The Mathematical Model for Predicting the Probability of Minimal Change Nephrotic Syndrome Using Clinical Parameters / 대한신장학회잡지

PURPOSE: We retrospectively investigated to find out the equation of calculating the probability of minimal change nephrotic syndrome (MCNS) using clinical parameters. We prospectively investigated to determine the usefulness of the mathematical model. METHODS: We retrospectively examined 56 patients with nephrotic syndrome (NS) (30 MCNS and 26 non-MCNS) diagnosed by kidney biopsy. A mathematical model for calculating the probability of MCNS was obtained through multiple logistic analysis in SAS statistics package. In addition, we prospectively studied 28 patients with NS. Clinical MCNS and non-MCNS were classified according to the probability of 85% in the mathematical model. Kidney biopsy was performed, and serum albumin and urinalysis were measured after 2 weeks of steroid treatment. RESULTS: In the retrospective study, the mathematical model was P=ea/(1+ea), a=17.2507 - 5.5777xON - 4.2256xALB-0.000579x24PROT - 1.2569xUBL+2.1703xUAL. The mode of onset (ON), 24 hours urine protein (24PROT), serum albumin concentration (ALB), the grade of hematuria (UBL) and proteinuria (UAL) were included as clinical parameters. At the probability of 85%, the sensitivity and specificity for predicting MCNS was 73.3% and 100% respectively. In the prospective study, the result of kidney biopsy was consistent with clinical MCNS and non-MCNS according to a mathematical model. All clinical MCNS showed negative proteinuria on urinalysis and a significant increase in serum albumin after 2 weeks treatment (1.85+/-0.30 g/dL to 2.88+/-0.26 g/dL, p<0.05). CONCLUSION: We conclude that the mathematical model for predicting the probability of MCNS may be useful in diagnosis of the MCNS.

A case of pure red cell aplasia in a chronic hemodialysis patient with erythropoietin-resistant anemia / 대한내과학회지

The resistance to recombinant human erythropoietin (r-HuEPO) in patients with chronic renal failure can develop in conditions such as iron deficiency, chronic bleeding, or chronic inflammatory disease. Recently, there have been several case reports of pure red cell aplasia due to antibody production to r-HuEPO in chronic hemodialysis patients. A 59-year old female undergoing chronic hemodialysis responded well to r-HuEPO for 6 years. But, a rapidly progressive anemia was then noted which was unresponsive to maximal doses of r-HuEPO and the patient became transfusion-dependent. Bone marrow examination showed absence of red cell precursors. A detailed search for the cause of this pure red cell aplasia was unrevealing. We conclude that although very rare, pure red cell aplasia should be considered in evaluating chronic hemodialysis patients with erythropoietin-resistant anemia.

The Changes of Aquaporin-2 Expression in Rats with Lithium Induced Nephrogenic Diabetes Insipidus after Hydrochlorothiazide Administration / 대한신장학회잡지

BACKGROUND: Thiazides have been used in nephrogenic diabetes insipidus (NDI) patients to decrease urine volume, but the mechanism of antidiuretic effect is not known yet. Recently, it has been demonstrated that abundance of aquaporin-2 (AQP2) was decreased in lithium induced NDI. We performed this study to investigate the effect of hydrochlorothiazide (HCTZ) in lithium induced NDI rats and the change of AQP2 expression. METHODS: NDI was induced in 7 male Spraque- Dawley rats by feeding lithium carbonate containing rat chow (40 mmol/kg) for 5 weeks. 4 rats were control group. HCTZ 3.75 mg/day (n=3 among lithium treated; Li+TZ) or vehicle (n=4 among lithium treated and control; Li and Control, respectively) was infused to the rats through osmotic minipump for the last 7 days. Urine volume and urine osmolality were measured. Kidneys were processed for immunohistochemistry and immunoblotting using antibody to AQP2. RESULTS: Li+TZ showed decreased urine volume (46+/-11 mL/day for Li+TZ vs. 127+/-1 mL/day for Li, p<0.05) and higher urine osmolality (557+/-139 mmol/kgH2O for Li+TZ vs. 207+/-9 mmol/kgH2O for Li, p<0.05) comparing to Li. In semi-quantitative immunoblotting using whole kidney homogenate, Li+TZ showed increase in AQP2 expression comparing to Li (39+/-2% for Li+TZ vs. 20+/-9% for Li, p<0.05, % of normal controls). In immunohistochemistry, AQP2 expression in cortex was markedly decreased after lithium treatment. But, AQP2 expression was slightly increased after HCTZ treatment. CONCLUSION: HCTZ treatment partially increased urine concentrating ability and AQP2 expression in rats with lithium induced NDI. We concluded that partial improvement in urine concentrating ability might be associated with upregulation of AQP2.

Changes of Urinary Acidification and Collecting Duct H(+)-ATPase Abundance in Response to Chronic Diuretic Administration / 대한신장학회잡지

PURPOSE: Commonly used diuretics such as furosemide and hydrochlorothiazide may cause metabolic alkalosis by increasing proton secretion from distal nephron. We evaluated changes in urinary acidification and abundance of proton-secreting transporters in response to chronic subcutaneous infusion of diuretics. METHODS: Osmotic minipumps were implanted into Sprague-Dawley rats to deliver 12 mg/day furoemide or hydrochlorothiazide 7.5 mg/day for 7 days. All animals were offered tap water and a solution containing 0.8% NaCl and 0.1% KCl as drinking fluid. RESULTS: Compared with vehicle-infused controls, diuretic and natriuretic responses were evident from furosemide or hydrochlorothiazide infusion. However, there were no changes in body weight, serum aldosterone and creatinine clearance between diuretic- infused(n=6) and control(n=6) rats. In both furosemide-infused and hydrochlorothiazide-infused rats, urine pH was significantly lowered compared with controls. Furosemide-infused rats showed significantly larger excretion of urinary ammonium. Semiquantitative immunoblotting was carried out from rat kidneys to investigate abundance of proximal tubule or medullary thick ascending limb Na(+)/H(+) exchanger type 3(NHE3) and collecting duct H(+)- ATPase using specific polyclonal antibodies to NHE3 and H(+)-ATPase B1 subunit, respectively. The abundance of NHE3 from cortical homogenates was not changed by either furosemide or hydrochlorothiazide infusion. However, the abundance of NHE3 from outer medullary homogenates was increased by furosemide infusion. The H(+)-ATPase B1 subunit abundance was increased by furosemide or hydrochlorothiazide infusion in both cortical and outer medullary homogenates. CONCLUSION: These increases in the abundance of proton-secreting transporters may account for the enhanced distal urinary acidification in response to chronic diuretic administration.

Change of Autonomic and Peripheral Nerve Function after the First Twelve Months of Dialysis in End-stage Renal Disease / 대한신장학회잡지

BACKGROUND: The efficacy of dialysis on the autonomic and peripheral nerve function has been a subject of considerable debate. In addition, no longitudinal study on the course of uremic neuropathy in end-stage renal disease (ESRD) during dialysis has been reported. We carried out a prospective study to investigate the effect of dialysis on the autonomic and peripheral nerve function during the first 12 months of dialysis. METHODS: Twenty-five patients with ESRD (14 on HD and 11 on CAPD; 11 diabetic and 14 non- diabetic) were enrolled. Autonomic nerve function test and median nerve conduction velocity study were done at the initiation of dialysis and then repeated after 12 months of dialysis. RESULTS: At the initiation of dialysis, sympathetic nerve function and parasympathetic nerve function were abnormal in all HD and CAPD patients. After 12 months of dialysis, no significant changes occurred in autonomic function test. There was no significant difference in autonomic function test between HD and CAPD patients. There was no significant difference in median nerve conduction velocity between HD and CAPD patients after 12 months of dialysis. At the initiation of dialysis, 6 of 11 diabetic and 4 of 14 non-diabetic patients had abnormal median nerve conduction velocity. After 12 months of dialysis, normalization of median nerve conduction velocity occurred only in 3 non-diabetic patients. There was a singinficant difference in median nerve conduction velocity between diabetic and non-diabetic patients after 12 months of dialysis. CONCLUSION: We conclude that dialysis does not significantly alter the autonomic nerve function during the first 12 months of dialysis, but may improve the peripheral nerve function in non-diabetic uremic patients.

A Case of Spontaneous Renal Artery Dissection Causing Renal Infarction in a Previously Healthy Man / 대한신장학회잡지

Spontaneous renal artery dissection is an uncommon cause of renal infarction. Previous reports of spontaneous renal artery dissection has been associated with hypertension or fibromuscular dysplasia. We report herein the case of a previously healthy, normotensive patient with renal infarction due to spontaneous renal artery dissection who remained normotensive throughout his course without therapy. A previously healthy 31-year-old man with well- documented normotension had a sudden onset of right flank pain and delayed onset of elevation of lactic dehydrogenase, hematuria, and proteinuria. Thin section spiral computerized tomogram shows linear intraluminal filling defect suggesting intimal flap. Angiography shows dissection of main right renal artery. Six months later, he has remained well and normotensive without therapy. To our knowledge, this is the first case of spontaneous renal artery dissection in normotensive patients in Korea.

Two Cases of Gitelman's Syndrome Diagnosed by Renal Clearance Study / 대한신장학회잡지

We have experienced two patients who had hypokalemic metabolic alkalosis as well as hypomagnesemia and hypocalciuria with elevated plasma renin activity. We have performed renal clearance study after water loading, administration of furosemide and thiazide in two patients and two normal controls. Maximal free water clearance per 100 mL glomerular filtration rate(CH2O) and distal fractional chloride reabsorption[CH2O/(CH2O+CCl)] in our patients were reduced than the controls. Chloride clearance(CCl) was increased after furosemide administration but not after thiazide administration. Distal fractional chloride reabsorption[CH2O/(CH2O+CCl)] was dramatically decreased by furosemide administration in our patients, whereas thiazide had little effect on it. Fractional excretion of sodium, chloride, magnesium, calcium was increased by furosemide administration, whereas thiazide administration had little effect on this parameters. These findings suggested the presence of a defect in the distal convoluted tubule rather than in the thick ascending loop of Henle. Herein, we report two cases of Gitelman's syndrome diagnosed by renal clearace study after water loading, administration of furosemide and thiazide.

Effects of Low-dose Androgen in Combination with Subcutaneous Recombinant Human Erythropoietin (r-HuEPO) on Anemia and Nutritional Parameters in Hemodialysis Patients / 대한신장학회잡지

Recombinant human erythropoietin(r-HuEPO) is the mainstay of anemia therapy in patient with end stage renal disease(ESRD), but the use of r-HuEPO is primarily limited by its high cost. So, it encourages any strategies that potentially enhance the erythropoietic response. However, studies designed to assess whether androgens would enhance the response to r-HuEPO were inconclusive. While androgens may be less expensive and may improve several nutritional parameters, their potential adverse effects discourage usage. We carried out a prospective study to examine the effect of low-dose androgen in combination with subcutaneous r-HuEPO on anemia and nutritional paramenters in hemodialysis patients. Twenty-four hemodialysis patients with hematocrit <24% or hemoglobin <8.0g/dL were randomly assigned into two groups. Group A(n=12) received 2000U r-HuEPO subcutaneously twice a week for six months. Group B(n=12) received the same dose of r-HuEPO plus nandrolone decanoate 100mg intramuscularly biweekly. Anthropometry, albumin, cholesterol, prealbumin, and transferrin were measured as nutritional parameters. The groups showed no differences in baseline levels of the followings : Hemoglobin, hematocrit; transferrin saturation; serum ferritin; intact serum parathyroid hormon, Kt/V; vitamin B12, folate; nutritional parameters. At the completion of the study, both groups showed significant increase in hematocrit compared with baseline levels(group A 20.7+/-2.2% to 26.0+/-3.8%; group B : 21.5+/-3.5% to 30.1+/-2.8%). The mean hematocrit in group B was significantly higher than in group A after 4 month study period(p<0.05). Ten of 12 patients in group B achieved a target hematocrit of 30%, as compared with four of 12 patients in group A. Both groups didn't show significant changes in any nutritional parameters. No significant side effects of androgen were noted during this short-term study. We conclude that low-dose androgen in combination with subcutaneous r-HuEPO is effetive treatment on anemia in hemodialysis patients, but does not improve nutritional status.

Diagnostic Significance of Fractional Excretion of Unmeasured Anion(FEua)in Metabolic Acidosis / 대한신장학회잡지

Alcohol can cause rhabdomyolysis by either direct toxicity or associated metabolic abnormality such as hypophosphatemia and hypokalemia. It can also predispose to or cause trauma, seizures, or coma- induced ischemic pressure necrosis. In order to investigate the clinical features of acute renal failure caused by alcohol induced rhabdomyolysis, we reviewed the medical records of the 12 patients. All patients had been drinking much amounts of alcohol for several years. All patients showed elevation of muscle enzyme such as creatine phosphokinase, lactic dehydrogenase, aspartate transaminase and blood urea nitrogen and serum creatinine. Predisposing factors of rhabdomyolysis were ischemic compression due to unconsciousness and dehydration(2 cases), and hypophosphatemia and dehydration(1 case), seizure and dehydration(1 case), and only severe dehydration(3 cases). Initial symptoms were painful swelling at lesion site(5 cases), abdominal pain(2 cases), general ache(2 cases), leg pain without swelling(1 case), dyspnea(1case), and lethargy(1 case). Seven patients developed delirium tremens during recovery stage. Eight patients showed oliguric acute renal failure and 8 patients were treated with hemodialysis. Complications were disseminated intravascular coagulation(DIC)(3 cases), compartment syndrome(2 cases), capillary leak syndrome and DIC(1 case). One of 12 patients died of disseminated intravascular coagulation and other patients showed complete recovery of renal function.

Does Albumin Infusion Enhance the Diuretic Action of Furosemide in NePhrotic Syndrome? / 대한신장학회잡지

There have been controversies on the effect of albumin in treating edema in nephrotic syndrome patients. We evaluated the additive diuretic effect of coadministration of furosernide with albumin in the six patients with nephrotic syndrome. We administered 160mg of furosemide intravenously for 1 hour with 100rnl of 20% albumin or 5% dextrose by random cross-over design. The urine and plasma furosemide concentrations were measured by HPLC. After the administration of furosemide alone, urine volume, urinary excretions of sodium and chloride were increased significantly compared to those of basal state (P<0.05). But, coadministration of furose-mide with albumin did not increase significantly the urine voume (2285+/-445ml vs. 3023+/-715ml), urinary excretions of sodium (194+/-58rnmol/day vs. 282+/-85 mmol/day) and chloride (213+/- 54mmoVday vs. 286+/- 74mmoVday) comparing to those of furosemide only cases. Addition of albumin to furosemide did not significantly changed pharmacokinetic parameters such as AUC (28.3+/-5.5ug/ml hr vs 36.0+/-6.7ug/ml hr), total plasma clearance (115+/-30mVmin vs 108+/-41ml/min), volume of distribution (0.13+/-0.02L/kg vs 0.10+/- 0.01L/kg), elirnination half life (1.4+/-0.3hr vs 1.5+/-0.3hr), and urine furosemide excretion (44+/-8% vs 43+ 10%). We concluded that albumin infusion did not enhance the diuretic action of furosemide pharmacodynamically and pharmacokinetically in patients with nephrotic syndrome.

The Comparison of the Urine RBC Phase Contrast Microscopy and Immunoperoxidase Stain in Differentiation of Hematuria / 대한신장학회잡지

Differentiation of renal(RH) and non-renal(NRH) hematuria is important in the diagnosis and treatment of the patients with hematuria. Recently, urine RBC immunoperoxidase(IPx) staining method was developed, but there was no report on the usefulness of IPx in Korea. We validated the usefulness of IPx by comparing with the PCM. Both PCM and IPx were performed at the same time in 26 patients with RH confirmed by renal biopsy and 23 patients with NRH confirmed by radiologic and/or pathologic studies who were admitted to Chungbuk National University Hospital from January 1996 to December 1996. The age of RH and NRH group were 36.6+/-15.0 and 56.5+/-22.2 years. 35.7+/-30.4% of urine RBC were stained by IPx in RH group and only 1.6+/-4.4% were stained in NRH group(P<0.001). 23.4+/-29.9% of urine RBC by PCM were counted as dysmorphic RBC in RH group and 5.7+/-13.6% were counted in NRH group(P<0.05). At the cut-off value of 20%, the sensitivity and specificity of IPx were 57.7% and 100%. At the cut-off value of 30%, those of PCM were 30.9% and 95.7%, respectively. When comparing overall test performance by calculating AUCs of ROC(receiver operating characteristics) curve, IPx was better than PCM. IPx was better than PCM in localizing the origin of hematuria. The NRH might be excluded when IPx(+) cells are more than 20% of total urine RBC.

A Case of Aconite Intoxication and Recurrent Ventricular Arrhythmia without Apparent Myocardial Damage after 20,680 Joules DC Shock

The aconite root has been used in oriental medicine to improve metabolism of debilitated patient and to cure acute dysuria, cardiac weakness, gout, neuralgias and rheumatism. The crude drug "bu-shi" or "cho-oh", which is obtained from the Aconitum roots, contains the potent poisons aconitine, mesaconitine, jesaconitine, and hypaconitine, which are C

Fine Needle Aspiration Cytology of Metastatic Pulmonary Seminoma: A Cese Report / 대한세포병리학회지

Fine needle aspiration cytologyof a pulmonary mass was performed on a 51-year-old man who had a left testicular mass. Cytologic features were composed of a homogeneous population of malignant cells associated with a background of foamy and lacelike material. The cellular features were characterized by monomorphous cell proliferation of relatively regular large cells, generally isolated or grouped. Occasionally, fine branching stroma with large tumor cells and scanty lymphocytes were noted. The tumor cells had a round, regular nucleus, prominent round nucleoli, and a thin rim of cytoplasm containing large vacuoles or lacunae filled with glycogen. The fine needle aspiration cytologic diagnosis was highly consistent with metastatic seminoma from testis and less likely primary or other metastatic carcinoma. The diagnosis of resected testicular mass was classic seminoma. Despite the fact that cytopathologists were not familiar with diagnosis of seminoma due to clinician's lack of interest in fine needle aspiration cytology of germ cell tumors including seminoma, it appears that a diagnosis of this tumor should not be problematic in cytologic material if specific histologic criteria are applied.

A Case of Primary Ovarian Choriocarcinoma / 대한부인종양콜포스코피학회잡지

Pure, nongestational ovarian choriocarcinomas is extremely rare. Most ovarian choriocarcinoma are combined with other malignant germ cell tumors or can arise as a metastaais from a primnry gestational choriocarcinoma. We experienced a case of primary ovarian choriocarcinoma that probably was associated with a past history of the mixture of germ cell tumor and present it with a review of literature.

Comparative Study of Captopril Tablets on the Bioavailability and the Time Course of Plasma Angiotensin-Converting Enzyme Inhibition

Captopril tablets of two different producers were tested for bioequivalence as well as therapeutic equivalence. The pharmacokinetics, the time course of plasma angiotensin-converting enzyme inhibition, and the changes of systolic and diastolic blood pressure after administration of drugs were studied. In a balanced, randomized two-way crossover design, two single doses of 50mg each of captopril were administered orally to twelve male volunteers. Peak blood levels of free captopril were observed about 0.85 hour after the dose, and practically free captopril could not be detected in blood within 8 hours. Peak free captopril levels of both compounds were almost identical(Capoten(R), 464.3ng/ml ; Capril(R), 504.6ng/ml). No statistically significant difference was identified between two compounds when area und the concentration time curve, peak level, time to peak were compared. Inhibition of plasma angiotensin-converting enzyme to blood free captopril concentration showed the hyperbolic concentration-response relationship with IC50 value of 7.4ng/ml. The area under the percent angiotensin-converting enzyme inhibition versus time curve were quite similar after administration of both drugs. The compounds were also found to be equivalent on the premise that no significant difference was detected when the time courses of systolic and diastolic blood pressure reduction were compared.