A Case Report of Kidney Graft Failure after Duodenal Bypass Surgery / 대한내과학회지

The calcineurin inhibitor-immunosuppressant tacrolimus is widely used in patients undergoing kidney transplantation. Although tacrolimus is absorbed from the entire gastrointestinal tract, the duodenum is the primary site of its absorption and metabolism. Therefore, duodenal bypass surgery in a renal transplant recipient can significantly disrupt tacrolimus absorption and metabolism. Here, we report a case of allograft failure that developed after duodenal bypass surgery. The patient was a 41-year-old woman who received a deceased donor kidney transplantation. She underwent a gastrojejunostomy due to a duodenal perforation and pancreatitis after endoscopic retrograde cholangiopancreatography. After the surgery, her blood tacrolimus level decreased gradually, and remained lower than therapeutic target levels, even after the tacrolimus dose was increased from 5 to 12 mg/day. Repetitive rejection developed and the patient suffered allograft failure 3 months after bypass surgery. This case raises the importance of drug absorption in renal transplant recipients undergoing duodenal bypass surgery.

Complete Atrioventricular Block due to Infective Endocarditis of Bicuspid Aortic Valve

A 38-year-old man visited our emergency department presenting with a 6-day persistent fever. The man had undergone an orthodontic procedure 7 days prior to the visit. He had a fever with a temperature of 38.2degrees C and a diastolic murmur (grade III) was detected at the left sternal border. Reddish-brown lines beneath the nails were present, and raised lesions which were red and painful were detected on the soles of the patient's feet. Laboratory findings showed an elevated inflammatory marker. Transthoracic and transesophageal echocardiograms, showed a bicuspid aortic valve, and moderate aortic regurgitation and vegetation were noted. Treatment with antibiotics was given, but 4 days later, a 12 lead electrocardiogram revealed complete atrioventricular (AV) block. Immediately, a temporary pacemaker was inserted, and the following day an aortic valve replacement was performed. Intraoperative findings revealed a fistula around the AV node. He has suffered no subsequent cardiac events during the follow-up.

Depression and Self-care Behavior in Patients with Diabetes Mellitus / 당뇨병

BACKGROUND: Depression is known to be a risk factor for type 2 diabetes mellitus. Conversely, diabetes is also a risk factor for depression, and patients with diabetes have nearly twice the risk of comorbid depression as the general population. Depression in patients with diabetes may cause poor clinical outcomes through lower adherence to self-care activities such as exercise, diet control, and glucose monitoring. Furthermore, diabetic patients with depression are more likely to suffer from microvascular or macrovascular complications. We explored the prevalence of major depressive disorder in Korean diabetic patients and its impact on self-care activities and glucose control. METHODS: We surveyed depressive symptoms and self-care activities in 191 type 2 diabetic patients from the outpatient clinic of the St. Mary's hospital. Two questionnaires were used for assessment, the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS) and the Summary of Diabetes Self-Care Activities (SDSCA). RESULTS: Of the 191 respondents who completed questionnaires, 39 (20.4%) patients were categorized as having major depressive disorder. Among the depressed patients, only six (15.3%) had been previously evaluated and managed for their psychiatric problems. The incidence of depression was significantly higher in female diabetic patients compared to patients without depression (74.4% vs. 45.4%, P<0.001). Patients with depression showed significantly poorer diet control (18.5 vs. 15.9, P = 0.046) and less glucose monitoring (4.1 vs. 2.7, P = 0.047). However, there were no differences in exercise, foot care, or smoking status between the two groups. Additionally, metabolic parameters such as HbA1C and lipid profile were not significantly different between the two groups. CONCLUSION: Many diabetic patients are suffering from depression and exhibit poorer self-care activities than patients without depression. Identifying and managing depressed diabetic patients may help improve their self-care activities.