and recipient ABO blood groups. Group 1, O renal allografts given to A patients (13 patients); Group 2, O to B (9), Group 3, O to AB (2); Group 4, A to AB (9); and Group 5, B to AB (12). From September 1999 to April 2002, we performed 127 allograft biopsies in these 45 ABO minor-mismatched kidney transplant recipients. Among a total of 127 biopsy specimens, 47 specimens were taken as 0- or 1-h biopsies and 6 were protocol biopsies. Pathological analysis of 74 episode biopsy specimens showed: acute humoral rejection (AHR) in 13 (18%); acute cellular rejection (ACR) in 17 (23%); combined AHR and ACR in eight (11%); borderline change in six (8%); chronic rejection in 10 (12%); cyclosporin or tacrolimus nephrotoxicity in seven (10%) and chronic allograft nephropathy in three (4%). In total, some form of acute rejection (AR) was seen histologically in 38 biopsy specimens (48%) from 19 patients (42%). When we investigated AR in two separate categories, i.e. AHR and ACR, AHR was diagnosed in 21 biopsy specimens (26%) from 15 patients (33%) and ACR was seen in 25 biopsy specimens (31%) from 13 patients (29%). We compared the incidence rate of acute rejection in the cases of ABO minor-mismatched renal transplantation with ABO-incompatible and ABO-compatible cases between January 1989 and December 1999. The incidence rate of AR in ABO minor-mismatched cases (42%) was statistically lower than that in ABO-incompatible cases (63%). There was no statistical difference in the incidence rate of AR between ABO minor-mismatched cases and ABO-compatible cases (49%). There was statistical difference in the incidence of AR among the donor and recipient ABO blood groups. Group 4 (A allografts given to AB patients) had the statistically highest rate of AR (89%), followed by Group 1 (54%), Group 5 (33%) and Group 2 (11%), and there was no AR case in Group 3 (O to AB). In conclusion, the incidence rate of AR in ABO minor-mismatched kidney transplantation is statistically lower than ABO-incompatible cases and is not statistically different from that in ABO-compatible cases. The incidence cases of AHR are slightly higher than that of ACR in ABO minor-mismatched kidney transplantation and this finding is similar to findings of ABO incompatible kidney transplantation. Finally, there is a statistical difference in AR incidence among the donor and recipient ABO blood groups.