Study on the Prevalence of Coronary Heart Disease and Albuminuria in Type 2 Diabetic Patients / 대한신장학회잡지

There are opinions that microalbuminuria acts as an independent risk factor for cardiovascular diseases, related to other risk factors such as endothelial cell dysfunction, hypertension, insulin resistance, obesity, hyperlipidemia and platelet aggregation dysfunction in diabetic and non-diabetic patients. We examined the prevalence of microalbuminuria and macroalbuminuria and the relationship of microalbuminuria and macroalbuminuria to coronary heart disease in type 2 diabetic patients. Out of 798 type 2 diabetic patients who were hospitalized at Yonsei medical center from Oct. 1997 to Feb. 1999, we studied 181 patients who had normal renal function and were examined 24 hour urine albumin excretion. According to the amount of urine albumin excretion, 181 patients were categorized into three groups; normoalbuminuria(less than 30mg/24hour), microalbuminuria(30-300mg/24hour) and macroalbuminuria (more than 300mg/24hour). Patients were tested using treadmill test, stress thallium scan, echocardiography, and coronary angiography for the evaluation of coronary heart disease. The freguency of normoalbuminuria, microalbuminuria, and macroalbuminuria in our patients were 50.3%(91/181), 30.9%(56/181), and 18.3%(34/181), respectively. In each group, the prevalence of hypertension were 42.5%, 78.5%, and 82.3%, respectively and the prevalence of cardiovascular disease were 24.7%, 50.0%, and 46.0%, respectively. Microalbuminuria and macroalbuminuria groups showed statistically significant differences in the prevalence of hypertension and coronary heart disease compared with normoalbuminuria group(p<0.05). In addition, the prevalence of diabetic retinopathy were 37.3%, 58.9%, and 55.8%, respectively and microalbuminuria and macroalbuminuria groups showed statistically significant differences in the prevalence of diabetic retinopathy compared with normoalbuminuria group(p<0.05). We conclude that microalbuminuria and macroalbuminuria is a strong predictor of coronary heart disease in patients with type 2 diabetes.

A Case of Massive Perirenal Hematoma in a Patient with Hemorrhagic Fever with Renal Syndrome / 대한신장학회잡지

Hemorrhagic fever with renal syndrome is characterized clinically by the triad of fever, hemorrhage and renal failure. The hemorrhage in hemorrhagic fever with renal syndrome(HFRS) varies from transient petechial lesions to fulminant and massive bleeding. The latter can be an important cause of death in HFRS. We here report a case of massive perirenal hematoma in a patient with HFRS. A 17-year-old male was admited to our hospital presenting with fever, sore throat, nausea and oliuria. Computed tomography was performed at the 2nd day of hospitalization due to abruptly developing right flank pain and anemia and showed perirenal hematoma on the right kidney. He was diagnosed as HFRS and treated with hemodialysis, fluid infusion, and transfusion. There was no evidence of further blood loss at the 7th day of hospitalization. After conservative treatment, he recovered from HFRS.

Extrarenal manifestations of autosomal dominant polycystic kidney disease

Recently, with the widespread use of new imaging techniques, the diagnosis of autosomal dominant polycystic kidney disease (ADPKD) is increasing. To analyze the extrarenal manifestations of ADPKD in Korean patients, we retrospectively studied the clinical characteristics of 30 patients with ADPKD. Thirty Patients with ADPKD who had been diagnosed at Yongdong Severance Hospital from 1988 through 1994 were recruited for this study. All patients' past and family histories were re-evaluated, and charts and radiologic images were reviewed retrospectively. The male to female ratio was 9:21, and the age of initial diagnosis was 39.2 +/- 13.8 (mean +/- SD) years. In 15 cases (50%), ADPKD had been diagnosed by renal symptoms; in 8 cases (26.7%), by chance during evaluation of extrarenal diseases; in 5 cases (16.7%), by family screening; and in 2 cases (6.7%), by uremic symptoms. Extrarenal involvement included hepatic cysts (70%), pancreatic cysts (16.7%), splenic cysts (6.7%), thyroid cysts (6.7%), inguinal hernia (3.3%), and colonic diverticula (3.3%). In 5 cases (16.7%), cardiac valvular abnormalities were noted by echocardiography. Seven patients underwent hemodialysis, and the duration from the initial diagnosis to initiation of dialysis was 9.9 +/- 8.5 (mean +/- SD) years. We investigated the extrarenal manifestations of 30 cases of ADPKD in Koreans, which were also common and clinically important as renal manifestations. Renal cysts are only one of a myriad of renal and extrarenal manifestations of ADPKD. ADPKD should be managed systematically since this disorder is a systemic disease with clinically important involvement of the cardiovascular system, the gastrointestinal tract, the genitourinary system, and the musculoskeletal system.

Primary Sclerosing Cholangitis: Report of a Case with a Clinical Analysis of the Cases Reported in the Korean Literature / 대한내과학회지

We experienced a case of primary sclerosing cholangitis(PSC) in a 40-year-old female who complained of jaundice and pruritus. Marked elevation of serum alkaline phophatase level, typical beaded appearance and pruned-tree appearance on endoscopic retrograde cholangiography, together with a finding of chronic obliterative fibrosing cholangitis on sono-guided gun biopsy specimen of the liver led to a confirmative diagnosis of PSC. The patient responded to ursodeoxycholic acid (UDCA), but was reluctant to treatment and died of hepatic failure 7 months later. PSC is a very rare disease in Korea. So far, only 5 cases including our present case have been reported in the Korean literature. Male-to-female ratio was 2:3 and the median age was 40(27-80 years old). Ulcerative colitis was associated in one case. Four cases involved both intra, and extrahepatic bile ducts and one case was reported to be confined in the intrahepatic bile ducts. Fatality was in 3 cases, 20 days, 36 days, and 7 months after the initial presentaion, respectively. The causes of death were acute cholangitis and sepsis in two, and hepatic failure in one. We herein report a case of PSC and clinical charateristics of the reported cases in Korea, and review the literature with an emphasis on UDCA treatment in PSC.

Association between ACE Gene Polymorphism and Nephropathy in NIDDM Patients / 대한신장학회잡지

It has been reported that the genetic susceptibility may be an important factor in the development of nephropathy in diabetic patients, and the genetic polymorphism of angiotensin-converting enzyme (ACE) has been extensively studied for its possible role. The ACE affects the cardiovascular system through angiotensin II formation and inactivation of bradykinin. The 21 kilobases-long ACE gene located on the long arm of chromosome 17 is composed of 26 exons and 25 introns. The presence/absence of a 287 base pairs fragment in the 16th intron of the ACE gene determines its genotype either as insertion(I) or deletion(D). These genotypes in turn are used to characterize the polymorphism as II, ID or DD type. Each of these genotypes has been reported to show different activity of serum ACE. Recent reports have suggested that genotype DD or D allele may be involved in the nephropathy in diabetics while genotype II may lower the chance for diabetic nephropathy. The present study investigates the effects of genetic polymorphism of ACE on the nephropathy in NIDDM by assessing ACE genotypes and activities on 148 NIDDM patients who have been diagnosed at least 10 years prior to the study, as well as 146 normal controls. The NIDDM group is composed of 70 patients with nephropathy and 78 without nephropathy. The results were as follows. 1) In the diabetic group, the absence/presence of nephropathy showed no significant difference in terms of age, gender, body mass index, HbA1C, cholesterol, triglyceride and HDL cholesterol(p>0.05). No significant differences on the clinical parameters were noted according to the ACE genotypes either(p>0.05). 2) The ratio of ACE genotypes(II:ID:DD) was 0.36:0.48:0.16 for the normal control group, 0.28:0.56: 0.16 for the NIDDM without nephropathy group, and 0.26:0.51:0.23 for the NIDDM with nephropathy group. The ratios of I and D allele were 0.60:0.40, 0.56:0.44 and 0.51:0.49, respectively. In all three groups, higher ratio I allele over D allele was noted and the ID genotype was most frequent followed by II and DD types, although the differences between the groups were not statistically significant(p>0.05). 3) In the normal controls group, ACE activities for DD, ID and II genotypes were 54.0 15.0, 40.4 12.4 and 30.1 11.8U/L, respectively, with significant difference among the genotypes. In the NIDDM without nephropathy group, there was no difference among the three genotypes(DD, ID, II; 47.2 15.1 vs. 36.6 18.7 vs. 32.0 13.4). In the NIDDM with nephropathy group, the activity for DD and ID genotypes were significantly higher than II genotype(47.7 31.0, 47.4 30.7 vs. 17.8 17.9U/L, p0.05). The results of the present study show that in the normal group genotype ID is most frequent followed by II and DD, and the I allele is more frequent than D allele. These results are similar to the reports from China and Japan, unlike the results from Europe or USA where genotype DD and D allele are more frequent than II genotype and I allele, suggesting an ethnic difference. Furthermore, the NIDDM patients group, regardless of the presence of nephropathy, showed no significant difference from the normal group in terms of ACE genotypes or allele types, suggesting lack of association between the nephropathy and the ACE gene polymorphism. The ACE activity also showed no significant relationship with various clinical parameters or complications. Further studies on the effects of ACE polymorphism and ACE activity on the progression of nephropathy may be needed.

Clinical Significances of Scrum Protein C and S in Chronic Renal Failure / 대한내과학회지

OBJECTIVES: Patients with chronic renal failure have increased hemorrhagic tendency due to an uremic platelet dysfunction and complications from anticoagulants used in hemodialysis. They are also prone to have thrombotic complications in the cerebral vessels, coronary arteries and A-V fistula, due to hypercoagulability from changes in various factors. Recently, deficiencies in plasma protein C and S, which are physiological anticoagulants, have been reported to cause thrombosis. In chronic renal failure, plasma protein C and S activities are known to be decreased. METHODS: In the present study, activities and antigen concentrations of plasma protein C and S, as well as AT-III activities were investigated in three groups; the normal control group, the predialysis group of chronic renal failure patients treated conservatively, and the hemodialysis group. The findings were analyzed for their relationship to hypercoagulability. RESULTS: 1) The activities of plasma protein C, S and antithrombin-III were significantly lower in the predialysis chronic renal failure group as compared to the control. Antithrombin-III concentrations in the hemodialysis group assayed immediately prior to dialysis were significantly lower than those of the control group. But, protein C antigen concentrations in the hemodialysis group assayed immediately prior to dialysis were significantly higher than those of the control group. There was no significant difference between these groups in plasma protein C activities, and plasma protein S activities and antigen concentrations. 2) In the hemodialysis group, antithrombin-III activities, antigen concentration and activities of plasma protein C were significantly higher than after dialysis as compared to those before the dialysis. 3) There were no significant difference in plasma protein C, S and antithrombin-III activities and plasma protein C and S antigen concentrations in hemodialysis patients between with and without thrombosis at arterio-venous fistula site. However, plasma protein C and antithrombin-III activities were significantly lower in those with thrombosis as compared to those of the normal control group. There were no significant difference in plasma protein C and S activities and antigen concentrations in those without thrombosis as compared to those of the normal control group. 4) There were no significant diffrences in plasma protein C, protein S and antithrombin-III activities and antigen concentrations in dialysis patients with and without recombinant erythropoietin treatment. 5) There were no significant correlations between serum creatinine and creatinine clearance, and plasma antithrombin-III, protein C and protein S activities and antigen concentrations in predialysis group. CONCLUSION: These results suggest that the decrease in plasma antithrombin-III, protein C and S could be the factors causing hypercoagulability in chronic renal failure patients, and the decreased activities of these factors may return to normal by dialysis. In the hemodialysis group, there were no significant diffrences in plasma protein C and S and antithrombin-III activities and antigen concentrations between the group which showed clinical thrombosis and the group which did not. However, in those who had thrombosis, plasma protein C and antithrombin-III activities are significantly lower than the control group. Administration of recombinant human erythropoietin does not appear to affect the activities of plasma protein C and S and antithrombin-III. In predialysis chronic renal failure patients, there was no significant relationship between renal function and plasma protein C and S and antithrombin-III.

Studies on bone markers and bone mineral density in patients with chronicrenal failure

Renal osteodystrophy has become a frequent complication in patients with chronic renal failure (CRF), and various histologic forms such as high turnover, low turnover and mixed bone disease have been demonstrated. The only reliable method for distinguishing patients with high turnover from those with low turnover bone disease is bone histomorphometric study, but its clinical utility is restricted. Because of its invasive nature, efforts have been made to predict indirectly the type and severity of thi metabolic bone disease by serum assays. In this cross-sectional study, we measured total and regional (head, arms, trunk, ribs, legs, spine and pelvis) bone mineral densities (BMD) by dual X-ray absorptiometry (DXA) in patients with variable degrees of CRF and correlated them with various bone markers. Decreased BMDs were detected in various skeletal sites (trunk and pelvis) in the patients' group. Total BMD Z score was lower in predialysis CRF patients than in the control subjects. Decreased BMD Z scores on weight-bearing bone were pronounced at L1 lumbar vertebra, femur trochanter, femur neck and Ward's triangle. Positive linear correlations were found between creatinine clearance and trunk, ribs, pelvis, and spine BMDs. There were inverse linear correlations between total BMD and total BMD Z score and alkaline phosphatase (AP), urine deoxypyridinoline (U-DPD) in the patients' group. There were no correlations between regional and total BMD, total BMD Z score and serum calcium, ionized calcium, and serum phosphate. There were inverse linear correlations between BUN, creatinine and bone-specific alkaline phosphatase in the predialysis CRF group. We evaluated the correlations between intact parathyroid hormone (i-PTH) and biochemical and other bone markers. There was statistically significant linear correlation between i-PTH and AP. Other bone markers have no significant correlations with i-PTH. Our results demonstrated that there is significant bone loss in patients with CRF before the start of dialysis and also regional variations of BMDs in predialysis CRF patients. DXA is a useful method for evaluating regional and total BMDs and provides information about diverse regional skeletal changes. AP, i-PTH and U-DPD can predict BMD of predialysis CRF patients.

Studies on bone markers and bone mineral density in patients with chronicrenal failure

Renal osteodystrophy has become a frequent complication in patients with chronic renal failure (CRF), and various histologic forms such as high turnover, low turnover and mixed bone disease have been demonstrated. The only reliable method for distinguishing patients with high turnover from those with low turnover bone disease is bone histomorphometric study, but its clinical utility is restricted. Because of its invasive nature, efforts have been made to predict indirectly the type and severity of thi metabolic bone disease by serum assays. In this cross-sectional study, we measured total and regional (head, arms, trunk, ribs, legs, spine and pelvis) bone mineral densities (BMD) by dual X-ray absorptiometry (DXA) in patients with variable degrees of CRF and correlated them with various bone markers. Decreased BMDs were detected in various skeletal sites (trunk and pelvis) in the patients' group. Total BMD Z score was lower in predialysis CRF patients than in the control subjects. Decreased BMD Z scores on weight-bearing bone were pronounced at L1 lumbar vertebra, femur trochanter, femur neck and Ward's triangle. Positive linear correlations were found between creatinine clearance and trunk, ribs, pelvis, and spine BMDs. There were inverse linear correlations between total BMD and total BMD Z score and alkaline phosphatase (AP), urine deoxypyridinoline (U-DPD) in the patients' group. There were no correlations between regional and total BMD, total BMD Z score and serum calcium, ionized calcium, and serum phosphate. There were inverse linear correlations between BUN, creatinine and bone-specific alkaline phosphatase in the predialysis CRF group. We evaluated the correlations between intact parathyroid hormone (i-PTH) and biochemical and other bone markers. There was statistically significant linear correlation between i-PTH and AP. Other bone markers have no significant correlations with i-PTH. Our results demonstrated that there is significant bone loss in patients with CRF before the start of dialysis and also regional variations of BMDs in predialysis CRF patients. DXA is a useful method for evaluating regional and total BMDs and provides information about diverse regional skeletal changes. AP, i-PTH and U-DPD can predict BMD of predialysis CRF patients.

The Usefulness of Esophagogram with Marshmallow Bolus in Patients with Esophageal-Related Symptoms

PURPOSE: To evaluate the usefulness of the esophagogram using marshmallow bolus in the evaluation of the causes of variable esophageal-related symptoms. MATERIALS AND METHODS: Esophagograms using marshmallow bolus were performed on 44 patients with esophageal-related symptoms and on ten normal volunteers. Video fluoroscopic studies were also made. Patients were classified into three groups according to their esophageal-related symptoms ; those with dysphagia, those with globus symptom, and those with chest pain. Abnormal findings on an esophagogram with marshmallow were graded into three categories ; mild, moderate, and severe. Provocation of the same symptom wasalso evaluated. Esophageal manometric studies were performed on 16 patients and those results were compared with the results obtained from the esophagogram using marshmallow bolus. RESULTS: The provocation rate of the same symptom was 33% in the first group, 47% in the second, and 24% in the third. The provocation rate was highest inthe second group. The provocation rate was also higher in patients with a severe degree of abnormality on anesophagogram using marshmallow bolus. Where there were abnormal findings, an esophagogram using marshmallow bolus showed a higher abnormality rate than did a conventional esophagogram. In cases showing abnormal findings on the esophageal manometric study, an esophagogram using marshmallow bolus showed a higher provocation rate and more severe abnormality than in cases showing normal findings on manometric study. CONCLUSION: An esophagogram using marshmallow bolus will a useful radiologic screening modality for the evaluation of patients with esophageal-related symptoms.

A Case of Parasitic Eosinophilic Granuloma of the Stomach Presenting with Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

The localized eosinophilic granulomatous lesions of the stomach are rare benign tumorous conditions resembling submucosal tumors. They can be divided into two types. One is an inflammatory fibroid polyp. The other is an eosinophilic granuloma due to migration of Anisakis-type larva in the alimentary tract. The latter is usually found in the gastric body and anterior wall of the angle, and appears as a submucosal tumor. Histologically, the granuloma exhibits a characteristic lamellated structure consisting of a necrotic center with or without the worm, surrounded by layers of granulation tissue and eosinophilic infiltration. The present case is a 50 year-old male presenting with an episode of profuse melena. An emergency esophagogastroduodenoscopy revealed a 2x1.5cm sized, irregularly shaped ulcerative lesion with elevated margins and prominent folds convergence. Despite the endoscopic injection of hypertonic saline-epinephrine solution due to a recent bleeding stigmata, the patient experienced a rebleeding during hospitalization, The locally excised specimen showed an eosinophilic granuloma having a central necrosis. Although the larval body of Anisakis was not found, the lesion was diagnosed as a parasitic eosinophilic granuloma of the stomach.