A Case of Recurrent Pulmonary Hemorrhage in p-ANCA-Related Vasculitis Patients on Hemodialyis / 대한신장학회지

ANCA-associated vasculitis is one of the immunologic cause of diffuse alveolar hemorrhage (DAH). We experienced a rare case of recurrent DAH in a 67-year-old man with ANCA-associated vasculitis who had been on maintenance hemodialysis. Two years ago, he presented with renal failure and hemoptysis. Hemoptysis caused by DAH was resolved immediately and hemodialysis was applied because of persistent uremic symptom. On maintenance hemodialysis, three recurrences have happened so far. At present, oral prednisolone and oral cyclophosphamide are being maintained during outpatient follow-up. Our report suggests that the nephrologist must be concerned about the possibility of recurrent aleveolar hemorrhage in ANCA associated renal disease patients and consider immunosuppressive treatment, even though the patient has been on maintenance hemodialysis.

Acute renal infarction : Clinical features in 23 cases / 대한내과학회지

BACKGROUND: Acute renal infarction is an uncommon disease which is often delyed or missed due to its rarity and unspecific clinical presentation. METHODS: In order to evaluate the clinical features and to elucidate diagnostic or therapeutic options, we analyzed the medical records of 23 patients who were admitted to Pusan National University Hospital from January, 1995 to July, 2004 and diagnosed as renal infarction. RESULTS: The mean age of the patients was 57.3 18.4 years and male to female ratio was 0.91:1. Underlying diseases were cardiovascular disease (n=18), tumor embolism (n=1), vasculitis (n=1), post kidney transplantation thrombosis (n=1), and trauma(n=1). One patient did not have any underlying disease. Initial symptoms were abdominal or flank pain (61%), fever (35%), anorexia (35%), nausea (26%), vomiting (17%), gross hematuria (9%), and oliguria (4%). On physical examination, costovertebral angle tenderness (43%), abdominal tenderness (9%), and hypertension (35%) were noted. Initial abnormal laboratory findings were elevated serum level of LDH (100%), AST (87%), ALT (83%), CK (22%), and creatinine (>1.4 mg/dL, 17%). Imaging diagnosis of renal infarction included renal angiography, isotope renal scan, computed tomography or ultrasonography. CT was done in 17/23 cases and useful in diagnosis of renal infarction. Nine patients were treated with heparin or warfarin. Thrombolysis was done in 3 patients. Others were treated conservatively. CONCLUSIONS: In a patients with an increased risk of thromboembolism, flank or abdominal pain, microscopic hematuria, and an elevated serum LDH are strongly supportive of diagnosis of renal infarction. Under such circumstances, enhanced CT is essential for the early diagnosis of renal infarction.

Pregnancy outcome in women with chronic kidney disease / 대한내과학회지

BACKGROUND: Chronic kidney disease has deleterious influences on pregnancy, both fetus and mother. To determine the pregnancy outcome and associated risk factors, we analyzed 36 pregnancies in 26 women with various chronic kidney diseases. METHODS: Retrospective analysis of 36 pregnancies was performed in women with chronic kidney disease who underwent antenatal care and delivery at Pusan National University Hospital from January 1993 to December 2002. RESULTS: The mean age of patients was 29.7 +/- 3.6 years. Underlying kidney disease was lupus nephritis in 10 patients (11 pregnancies), IgA nephropathy in 7 patients (8 pregnancies), focal segmental glomerulosclerosis in 4 patients (9 pregnancies), membranoproliferative glomerulonephritis in 4 patients (7 pregnancies), membranous glomerulonephritis in 1 patient (1 pregnancy). Of the 36 pregnancies, fetal loss occurred in 14 pregnancies (38.9%), premature delivery 7 pregnancies (19.4%) and normal delivery 15 pregnancies (41.7%). Deterioration of maternal renal function occurred in 10 pregnancies (27.8%), hypertension 18 pregnancies (50.0%) and aggravation of proteinuria 26 pregnancies (72.2%). Fetal loss and deterioration of maternal renal function were more frequent in patients with preconception serum creatinine value (SCr) >or=1.4 mg/dL than in those with SCr or=140/90 mmHg during pregnancy was associated with low birth weight (p=0.027, OR 0.034, 95% CI 0.002-0.682). Deterioration of maternal renal function during pregnancy was recovered in 40.0%, hypertension was recovered in 50.0% and proteinuria was recovered in 77.8% within 1 year after delivery. CONCLUSION: Preconceptional impairment of maternal renal function and uncontrolled hypertension during pregnancy seem to be an important factors associated with fetal loss and low birth weight, respectively.

Clinical Features of Acute Renal Failure Secondary to Acute Pyelonephritis: Comparison with Uncomplicated Pyelonephritis / 대한신장학회잡지

BACKGROUND: Acute pyelonephritis (APN) is an unusual cause of acute renal failure (ARF) in patients without urinary obstruction and other predisposing conditions. Therefore, in the differential diagnosis of ARF, APN is rarely considered. METHODS: We retrospectively analyzed the data from the patients with ARF secondary to APN (ARF group, n=8) with normal renal anatomy and no known predisposing conditions which lead to ARF during the course of acute bacterial pyelonephritis, and investigated the differences of clinical parameters to the patients with uncomplicated APN (control group, n=20). RESULTS: Female were predominant in both groups. The mean age was 49.2+/-14.4 years in control group and 56.3+/-16.4 years in ARF group. On admission, the body temperature was 37.5+/-1.14degrees C in control group and 36.62+/-0.32degrees C in ARF group (p= 0.003). The days of pyuria, duration days of costovertebral angel (CVA) tenderness and hospitalization days were significantly prolonged in ARF group. CVA tenderness was unilateral in 65% of control group and bilateral in 65% of ARF group. Amounts of daily urine protein excretion were 0.15+/-0.48 gm/ day in control group and 2.99+/-2.89 gm/day in ARF group (p=0.001). Creatinine clearance and FeNa were 24.04+/-15.98 mL/min and 2.80+/-2.68 in patients group, respectively. Development of ARF had positive correlation with the duration of pyuria (r=0.579, p< 0.01), amounts of daily urine protein excretion (r=0.854, p< 0.01), duration of CVA tenderness (r=0.461, p< 0.05) and had a negative correlation with body temperature (r=-0.402, p< 0.05). CONCLUSION: APN is a rare but important cause of acute renal failure. Patients with ARF secondary to APN seems to have more prolonged period of pyuria and CVA tenderness, apyrexia and excrete more protein in urine than patients with uncomplicated APN. Adequate treatment of the bacterial infection by prompt antibiotic treatment may lead to full recovery of renal function.

A clinicopathological study of the adult Henoch-Schonlein Purpura / 대한내과학회지

BACKGROUND: Henoch-Shnlein purpura is a systemic disease and has characteristic features of purpuric skin rash, abdominal pain, arthralgia and abnormal urinary findings and characterized by immunoglobulin A deposits in the involved organ. Renal involvement is the most important prognostic factor in Henoch-Shnlein purpura. METHODS: I retrospectively analyzed the clinical data of 48 patients with Henoch-Shoenlein purpura and 10 biopsy-proven Henoch-Schoenlein nephritis examined at Pusan National University Hospital. RESULTS: 23 cases were males and 25 cases females. Male to female ratio was 1:1.08. The peak of seasonal incidence was seen in spring (41.7%) and winter (27.1%) At presentation, skin purpura was present in 100% of patients, arthralgia was reported in 52.1% and gastrointestinal involvement in 70.8%. 75% of the patients showed renal involvement and pulmonary hemorrhage observed in 2 cases. Common types of skin rash were petechiae, purpura and erythematous maculopapular lesion on the lower extremities. The most common gastrointestinal symptom was abdominal pain (82.3%). Frequently involved joints were knee and ankle (48.0%). Renal involvement were microscopic hematuria (50.0%), proteinuria (50.0%), gross hematuria (29.2%). 25% of patients reached renal insufficiency (GFR<70 mL/min) and 4 cases (8.3%) reached acute renal failure (GFR<30 mL/min and anuria) and 3 patients of them experienced hemodialysis. All renal biopsies showed predominant IgA mesangial deposition. There were 2 cases of grade II, 6 cases of grade III and 2 cases of grade IV by classification of Meadow. Steroids were given in 16 patients (33.3%). Methylprednisolone pulse treatements were given in 4 patients for severe nephritis. 10 patients received angiotensin converting enzyme inhibitor. Clinical remission of extrarenal symptoms was achieved in 83.3% but relapses of purpura were observed in 27.1%. Clinical remissions of nephritis defined as the absence of proteinuria, hematuria and normal renal function was achieved in only 8.3%, Abnormal urinary finding continued in 37.8%. 8.3% of patients expired. CONCLUSION: Although it has been well known that Henoch-Shnlein purpura has benign courses, we experienced 4 case of deaths and The cause of death was acute renal faliure, pulmonary hemorrhage, adult respiratory distress syndrome, massive gastrointestinal bleeding, peritonitis due to bowel perforation.

Asymptomatic Bacteriuria in Patients with Chronic Renal Failure / 대한신장학회잡지

BACKGROUND: In patients with chronic renal failure, infection is caused by altered host defense mechanism, and contributes significantly to their morbidities and mortalities. Especially, urinary tract infection often occurs in patients with chronic renal failure and is due to azotemia, infrequent voiding, low urinary flow rate and urinary concentration defects. This study was designed to compare the incidence of asymptomatic bacteriuria with chronic renal failure with that of normal control group. We also investigated whether risk factors for urinary tract infections in patients with chronic renal failure are similar to those in normal control groups. METHODS: 34 patients (M : F=13 : 21) with chronic renal failure and 30 normal control groups (M : F= 11 : 19) were evaluated in the Pusan National University Hospital from January 2001 through December 2001. Etiology of chronic renal failure included diabetes mellitus (n=16, 47.1%), hypertension (n=14, 41.2%) and glomerular diseases (n=4, 11.7%). 25 patients were treated with hemodialysis and 5 patients were treated with peritoneal dialysis. Others (n=4) were not treated with dialysis. Clean-catch, first voided urine was collected in the morning and examined by routine urinalysis and urine culture. RESULTS: 7 of 34 (20.6%) patients with chronic renal failure were positive in urine cultures and only one of 30 (3.3%) from the normal control group were positive. E. coli (n=2), Acinetobacter baumanii (n=2), Enterococcus spp. (n=2), S. aureus (n=1), P. aeruginosa (n=1), S. epidermidis (n=1) and Str. viridans (n=1) are cultured from urine specimens. There was a significant difference between the incidence of asymptomatic bacteriuria in patients with chronic renal failure and that of normal control group. But there was no significant difference in the presence of bacteriuria according to sex, age, etiology of renal failure, dialysis modality and pyuria. CONCLUSION: Patients with chronic renal failure have higher frequency of asymptomatic bacteriuria and pyuria than healthy subjects and tend to lead to symptomatic urinary tract infections.

The correlation of microalbuminuria and glomerular filtration rate in normotensive patients with type 2 diabetes mellitus / 대한내과학회지

BACKGROUND: Diabetic nephropathy is one of the major causes of end-stage renal disease. Microalbuminuria predicts not only progressive renal disease, but also increased cardiovascular morbidity and mortality. But, the relationship between urinary albumin excretion rate (UAER) and glomerular filtration rate (GFR) remains an unresolved issue. In order to investigate the early renal function abnormalities, UAER and GFR were assessed and their relationship was examined in normotensive patients with type 2 diabetes mellitus (DM). METHODS: Between January 1997 and June 2001, in a cross sectional study of 112 normotensive patients with type 2 DM not showing overt proteinuria and thirty healthy subjects served as control group. According to UAER, type 2 DM patients were divided into normoalbuminuria group and microalbuminuria group. The GFR was measured using 99mTc-DTPA renal scan. Clinical values in type 2 DM patients and control subjects were compared using one-way analysis of variance (ANOVA) with Scheffe's F test. In type 2 DM patients, Univariate Chi-square analysis was used to evaluate the prevalence of diabetic retinopathy and the differences in anti-diabetic treatment. Pearson correlation coefficients were used to demonstrate a strength of an association between UAER and other variables including GFR. RESULTS: Three groups were well matched with regard to gender, age and body mass index. There were no significant differences in disease duration and anti-diabetic treatment in type 2 DM patients. The GFR in microalbuminuric patients was significantly higher than in normoalbuminuric patients (124.0 17.6 vs 102.9+/-15.5 mL/min/1.73 m2, p<0.05). The prevalence of diabetic retinopathy in microalbuminuric patients was significantly higher than in normoalbuminuric patients (53.8% vs 24.7%, p<0.05). Only there was significant positive correlation between log UAER and GFR (r=0.303, p<0.05). CONCLUSION: As in type 1 DM patients, there was a significant relationship between UAER and GFR in normotensive type 2 DM patients without overt proteinuria.