Impact of Model for End-Stage Liver Disease Score Based Allocation System in Korea

( Juhan Lee ),( Deok Gie Kim ),( Jee Youn Lee ),( Jae Geun Lee ),( Dong Jin Joo ),( Soon Il Kim ),( Myoung Soo Kim ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: In June of 2016, the Korean Network for Organ Sharing implemented model for end-stage liver disease (MELD) score based allocation system to better prioritize deceased donor liver transplant (DDLT) candidates. The aim of this study was to assess the impact of MELD based allocation system. Methods: We compared waitlist and post-transplant outcomes in the first 4 months of MELD allocation system (from June to September, 2016) to an equivalent time period before (from February to May, 2016). Results: A total of 1114 candidates were listed (510 pre-MELD, 604 post-MELD) and 340 patients (156 pre-MELD, 184 post-MELD) received DDLT during the study period. As expected, introduction of MELD allocation system increased mean MELD score at transplant (24.6 ± 8.6 pre-MELD, 35.0 ± 6.1 post-MELD, P<0.001). Although overall transplant rates remained similar between pre-MELD and MELD era, the transplant rate significantly increased for candidates with high MELD score (MELD ≥31) in MELD era. The proportion of inter- regional shift increased from 28.8% to 44.0%. Post-transplant patient survival rate was 85.6% before and 83.1% after MELD implementation (P=0.537). There was no significant correlation between MELD scores at transplant and post-transplant survival. Significant transplant survival benefit was observed at MELD scores of ≥20 compared to candidates on the waitlist, and the magnitude of transplant benefit increased with increasing MELD score. Conclusions: The MELD system addresses the goal of fairness well. The implementation of the MELD system was associated with reduction in geographic disparities. Although sicker patients received liver transplantation in the MELD era, post-transplant survival was similar in both periods.

Renal Function Difference between Anti-hepatitis B Immunoglobulin( HBIG) Monotherapy and HBIG Combined with Entecavir

( Jae Geun Lee ),( Juhan Lee ),( Jung Jun Lee ),( Seung Hwan Song ),( Jee Youn Lee ),( Su-kyung Kwon ),( Myoung Soo Kim ),( Man Ki Ju ),( Gi Hong Choi ),( Sub Choi ),( Soon Il Kim ),( Dong Jin Joo ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: To reduce the HBV reinfection after liver transplantation, anti- hepatitis B immunoglobulin (HBIG) alone or combination with antiviral nucleotide analogues are usually used regimen. However, antiviral nucleotide analogues have nephrotoxicity, which is a critical issue because renal dysfunction frequently happens after liver transplantation. Methods: Medical records of 171 liver recipients with HBV who underwent liver transplantation between Sep. 2005 and Dec. 2012 were retrospectively reviewed. The difference of renal function of HBIG mono-therapy group (HBIG) and HBIG combined with Entecavir group (HBIG+ETV) were analyzed. Results: There was no significant difference in age, gender, body mass index, intraoperative blood loss, and MELD score between the two groups. But the patients who had preoperative ascites, mean preoperative AST level, preoperative GFR level, and the applying event of CRRT was significantly different between the groups. The decrease of eGFR between preoperative and 1 year after transplantation was 31.5±27.2 mL/min/1.73m2 (p<0.001), in HBIG group and 40.0±45.9 mL/min/1.73m2 (p<0.001) in HBIG+ETV group. Also, the eGFR decrease between preoperative and 4-year after transplantation was 24.5±29.9 mL/min/1.73m2 (p<0.001) in HBIG group and 38.9±56.8 mL/min/1.73m2 (p<0.001) in HBIG+ETV group. Conclusions: There was no difference of recurrence rate of HBV. However, HBIG+ETV combination regimen showed more declination of eGFR in long-term period after liver transplantation than HBIG alone.

Outcomes of Living and Deceased Donor Liver Transplant Recipients according to the MELD Score

( Jae Geun Lee ),( Juhan Lee ),( Jung Jun Lee ),( Seung Hwan Song ),( Jee Youn Lee ),( Su-kyung Kwon ),( Dong Jin Joo ),( Man Ki Ju ),( Gi Hong Choi ),( Jin Sub Choi ),( Soon Il Kim ),( Myoung Soo Kim 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Living donor liver transplantation (LDLT) has developed as an alternative to decease donor liver transplantation (DDLT) to overcome the critical shortage of deceased organ donations. However, the evidence supporting a LDLT for high model for end stage liver disease (MELD) score recipient is weak. We compared the outcomes of LDLT and DDLT according to MELD scores. Methods: The study included 498 adult patients who underwent liver transplantation between 2006 and 2014 at Severance Hospital. Patients with re-transplantation and fulminant liver failure were excluded from the study. Recipients were categorized according to their MELD score into low (MELD score ≤25) and high (MELD score >25) MELD group. Results: About 76.5% of patients are male and median age is 53. Major origin of liver cirrhosis is Hepatitis B virus and 50% of patients had HCC. There were no significant difference gender, donor gender, age, HBV, HCV, HCC and DM. However, age of donor, CTP score and MELD score in DDLT were significantly higher than LDLT. In both LDLT and DDLT groups, patients with high meld score show significantly lower graft survival than patients with low MELD score. (p =0.019 in LDLT and p=0.009 in DDLT) However, in both high and low meld group, there were no significant difference of survival between LDLT and DDLT. Non-HBV, HCC, High MED are risk factor for graft mortality in overall patients. However, HCV and high MELD are risk factor in patients without HCC. Conclusions: High MELD score is risk factor for Graft mortality in liver recipients regardless combined HCC. There was no significant difference between LDLT and DDLT, in patients with both high MELD and low MELD. When deceased donor organs are scare, LDLT with donor safety maybe good therapeutic option in patient with high MELD score.

Complications and outcomes following inguinal lymphadenectomy for malignant melanoma in an Asian population

In A Lee,Hyun Jeong Kim,Eunjin Kim,Jee Youn Lee,Juhan Lee,Jae Geun Lee,Choong-kun Lee,Sang Joon Shin,Kee Yang Chung,Myoung Soo Kim 대한종양외과학회 2020 Korean Journal of Clinical Oncology Vol.16 No.2

Purpose: Melanoma is a potentially fatal cutaneous malignancy and regional lymph node (LN) metastases are the most important predictors of mortality. This study aimed to analyze clinical features and risk factors of complications associated with inguinal LN dissection (LND) to establish treatment protocols. Methods: This single-center retrospective study (2000 to 2018) consisted of patients who underwent inguinal area sentinel LN biopsy (SLNB) or LND due to malignant melanoma. Risk factors and outcomes were analyzed. Results: One hundred patients underwent SLNB alone (n=67; patients with negative SLNB), complete LND (CLND) after positive SLNB (n=19), or radical LND without SLNB (n=14). Five-year overall survival and disease-free survival rates among these groups were 87.3%, 57.4%, and 61.9%, and 59.0%, 22.7%, and 28.1%, respectively. The complication rate in the SLNB alone group was lower than the other groups (22.4% vs. 47.4% and 35.7%, respectively; P=0.048). Seroma was the most common complication in the SLNB alone group (15.0%); lymphedema was most common in the CLND after SLNB group (21.1%). Multivariate analysis of risk factors for postoperative complications found the hazard ratio for body mass index >28 kg/m² was 4.376 (95% confidence interval [CI], 1.243–15.401; P=0.022). The hazard ratio for LND (including CLND after SLNB and radical LND without SLNB) was 3.263 (95% CI, 1.248–8.529; P=0.016). Conclusion: Inguinal LND is a higher risk procedure compared to SLNB and other sites for postoperative complications, irrespective of meticulous surgical techniques. More studies are needed to establish treatment protocols (e.g., observation vs. CLND after a positive SLNB result) and the risks and benefits in Asian populations.

Measurement of Stiffness and Fatty Change of Graft by Transient Elastography after Living Donor Liver Transplantation

Jae Geun Lee,Su Hyung Lee,Jung Jun Lee,Juhan Lee,Sung Hoon Kim,Man Ki Ju,Gi Hong Choi,Myoung Soo Kim,Jin Sub Choi,Soon Il Kim,Dong Jin Joo 한국간담췌외과학회 2014 한국간담췌외과학회 학술대회지 Vol.2014 No.4

Laparoscopic Total Gastrectomy in a Gastric Cancer Patient with Intestinal Malrotation

Lee, Juhan,Lim, Joon Seok,Cho, In,Kwon, In Gyu,Choi, Yoon Young,Noh, Sung Hoon,Hyung, Woo Jin The Korean Gastric Cancer Association 2013 Journal of gastric cancer Vol.13 No.3

As the incidence of early gastric cancer increases, laparoscopic surgery has become one of the treatments of choice for gastric cancer. With the increase of laparoscopic surgery, the chance of discovering aberrant anatomy during the operation also increases. We present a case of laparoscopic total gastrectomy in gastric cancer patients with intestinal malrotation. Intestinal malrotation occurs in one in every 500 births. We found that laparoscopic total gastrectomy in such patients can be performed successfully when it is performed with a proper Roux limb orientation through an alternative minilaparotomy.

The Effect of Tacrolimus Intrapatient Variability on the Transplant Outcomes in Liver Transplantation

( Juhan Lee ),( Yoon Bin Jung ),( Deok Gie Kim ),( Dong Jin Joo ),( Myoung Soo Kim ),( Soon Il Kim ),( Jae Geun Lee ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Tacrolimus (TAC) is the mainstay of immunosuppression for liver transplantation. Although more than 20 years has passed since the introduction of TAC, its narrow therapeutic window and high intra-patient variability (IPV) remains a challenge in the management of transplant patients. We aimed to assess the impact of TAC IPV on graft outcomes and acute rejection after liver transplantation. Methods: We analyzed patients underwent adult liver transplantation between 2010 and 2016 and treated with TAC-based immunosuppressant. We excluded patients treated with mTOR inhibitors during the follow-up. TAC IPVs were calculated from the TAC concentrations between 1 and 12 months after transplantation. Patients were categorized as low (lowest quintile), normal (three middle quintiles), and high (highest quintile) IPV. Results: A total of 339 patients with a mean TAC concentration of 7.6 ± 1.6 ng/mL were included (68 low IPV, 203 normal IPV, and 68 high IPV groups). Mean TAC concentration was not different among three groups (P=0.35). During the 54 months of median follow-up, 43 patients (12.7%) reached the primary end point of graft failure. After adjusting for other risk factors, high IPV remained a significant risk factor for graft failure (HR, 3.89; 95% CI, 1.43-10.61; P=0.003). A total of 19 patients (5.6%) experienced biopsy proven acute rejection 1 month after liver transplantation. There was no difference among IPV groups with respect to the incidence of acute rejection (P=0.73). Conclusions: While acute rejection rates were similar among IPV groups, high TAC IPV is an independent risk factor for graft loss after liver transplantation.

Impact of leaf area index from various sources on estimating gross primary production in temperate forests using the JULES land surface model

Lee, HoonTaek,Park, Juhan,Cho, Sungsik,Lee, Minsu,Kim, Hyun Seok Elsevier 2019 Agricultural and forest meteorology Vol.276 No.-

<P><B>Abstract</B></P> <P>The effects of various types of leaf area index (LAI) on simulations of stand scale gross primary production (GPP) in evergreen needleleaf (TCK) and deciduous broadleaf (TBK) temperate forests were analyzed using the Joint UK Land Environment Simulator (JULES) land surface model (LSM). LAI was observed during the period from 2015 to 2017 with an LAI-2200 plant canopy analyzer. Other LAIs included the enhanced vegetation index (EVI) of two satellites with different temporal and spatial resolutions (Landsat and MODIS), the LAI product of MODIS, and the JULES phenology model. These LAIs were compared with in situ observations of LAI, and their effects on GPP simulation were compared with simulated GPP using in situ observed LAI (GPP<SUB>obs</SUB>). Our results show that the JULES phenology model does not adequately express the LAI of either TCK or TBK forests. This misrepresentation was improved through simple modifications. LAI data from a remote-sensing EVI corresponded relatively well with the observations, whereas the MODIS LAI product, with a relatively low spatial resolution (500 m), could not discern the complex heterogeneity of a temperate forest and provided a 31% higher maximum value. Compared with GPP<SUB>obs</SUB>, the difference in annual GPP was smaller than in LAI, ranging from −3.48% to 6.0% in TCK and −6.52% to 10.9% in TBK. The differences in seasonal GPP estimates were up to 14.6% in spring for TCK and −17.4% in autumn for TBK. Our study identified limitations of the JULES leaf phenology model, and suggested modifications to reduce the differences in GPP estimation for temperate forests at the stand scale. In addition, we suggested using sufficiently high spatial resolution data, especially for LAI, as inadequately represented forest cover types resulted in seasonal GPP discrepancies.</P> <P><B>Highlights</B></P> <P> <UL> <LI> The effect of various LAIs on GPP simulation by JULES LSM were investigated. </LI> <LI> Satellite-based LAIs were better than phenology model based LAI. </LI> <LI> MODIS LAI (500 m) misrepresented forest cover type. </LI> <LI> Incorrect LAI resulted in seasonal error rather than yearly GPP. </LI> </UL> </P>

Duodenum-preserving pancreatic head resection in benign and low-grade malignant pancreatic tumors

Juhan Lee,Jin Hong Lim,Sung Hoon Kim,Hyun Ki Kim,Seung Woo Park,Jae Bock Chung,Kyung Sik Kim 한국간담췌외과학회 2013 한국간담췌외과학회지 Vol.17 No.3

Backgrounds/Aims: With development of imaging techniques, pancreatic tumors are being diagnosed more frequently. Applying the standard surgical procedures for pancreatic head tumors, such as pancreaticoduodenectomy and pylorus- preserving pancreaticoduodenectomy may seem too extensive for benign or low-grade malignant pancreas head tumors. Duodenum-preserving pancreatic head resection (DPPHR) has been safely performed in patients with chronic pancreatitis. Recently, DPPHR has been used as a limited surgical procedure to remove benign or low-grade malignant pancreatic head lesions. This study is aimed to evaluate the results of DPPHR in benign or low-grade malignant tumors. Methods: Between 2004 and 2012, six patients underwent DPPHR due to benign or low-grade malignant pancreas tumor. We performed this retrospective analysis based on the medical records. Results: Five of six patients were diagnosed as intraductal papillary mucinous neoplasms. Remaining one patient was diagnosed as solid pseudopapillary neoplasm. The median age of patients was 60.3 (27-75) years, and the median follow-up period was 24 months. The operation time, blood loss and length of stay were 442.5 minutes, 680 ml and 19.2 days, respectively. There was no mortality. Five patients experienced complications including 1 delayed gastric empting, 2 bile duct strictures, 1 pancreatic fistula and 1 duodenal stricture. No recurrence or metastasis was found during follow-up. Conclusions: In benign and low-grade malignant lesions of pancreatic head, DPPHR could be alternative to traditional surgery. For applying DPPHR in pancreas tumor, a thorough preoperative examination and utilization of frozen section for sufficient resection margin are required.

Successful kidney transplantation across a positive complement-dependent cytotoxicity crossmatch by using C1q assay-directed, bortezomib-assisted desensitization : A case report

Lee, Juhan,Park, Borae G.,Jeong, Hyang Sook,Park, Youn Hee,Kim, Sinyoung,Kim, Beom Seok,Kim, Hye Jin,Huh, Kyu Ha,Jeong, Hyeon Joo,Kim, Yu Seun Williams & Wilkins Co 2017 Medicine Vol.96 No.39

<P><B>Abstract</B></P><P><B>Rationale:</B></P><P>Human leukocyte antigen (HLA) is the major immunologic barrier in kidney transplantation (KT). Various desensitization protocols to overcome the HLA barrier have increased the opportunity for transplantation in sensitized patients. In addition, technological advances in solid-phase assays have permitted more comprehensive assessment of donor-specific antibodies. Although various desensitization therapies and immunologic techniques have been developed, the final transplantation decision is still based on the classic complement-dependent cytotoxicity (CDC) crossmatch (XM) technique. Some patients who fail to achieve negative XM have lost their transplant opportunities, even after receiving sufficient desensitization therapies.</P><P><B>Patient concerns:</B></P><P>A 57-year-old male with end-stage renal disease secondary to chronic glomerulonephritis was scheduled to have a second transplant from his son, but CDC XM was positive.</P><P><B>Diagnoses:</B></P><P>Initial CDC XM (Initial T-AHG 1:32) and flow-cytometry XM were positive. Anti-HLA-B59 donor specific antibody was detected by Luminex single antigen assay.</P><P><B>Interventions:</B></P><P>Herein, we report a successful case of KT across a positive CDC XM (T-AHG 1:8 at the time of transplantation) by using C1q assay-directed, bortezomib-assisted desensitization. After confirming a negative conversion in the C1q donor-specific antibody, we decided to perform KT accepting a positive AHG-CDC XM of 1:8 at the time of transplantation.</P><P><B>Outcomes:</B></P><P>The posttransplant course was uneventful and a protocol biopsy at 3 months showed no evidence of rejection. The patient had excellent graft function at 12 months posttransplant.</P><P><B>Lessons:</B></P><P>The results of XM test and solid-phase assay should be interpreted in the context of the individual patient.</P>