A Case of Idiopathic Membranous Glomerulonephritis in association with Thin Glomerular Basement Membrane Nephropathy / 대한신장학회잡지

We report a rare case of the idiopathic membranous glomerulonephritis (IMGN) in association with the thin glomerular basement membrane nephropathy (TGBMN) in a 63-year-old female with hematuria. This is the first case reported in Korea. In renal biopsy of this case, direct immunofluorescence demonstrated anti-IgG Ab along the glomerular capillary wall with granular pattern. The basement membrane was thin, about 170-220 nm and small epimembranous electron dense deposits were observed by electron microscopy. As this case, the combination of TGBMN and IMGN is very uncommon because the IMGN is characterized morphologically by diffuse global thickening of the glomerular capillary wall, while the TGBMN is defined as an extreme thinning of the glomerular basement membrane, less than 200 nm. Our case showed no renal function deterioration and benign prognosis as other reports showed.

The Influence of Mycophenolate(MMF) and Azathioprine(AZA) in the Same Cadaveric Renal Transplantation / 대한신장학회잡지

OBJECTIVE: In order to evaluate how immunosuppressive agents such as MMF and AZA would influence on the outcome of the graft kidney, we analyzed the incidence of acute rejection episodes and one year graft survival rate after minimizing influences of donor factors by grafting the same cadaveric donor kidney. METHODS: From April, 1998 to January, 2000, sixty eight patients grafted by 34 cadaver donors were enrolled in our study. From the same donor, one was randomly assigned to the MMF group(n=34) who were treated with cyclosporine, MMF, prednisolone while the other kidney was assigned to the AZA group(n=34) with cyclosporine, AZA, prednisolone. We analyzed the incidence of acute rejection episodes and CMV infection within the first 6 months of renal transplantation and one year graft survival rate was studied prospectively. RESULTS: There were no significant differences in sex, HLA mismatch, cold ischemic time, and patients' weight between two group. Acute rejection or treatment failure occurred in 35.3% in the MMF group by 6 months after transplant, compared with 32.4% in the AZA group without statistic significance(12/34 vs. 11/34, p>0.05). One year graft survival rate was 91.2% and 97.1%, respectively, and CMV infection was documented in 4 patients(1/34 vs. 3/34, p>0.05). CONCLUSION: There were no significant differences in the incidence of acute rejection episodes and one year graft survival rate between two groups. In contrast, previous studies showed that MMF could have lowered the incidence of acute rejection episodes and improved graft survival rate. This discrepancy in results might be explained that donor factors were important to cadaveric renal transplantation. Thus, we suggest that the influences of donor factors should be considered in further clinical study of cadaveric renal trans-plantation.

Cadaveric Renal Transplantation between Donor and Recipient Both are Hepatitis B Virus Positive / 대한신장학회잡지

There has been studies constantly reporting on high rate mortality of renal transplantation of hepatitis B virus(HBV)-positive subject because the direct and indirect effect of immunosuppressive agent which was administrated after a transplantation worsens hepatitis or causes hepatic failure. But recent studies have reported that there is no difference in graft rejection, infection and survival rate of the graft or the host between hepatitis positive and negative groups. And, after lamivudine which suppresses HBV replication is introduced into renal transplantation, transplantation of HBV-positive subjects has taken on a new aspect. But it has been hard to find the reports about renal transplantation between donor and recipient both are hepatitis B virus positive in documents, because, in most cases of those reports, the recipient was hepatitis B virus positive but the donor who offers kidney was hepatitis virus negative. This study selected all 9 cases of cadaveric renal transplantation between HBV-positive cadaveric donor and HBV-positive chronic renal failure(CRF) patient who were operated at Samsung medical center from March of 1997 to August of 2000, then analyzed the medical records of five donors and nine recipients retrospectively. Six cadaveric donors(5 male, 1 female, age 15-52) and nine recipients(4 male, 5 female, age 23-52, median dialysis period 23 months) were included. During following up periods of 42 to 12 months (median 24 months) after renal transplantation with HBV DNA, serum ALT and serum creatinine change of hepatic function and renal function were observed and a development of infection and other complication were also investigated. Any case didn't come out fulminant hepatitis or liver cirrhosis. Four cases came out hepatic dysfunction. Among these, one case was diagnosed to CsA hepatotoxicity. One case came out a transient increase of ALT more than six months, since then was normilized. One case came out acute hepatitis and one case recurrent hepatitis. The rest constantly came out normal hepaitc function. In all the cases lamivudine treatment was practiced and the major indication were positive HBV DNA and a increase of ALT. In the recent test the eight cases came out a normal ALT and the only one case came out a little increase of ALT, 60 IU/L. Renal function was relatively well maintained. Three cases came out acute rejection, but it was successfully recovered. Chronic rejection didn't occur. In the recent test the eight cases came out a normal serum creatinine except one case(28 month after transplantation) which 1.5 mg/dL of serum creatinine appeared. When we consider our situation possessing much more recipients than donors of renal transplantation, this trial to expand the scope of donor to HBV- positive patients as well as the activation of cadaveric renal transplantation is a clinically meaningful effort especially in Korea and Asian countries which have a plenty of hepatitis carriers and chronic hepatitis patients. And we consider this new trial needs to continue comparative analyzation through long term observation.

Medullary Nephrocalcinosis Associated with Long-term Furosemide Abuse in Adults / 대한신장학회잡지

BACKGROUND: The use of furosemide is well recognized as a predisposing factor to nephrocalcinosis (NC) in infants. Although furosemide is widely used for various clinical settings in adults, the association of furosemide use and nephrocalcinosis in adults is not well established. METHODS: We studied 18 consecutive adult patients(male : female=1 : 17, age range 21-59 years) who took furosemide habitually to control their weights or edema for a long-term period(range 3-25 years). NC was evaluated using renal ultrasonography(US), computed tomography(CT) and/or kidney biopsies. Patients were categorized into NC(+) and NC(-) groups while the difference in clinical features were investigated. RESULTS: Renal US and CT revealed nephrocalcinosis in the bilateral medullary pyramids in 15(83.3 %) out of 18 patients. The duration of furosemide abuse was not different between NC(+) and NC(-) groups(10.1+/-1.7 years vs. 15.3+/-0.9, p>0.05). The daily dose of furosemide was higher in NC(+) group than the NC(-) group(538+/-174 vs. 67+/-13 mg/day, p0.05). The kidney biopsies performed in three patients showed focal tubulointerstitial fibrosis and atrophy and calcifications were observed at outer medullary tubulointerstitium. CONCLUSION: Long-term furosemide abuse could cause medullary nephrocalcinosis in adults and the risk of developing of nephrocalcinosis is correlated with the daily dose of furosemide. We suggest that long-term furosemide abuse should be suspected in adult patients when medullary nephrocalcinosis is incidentally detected by US and/or CT.

Dissociation between Clearances of Small and Middle Molecules in Incremental Peritoneal Dialysis / 대한신장학회잡지

OBJEVTIVE: To evaluate the peritoneal clearance of the middle molecule compared with that of the small molecule in incremental peritoneal dialysis(PD). METHODS: Peritoneal clearances of the creatinine and beta2-microgloblulin were compared in 57 continuous ambulatory PD patients with full dose 4 times exchange and in 54 incremental PD patients with 2 or 3 times exchange over 24 hours. The clearances were also compared when there were changes in the peritoneal dialysis regimen such as in the number of exchanges and dwelling time. RESULTS: Peritoneal creatinine clearance increased almost linearly along with the increase in the number of exchanges. In contrast, peritoneal clearance of beta2-microglobulin was 9.1+/-3.6 L/week, 8.8+/-4.4 L/ week, and 7.9+/-2.5 L/week respectively with 2, 3 and 4 exchanges per day, not different from each other. Peritoneal clearance of beta2-microglobulin did not change when there was an increase in the number of exchange from 2 to 3 times and 3 to 4 times over a period of 24 hours, whereas the peritoneal clearance of creatinine increased. Peritoneal clearance of beta2-microglobulin almost doubled from 5.4+/-2.7 L/ week with 2 times exchange over 12 hours per day, to 9.5+/-4.4 L/week with 2 times exchange over 24 hours, whereas the creatinine clearance did not change. CONCLUSION: In contrast to peritoneal clearance of small molecule which depends on the number of dialysate exchange, peritoneal clearance of middle molecule depends mainly on the total dwelling hours rather than the number of exchange per day in incremental PD. This can be another advantage of incremental PD since peritoneal clearance of middle molecules in incremental PD over 24 hours is comparable to that in full dose PD.

A Magnetic Resonance Angiographic Diagnosis and Successful Thrombolytic Therapy in The Thrombosis of Renal Vein Complicated from Nephroitc Syndrome / 대한신장학회잡지

The nephrotic syndrome has been considered a hypercoagulable state since it may be complicated by thromboembolic events of the venous or the arterial circulations. Diverse pathogenetic factors leading to the hypercoagulable state in nephrotic syndrome have been recognized. Renal vein thrombosis is a serious complication, which might lead to either renal failure or to secondary thromboembolic processes like pulmonary thromboembolism. Although it may present acutely with flank pain and macroscopic hematuria, the majority of cases run an indolent course. Until relatively recently, the diagnosis could only be confidently confirmed or excluded with selective renal venography but, more recently, computerized tomography and magnetic resonance imaging have been used. Anticoagulant therapy with heparin and warfarin apparently halts the natural progression of the disease and allowing for slow recovery. The possibility of more rapid and complete resolution with thrombolytic agents warranted their application. We described a case of bilateral renal vein thrombosis diagnosed by the new technique of magnetic resonance angiography and successful treatment by thrombolytic agent.

The Effect of Hemodialysis During Break-in Period on Residual Renal Function in CAPD Patients / 대한신장학회잡지

To avoid later complication of peritoneal dialysis catheter, it is recommended to delay regular exchange of peritoneal dialysis for about 2-4weeks after insertion of catheter(break-in period). During break-in period some patients need hemodialysis(HD) or other intermittent dialysis. In such cases residual renal function(RRF) can decrease substantially compared with patients who do not need HD during break-in period since RRF is preserved better in CAPD patients than HD patients. This is prospective observational study to examine such an effect of HD during break-in period on residual renal function in CAPD patients. 20 patients who were clinically stable and had been on CAPD since March, 1999 were observed. 6 patients were treated with HD for 1month during break-in period and CAPD thereafter(group A). 14 patients were treated with CAPD without HD(group B). GFR(mean of creatinine and urea clearance of urine) and urine Kt/V urea were measured at start, and 1, 3, 6 months of renal replacement therapy. Covariables analyzed in this study were mean arterial blood pressure, serum albumin, hemoglobin, hematocrit, age, sex, the presence of diabetes mellitus, and peritonitis episode. There was no significant difference in initial RRF, mean arterial blood pressure, serum albumin, hemoglobin, hematocrit, age, sex, and the presence of diabetes mellitus between 2 groups. Initial GFR was a little smaller in group A than group B(45.0+/-10.1 L/week vs. 54.6+/-5.7L/week) which was not statistically significant. GFR after 1, 3 and 6months of dialysis(including 1month of HD in group A) were smaller in group A than B(28.6+/-5.3L/week vs. 54.4+/-5.7L/week, 32.7+/-5.2L/week vs 56.9+/-6.1L/week, 21.0+/-4.1L/week vs 53.6+/-5.4L/week at 1,3,6 months after dialysis in group A and B), which were significant. Urine Kt/V showed same pattern. The change of GFR and urine Kt/V have no correlation with serum albumin, hemoglobin, hematocrit, and change of mean arterial blood pressure and is not affected by sex, and presence of DM or peritonitis. We concluded that HD during break-in period can decrease RRF in CAPD patients, which may not recover after 6months of dialysis. Avoiding HD during break-in period with appropriate preparation can preserve RRF in CAPD patients.

Involvement of Macrophage Migration Inhibitory Factor(MIF) in Experimental Uric Acid Nephropathy / 대한신장학회잡지

Chronic deposition of uric acid in the kidney can lead to progressive tubulointerstitial injury with granuloma formation. We hypothesized that uric acid crystal deposition may induce granuloma formation by stimulating local expression of macrophage migration inhibitory factor(MIF), which is a known mediator of delayed type hypersensitivity(DTH). A model of acute uric acid nephropathy was induced in rats by the administration of oxonic acid (an inhibitor of uricase) together with uric acid supplements. Kidney tissue examined at 35 days showed widespread tubulointerstitial damage with intratubular uric acid crystals deposition and granuloma formation. Tubules within the areas of granuloma showed a six-fold increase in MIF mRNA compared to uninvolved areas by in situ hybridization. Moreover, the areas of increased MIF mRNA expression correlated with sites of dense accumulation of macrophages and T cells. Control rats fed a normal diet had no discernible evidence of renal disease by routine light microscopy and minimal tubular expression of MIF mRNA and protein. These data suggest that intrarenal granulomas in urate nephropathy may be the consequence of a crystal induced DTH-like reaction mediated by MIF.

Change of QT Dispersion Following Successful Percutaneous Transluminal Coronary Angioplasty(PTCA) / 대한내과학회지

OBJECTIVES: QT dispersion(QTd) is defined as the difference between the maximum and minimum average QT interval in any of the 12 leads of the surface ECG. QTd has been shown to reflect regional variations in ventricular repolarization. It was reported previously that QTd was dependent on the degree of reperfusion in myocardial infarction. The purpose of this study is to investigate the effects of percutaneous transluminal coronary angioplasty(PTCA) on QTd. METHODS: We studied in 21 patients(15 men and 6 women: mean age, 53 +/- 7.5 years: 14 acute myocardial infaction, 4 angina pectoris and 3 unstable angina). All standard 12-lead ECGs were recorded at a paper speed of 25mm/sec and examined retrospectively by single observer. QT interval was measured from 11.3 +/- 1.1 leads using a computerized program interfaced with digitizer. QTd corrected for heart rate(QTcd) was calculated by Bazett`s formula. Each cases were divided to 2 stages, before and after PTCA(mean obsevation duration, 16.8 +/- 9.7 days vs. 22.5 +/- 21.9 hours). The difference of QT dispersions was assessed by comparing by paired t-test. RESULTS: There were significant difference in QTd (mean 110.2 +/- 37.4 vs. 90.4 +/- 37.6 msec, p<0.05). Results did not change when Bazett`s QTc was substituted for QT(QTcd: mean 125.5 +/- 38.3 vs. 97.9 +/- 29.8 msec, p<0.05). CONCLUSION: Successful PTCA is associated with less QTd after PTGA. The results are equally significant when either QT or QTc is used for analysis. In our limited study, measurement of QT dispersion, an easily accessible, resonably accurate, noninvasive method, may be a valuable tool in assessment of patients before and after PTCA. However, this study must be confirmed in prospective trial.