The Colonoscopic Characteristics and Clinical Manifestations Associated with Lower Gastrointestinal Tract Bleeding in Patients with Chronic Kidney Disease / 대한내과학회지

BACKGROUND/AIMS: Patients with chronic kidney disease (CKD) have a high risk of gastrointestinal tract bleeding because of platelet dysfunction attributable to uremia, a poor blood supply, and frequent use of anticoagulant agents. We describe the colonoscopic characteristics of lower gastrointestinal tract bleeding (LGIB) in patients with CKD. METHODS: A total of 230 hospitalized patients with CKD who underwent colonoscopy because of suspected LGIB between January 2003 and August 2016 were reviewed retrospectively. We categorized CKD into five stages according to the estimated glomerular filtration rate and compared the colonoscopic findings and clinical manifestations among these five subgroups. RESULTS: Of the 230 patients with CKD suspected of LGIB, 73 (31.7%, 103 cases) were colonoscopically confirmed to exhibit LGIB. Their mean age was 65.7 ± 12.8 years, and 52.1% were female (n = 38). The most common causes of LGIB were hemorrhoidal bleeding (32 cases, 43.8%), followed by bleeding of colorectal ulcers (21 cases, 28.8%), diverticular bleeding (12 cases, 16.4%), colitis-related bleeding (12 cases, 16.4%), and angiodysplastic bleeding (12 cases, 16.4%). As the CKD stage progressed, the incidence of LGIB increased (p = 0.043). On multivariate logistic regression analysis, LGIB was more common in CKD patients with hemorrhoids (odds ratio [OR]: 4.349, 95% confidence interval [CI]: 2.043–9.256, p < 0.001) or colorectal ulcers (OR: 20.001, 95% CI: 4.780–83.686, p ℃ 0.001) and in those on hemodialysis (OR: 6.863, 95% CI: 1.140–41.308, p = 0.035). CONCLUSIONS: In CKD patients, the risk of LGIB is significantly increased by hemorrhoids, colorectal ulcers, and a positive hemodialysis status.

The Colonoscopic Characteristics and Clinical Manifestations Associated with Lower Gastrointestinal Tract Bleeding in Patients with Chronic Kidney Disease / 대한내과학회지

BACKGROUND/AIMS@#Patients with chronic kidney disease (CKD) have a high risk of gastrointestinal tract bleeding because of platelet dysfunction attributable to uremia, a poor blood supply, and frequent use of anticoagulant agents. We describe the colonoscopic characteristics of lower gastrointestinal tract bleeding (LGIB) in patients with CKD.@*METHODS@#A total of 230 hospitalized patients with CKD who underwent colonoscopy because of suspected LGIB between January 2003 and August 2016 were reviewed retrospectively. We categorized CKD into five stages according to the estimated glomerular filtration rate and compared the colonoscopic findings and clinical manifestations among these five subgroups.@*RESULTS@#Of the 230 patients with CKD suspected of LGIB, 73 (31.7%, 103 cases) were colonoscopically confirmed to exhibit LGIB. Their mean age was 65.7 ± 12.8 years, and 52.1% were female (n = 38). The most common causes of LGIB were hemorrhoidal bleeding (32 cases, 43.8%), followed by bleeding of colorectal ulcers (21 cases, 28.8%), diverticular bleeding (12 cases, 16.4%), colitis-related bleeding (12 cases, 16.4%), and angiodysplastic bleeding (12 cases, 16.4%). As the CKD stage progressed, the incidence of LGIB increased (p = 0.043). On multivariate logistic regression analysis, LGIB was more common in CKD patients with hemorrhoids (odds ratio [OR]: 4.349, 95% confidence interval [CI]: 2.043–9.256, p < 0.001) or colorectal ulcers (OR: 20.001, 95% CI: 4.780–83.686, p ℃ 0.001) and in those on hemodialysis (OR: 6.863, 95% CI: 1.140–41.308, p = 0.035).@*CONCLUSIONS@#In CKD patients, the risk of LGIB is significantly increased by hemorrhoids, colorectal ulcers, and a positive hemodialysis status.

A Case of Bad Prognosis for Membranous Nephropathy in a Patient with Mixed Connective Tissue Disease

Incidence of renal involvement in mixed connective tissue disease (MCTD) is low. In the presence of glomerulonephritis, membranous nephropathy (MN) in MCTD is common. A 47-year-old woman presented with hypothyroidism. She developed Raynaud's phenomenon, arthralgia, and incomplete lupus erythematosus, diagnosed with MCTD. One year after then, the patient developed persistent proteinuria (1+) without hematuria. Following diagnosis with MCTD, her renal function began to deteriorate. The renal biopsy showed late stage MN. For the treatment of MN with mild proteinuria and MCTD, we prescribed an angiotensin II receptor blocker and 7.5 mg of methotrexate per week and 300 mg of hydroxychloroquine daily. The patient had a reduced estimated glomerular filtration rate of 55% for the subsequent eight years. The MN in MCTD is known to show good renal prognosis. Here, we report on a rare case of MN in MCTD in Korea with a bad prognosis.

A Case of Primary Aldosteronism due to Remnant Adenoma after Adrenalectomy in Pregnant Woman / 대한신장학회지

Primary aldosteronism is present in approximately 1 percent of hypertensive patients, and is rarely associated with pregnancy. We report a case of unilateral aldosterone producing adenoma in a pregnant woman. A 29-year-old woman was referred to with hypertension and proteinuria at 14 weeks' gestation. She had known that she had unilateral aldosterone producing adenoma for 18 months and refused medical or surgical treatment. She was prescribed antihypertensive medication and preformed laparoscopic adrenalectomy in left adrenal gland at 22 weeks' gestation. After adrenalectomy, her blood pressure was normal. At 29 weeks' gestation, she complained headache, and her blood pressure was 200/100 mmHg with pitting edema. We thought preeclampsia and performed cesarean section. After the baby was delivered, she had uncontrolled hypertension, hypokalemia with persistent proteinuria. We checked plasma renin activitity, aldoterone and abdminopelvic computed tomography. We found remnant left adrenal adenoma and perfomed laparoscopic operation. After reoperation, her blood pressure was normal and no proteinuria.

A Case of Invasive Aspergillosis in Transplanted Kidney and Perirenal Area / 대한이식학회지

Recently, the incidence of fungal infection increases because of immunosuppressive therapy and chemotherapy. In immunosuppressed transplant recipients, Aspergillus can be a dangerous pathogen, capable of inducing fulminant clinical disease. Invasive fungal infections are life-threatening complications in solid-organ transplantation. Although the rate of fungal infections in transplant recipients is lower than that of other infections, the mortality rate is higher. A 34 year-old male was admitted to our hospital with fever and gross hematuria. He had received renal transplantation 2 years ago and had been transferred the other hospital 1 month ago. Initial laboratory data evaluation showed a pancytopenia and azotemia. We thought that pancytopenia was caused by immunosuppressive agents and infection. The patient was treated with antibiotics but fever was not subsided. After 4 days, he complained of transplant site pain and tenderness to percussion. A percutaneous renal biopsy was performed. Microscopic examination showed invasive aspergillosis in transplanted kidney and perirenal area. We removed the transplanted kidney and perirenal tissue, and prescribed antifungal agents for 3 months.

Transfusion Free Kidney Transplantation in Jehovah's Witness Patients / 대한이식학회지

Transfusion free surgery is of increasing interest as more patients are refusing a blood transfusion because of religious belief, infection or fear of a blood-transmitted disease such as AIDS. Patients of the Jehovah's Witness faith generally do not accept transfusions of blood or blood products but some will accept cadaveric organs for transplantation. Recently, it is possible to perform 'bloodless' autologous or reduced-intensity allogeneic transplants in properly selected patients. The success of these procedures depends on the transplantation technique and on meticulous attention to blood conservation and supportive care. In our center, nine Jehovah's Witness received a kidney transplantations and transfusion free surgery. All the patients received erythropoietin injection and iron supplement before kidney transplantation. They were not serious bleeding in surgery and graft dysfunction after surgery. All the recipients are alive and have well functioning grafts. Elective living donor kidney transplantation allows implementation of a transfusion free strategy. We think that various methods replaced blood transfusion reduced risk of postoperative anemia and unnecessary transfusion.

Licorice-nduced Hypokalemia and Myopathy / 대한신장학회잡지

Chronic ingestion of licorice or licorice-like compounds induces a syndrome with typical findings of mineralocorticoid excess such as hypertension, hypokalemia, metabolic alkalosis, low plasma renin activity. The only unique feature is that plasma aldosterone concentration is decreased. We described a 79-year-old woman who, with a plasma K+ 1.75 mEq/L, showed a paralysis and severe rhabdomyolysis after the habitual comsumption of licorice in the form of a herbal medication. Following potassium replacement therapy and discontinuation of licorice ingestion, complete clinical recovery was observed within ten days. It is important for physicians to keep licorice consumption in mind as a cause for hypokalemic paralysis and rhabdomyolysis.

A Case of Primary Aldosteronism with End Stage Renal Disease

A 52-year-old woman was referred to our hospital due to chronic renal failure with a 10-year history of hypertension. We found polycystic kidney disease, pulmonary tuberculosis and an aldosterone-producing adrenocortical mass. At this time, her serum potassium level and blood pressure were within the normal range. She refused hemodialysis and then was hospitalized because of uremic encephalopathy. On admission, her serum potassium level was normal without treatment and plasma aldosterone concentration highly elevated. She received hemodialysis, and thereafter hypokalemia developed. We then administered spironolactone, whereupon serum potassium level returned to the normal range. In this case, we thought that normokalemia was balanced hypokalemia of primary aldosteronism with hyperkalemia of chronic renal failure, and that hypokalemia developed after hemodialysis was due to an imbalanced primary aldosteronism with end stage renal disease.

Aortic Stenosis in Systemic Lupus Erythematosus Syndrome / 대한흉부외과학회지

Systemic lupus erythemotosus (SLE) is an autoimmune disorder with dermal, renal, and cardiac manifestations. It frequently has cardiovascular complications such as pericarditis, myocarditis, and valvular heart diseases. Valvular heart diseases in SLE comes mainly in the form of mitral or aortic insufficiencies. Report of aortic stenosis is extremely rare. Surgical treatments of valvular heart disease in SLE are not done frequently because of complications in other organs. Aortic stenosis developed in a 59 year-old woman with SLE, and aortic valve replacement was done successfully.

Cytomegalovirus colitis causing toxic megacolon in a patient with focal segmental glomerulosclerosis / 대한내과학회지

Cytomegalovirus is a frequent opportunistic pathogen in immunosuppressed patients and CMV colitis is one of its major complications. It usually presents as gastrointestinal ulceration with bleeding or perforation, but it can also take less common forms resembling many other entities, including viral gastroenteritis, ischemic colitis, intestinal pseudo-obstuction, toxic megacolon. We experienced a 49-year-old man with symptom of severe constipation and lower abdominal pain. He was diagnosed as having focal segmental glomerulosclerosis by renal biopsy, but he was an immunocompetent state. An abdominal X-ray showed marked dilatation of descending colon without air-fluid level. At colonoscopy and biopsy, he was diagnosed as having CMV colitis with focal stenosis. Treatment for two weeks with ganciclovir resulted in resolution of colitis, but stenosis was remained. We report a case of toxic megacolon and focal stenosis due to CMV colitis in a FSGS patient. It was not certain whether FSGS was related with immunosuppressive state.

The Clinical Profiles and Risk Factors and Outcome of CAPD Peritonitis : A Single Center Study / 대한신장학회잡지

Peritonitis remains the leading cause of the patient dropout in CAPD in many developing countries. In Korea, 71% of CAPD patients dropout is caused by peritonitis. To elucidate an adequate guideline for treating peritonitis in our country, we analyzed clinical and bacteriologic profiles of peritonitis(1995. 1. 1- 1999. 12. 31). Two hundred and twenty eight episodes of peritonitis were developed in 127/247 patients. The incidence of peritonitis was 0.41/patient-year in general, which was decreased to 0.24/patient-year in 1999. The incidence of causative organisms were as follows; 82(36.0%) by Gram positive organisms, 38 (16.2%) by gram negative organisms, 16 cases(7.0%) by mixed organsisms, and 5 cases(2.2%) by fungus. During study period, the incidence of peritonitis by gram positive organsism was decreased while the incidence of peritonitis by gram negative organism was not changed. Recurrent infection/relapse was noted in 58 patients(45%). Peritonitis were eradicated only in 66% of the cases by initial antibiotics(cefazolin+aminoglycoside); and another 17% responded by second line antibiotics. Peritoneal catheters were removed in 38 episodes(16.7%). Patients with exit infection were more frequent in removal of catheter. Risk factor analysis was performed in 146 patients, who were newly started CAPD. There were 60 initial episodes of peritonitis(mean duration of follow up was 16.7 patient months). Sixty-five percent were free of peritonitis at the end of first year, 54% at the end of second year and 45% at the end of third year (Kaplan-Meier). Factors such as age, sex, underlying DM, were not risk factor for CAPD peritonitis. In conclusion, we observed that the incidence of peritonitis decreased every year. It was revealed however that only 66% of peritonitis can be successfully treated by first line antibiotics. Second line antibiotics such as ceftazidime may need to be introduced in early phase of CAPD peritonitis. Up to one third of patients had recurrent infection/relapse, which raised the incidence of peritonitis. Continuing education as well as better exit care is needed to improve technical survival of CAPD patients in Korea.

The Clinical Significance of tCO2 as a Marker of Nutritional Status in Stable Hemodialyzed Patients / 대한신장학회잡지

Metabolic acidosis is a well-recognized complication of chronic hemodialyzed patients. The metabolic acidosis in stable hemodialyzed patients is mainly resulted from the consequences of the inability to excrete nonvolatile acid and the patients daily protein intake. So severe metabolic acidosis in patients on hemodialysis is known as an independent determinant of protein catabolic rate and high mortality rate but the moderate degree of metabolic acidosis in stable patients on maintenace hemodialysis can be explained by the patients nutritional status. On the other hand, patients having adequate daily protein intake could have lower total CO2 levels than those of patients having inadequately lower daily protein intake. To identify this relationship, we analyzed correlations between pre-hemodialysis total CO2 and various factors reflecting the patient's nutritional status in 37 patients on stable hemodialysis. The total CO2 was ranged from 15.6 to 26.5mMol/L. Among various factors, total CO2 had negative linear correlation with normalized protein catabolic rate(nPCR) reflecting the patient's daily protein intake indirectly(Y= -0.0371X+1.75, r=-0.1319, P=0.014). Moreover, metabolic acidosis having CO2 lower than 18mMol/L may modulate protein kinetics as showing steeper slope than those of more than 18mMol/L(Y=-0.1321 X +3.342, r2=0.1074 vs Y=-0.03373X+1.7543 r2=0.1001, P=0.0001). However other factors including serum albumin, body mass index, pre-hemodialysis BUN, and Kt/V, had no correlation with the total CO2. The result suggested that moderately lower pre- hemodialysis total CO2 ranging from 18 to 26.5 mMol/L was usually resulted from the high intake of the patient's daily protein intake and should be of no concern in stable patients on maintenance hemodialysis and it may use as a parameter of nutritional status. However metabolic acidosis having CO2 lower than 18mMol/L may modulate protein-kinetics, which may make the protein catabolic rate increased and can not reflect the patient's nutritional status. But it should be recommended that further studies should be needed to confirm this factor.

nPCR as an Influencing Factor on rHuEPO Response / 대한신장학회잡지

Owing to the mass production of recombinant human erythropoietin(rHuEPO), anemia in hemodialysis patients is effectively treated by intravenous or subcutaneous injection of rHuEPO at each dialysis session. But considerable portion of patients being injected rHuEPO have the resistance of EPO treatment. The most common cause of EPO resistance is caused by functional and storage iron deficiency and followed by chronic inflammation, hyperparathyroidism and aluminum intoxication in its incidence. But the rHuEPO resistance is not fully explained by these causes. In the present study, the relationship between nPCR reflecting daily protein intake and the weekly doses of rHuEPO required to maintain hemoglobin levels at approximately 10gm/dL was analyzed in 34 hemodialysis patients All subjective patients of 34 hemodialysis were injected rHuEPO subcutaneously and divided into two group:Group A composing 22 hemodialysis patients is nPCR=1.0gm/kg/day. There were no significant differences in age, duration of hemodialysis, serum ferritin, serum iron, TIBC, transferrin saturation(%) of each group. The patients who had serum ferritin below 100 micro gm/dL or transferrin saturation(%) below 20% were excluded in this study. The weekly rHuEPO doses in patients with Group B was lower than those of patients with Group A(58.7627+/-20.465IU/kg/week vs 80.4317+/-38.6258IU/kg/week, P=0.041). Moreover Serum albumin levels in Group A were significantly lower than those of Group B(3.6522+/-0.4461gm/dL vs 4+/-0.3606gm/dL, P=0.031) and Kt/V in Group B were significantly higher than those of Group A (1.145+/-0.2049+/-1.4021+/-0.2981, P=0.021). Serum parathyroid hormone levels were significantly higher in Group A than those of Group B(171.9783+/-150.3378 pg/dL vs 72.8809+/-79.7226 pg/dL, P=0.049). But other various factors including serum aluminum, body mass index and acute phase reactant proteins such as C-reactive protein and ESR had no significant differences in each group. CONCLUSION: Our result showed that nPCR presenting daily protein intake is related with rHuEPO response and the patient's nutritional status. So we think that the nutrition aspect in EPO treatment should be considered. However, to prove this relationships completely between nutritional factors and rHuEPO response, further study shoud be needed.

Increased mRNA Encoding for Transforming Growth Factor-beta in Peripheral CD4+ Lymphocytes Stimulated with Mitogen from Patients with IgA Nephropathy / 대한신장학회잡지

NO abstract available.

Echocardiographic Differences between Hemodialysis and Essential Hypertension Patients and the Correlations with Factors Affecting the Differences / 대한신장학회잡지

To compare the differences between hemodialysis and essential hypertension patients and its affecting factors of left ventricular hypertrophy and left ventricular systolic dysfucntion in patients with hemodialysis, M-mode and two dimensional echocardiography were performed in 77 essential hypertension without azotemia and 78 chronic renal failure patients receiving maintenance hemodialysis. M-mode measurement including LV mass (192.56+/-63.6g vs 300.01+/-95.99g, P=0.000), r/th (radius/LV thickness, 4.41+/-0.97 vs 4.74+/-1.0, P=0.039), LV dimemsion and fractional shortening (4.68+/-0.6 vs 5.63+/-0.97, P=0.000, 30.0+/-19.7% vs 36.6+/-97%, P=0.000 respectively) showed more severe eccentric LV hypertrophy and LV dysfunction in patients with hemodialysis than those of essential hypertension. Using Pearson correlation in hemodialysis patients, Interdialytic weight gain was positively correlated with LVEDD (r=0.318, P=0.005). In addition to the determinant, serum PTH level was negatively (r=-0.344, P=0.002) and Kt/V (r= 0.0487, P=0.003) was positively correalated with systolic function. The hypertension and dialysis duration, patient's age, had no relationship with LV function and mass in this study. In Conclusion, LV hypertrophy and LV systolic dysfunction occur more frequently in hemodialysis patients than in essential hypertension patients. And the LV systolic dysfunction, which is acutally related with the patient's quality of life, was partially explained by serum parathyroid level and Kt/V. But additional laboratory and prospective clinical studies are needed to further elucidate the mechanisms involved in the development of LVH and LV impairment in hemodialysis patients.