The Long-term Nutritional Effects of Amino-Acid Based Dialysis Solution (IPAA) in Malnourished CAPD Patients : Comparison of Responders and Non-responders / 대한신장학회잡지

BACKGROUND: IPAA provide nutritional benefit, at least in the short term. However, the long-term efficacy of IPAA in PD patients remains unclear. An attempt was made to evaluate long-term efficacy of IPAA and to ascertain possible factors associated with improved nutritional status after IPAA. METHODS: The 46 malnourished CAPD patients were treated with IPAA (one exchange of Nutrineal daily) for one year. Various nutritional, boichemical variables, urea kinetic study and measurement of lean body mass based on creatinine excretion (LBMCr) were carried out at baseline, and at 3- month interval thereafter. Responders was defined as those patients who had an increment of mean LBMCr more than 2.0 kg and/or an increase in mean %LBMCr (LBMCr/Body weight) more than 5% during IPAA treatment. RESULTS: After administration of IPAA, BUN, Cr, LBMCr, %LBMCr, nPNA, SGA, and exercise capacity increased significantly. But, protein and albumin level showed no significant change. Increment of IGF-1 level was significant. At baseline, responders had a significantly higher hand grip and back lift strength compared to non-responders. IPAA treatment significantly increased in BUN, PNA and nPNA in both groups, but the increment of them was pronounced in responders. IPAA resulted in a significant increase in serum creatinine (10.6+/-2.1 vs. 11.8+/-2.6 mg/dL, p<0.05) and %LBMCr (70.8+/-8.9 vs. 76.4+/-9.2%, p<0.05), hand grip strength (23.2+/-7.3 vs. 24.3+/-7.7 kg, p<0.05) and back lift strength (67.0+/-27.4 vs. 75.3+/-26.6 kg, p<0.05) only in responders. Serum albumin level remained stable after IPAA treatment in responders. CONCLUSION: IPAA treatment for 12 months provided some nutritional benefits in malnourished CAPD patients. And, our data suggest that response to IPAA is more pronounced in CAPD patients with a better preserved nutritional status, especially in those patients with higher back lift and hand grip strength at baseline.

Clinical Factors Affecting Peritoneal Membrane Function in Long-Term Continuous Ambulatory Peritoneal Dialysis Patients / 대한신장학회잡지

BACKGROUND: According to previous studies on peritoneal membrane function, solute transport significantly increased 3 years after the begining of peritoneal dialysis. However, there were only few reports regarding the change of peritoneal membrane function in long-term CAPD patients in Korea. METHODS: Clinical factors affecting peritoneal membrane function were analyzed, in patients who maintained CAPD more than 5 years. 124 patients performed peritoneal equilibration test(PET) 5 years after CAPD were included. Cross sectional study was performed to know the differences of clinical characteristics among 4 types of peritoneal membrane transport characteristics based on PET. Also, clinical factors affecting peritoneal memebrane function were analyzed in 31 patients who had undertaken PET initially and 5 years after the beginning of CAPD. RESULTS: D/P Cr was the highest(p<0.001) and ultrafiltration was the lowest(p=0.011) in high transport group. Also, the number of hypertonic glucose exchanges(more than 2.5%) per day was the highest (p=0.02), and serum albumin was the lowest(p<0.001) in this group. 17 patients were included in ultrafiltraion failure group. D/P Cr and the number of hypertonic glucose exchanges was significantly higher (p<0.001, p<0.001, respectively) and the duration of peritoneal dialysis was significantly longer(p=0.033) in ultrafiltration failure group compared with the others. D/P Cr of 124 patients was well correlated with the number of peritonitis(gamma=0.246, p=0.006), and the number of hypertonic glucose exchanges(gamma=0.33, p<0.001), but inversely correlated with serum albumin(gamma=-0.452, p<0.001) with the statistical significance. In 31 patients who undertook PET within 1 year after the begining of CAPD, although not significant, D/P Cr increased and ultrafiltration decreased after 5 years. A significant increase in D/P Cr(p=0.014) was seen in patients who experienced more than 2 episodes of peritonitis(n=14), compared with patients who experienced either peritonitis free or single episode of peritonitis(n=17). The linear regression analysis showed that the number of peritonitis and the number of hypertonic glucose exchanges per day were significantly correlated with the increased D/P Cr after 5 years(p=0.001, p=0.003, respectively). CONCLUSION: Clinical factors affecting peritoneal membrane function were the number of peritonitis, the use of hypertonic glucose exchanges and the duration of peritoneal dialysis. To preserve peritoneal membrane function, it is recommended to avoid hypertonic glucose exchanges and to reduce the number of peritonitis.

Clinical Characteristics of ESRD Patients with Severe Hyperparathyroidism Who Undertook Surgical Parathyroidectomy / 대한신장학회잡지

BACKGROUND: Medical treatments such as restriction of phosphate, phosphate binder use, and active vitamine D therapy have been widely used for hyperparathyroidism in ESRD patients, and surgical parathyroidectomy should be considered in patients with uncontrolled hyperparathyroidism. METHODS: A retrospective study was performed in 24 ESRD patients with severe and uncontrolled hyperparathyroidism despite of medical treatment who undertook surgical parathyroidectomy in Severance hospital from 1990 to 1999. RESULTS: Sixteen patients had total parathyroidectomy with immediate autotransplant, 7 patients had subtotal parathyroidectomy and only 1 patient had minimally invasive parathyroidectomy. An excellent short-term control of hyperparathyroidism was achieved in all patients after parathyroidectomy. Preoperative bone and joint pain improved in 16 of 19 patients. Muscle weakness and pain improved in 11 of 17 patiens, malaise improved in 8 of 10 patients and pruritus improved in 10 of 13 patients. In addition, clinical laboratory finding improved after parathyroidectomy. No clinical differences were seen between 16 patients who undertook total parathyroidectomy with immediate autotransplant and 7 patients who undertook subtotal parathyroidectomy. Recurrence of hyperparathyroidism ocurred in 5 of 24 patients with 4 nodular hyperplasia and 1 diffuse hyperplasia in pathologic finding. The less degree of attenuated response of intact PTH levels immediately after operation was observed in 5 recurrent cases. CONCLUSION: Good results were obtained after parathyroidectomy. We believe that histologic subtype and the attenuated response of intact PTH after surgical parathyroidectomy could be possible predictors of the recurrent hyperparathyroidism.

A Case of Hemorrhagic Fever with Renal Syndrome Complicated by Retroperitoneal Hematoma and Hemothorax / 대한신장학회잡지

Hemorrhagic fever with renal syndrome frequently found in Korea is a acute infectious disease caused by Hantaan virus. Its clinical manifestations include high fever, cardiovascular collapse, hemorrhagic tendency and acute renal failure. Many patients with hemorrhagic fever with renal syndrome show hemorrhagic tendency such as subconjunctival hemorrhage and mucocutaneous petechia. In vital organs such as lung, kidney, spleen, brain, and pituitary, hemorrhage occasionally occurs spontaneously or by minor trauma. As a results, hematemesis, hemoptysis, melena and gross hematuria can be developed in some patients. Anemia and circulatory shock may result from large hematoma formed in third spaces like retroperitoneal and pleural space. But retroperitoneal hematoma and hemothorax was rarely reported. We report a case of hemorrhagic fever with renal syndrome complicated by retroperitoneal hematoma and hemothorax with review of literatures.

A Case of Copper Intoxication / 대한신장학회잡지

Copper is an essential trace element for numerous vital enzymes. Recently, copper can be used clinically as assessing the disease activity, prognosis, therapeutic effect and early prediction of recurrence in patient with neoplasia. But overloading of copper can cause fatal outcome. Copper intoxication is usually encountered following accidental ingestion or suicidal intoxication. A 43-year old male was admitted because of epigastric pain and hematuria after ingestion of the copper hydroxide and organophosphate for suicidal purpose. The laboratory findings showed that the serum and urinary copper concentration are elevated, then the acute renal failure, hemolytic anemia and liver injury progressed. With conservative management, the hemolytic anemia was improved, but disseminated intravascular coagulation with sepsis and respiratory failure by pneumonia were developed, and then finally expired on the eighth hospital days. We experienced a case of a patient who presented with acute renal failure, hemolytic anemia and liver injury after ingestion of copper, and we reported with review of literature.

Lymphocyte Subpopulations in Patients with Minimal Change Disease and IgA Nephropathy / 대한신장학회잡지

The pathogenetic mechanisms of minimal change disease and immunoglobulin A nephropathy remain uncertain, but recently various reports have reported the important role of the immunological aspect in the pathogenesis of glomerular injury. To assess the abnormalities of immunoregulatory system in these glomerular disease, the percentages of lymphocyte subpopulations in peripheral blood were studied in 24 cases of minimal change disease and 28 of immunoglobulin A nephropathy diagnosed by renal biopsy. The results were as follows: 1) CD4/CD8 ratio of the minimal change disease was significantly increased, compared with normal controls and immunoglobulin A nephropathy(P<0.05). 2) No significant difference in T helper cell and T suppressor cell was found between steroid response group and steroid non-response group in minimal change disease. 3) No significant difference in lymphocyte subpopulation was found between group with nephrotic range of proteinuria and group without nephrotic range of proteinuria in minimal change disease. 4) The discrepancies in lymphocyte subpopulations was not observed between group with infection and group without infection in immunoglobulin A nephropathy. 5) The pathologic grade (criteria of WHO) did not demonstrate a significant difference in lymphocyte subpopulation in immunoglobulin A nephropathy. In conclusion, these results suggest that the dysregulation of cell-mediated immunologic system is involved in the pathogenesis of minimal change disease and immunoglobulin A nephropathy, and some differences of immunoregulatory abnormalities between minimal change disease and immunoglobulin A nephropathy exist. But in this study the change in lymphocyte subpopulation does not anticipate the clinical course and prognosis of minimal change disease and immunoglobulin A nephropathy.