Comparison of circuit patency and exchange rates between the original and generic versions of nafamostat mesylate in critically ill adults receiving continuous renal replacement therapy / 고신대학교의과대학학술지

Background@#Nafamostat mesylate is widely used as an anticoagulant in continuous renal replacement therapy (CRRT). The generic versions of nafamostat mesylate have identical main components to the original product. However, it is questionable whether the generic versions have the same efficacy as the original. Therefore, we compared the circuit patency and exchange rates of the original nafamostat mesylate and a generic version to determine which is more efficient as an anticoagulant in CRRT. @*Methods@#This retrospective study enrolled 1,255 patients hospitalized to receive CRRT who received the original version of nafamostat mesylate or a generic version between January 2010 and July 2018. We evaluated the filter lifespan, number of filters used per day, mean blood flow, and transmembrane pressure (TMP). @*Results@#The mean filter lifespan was 36.3±15.1 hours in the original product group and 22.2±16.2 hours in the generic product group, which was not a statistically significant difference (p=0.060). The mean TMP was 62.2±47.3 mmHg in the original product group and 74.5±45.6 mmHg in the generic product group (p=0.045). @*Conclusions@#This retrospective study suggests no meaningful difference in filter lifespan between the original and generic versions of nafamostat mesylate. However, TMP was lower in the original product group than in the generic product group.

The Natural Course of Total Kidney Volume in Patients with Autosomal Dominant Polycystic Kidney Disease undergoing Hemodialysis / 고신대학교의과대학학술지

Objectives@#The natural course of native kidneys after hemodialysis initiation in patients with autosomal dominant polycystic kidney disease (ADPKD) remains poorly understood. @*Methods@#We measured the total volumes of native kidneys in 12 patients who had at least one enhanced computed tomography (CT) image both before and after initiation of hemodialysis (group 1) and in 18 patients who had no image before dialysis but more than two images after dialysis (group 2). In patients with images, the last image was used for analysis only after dialysis. @*Results@#The mean total kidney volume (TKV) (± SD) before hemodialysis initiation was 3132 ± 1413 mL and the mean TKV of the last image was 3047 ± 1323 mL in group 1. The mean TKV change rate (%) was - 5.2 ± 27.4% (P > 0.05) during follow-up of 3.9 ± 1.9 years in group 1. The mean TKV change rate was 2.8 ± 34.4% (P > 0.05) in group 2. The follow-up period after dialysis initiation ranged from 4.2 ± 4.7 to 8.0 ± 5.2 years. @*Conclusions@#The results suggest that the TKV of native polycystic kidneys decreases substantially after hemodialysis initiation. This reduction occurs mainly during the early post-hemodialysis period and followed by a slow enlargement of TKV.

The influence of hypophosphatemia on outcomes of low- and high-intensity continuous renal replacement therapy in critically ill patients with acute kidney injury

BACKGROUND: The purpose of this study was to assess the role of hypophosphatemia in major clinical outcomes of patients treated with low- or high-intensity continuous renal replacement therapy (CRRT). METHODS: We performed a retrospective analysis of data collected from 492 patients. We divided patients into two CRRT groups based on treatment intensity (greater than or equal to or less than 40 mL/kg/hour of effluent generation) and measured serum phosphate level daily during CRRT. RESULTS: We obtained a total of 1,440 phosphate measurements on days 0, 1, and 2 and identified 39 patients (7.9%), 74 patients (15.0%), and 114 patients (23.1%) with hypophosphatemia on each of these respective days. In patients treated with low-intensity CRRT, there were 23 episodes of hypophosphatemia/1,000 patient days, compared with 83 episodes/1,000 patient days in patients who received high-intensity CRRT (P < 0.01). Multiple Cox proportional hazards analysis showed that Acute Physiology and Chronic Health Evaluation (APACHE) III score, utilization of vasoactive drugs, and arterial pH on the second day of CRRT were significant predictors of mortality, while serum phosphate level was not a significant contributor to mortality. CONCLUSION: APACHE score, use of vasoactive drugs, and arterial pH on the second CRRT day were identified as significant predictors of mortality. Hypophosphatemia might not be a major risk factor of increased mortality in patients treated with CRRT.

Changes in Insulin Sensitivity and Lipid Profile in Renal Transplant Recipients Converted from Cyclosporine or Standard Release Tacrolimus to Once-Daily Prolonged Release Tacrolimus / 대한이식학회지

BACKGROUND: Tacrolimus (Tac) can cause impaired insulin release and dyslipidemia, and may affect the development of post-transplant diabetes mellitus. However, these effects on insulin sensitivity and lipid profile have not been compared in renal transplant recipients receiving traditional twice-daily tacrolimus (TacBID) or cyclosporine and those receiving once-daily prolonged release formulation of tacrolimus (TacOD). METHODS: We conducted an observational prospective study of 15 stable non-diabetic renal transplant recipients to observe the changes in insulin sensitivity and lipid profiles for 1 year at a tertiary hospital. We evaluated the levels of hemoglobin A1c, total cholesterol, high density lipoprotein, low density lipoprotein, triglycerides, apolipoprotein A1, apolipoprotein B, serum creatinine, fasting plasma glucose, fasting insulin, homeostatic model assessment of β-cell (HOMA-β) and HOMA-insulin resistance index at baseline and at 2 and 4 months. To analyze differences in parameters, we conducted a Wilcoxon rank sum test and general linear model (GLM)-repeated measures analysis of variance (ANOVA) in both groups (cyclosporine to TacOD conversion group/TacBID to TacOD conversion group). RESULTS: At baseline, parameters did not differ between groups. GLM-repeated measures ANOVA revealed no change in insulin sensitivity or lipid profile after conversion at baseline or at 2 and 4 months. There were no complications after conversion from standard TacBID or cyclosporine to TacOD. CONCLUSIONS: There was no change in insulin sensitivity or lipid profile in renal transplant recipients. Any conversion from TacBID to TacOD should be performed in a controlled manner under close surveillance.

Relationships of Total Lymphocyte Count and Subpopulation Lymphocyte Counts with the Nutritional Status in Patients Undergoing Hemodialysis/Peritoneal Dialysis / 고신대학교의과대학학술지

OBJECTIVES: Dialysis patients' nutritional indicators are quite subjective and complex and cannot be easily measured in clinical settings. Based on previous reports that total lymphocyte count (TLC) and subpopulation lymphocyte counts (SLCs) are associated with nutritional status in patients with dialysis, we designed this study to examine the relationships of the TLC and SLCs with clinical outcome and nutritional status in patients undergoing maintenance hemodialysis (HD) and peritoneal dialysis (PD). METHODS: In this prospective, observational study, we enrolled 66 patients (50 HD patients and 16 PD patients) receiving stable maintenance dialysis. We evaluated the baseline parameters of height; weight; TLC; SLCs expressing CD3, CD4, CD8 and CD19; CBC; iron profile (iron, TIBC, ferritin); BUN; Cr; Na; K; total CO2; Ca; P; iPTH; protein; albumin; total cholesterol; HDL; LDL; uric acid and CRP and calculated Onodera's prognostic nutritional index (OPNI) and the Geriatric Nutritional Risk Index (GNRI) at baseline and three months. To analyze differences in the TLC and SLCs between the HD group and the PD group, we performed an independent samples t-test. Logistic regression analysis was performed to predict malnutrition in dialysis patients. In addition, to analyze changes in TLC, SLCs expressing each marker (CD3, CD4, CD8 and CD19) and other nutritional markers, we performed general linear model (GLM)-repeated measures ANOVA. RESULTS: Mean age was 55.8 ± 12.7 years in HD paitents and 49.8 ± 14.5 years in PD patients. The duration of dialysis was 59.7 ± 52.9 months in HD patients and 66.1 ± 33.6 years in PD patients. Logistic regression analysis revealed that patients aged 60 years or older, women, and those whose CD19 SLCs were lower than 100 had a higher risk of developing malnutrition. In GLM-repeated measures ANOVA, CD19 SLCs were significantly higher in women and in patients with a shorter period of dialysis. CONCLUSIONS: Our results indicate that GNRI, OPNI, TLC and SLCs (especially CD19 count) may be significant nutritional markers in HD and PD patients.

Acute Focal Myelitis Presented with Painful Tonic Spasm Involving Both Legs

No abstract available.

Acute Focal Myelitis Presented with Painful Tonic Spasm Involving Both Legs

No abstract available.

The Correlation Study between Plasma Aβ Proteins and Cerebrospinal Fluid Alzheimer's Disease Biomarkers

BACKGROUND AND PURPOSE: Alzheimer's disease (AD) is characterized by the accumulation of amyloid-β proteins (Aβ). In this study we explored the correlation of plasma Aβ40 and Aβ42 concentrations with Aβ42, total tau (tTau) and phosphorylated tau 181 (pTau181) levels in cerebrospinal fluid (CSF) in AD and control subjects to further understand the characteristics of plasma Aβ proteins levels. METHODS: The consecutive subjects (44 AD and 47 controls) in this study were recruited. The plasma levels of Aβ40 and Aβ42 were measured using a commercially available sandwich enzyme-linked immunosorbent assay (ELISA) kits. And the corresponding CSFs were analyzed in terms of Aβ42, tTau and pTau181 concentrations using INNOTEST ELISA kits. Further, the albumin levels were measured both in serum and CSF and albumin ratio was obtained to check the integrity of blood-brain barrier. RESULTS: CSF Aβ42 concentrations were significantly decreased while tTau and pTau181 levels were significantly increased in AD subjects. The plasma levels of Aβ42 were significantly lower (p=0.007), while the Aβ40/Aβ42 ratio was significantly higher (p<0.001) in AD patients than in controls. The overall plasma Aβ42 levels showed a positive correlation with those of CSF Aβ42 (p=0.001), but not with the others in CSF. In subgroup analysis, the CSF Aβ42 demonstrated positive correlation with not only plasma Aβ42 but also Aβ40 levels in controls. However, no significant relationship was noted between plasma and CSF Aβ proteins in AD group. CONCLUSIONS: The plasma Aβ42 and Aβ40 concentrations were shown to have a close relationship with CSF Aβ42 levels in controls, but not in AD subjects. Our results suggest that the correlation between plasma Aβ40 and CSF Aβ42 levels is perturbed in AD.

Atypical Early-Onset Alzheimer's Disease Dementia Diagnosed by Biomarker Study

BACKGROUND: The described clinical characteristics of early-onset Alzheimer's disease (EOAD) are distinct from that of late-onset AD. We reported a patient with atypical EOAD. CASE REPORT: A 54-year-old, truck driver developed gradual visuospatial, language and calculation deficits for 3 months. The neuropsychological impairments were extensive. Brain MRI revealed asymmetric atrophy in left medial temporal lobe along with distinct widening of sylvian fissure. (18)F-florbetapir-positron emission tomography (PET) showed a high uptake in the cortex. Further, the profiles of cerebrospinal fluid (CSF) biomarker were compatible with AD. CONCLUSIONS: We diagnosed the patient as EOAD based on the result of biomarker study. Increased Abeta burden was identified through amyloid PET imaging and decreased CSF Abeta level. The high rise of CSF Tau proteins was in agreement with the patient's extensive and rapid cognitive decline. This case report demonstrates the importance of AD biomarker study in confronting early-onset dementia with atypical clinical presentation.

Systemic Air Embolism after CT-guided Transthoracic Needle Biopsy

Systemic air embolism is rare event that occurs when air bubbles enter into the multiple organs through blood circulation. We report a case of a 76-year-old man who developed systemic embolism in cerebral, coronary and renal artery after computed tomography guided trans-thoracic needle biopsy. It is assumed that cerebral infarction in the inferior branch of right middle cerebral artery and renal artery infarction might be occurred because of both the procedure performed in prone position and the physical characteristics of the air.

The Clinical Characteristics according to the Educational Level in the Elderly Patients with Mild Alzheimer's Disease Dementia

BACKGROUND AND PURPOSE: Cognitive reserve is important for the individual susceptibility to dementia. Among the various determinants of cognitive reserve, the number of years of formal education would be of prime importance. We performed this study to explore its contribution to the clinical characteristics of dementia. METHODS: We included consecutive mild Alzheimer's disease (AD) dementia patients (clinical dementia rating, CDR=0.5 or 1) who visited our memory clinic and were older than 70 years at the evaluation from October 2013 to September 2015. According to the number of years of education, the corresponding subjects was grouped into two extreme educational groups, low education (illiterate or partially illiterate, LE, n=43) vs. high education (more than 9 years of education, HE, n=34). Among these patients, we compared various demographic, neuropsychological and neuroimaging characteristics. RESULTS: The groups were comparable in terms of age, frequency of hypertension and diabetes, and CDR and its sum of box. However, female gender was more frequent in the LE group (p=0.000). Also this group showed a more depressive mood on the geriatric depression scale (p=0.007). The raw scores on Korean Version of Mini-Mental State Examination and well-validated neuropsychological tests were lower in the LE group. However, the cognitive performance was found to be more preserved in the LE group than in the HE group when assessed using the z-score in certain specified tests on univariate and multivariate analyses (p<0.05). The Schelten's grade of medial temporal atrophy was similar between the two educational groups. Also, the degree of combined ischemic burden did not differ between the two groups. CONCLUSIONS: We identified that the prevalence of depressive mood and the extent of decline from the corresponding norm in a particular neuropsychological performance differ according to the educational level of mild AD patients.

Acute Ischemic Stroke Showing Microembolic Signals in a Patient With Autoimmune Hemolytic Anemia

Autoimmune hemolytic anemia (AIHA) can be considered in the differential diagnosis of hemolytic anemia with a concomitant cerebral infarction. We report a 79-year-old woman who was stuporous at presentation, and ultimately diagnosed with AIHA and cerebral infarction. Microembolic signals (MES) were detected by transcranial Doppler monitoring on the first hospitalization day. MES disappeared on the sixth hospitalization day following treatment with steroid and anticoagulation. This case represents a rare arterial ischemic complication of AIHA possibly associated with a hypercoagulable state.

A Case of Hydrothorax Aggravated by Peritoneal Dialysate Leakage in Compensated Liver Cirrhosis Patient with Ascites / 고신대학교의과대학학술지

The cirrhotic patients with ascites present unique challenge to the renal caregiver. Hydrothorax in a cirrhotic patient treated with PD poses a diagnostic dilemma. Proposed mechanisms for the development of a pleuro-peritoneal communication include congenital diaphragmatic defects, acquired weakening of diaphragmatic fibers caused by high intra-abdominal pressures during peritoneal dialysis, and impairments in lymphatic drainage. Pleural fluid analysis and diagnostic imaging assist in differentiation from other causes of pleural effusion. We report a case of hydrothorax in a compensated cirrhotic patient after recent introduction to peritoneal dialysis.

Bladder Pheochromocytoma Presented as Thunderclap Headache Triggered by Urination and Angina Pectoris / 고신대학교의과대학학술지

Pheochromocytoma is a catecholamine-producing tumor characterized by hypertension, headache, tachycardia, excessive diaphoresis, and angina pectoris. The thunderclap headache is so named because the pain strikes suddenly and severely. Although the symptoms of bladder pheochromocytoma are rather evident, the diagnosis of this rare neuroendocrine tumor can be missed. This study reports the case of a woman diagnosed with bladder pheochromocytoma who experienced thunderclap headache triggered by urination and angina pectoris as an initial manifestation. This case study suggests that thunderclap headache and angina pectoris occurring concurrently with sudden blood pressure elevation during or immediately after urination are important diagnostic clues of bladder pheochromocytoma.

Correlation between peripheral venous and arterial blood gas measurements in patients admitted to the intensive care unit: A single-center study

BACKGROUND: The objective of this study was to examine the correlation between arterial blood gas (ABG) and peripheral venous blood gas (VBG) samples for all commonly used parameters in patients admitted to a medical intensive care unit (ICU). METHODS: A single-center, prospective trial was carried out in a medical ICU in order to determine the level of correlation of ABG and peripheral VBG measurements. A maximum of five paired ABG-VBG samples were obtained per patient to prevent a single patient from dominating the data set. RESULTS: Regression equations were derived to predict arterial values from venous values as follows: arterial pH=-1.108+1.145xvenous pH+0.008xPCO2-0.012xvenous HCO3+0.002xvenous total CO2 (R2=0.655), arterial PCO2=88.6-10.888xvenous pH+0.150xPCO2+0.812xvenous HCO3+0.124xvenous total CO2 (R2=0.609), arterial HCO3=-89.266+12.677xvenous pH+0.042xPCO2+0.675xvenous HCO3+0.185xvenous total CO2 (R2=0.782). The mean ABG minus peripheral VBG differences for pH, PCO2, and bicarbonates were not clinically important for between-person heterogeneity. CONCLUSION: Peripheral venous pH, PCO2, bicarbonates, and total CO2 may be used as alternatives to their arterial equivalents in many clinical contexts encountered in the ICU.

Correlation between peripheral venous and arterial blood gas measurements in patients admitted to the intensive care unit: A single-center study

BACKGROUND: The objective of this study was to examine the correlation between arterial blood gas (ABG) and peripheral venous blood gas (VBG) samples for all commonly used parameters in patients admitted to a medical intensive care unit (ICU). METHODS: A single-center, prospective trial was carried out in a medical ICU in order to determine the level of correlation of ABG and peripheral VBG measurements. A maximum of five paired ABG-VBG samples were obtained per patient to prevent a single patient from dominating the data set. RESULTS: Regression equations were derived to predict arterial values from venous values as follows: arterial pH=-1.108+1.145xvenous pH+0.008xPCO2-0.012xvenous HCO3+0.002xvenous total CO2 (R2=0.655), arterial PCO2=88.6-10.888xvenous pH+0.150xPCO2+0.812xvenous HCO3+0.124xvenous total CO2 (R2=0.609), arterial HCO3=-89.266+12.677xvenous pH+0.042xPCO2+0.675xvenous HCO3+0.185xvenous total CO2 (R2=0.782). The mean ABG minus peripheral VBG differences for pH, PCO2, and bicarbonates were not clinically important for between-person heterogeneity. CONCLUSION: Peripheral venous pH, PCO2, bicarbonates, and total CO2 may be used as alternatives to their arterial equivalents in many clinical contexts encountered in the ICU.

A Case of Idiopathic Acute Renal Infarction / 대한내과학회지

Renal thromboembolism almost always occurs in the setting of cardiac disease. Acute renal infarction may occur rarely in middle-aged patients without apparent risk factors for cardiac thromboembolism. We report a 40-year-old man who developed bilateral renal infarction and had no cardiovascular risk factors, except smoking. In middle-aged healthy patients with renal colic without lithiasis, the diagnosis of idiopathic renal infarction should be considered, especially if lactate dehydrogenase is elevated.

A Case of Invasive Aspergillosis of the Paranasal Sinuses Treated with Surgery and Voriconazole after Kidney Transplantation / 고신대학교의과대학학술지

Invasive fungal sinusitis is a rare, severe disease, most commonly presenting in immunocompromised patients who have impaired neutrophil function or who have received long term immunosuppressive therapy. The gold standard for treatment has been wide surgical debridement, intravenous administration of antifungal agents such as amphotericin B (AMB), and correction of the underlying immunocompromised state. A 51-year-old female was admitted to our hospital with fever and headache who had received renal transplantation 14 years ago in the other hospital. Paranasal sinus CT scan revealed hyperplasia and soft tissue density of the left maxillary sinus. Histological examination of the fungus ball and edematous mucosa of the left maxillary sinus revealed suspicious invasion of Aspergillus in the mucosa. Clinical improvement occurred after a combination of surgery and post-operative systemic antifungal therapy with voriconazole. We think that voriconazole as initial treatment may be initiated for invasive sinonasal aspergillosis, if the infection is known to be due to Aspergillus species.

Reference Values for Serum Cystatin C by Nephelometric Immunoassay in Healthy Young Korean Men / 대한신장학회지

PURPOSE: In recent years, cystatin C (CysC) was proposed as a new marker for evaluating the glomerular filtration rate due to a constant serum level. The aim of this study was to measure serum CysC values of healthy young Korean men in assessment of kidney function and compare it with other reports until now in male populations, using nephelometric immunoassay. METHODS: CysC and creatinine levels were measured by particle enhanced nephelometric immunoassay and Jaffe method, respectively, in 145 young Korean men without evidence of kidney disease. Medline was searched for CysC reference values in healthy male populations. RESULTS: CysC values showed a normal distribution (Kolmogorov-Smirnov, K-S, p=0.2). The CysC reference interval for healthy young Korean men (age 19-29) was 0.58 to 0.94 mg/L (0.76+/-0.09 mg/ L, X+/-2SD, range 0.60 to 1.25 mg/L). Reference intervals for creatinine was 0.79 to 1.27 mg/dL (1.03+/-0.12 mg/dL, X+/-2SD, range 0.8 to 1.3 mg/dL) in subjects. Creatinine serum values did not show a normal distribution (K-S, p=0.001). The correlation coefficient for CysC and creatinine was only 0.308. (p=0.0001) Nephelometric CysC reference intervals we determined were consistent among different male populations. CONCLUSION: We determined reference intervals for CysC values in healthy young Korean men, and CysC reference values established by nephelometric immunoassay were consistent among different men population. This information could be useful in assessing renal function in healthy young Korean men.

A case of rapidly progressive renal failure induced by cadmium intoxication / 대한내과학회지

Cadmium (Cd)-induced renal damage primarily affects the cellular and functional integrity of the proximal tubules. Cd intoxication is a rare cause of Fanconi syndrome. We report a 31-year-old woman with Fanconi syndrome confirmed by laboratory findings and a renal biopsy that also showed an elevated urinary Cd. Seven months before admission, the patient had a normal urinalysis and renal function. Six and 3 months before admission, the patient ingested Chinese herbal mixtures. On admission, the blood Cd concentration was normal, and the urine Cd concentration was 58 microgram/g of creatinine, 29-times higher than the normal range. A renal biopsy showed degeneration of the proximal tubules with normal glomeruli. The serum creatinine had increased from 1.2 to 3.2 mg/dL over 8 months. This case of Fanconi syndrome and rapidly progressive renal damage over a short period was associated with elevated urinary Cd levels.