Cytomegalovirus Infection in Seropositive Kidney Transplant Recipients With Diverse Immunological Risks Under Preemptive Strategy Mun Chae Choi, Minyu Kang, Hwa‐hee Koh, Seung Hyuk Yim, Hyun Jeong Kim, et al. Journal of Medical Virology, 2025 Cytomegalovirus (CMV) infection remains the most prevalent viral infection in kidney transplant recipients. Despite effective preventive strategies, the use of desensitization therapies and potent immunosuppressive agents in patients with high immunological risks underscores the continued importance of CMV as a major concern. This study aims to determine the incidence and outcomes of CMV infection in patients with diverse immunological risks under preemptive stategies. We analyzed 614 CMV‐seropositive kidney transplant recipients managed under preemptive strategies. Of them, 231 patients (37.6%) underwent immunologically incompatible transplantation, including 75 ABO‐ and 156 HLA‐incompatible transplants. During the median follow‐up of 60 months, 354 patients (57.7%) experienced CMV infection. Multivariable analysis identified older recipient age, deceased donor, rituximab, and anti‐thymocyte globulin as independent risk factors for CMV infection, while the use of mammalian target of rapamycin inhibitor was protective. Multivariable Cox regression analysis confirmed that CMV infection was independently associated with increased risks of death‐censored graft loss (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.17–3.59) and all‐cause mortality (aHR, 3.40; 95% CI, 1.60–7.23). CMV infection adversely affects graft and patient outcomes in seropositive recipients managed under preemptive strategies. These findings emphasize the need for optimized CMV prevention strategies in recipients with high immunological risks, hereby intensified preemptive strategies or immunological risk‐adapted antiviral prophylaxis are key options.
Robust Predictive Performance of the SALT-M Score for Clinical Outcomes in Asian Patients With Acute-on-Chronic Liver Failure Kunhee Kim, Seung Hyuk Yim, Jae Geun Lee, Dong Jin Joo, Myoung Soo Kim, et al. Alimentary Pharmacology and Therapeutics, 2025 BackgroundAcute‐on‐chronic liver failure (ACLF) is a syndrome of patients with chronic liver disease presenting with multiple organ failures. Recently, Sundaram‐ACLF‐LT Mortality (SALT‐M) score has been developed to predict 1‐year post‐liver transplantation mortality. We validated the SALT‐M score in a large‐volume, Asian single‐centre cohort.AimsWe validated the SALT‐M score in a large‐volume, Asian single‐centre cohort.MethodsWe analysed 224 patients of ACLF grade 2–3. Area under the receiver operating characteristic curve (AUROC) and concordance index (c‐index) were used to assess and compare the predictability of posttransplant mortality of SALT‐M and other scores. Moreover, we compared the survivals of patients with high and low SALT‐M, in conjunction with MELD score and ACLF grade.ResultsThe AUROC for prediction of 1‐year post‐LT survival was higher in SALT‐M (0.691) than in MELD, MELD‐Na, MELD 3.0 and delta‐MELD. Similarly, the c‐index of the SALT‐M (0.650) was higher than aforementioned MELD systems. When categorised by the cut‐off of SALT‐M ≥ 20 and MELD ≥ 30, patients with high SALT‐M exhibited lower post‐LT survival than those with low SALT‐M scores regardless of high or low MELD (40.0% for high SALT‐M/high MELD vs. 42.9% for high SALT‐M/low MELD vs. 73.8% for low SALT‐M/high MELD vs. 63.7% for low SALT‐M/low MELD, p < 0.001). In patients with ACLF grade 3, SALT‐M effectively stratified the posttransplant mortality (39.4% for high SALT‐M vs. 63.1% for low SALT‐M, p = 0.018).ConclusionsSALT‐M outperformed previous MELD systems for predicting posttransplant mortality in Asian LT cohort with severe ACLF. Transplantability for patients with severe ACLF could be determined based on SALT‐M.
Number of Pretransplant Therapeutic Plasma Exchange Sessions Increase the Recurrence Risk of Hepatocellular Carcinoma in ABO-Incompatible Living Donor Liver Transplantation Young Jin Yoo, Deok-Gie Kim, Eun-Ki Min, Seung Hyuk Yim, Mun Chae Choi, et al. Transplant International, 2025 Previous studies have reported comparable oncologic outcome between ABO-incompatible (ABOi) living donor liver transplantation (LDLT) and ABO-compatible (ABOc) LDLT in patients with hepatocellular carcinoma (HCC). We aimed to analyze the relationship between number of therapeutic plasma exchanges (TPE) before LDLT and HCC outcomes in ABOi LDLT. In this single-center retrospective study, 428 adult LDLT recipients with HCC were categorized into three groups according to ABO incompatibility and the number of pretransplant TPE: ABOc (n = 323), ABOi/TPE ≤5 (n = 75), and ABOi/TPE ≥6 (n = 30). The RFS and HCC recurrence rates were compared. Three groups showed similar characteristics in most demographics, pretransplant tumor markers and pathologies. The median initial isoagglutinin (IA) titer was 1:64 (range negative-1:512) in ABOi/TPE ≤5 group and 1:512 (range 1:128–1:4,096) in ABOi/TPE ≥6 group. Five-year RFS was significantly lower (75.7% vs. 72.7% vs. 50.0%, P = 0.005) and HCC recurrence was significantly higher in the ABOi/TPE ≥6 group than in the other groups(16.4% vs. 17.0% vs. 39.4%, P = 0.014). In multivariable Cox regression analysis, ABOi/TPE ≥6 was an independent risk factor for RFS (aHR 1.99, 95% CI:1.02–3.86, P = 0.042) and HCC recurrence (aHR 2.42, 95% CI:1.05–5.57, P = 0.037). More than six pretransplant TPE sessions may increase the risk of HCC recurrence after ABOi LDLT. Reducing TPE sessions to fewer than six should be considered while maintaining immunological stability through IA titer control.
Creatinine-cystatin C ratio and death with a functioning graft in kidney transplant recipients Mun Chae Choi, Deok Gie Kim, Seung Hyuk Yim, Hyun Jeong Kim, Hyoung Woo Kim, et al. Scientific Reports, 2024 Death with a functioning graft is important cause of graft loss after kidney transplantation. However, little is known about factors predicting death with a functioning graft among kidney transplant recipients. In this study, we evaluated the association between post-transplant creatinine-cystatin C ratio and death with a functioning graft in 1592 kidney transplant recipients. We divided the patients into tertiles based on sex-specific creatinine-cystatin C ratio. Among the 1592 recipients, 39.5% were female, and 86.1% underwent living-donor kidney transplantation. The cut-off value for the lowest creatinine-cystatin C ratio tertile was 0.86 in males and 0.73 in females. The lowest tertile had a significantly lower 5-year patient survival rate and was independently associated with death with a functioning graft (adjusted hazard ratio 2.574, 95% confidence interval 1.339–4.950, P < 0.001). Infection was the most common cause of death in the lowest tertile group, accounting for 62% of deaths. A low creatinine-cystatin C ratio was significantly associated with an increased risk of death with a functioning graft after kidney transplantation.
Learning Curve of Autologous Arteriovenous Fistula Formation for Junior Vascular Surgeons Mun Chae Choi, Seung Hyuk Yim, Seong Wook Shin, Seok Jeong Yang, Deok-Gie Kim, et al. Vascular Specialist International, 2024 Purpose Autologous arteriovenous fistulas (AVFs) are considered the gold standard for hemodialysis access, with outcomes largely dependent on the surgeon’s experience. Nevertheless, few studies have been conducted on the learning curve of junior vascular surgeons in AVF creation. This study aims to address this by examining the development of surgical skills among junior vascular surgeons. Materials and Methods A retrospective analysis was conducted on 100 patients who underwent autologous AVF procedures performed by five junior surgeons between January 2018 and December 2023. To establish the cutoff number of cases for the learning curve, we examined the cubic spline curve using the hazard ratio for primary failure. Results The cutoff number for operation cases was 15.33, and we divided the analysis into a pre-learning curve period (≤15 cases of AVF) and a post-learning curve period (>15 cases of AVF). The 1-year primary patency rate for AVF during the post-learning curve period was 84.0%, which was higher than the 65.5% rate observed during the pre-learning curve period. In a subgroup analysis based on AVF type, the radiocephalic fistula patient group demonstrated a significant increase in 1-year primary patency in the post-learning curve period compared to that in the pre-learning curve period (80.0% vs. 43.0%, log-rank P=0.033). In contrast, there was no significant difference in the primary patency rates between the post- and pre-learning curve periods in the brachiocephalic fistula patient group (90.0% vs. 89.2%, log-rank P=0.930). Conclusion Junior vascular surgeons demonstrated improved primary AVF patency beyond the learning curve benchmark in 15 patients, with particularly notable enhancements in radiocephalic fistulas.
High Number of Plasma Exchanges Increases the Risk of Bacterial Infection in ABO-incompatible Living Donor Liver Transplantation Mun Chae Choi, Eun-Ki Min, Seung Hyuk Yim, Deok-Gie Kim, Jae Geun Lee, et al. Transplantation, 2024 Background. Bacterial infections are major complications that cause significant mortality and morbidity in living donor liver transplantation (LDLT). The risk of bacterial infection has not been studied in ABO-incompatible (ABOi) recipients with a desensitization protocol in relation to the number of plasma exchanges (PEs). Therefore, we aimed to analyze the risk of bacterial infection in ABOi LDLT recipients with a high number of PEs compared with recipients with a low number of PEs. Methods. A retrospective study was performed with 681 adult LDLT recipients, of whom 171 ABOi LDLT recipients were categorized into the high (n = 52) or low (n = 119) PE groups based on a cutoff value of 6 PE sessions. We compared bacterial infections and postoperative bacteremia within 6 mo after liver transplantation with the ABO-compatible (ABOc) LDLT group (n = 510) as a control group. Results. The high PE group showed a bacterial infection rate of 49.9% and a postoperative bacteremia rate of 28.8%, which were significantly higher than those of the low PE group (31.1%, 17.8%) and the ABOc group (26.7%, 18.0%). In multivariate analysis, the high PE group was found to have a 2.4-fold higher risk of bacterial infection (P = 0.008). This group presented a lower 5-y survival rate of 58.6% compared with the other 2 groups (81.5% and 78.5%; P = 0.030 and 0.001). Conclusions. A high number of preoperative PEs increases bacterial infection rate and postoperative bacteremia in ABOi LDLT.