Hypertension Management in Patients with Chronic Kidney Disease in the Post-SPRINT Era

The management of high blood pressure (BP) is crucial for improving outcomes in patients with chronic kidney disease (CKD). The updated Kidney Disease: Improving Global Outcomes 2021 BP guideline proposes treating adults with CKD to a target systolic BP (SBP) of <120 mmHg based on the standardized office BP measurement.This suggestion is largely based on the finding of SPRINT (Systolic Blood Pressure Intervention Trial) that targeting an SBP of <120 mmHg versus <140 mmHg is beneficial for cardiovascular and mortality outcomes, regardless of the patient’s kidney disease status. However, extended follow-up studies of CKD trials showed that intensive versus usual BP control was associated with a lower risk of kidney failure in patients with, but not in those without, proteinuria. Similarly, a recent population-based study in Korea demonstrated that the optimal on-treatment BP for composite cardiorenal and mortality outcomes was left-shifted in adults with CKD, particularly in those with albuminuria, relative to that in patients without CKD. Moreover, in meta-analyses of randomized trials, more intensive versus standard BP control was associated with a lower risk of all-cause mortality in patients with CKD and albuminuria but not in those without CKD. Meanwhile, a 2020 Cochrane review reported that lower BP targets (≤135/85 mmHg), compared with standard targets (≤140/90 mmHg), resulted in a small reduction in cardiovascular events, an increase in other serious adverse events, and no reduction in total serious adverse events. Lowering SBP to <120 mmHg can potentially increase the risk of treatment-related adverse events beyond the cardioprotective benefits, and standardized BP measurement increases the burden on patients and resources.Thus, targeting a BP of <130/80 mmHg with appropriate office BP measurement can be an option in patients with CKD. The presence of albuminuria would need to be additionally considered to determine individualized BP targets.

Prevalence of Chronic Kidney Disease in Korea: the Korean National Health and Nutritional Examination Survey 2011-2013

Chronic kidney disease is a leading public health problem related to poor quality of life and premature death. As a resource for evidence-informed health policy-making, we evaluated the prevalence of chronic kidney disease using the data of non-institutionalized adults aged ≥ 20 years (n = 15,319) from the Korean National Health and Nutrition Examination Survey in 2011-2013. Chronic kidney disease was defined as a urine albumin-to-creatinine ratio ≥ 30 mg/g or an estimated glomerular filtration rate < 60 mL/min/1.73 m2 using the Chronic Kidney Disease-Epidemiology Collaboration equation. The total prevalence estimate of chronic kidney disease for adults aged ≥ 20 years in Korea was 8.2%. By disease stage, the prevalence of chronic kidney disease was as follows: stage 1, 3.0%; stage 2, 2.7%; stage 3a, 1.9%; stage 3b, 0.4%; and stages 4-5, 0.2%. When grouped into three risk categories according to the 2012 Kidney Disease: Improving Global Outcomes guidelines, the proportions for the moderately increased risk, high risk, and very high risk categories were 6.5%, 1.2%, and 0.5%, respectively. Factors including older age, diabetes, hypertension, cardiovascular disease, body mass indexes of ≥ 25 kg/m2 and < 18.5 kg/m2, and rural residential area were independently associated with chronic kidney disease. Based on this comprehensive analysis, evidence-based screening strategies for chronic kidney disease in the Korean population should be developed to optimize prevention and early intervention of chronic kidney disease and its associated risk factors.

Polyuria and Natriuresis of Unknown Origin Accompanied with Hypotension in Critically Ill Patients / 대한신장학회지

PURPOSE: We observed excessive renal excretion of salt and water, without underlying renal diseases or definite causes, accompanied with severe hypotension in critically ill patients. This study investigates the clinical courses and characteristics of these patients. METHODS: We retrospectively analyzed 13 patients with polyuria of unknown origin, which persited equal to or longer than 3 days, among hypotensive patients, who were admitted to intensive care unit. RESULTS: The causes of hypotension included sepsis in 11 patients and adrenal insufficiceny in one patient. The cause of hyptension was unknown in one patient. Vassopressors were used in all patients, and hypotension persisted for 13.2+/-8.6 days. Polyuria persisted for 10.6+/-8.2 days, and the duration of polyuria was strongly correlated with that of hypotension (R=0.919, p<0.001). Low dose steroid was used in 8 patients for the treatment of hypotension, and hypotension improved in 3 patients within 2 days after steroid administration. Four patients died during the hosptialization, and the duration of hypotension in non-survivors was greater than that in survivors (21.2+/-9.7 days and 9.6+/-5.2 days respectively, p=0.020). CONCLUSION: In critically ill patients with severe hypotension, we observed 13 cases of inappropriate natriuresis and polyuria. These results suggest that the persistence of poyluria and hypotension might affect the prognosis of these patients, and adrenal insufficicieny might be associated with this appearance in some patients. Further studies are needed to establish causes and treatments for this appearance.

Nocturnal Sleep Related with Metabolic Markers in End-Stage Renal Disease Patients Receiving Hemodialysis

OBJECTIVE: It has been suggested that oxidative stress and inflammation are associated with the pathophysiology of sleep disorders in end-stage renal disease (ESRD) patients. We examined the relationship of the sleep variables reflecting sleep breathing disorder and limb movements during sleep with the clinical variables reflecting the metabolic abnormalities in ESRD patients receiving hemodialysis. METHODS: Nocturnal polysomnography was conducted in 30 ESRD patients (21 men, 9 women), who were receiving hemodialysis. Blood was sampled before hemodialysis for each patient in order to measure uric acid (UA), C-reactive protein (CRP), and interleukin-6 (IL-6). RESULTS: UA was correlated positively with the total sleep time (TST)(r=0.407) and negatively with the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI)(r=-0.377, -405). CONCLUSION: CRP was positively correlated with the limb movement index (LMI)(r=0.401). Our study showed that increased UA was related to decreased respiratory disturbance during sleep in ESRD patients receiving hemodialysis.

Serum osteoprotegerin and fetuin-A level is associated with coronary artery calcification score in the patients with end-stage renal disease / 대한내과학회지

BACKGROUND: Coronary artery calcification is frequently seen in hemodialysis patients. The development and progression of coronary artery calcification is similar to osteogenesis, and a naturally occurring serum inhibitor of calcification may be involved. The aim of this study was to evaluate the relationship between coronary artery calcification, bone remodeling related factor, serum osteoprotegerin (OPG), calcification inhibitor and the serum fetuin-A levels in hemodialysis patients. METHODS: A total of 51 hemodialysis patient were assessed for their coronary artery calcium (CAC) scores with using multirow spiral computed tomography and measuring the serum OPG level, the serum fetuin-A level, the biochemical markers of inflammation, the lipid profile and the mineral metabolism. RESULTS: The mean serum OPG level was 3,561+/-1,160 pg/mL and the mean serum fetuin-A level was 28.5+/-4.1 mg/dL. The CAC scores were significantly correlated with the duration of dialysis (p=0.0225), hs-CRP (p=0.0392), serum phosphate (p=0.0341), Ca x P (p=0.0434), the serum OPG level (p=0.0026) and LDL-cholesterol (p=0.0438), after adjusting for age, gender, BMI, smoking history and the presence of diabetes. Multiple regression analysis showed that the CAC scores were significantly associated with the serum OPG level (p<0.0001) and the serum phosphate level (p=0.0003). The subgroup of the patients with a CAC score greater than 400 (the severe CAC group) had significantly higher OPG levels and lower fetuin-A levels than the groups of the patients with lower CAC scores. CONCLUSIONS: Our data suggest that the CAC scores in the patients undergoing hemodialysis were related with higher serum OPG and higher serum phosphate levels. The serum fetuin-A level was significantly lower in the patients with severe coronary artery calcification.

Serum adiponectin level and cardiovascular disease in patients with end-stage renal disease / 대한내과학회지

BACKGROUND: Adiponectin is a fat-based protein that alters the insulin sensitivity, has anti-inflammatory properties, and reduces the incidence of cardiovascular disease (CVD). However, this connection is unclear in patients with chronic wasting disease, such as heart failure or end-stage renal disease (ESRD). Therefore, this study examined the relationship between adiponectin and the cardiovascular risk/predictive factors in ESRD patients. METHODS: The serum concentrations of adiponectin and leptin were measured in 48 adult patients on maintenance hemodialysis. In addition, the blood levels of B-type natriuretic peptide (BNP) and cardiac troponin T (cTnT) as cardiovascular biomarkers were measured, and the CVD history was reviewed in order to determine if there was any correlation with adiponectin. RESULTS: There was a significant correlation between the adiponectin levels and the serum concentrations of HDL-cholesterol (r=0.456, p=0.001), triglyceride (r=-0.528, p<0.001), and leptin (r=-0.427, p=0.002) and an inverse correlation with the body mass index (BMI) (r=-0.326, p=0.024). The BNP levels were positively correlated with the adiponectin concentrations (r=0.372, p=0.009) and negatively correlated with the BMI (r=-0.310, p=0.032), and there was a slight positive correlation between cTnT and adiponectin (r=0.276, p=0.058). Patients with a history of CVD had higher levels of cTnT (p=0.012) and BNP (p=0.017), and a lower BMI (p=0.026) than patients without such a history. There was no significant difference in the adiponectin levels between the two patient groups. CONCLUSIONS: A higher adiponectin level is related to a favorable lipid profile. However, adiponectin is not directly associated with a history of CVD, and there was a correlation between a higher adiponectin level and a higher BNP and lower BMI, which are cardiovascular predictive factors, in ESRD patients. However, further research with more patients will be needed to properly determine the complicated relationship between adiponectin and the development of CVD.

Clinical benefits of serum BNP measurement in patients with chronic kidney disease / 대한내과학회지

No abstract available.

Characteristics of Sleep Disturbances Correlated with Clinical Parameters in Hemodialysis Patients with Chronic Renal Failure / 신경정신의학

OBJECTIVES: Sleep disturbances are very common in hemodialysis (HD) patients with chronic renal failure (CRF). This study aimed to examine the characteristics of sleep disturbances, and to illustrate the relationship of sleep parameters with clinical parameters reflecting metabolic dysfunction in HD patients with CRF. METHODS: The Epworth Sleepiness Scale (ESS) and Sleep Disorders Questionnaire (SDQ) were administered in 26 HD patients with CRF. For fifteen patients with the risk of sleep disorder, nocturnal polysomnographic study (NPSG) and blood sampling were done. RESULTS: Among 15 patients, 14 patients (93%) were diagnosed as sleep disorders, sleep breathing disorder or periodic limb movements in sleep. Uric acid (UA) was positively correlated with sleep efficiency (r=0.571), and negatively correlated with waking after sleep onset, the amount of stage 1 sleep, and respiratory disturbance index (r=-0.515, -0.564, -0.646). Interleukin-6 was positively correlated with obstructive apnea index (r=0.661). CONCLUSION: In our study, the difficulty in maintaining sleep was found in HD patients with CRF. It also showed that increased UA was associated with improved sleep maintenance and decreased breathing disturbance during sleep. This might be related with antioxidant effect of UA in CRF. Further studies on total CRF patients including those without the risk of sleep disorder are necessary.

An Association Between Coronary Artery Calcification Score, C-Reactive Protein, and Antibodies to Infectious Disease in Patients on Maintenance Hemodialysis / 대한신장학회잡지

BACKGROUND: Cardiovascular mortality is high in patients with end-stage renal disease (ESRD). Although the factors contributing to ESRD-related vascular disease are incompletely understood, recent studies suggest that inflammatory reaction or chronic infectious disease may play an important role as new risk factors. The aim of present study was to measure coronary artery calcification score (CACs) and to investigate the association with various markers of systemic inflammatory reaction. METHODS: We conducted a cross-sectional study in 33 patients (M: F=23: 10, age=57+/-2 years) on maintenance hemodialysis. Multirow spiral CT (MSCT) was performed in all patients to measure CACs utilizing area and volume calculations. We measured high sensitivity C-reactive protein (hs- CRP) and interleukin-6 (IL-6) as indicators of inflammatory reaction, and measured IgA and IgG antibodies to C. pneumoniae, and IgG antibodies to H. pylori, cytomegalo virus, and herpes simplex. RESULTS: Median CACs equaled 379 (range, 0- 3, 662) by area and 338 (range, 0-2, 968) by volume. CACs more than 100 was present in 24 (73%) patients. Log (hs-CRP) was positively correlated with log (CACs) (area: r=0.37, p<0.05, volume: r=0.39, p< 0.05), but log (IL-6) was not. There was no significant relationship between CACs and antibody titers to C. pneumoniae, H. pylori, cytomegalovirus, and herpes simplex. Age was positively correlated with log (CACs) (area: r=0.39, p<0.05, volume: r=0.39, p< 0.05), but the presence of diabetes, smoking history, the duration of dialysis, body mass index, blood pressure, and serum cholesterol, albumin, PTH, calcium, and phosphorous levels were not. CONCIUSION: Coronary artery calcification was common in ESRD patients on hemodialysis, and associated with increased hs-CRP, an indicator of the presence of inflammatory reaction. There was no significant relationship between antibodies to chronic infections such as C. pneumoniae, but large-scale longitudinal studies are needed to evaluate fully that.

An Association Between Coronary Artery Calcification Score, C-Reactive Protein, and Antibodies to Infectious Disease in Patients on Maintenance Hemodialysis / 대한신장학회잡지

BACKGROUND: Cardiovascular mortality is high in patients with end-stage renal disease (ESRD). Although the factors contributing to ESRD-related vascular disease are incompletely understood, recent studies suggest that inflammatory reaction or chronic infectious disease may play an important role as new risk factors. The aim of present study was to measure coronary artery calcification score (CACs) and to investigate the association with various markers of systemic inflammatory reaction. METHODS: We conducted a cross-sectional study in 33 patients (M: F=23: 10, age=57+/-2 years) on maintenance hemodialysis. Multirow spiral CT (MSCT) was performed in all patients to measure CACs utilizing area and volume calculations. We measured high sensitivity C-reactive protein (hs- CRP) and interleukin-6 (IL-6) as indicators of inflammatory reaction, and measured IgA and IgG antibodies to C. pneumoniae, and IgG antibodies to H. pylori, cytomegalo virus, and herpes simplex. RESULTS: Median CACs equaled 379 (range, 0- 3, 662) by area and 338 (range, 0-2, 968) by volume. CACs more than 100 was present in 24 (73%) patients. Log (hs-CRP) was positively correlated with log (CACs) (area: r=0.37, p<0.05, volume: r=0.39, p< 0.05), but log (IL-6) was not. There was no significant relationship between CACs and antibody titers to C. pneumoniae, H. pylori, cytomegalovirus, and herpes simplex. Age was positively correlated with log (CACs) (area: r=0.39, p<0.05, volume: r=0.39, p< 0.05), but the presence of diabetes, smoking history, the duration of dialysis, body mass index, blood pressure, and serum cholesterol, albumin, PTH, calcium, and phosphorous levels were not. CONCIUSION: Coronary artery calcification was common in ESRD patients on hemodialysis, and associated with increased hs-CRP, an indicator of the presence of inflammatory reaction. There was no significant relationship between antibodies to chronic infections such as C. pneumoniae, but large-scale longitudinal studies are needed to evaluate fully that.

Sleep Disturbance and Myocardial Damage in Patients with End-Stage Renal Disease / 대한신장학회잡지

BACKGROUND: Recently, it was suggested that sleep disorders, like sleep apnea and periodic limb movements during sleep, are associated with the cardiovascular complications and outcomes seen in ESRD patients. This study investigated the association between sleep disturbances, including nocturnal hypoxemia, and myocardial damage in ESRD patients. METHODS: We conducted a cross-sectional study of 15 hemodialysis patients (age=50+-8 years, M: F= 11: 4, diabetes=6) who were classified as at high risk of sleep disturbance using the Epworth Sleepiness Scale and Sleep Disorders Questionnaire. Overnight polysomnographic studies were performed in these 15 patients to evaluate sleep parameters. The predialysis serum concentration of cardiac troponin T (cTnT) was measured as a marker of myocardial damage. RESULTS: Apnea+hypopnea index >5, which is a diagnostic criterion of sleep-related breathing disorder, was found in 12 (80%) patients. Several sleep parameters were associated with cTnT concentration. Sleep efficiency and lowest oxygen saturation decreased (p<0.05 and p=0.06, respectively), and average desaturation increased (p<0.05) with increasing cTnT concentration. Spearman's Rho, which was used to assess the relationships between the severity of sleep apnea and clinical parameters, showed that apnea+hypopnea index and oxygen desaturation index were negatively correlated (both p<0.01) with the serum concentration of uric acid. In multivariate analysis, the uric acid concentration was also independently associated with apnea+hypopnea index and oxygen desaturation index. CONCLUSION: Elevated concentration of cTnT was associated with poor sleep efficiency and severe oxygen desaturation during sleep, and the serum concentration of uric acid was lower in patients with severe sleep apnea.

A Medically Treated Case of Renal Artery Stenosis Presented with `Flash Pulmonary Edema' / 대한신장학회잡지

Renal artery stenosis is a rare cause of acute pulmonary edema. So-called flash pulmonary edema is associated with bilateral renal artery stenosis or stenosis in a single functioning kidney. Most patients have co-morbid cardiovascular disease and a renovascular etiology is overlooked. Flash pulmonary edema has been recognized as an absolute indication for vascular intervention. However, our case could be treated with medical treatment directing a complete inhibition of renin-angiotensin system. A 81- year old man was admitted with acute shortness of breath. During that admission, despite the dialysis therapy for renal insufficiency, he had four severe episodes of acute pulmonary edema requiring mechanical ventilation. CT angiography showed bilateral renal artery stenosis. After administration of ACE inhibitor, angiotensin receptor blocker, and spironolactone, there was no further attack of pulmonary edema.

Effect of Transforming Growth Factor-beta1 (TGF-beta1) on the Expression of Vascular cell Adhesion Molecule-1 (VCAM-1) in Cultured Human Peritoneal Mesothelial Cells (HPMCs) / 대한신장학회잡지

BACKGROUND: In early phase of peritonitis, mononuclear cells as well as polymorphonuclear leukocytes migrate rapidly into peritoneal cavity. For the migration of mononuclear cells, the expression of VCAM-1 on peritoneal mesothelial cells is important. In this study, we investigated the effect of TGF-beta1 on tumor necrosis factor-alpha (TNF-alpha) or interleukin-1beta(IL-1beta) induced VCAM-1 expression in the cultured HPMCs. METHODS: HPMCs were cultured in the presence of TNF-alpha, IL-1beta and/or TGF-beta1. VCAM-1 mRNA level was measured by Northern blot. VCAM-1 in total cell lysate and VCAM-1 expressed on cell surface were measured by Western blot and cellular ELISA, respectively. RESULTS: Incubation of the cultured HPMCs with TNF-alpha (10 ng/mL) or IL-1beta (1 ng/mL) caused an increased level of VCAM-1 mRNA, VCAM-1 protein in total cell lysate, and VCAM-1 expressed on cell surface. This stimulatory effects of TNF-alpha or IL- 1beta were inhibited by TGF-beta1 (0.1, 1, 10 ng/mL), dose-dependently. The level of VCAM-1 mRNA, VCAM-1 protein in total cell lysate, and VCAM-1 expressed on cell surface in the unstimulated cells were also inhibited by TGF-beta1 (10 ng/mL). The rate of VCAM-1 mRNA degradation after an application of actinomycin D was not affected by TGF-beta1. CONCLUSION: TGF-beta1 inhibited inflammatory cytokine induced VCAM-1 production and expression in the cultured HPMCs. Treatment of the cells with TGF-beta1 seems to suppress TNF-alpha or IL-1beta induced VCAM-1 mRNA transcription rather than decrease stabilization of VCAM-1 mRNA.

A Case of Idiopathic Fibrillary Glomerulonephritis / 대한신장학회잡지

A 17-year-old girl was admitted to our hospital due to mild generalized edema. Laboratory tests revealed a serum creatinine was 0.7mg/dL, protein/albumin 6.7/3.5g/dL, cholesterol 190mg/dL, hemoglobin 10.0g/dL, and 24 hour urinary protein 4,40mg/day. Chest X-ray and renal ultrasound were normal. There were no clinical or serologic evidences of paraproteinemia, cryoglobulinemia, light chain disease or systemic lupus erythematosus. Renal biopsy showed membranoproliferative glomerulonephritis-like pattern with lobular accentuation, hypercellularity and diffuse GBM thickening by light microscope. Congo red staining was negative. Granular IgG and C3 deposits were found along the glomerular capillary wall and mesangium by immunofluorescence microscope. Ultrastructurally, abundant subendothelial and mesangial fibrillary deposits were found associated with thickening and wrinkling of GBM. These fibrils, measured about 20-30nm in diameter, were nonbranching and randomly arranged without either periodicity or an organized structure. These findings were compatible with those of fibrillary glomerulonephritis. Thus we report a case of idiopathic fibrillary glomerulonephritis, which is a rare cause of nephrotic syndrome.

Clinical Significance and Prognostic Factors of IgA Nephropathy Developed in Renal Allograft / 대한신장학회잡지

Recently IgA nephropathy(IgAN) in transplanted kidney have been reported a more grave prognosis of the disease, which account for progressive allograft loss as 12-16%. But, the studies for the clinical significance and the prognostic factors of IgAN developed in transplanted kidney were not sufficient. We analyzed the frequency and the prognostic factors of IgAN developed in patients who underwent Kidney transplantation(KT) between January 1990 and October 1998. Total 231 renal biopsies was done. IgAN was diagnosed in 31 cases, and it was 13.4% of total cases and 24.4% of cases that acute rejection(AR) were excluded. After the 3 patients of IgAN was excluded due to combined AR, 28 patients were followed. The allograft dysfunction, which defined as serum creatinine at last follow-up was above 2.0 mg/dL, was observed in 10 patients(35.7%) and 4 patients(14.3%) of them had graft failure and restarted hemodialysis. The serum crcatinine and creatinine clearance at renal biopsy were significantly correlated with allograft dysfunction, also interstitial fibrosis, tubular atrophy and vascular fibrous intima1 thickening showed similar correlation with prognosis. In conclusion, when allograft dysfunction was developed, IgAN in transplanted kidney should be considered and if the evidences of elevated serurn creatinine and decresed creatinine clearence at biopsy, severe interstitial fibrosis and tubular atrophy, severe vascular fibrous intimal thickening were present, more closer follow-up and careful treatment should be taken.

Clinical Analysis on REnal Transplants at Asan Medical Center / 대한신장학회잡지

From June 1990 to December 1998, 792 kidney transplantations were performed at Asan Medical Center. 436 cases(55M) were from living-related donors, 139 cases(17.6%) were from living-unrelated donors and 217 cases(27.4%) were from cadaveric donors. The results of the trasnplantation were analyzed according to the various factors known to influence the outcome of transplantation. In living transplants, the overall patients survival rate was 98.2% at 1 year and 95.8% at 5 years, the corres-ponding allograft survival rate was 96.9 and 86.1N. In cadaveric transplants, the overall patients survival rate was 94.3% at 1 year and 94.3% at 5 years, the corresponding allograft survival rate was was 90.296 and 84.8%. In living transplants, donor age(>50yrs), recipient age(>50yrs), ABO compatability, pretrans-plant blood transfusion, diabetic history had no effect on allograft survival rate. But HLA DR cornpa-tability, serum creatinine(2.5mg/dL) at discharge and rejection history had effect on allograft survival(p50yrs), recipient age(>50yrs), ABO compatability, HLA DR match, diabetic history, pretransplant transfusion had no effect on allograft survival. But serum creatinine at discharge(>2.5mg/dL) and posttransplant rejection had effect on allograft survival.

A Case of Perigraft Seroma in Chronic Hemodialysis Patient / 대한신장학회잡지

Perigraft seroma is uncommon complication of polytetrafluoroethylene(PTFE) grafts applied as an arteriovenous shunt for hemodialysis. It is a collection of clear, sterile fluid confined to nonsecretory fibrous pseudomembrane, most commonly localized around the middle and distal portion of graft. The possible etiologic factors of perigraft seroma include poor graft incorporation, mechanical graft damage caused by alcohol and povidone-iodine, intraoperative streching of the graft, variations in quality control at the time of manufacture and contributing factors such as anemia and coagulopathy in uremia. The best strategy for management of perigraft seroma is not clear. spiration or drainage alone is not effective, and some authors advocate graft removal. We report a case of perigraft seroma around arterial end of PTFE graft along with a brief review of the literatures.

Difference of Pertoneal Solute Transport in CAPD Patients with and without Diabetes Mellitus: Measurement by Personal Dialysis Capacity(PDC) Test / 대한신장학회잡지

Using PDC test, peritoneal function in CAPD patients was compared between diabetes and non- diabetes. PDC test were performed in 12 diabetic and 11 nondiabetic CAPD patients. Urea, creatinine, and albumin were measured in each dialysate effluent. Blood urea nitrogen, creatinine, glucose, albumin, and sodium were measured in blood sample at the start and the end of the study. Area parameter(Ao/d x), hydraulic conductance(LpS), final absorption rate (JVAR), large pore fluid flux(JVr.), urea generation rate(UGR), creatinine generation rate (CGR), protein nitrogen appearance/protein catabolic rate(PNA/PCR), residual renal Ccr, total Ccr(PD Ccr+renal Ccr), water removal via PD, total ultrafiltration, and PD clearance of urea, creatinine, vitamin B12 b2 microglobulin, and albumin were calculated. In diabetic patients(n=12), serum albumin was lower in patients on CAPD for less 6 months than patients on CAPD for more 15 months. But total ultrafiltration was lower in patients on CAPD for more 15 months. In non-diabetics(n=ll), protein loss across the peritoneum was lower in patients on CAPD for more 15 months. Other PDC parameters were not different in diabetic and non-diabetic patients according to CAPD duration. In patients on CAPD for less 6 months, serum albumin and PNA/PCR were lower in diabetics than non-diabetics.

Hyperfiltration Affecting the Outcome of Living-related Renal Allograft / 대한신장학회잡지

It is well known that immunologic factors like rejection episode and HLA missmatch influence allograft loss and prognosis. However, non-immu- nologic factors such as glomerular hyperfiltration may also have an effect on the survival of the allograft. We measured relative kidney function(dkRF) by DMSA scan, GFR(dGFR) using EDTA and CCr dCCr) by 24-hour urine collection in donors of 70 adult living-related renal allografts engrafted at a single center between December 1992 and January 1994 as a donor work-up before transplantation, and calculated donated kidney GFR(dkGFR=dGFRxdkRF) and CCr(dkCCr=dkCCrxdkRF). We observed graft function for 5 years and analyzed the prognostic factors for the graft. Graft dysfunction was defined as the increase of serum creatinine 5 years after transplantation more than 1.5 times of stabilized serum creatinine at 3 months after transplantation. 1) Sixty patients were followed up for 5 years. Graft dysfunction was observed in 22 patients(37%) and maintenance renal replacement therapy was required in 9(15%) of them. 2) Of the non-immunologic factors, donor age was older in patients with graft dysfunction(51 +/- 12 years) than those without it(34 +/- 11 years, p<0.01), but dkGFR(54.1 +/- 12.2ml/min vs. 58.5 +/- 11.9mVmin), dkCCr(44.8 +/- 14.3mVmin vs. 50.74 13.4ml/min) and the ratio of body surface area(recipient/donor, 0.964 0.14 vs. 0.990.12) were not different in the two groups. Age of recipients and occurrence of graft glomerulopathy also were not different in the two groups. The episode of acute rejection was more frequent in patients with graft dysfunction(32%, 7/ 22) than those without it(3%, 1/38, p<0.01), but the degree of HLA missmatch was not different. In multivariate analysis, donor age(p<0.01) and the episode of acute rejection(p<0.05) were independent factors affecting graft dysfunction. 3) Donor age was older(52 +/- 12 vs. 3814 years, p<0.01) and the episode of acute rejection was more frequent(56%, 5/9 vs. 696, 3/51, p<0.01) in 9 patients with graft loss than those without it. However, dkGFR, dkCCr, body surface area ratio, recipient age, occurrence of glomerulopathy and HLA missmatch were not different. In multivariate analysis, donor age(p<0.05) and the experience of acute rejection(p<0.01) were independent factors affecting graft loss. We therefore conclude that donor age is more important as non-immunologic prognostic factors in graft dysfunction than GFR of the donated kidney and the difference in body mass between recipient and donor.

A Case of Vancomycin Resistant Enterococci(VRE) Peritonitis in a Patient on CAPD / 대한신장학회잡지

Peritonitis is a major complication of continuous ambulatory peritoneal dialysis and it remains the leading cause of patient droupout. VRE is a very serious pathogen because it is difficult to eradicate due to very limited effective antibiotics and because there is a possibility of transfer of this resistance to other gram-positive organisms including Staphylo-coccus aureus. We experienced a case of CAPD peritonitis by VRE, which was treated with high dose ampicillin and streptomycin without removal of CAPD catheter. We report our experience of CAPD peritonitis caused by VRE and review the literature.