A case of hyperphosphatemia and acute renal failure following the administration of solin(R) (oral sodium phosphate) / 대한내과학회지

Solin(R) (oral sodium phosphate) is a commonly used osmotic laxative solution that has replaced polyethylene glycol in bowel preparation for colonoscopy as it has equal or greater efficacy and patient compliance. However, its use has been associated with several cases of acute renal failure and electrolyte imbalance, especially hyperphosphatemia and hypocalcemia. Those at higher risk of complications are patients who are older and have intestinal obstruction, inflammatory bowel disease, renal failure, or congestive heart failure. We report the case of a 61-year-old woman presenting with paresthesia in both hands after using Solin(R) for bowel preparation for colonoscopy. The patient had hypocalcemia and hyperphosphatemia combined with acute renal failure. She recovered from the renal failure and electrolyte imbalance with intravenous hydration and treatment with phosphate-binding agents.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients with Coronary Artery Disease and Diabetic Nephropathy: A Single Center Experience

BACKGROUND: Patients with diabetic nephropathy (DN) and coronary artery disease (CAD) represent a subset of patients with high cardiovascular morbidity and mortality. The optimal revascularization strategy using either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. The purpose of this study was to compare the clinical outcomes of PCI to CABG in DN patients with CAD. METHODS: The clinical and angiographic records of DN patients with CAD who underwent either CABG (n=52) or PCI (n=48) were retrospectively analyzed. RESULTS: The baseline characteristics were similar in the two groups except for the severity of the CAD. At 30 days, the death rate (PCI: 2.1% vs. CABG: 9.6%, p=0.21) and major adverse cardiac events (MACE) rate (PCI: 2.1 % vs. CABG: 9.6%, p=0.21) were similar in comparisons between the PCI and CABG groups. At three years, the death rate (PCI: 18.8% vs. CABG: 19.2%, p=0.94) was similar between the PCI and CABG groups but the MACE rate (PCI: 47.9% vs. CABG: 21.2%, p=0.006) was higher in the PCI group compared to the CABG group. In addition, the repeat revascularization rate was higher in the PCI group compared to the CABG group (PCI: 12.5% vs. CABG: 1.9%, p=0.046). CONCLUSIONS: The CABG procedure was associated with a lower incidence of MACE and repeat revascularization for up to three years of follow-up in DN patients with CAD. However, the overall survival rate was similar in the CABG and PCI groups. Therefore, CABG may be superior to PCI with regard to MACE and repeat revascularization.

Effects of Short-Term Partial Correction of Anemia in End-Stage Renal Disease (ESRD) Patients on Maintenance Hemodialysis : Changes of Amino-Terminal Pro B-type Natriuretic Peptide (NT-pro BNP) and Echocardiographic Parameters / 대한신장학회잡지

BACKGROUND: Anemia is known to be one of the important risk factors in the development and the aggravation of cardiovascular diseases. This study was undertaken to evaluate the effect of anemia correction on blood NT-pro BNP level and echocardiographic parameters in ESRD patients on hemodialysis. METHODS: Recombinant human erythropoietin (rHuEPO) was administered in 20 hemodialysis patients (median age 51.5, M:F=2.3:1) with a target hemoglobin>12.0 g/dL for 3 months. All patients were subjected to a serial follow-up of hemoglobin, hematocrit, and NT-pro BNP. Echocardiographic examination was also performed before and after 3 months of therapy. RESULTS: Hemoglobin was increased at 3 months [12.3 g/dL (11.8-13.6)] compared with baseline [9.8 g/dL (9.1-10.4)] (p<0.01), and NT-pro BNP was significantly decreased at 3 months [3415 pg/mL (2717- 8160)] compared with baseline [6371 pg/mL (2338- 18269)] (p<0.05). Echocardiographic examination revealed no significant changes in left ventricular ejection fraction and left ventricular mass index. In Doppler imaging, however, there was significant decrease in E velocity [62.5 cm/sec (52.8-83.5) vs. 57.0 cm/sec (45.0-60.0), p<0.05], thereby decrement in E/E' [15.6 (13.4-25.7) vs. 14.3 (11.5-22.2), p<0.05]. CONCLUSION: Partial correction of anemia with rHuEPO in ESRD patients on hemodialysis results in the reduction of blood NT-pro BNP level and the decrease of E velocity and E/E'.

Effects of Short-Term Partial Correction of Anemia in End-Stage Renal Disease (ESRD) Patients on Maintenance Hemodialysis : Changes of Amino-Terminal Pro B-type Natriuretic Peptide (NT-pro BNP) and Echocardiographic Parameters / 대한신장학회잡지

BACKGROUND: Anemia is known to be one of the important risk factors in the development and the aggravation of cardiovascular diseases. This study was undertaken to evaluate the effect of anemia correction on blood NT-pro BNP level and echocardiographic parameters in ESRD patients on hemodialysis. METHODS: Recombinant human erythropoietin (rHuEPO) was administered in 20 hemodialysis patients (median age 51.5, M:F=2.3:1) with a target hemoglobin>12.0 g/dL for 3 months. All patients were subjected to a serial follow-up of hemoglobin, hematocrit, and NT-pro BNP. Echocardiographic examination was also performed before and after 3 months of therapy. RESULTS: Hemoglobin was increased at 3 months [12.3 g/dL (11.8-13.6)] compared with baseline [9.8 g/dL (9.1-10.4)] (p<0.01), and NT-pro BNP was significantly decreased at 3 months [3415 pg/mL (2717- 8160)] compared with baseline [6371 pg/mL (2338- 18269)] (p<0.05). Echocardiographic examination revealed no significant changes in left ventricular ejection fraction and left ventricular mass index. In Doppler imaging, however, there was significant decrease in E velocity [62.5 cm/sec (52.8-83.5) vs. 57.0 cm/sec (45.0-60.0), p<0.05], thereby decrement in E/E' [15.6 (13.4-25.7) vs. 14.3 (11.5-22.2), p<0.05]. CONCLUSION: Partial correction of anemia with rHuEPO in ESRD patients on hemodialysis results in the reduction of blood NT-pro BNP level and the decrease of E velocity and E/E'.

Uremic Encephalopathy Associated with Bilateral Basal Ganglia and Cerebellar Lesion in a Non-diabetic Hemodialysis Patient / 대한신장학회잡지

Involvement of central nervous system is a well- known compication in uremic patients. However, development of acute extrapyramidal symptoms with bilateral basal ganglia involvement (acute basal ganglia syndrome), especially in non-diabetic hemodialysis patient is very rare. We report a case of acute basal ganglia syndrome in a non-diabetic hemodialysis patient. A 45-year-old man with autosomal dominant polycystic kidney disease (ADPKD) on chronic hemodialysis treatment for the last 4 years was admitted due to generalized myalgia. On admission, the patient was found to have rhabdomyolysis and intractable metabolic acidosis. Nine days after admission, he suddenly developed dysarthria, lateralizing ataxia, and bradykinesia. Brain MRI demonstrated low and high signals in bilateral basal ganglia and cerebellar vermis in T1-weighted and T2-weighted images, respectively. Intensified hemodialysis treatment combined with general supportive therapy resolved the severe metabolic acidosis and the neurologic manifestations gradually improved. Follow up brain CT scan taken 3 months later showed decreased size of initial low attenuation lesions in bilateral basal ganglia and cerebellar vermis. Although no definite pathophysiology is yet established, severe metabolic disorder is believed to play an important role in development of acute basal ganglia syndrome. Correction of metabolic acidosis and hypoglycemia in our patient lead to improvement in neurologic manifestations and organic brain lesions. Our case suggests that severe metabolic acidosis and hypoglycemia in uremic patient may act as risk factors for acute basal ganglia syndrome even in non-diabetic patient.

The Short Term Prognosis in Alcoholic Liver Disease with Metabolic Acidosis / 대한간학회지

BACKGROUND/AIMS: Alcoholic liver disease with metabolic acidosis may have possible causes such as alcoholic ketoacidosis, diabetic ketoacidosis, lactic acidosis. Salicylate, methanol, and ethylene glycol intoxication should also be considered. The aim of this study was to investigate the short-term prognostic factors in patients with alcoholic liver disease with metabolic acidosis. METHODS: Clinical data related to twenty-nine patients with alcoholic liver disease and metabolic acidosis was analysed retrospectively. Patients were divided into two groups according to the outcome (survival or death). Past medical history, and physical, laboratory and radiologic data at admission were compared. RESULTS: The amount of daily alcohol intake differed significantly between the two groups (P=0.034), but duration and total amount of alcohol intake did not differ significantly between the two groups (P=0.128; P=0.360). The presence of ascites differed significantly between two the groups (P=0.019). On laboratory testing, the following differed significantly: base excess (P=0.038), hemoglobin (P=0.019), platelet (P=0.040), total bilirubin (P=0.007), albumin (P=0.012), creatinine (P=0.014), phosphorus (P=0.021), chloride (P=0.010), ammonia (P=0.003), prothrombin time (P=0.033), fibrinogen (P=0.011) and D-dimer (P=0.024). Review of the medical history of the patients showed diabetes (10/29), cirrhosis (10/29), and hepatocellular carcinoma (1/29). Combined conditions at admission were sepsis (8/29), pneumonia (7/29), acute renal failure (6/29), rhabdomyolysis (5/29), gastrointestinal hemorrhage (4/29), acute pancreatitis (3/29), acute respiratory distress syndrome (2/29), and acute myocardial infarction (1/29). CONCLUSIONS: The amount of daily alcohol intake, base excess, hemoglobin, platelet, total bilirubin, albumin, creatinine, phosphorus, chloride, ammonia, prothrombin time, fibrinogen and D-dimer seemed to be useful parameters in predicting short-term prognosis of patients with alcoholic liver disease with metabolic acidosis. Further study is needed to define the significance of these factors.

Comparison of Midazolam versus Midazolam/Meperidine during Colonoscopy in a Prospective, Randomized, Double-Blind Study / 대한소화기학회지

BACKGROUND/AIMS: Colonoscopy is a painful procedure. Therefore conscious sedation is often used. However, the value of adding analgesics to sedatives has not been well evaluated. METHODS: The double blind, randomized controlled trial was carried out to compare patients' and endoscopist' assessments in both groups of patients: MP (Midazolam/Placebo) group (n=49) received midazolam plus placebo and MM (Midazolam/Meperidine) group (n=51) received midazolam plus meperidine. RESULTS: There was no significant difference of baseline characteristics except previous operation history. There were no significant difference of grade of tolerance, pain and willingness to another colonoscopy between the two groups. In endoscopist' satisfaction, the degree of difficulty was higher in MP group than in MM group (39.0 vs. 31.7,p<0.05). After the colonoscopy, systolic blood pressure, oxygen saturation, and pulse rate were significantly decreased (p<0.05) in both groups. However, there was no difference in the degree of decrease between the two groups. The incidence of adverse effect was not different in the two groups. However, one case of orthostatic hypotension with presyncope was noted in MM group. CONCLUSIONS: Adding meperidine to the midazolam before the colonoscopy does not seem to bring more beneficial effect to patients, whereas endoscopist favored the use of both medications.

Eradication Rate of Lansoprazole-Based Triple Therapy in Peptic Ulcer Patients with Helicobacter pylori and Efficacy of Urea Breath Test in Evaluating Helicobater pylori Eradication / 감염과화학요법

BACKGROUND: There are only a few studies on Helicobacter pylori (H. pylori) for its eradication rates of lansoprazole-based triple therapy in Korea, and the results are controversial. Therefore, we undertook to investigate the eradication rate of lansoprazole-based triple therapy, and compare the concordance rate of urea breath test (UBT) and rapid urease test (RUT) in evaluating H. pylori eradication. METHODS: Patients with acute peptic ulcer who were H. pylori-positive were recruited by prospective, consecutive manner. They received lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. for 1 week. Upper endoscopy was performed after 4 weeks to check for ulcer healing, and UBT and RUT were performed to evaluate H. pylori eradication status. RESULTS: A total of 46 patients were recruited, and they were all compliant. H. pylori eradication rate was 87.0% (40/46) and ulcer healing rate was 91.3% (42/46). Forty one patients showed negative in both UBT and RUT, and 4 patients revealed positive in both tests, therefore, the concordance rate of UBT and RUT was 97.8% (45/46). CONCLUSION: Our study showed that 1-week lansoprazole-based triple therapy was effective in H. pylori eradication and ulcer healing. UBT can be an effective, noninvasive method for evaluating H. pylori status after H. pylori eradication.

Disseminated Aspergillosis following Allogeneic Hematopoietic Stem Cell Transplantation in an Acute Leukemic Patient who was Previously Treated for Invasive Aspergillosis / 감염과화학요법

Invasive aspergillosis has been increasing as the number of severe immunocompromised hosts rises. Particularly, in allogeneic hematopoietic stem cell transplantation (HSCT) recipients, incidence of invasive aspergillosis ranges from 4 to 10%. Even with appropriate treatment, the prognosis of invasive aspergillosis in allogeneic HSCT recipients remains poor, showing high mortality rate. Herein, we report a case where invasive aspergillosis in a patient with acute myelogeneous leukemia progressed to disseminated aspergillosis after allogeneic HSCT. A 31-year-old woman with acute myelogenous leukemia had invasive aspergillosis after third reinduction chemotherapy. After administering amphotericin B, the patient underwent the wedge resection of lung, and HLA-matched allogeneic HSCT was then conducted. On day 14 of transplantation, the patient died of disseminated aspergillosis, including possible cerebritis and endocarditis despite the amphotericin B therapy.

Disseminated Aspergillosis following Allogeneic Hematopoietic Stem Cell Transplantation in an Acute Leukemic Patient who was Previously Treated for Invasive Aspergillosis / 감염과화학요법

Invasive aspergillosis has been increasing as the number of severe immunocompromised hosts rises. Particularly, in allogeneic hematopoietic stem cell transplantation (HSCT) recipients, incidence of invasive aspergillosis ranges from 4 to 10%. Even with appropriate treatment, the prognosis of invasive aspergillosis in allogeneic HSCT recipients remains poor, showing high mortality rate. Herein, we report a case where invasive aspergillosis in a patient with acute myelogeneous leukemia progressed to disseminated aspergillosis after allogeneic HSCT. A 31-year-old woman with acute myelogenous leukemia had invasive aspergillosis after third reinduction chemotherapy. After administering amphotericin B, the patient underwent the wedge resection of lung, and HLA-matched allogeneic HSCT was then conducted. On day 14 of transplantation, the patient died of disseminated aspergillosis, including possible cerebritis and endocarditis despite the amphotericin B therapy.

Eradication Rate of Lansoprazole-Based Triple Therapy in Peptic Ulcer Patients with Helicobacter pylori and Efficacy of Urea Breath Test in Evaluating Helicobater pylori Eradication / 감염과화학요법

BACKGROUND: There are only a few studies on Helicobacter pylori (H. pylori) for its eradication rates of lansoprazole-based triple therapy in Korea, and the results are controversial. Therefore, we undertook to investigate the eradication rate of lansoprazole-based triple therapy, and compare the concordance rate of urea breath test (UBT) and rapid urease test (RUT) in evaluating H. pylori eradication. METHODS: Patients with acute peptic ulcer who were H. pylori-positive were recruited by prospective, consecutive manner. They received lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. for 1 week. Upper endoscopy was performed after 4 weeks to check for ulcer healing, and UBT and RUT were performed to evaluate H. pylori eradication status. RESULTS: A total of 46 patients were recruited, and they were all compliant. H. pylori eradication rate was 87.0% (40/46) and ulcer healing rate was 91.3% (42/46). Forty one patients showed negative in both UBT and RUT, and 4 patients revealed positive in both tests, therefore, the concordance rate of UBT and RUT was 97.8% (45/46). CONCLUSION: Our study showed that 1-week lansoprazole-based triple therapy was effective in H. pylori eradication and ulcer healing. UBT can be an effective, noninvasive method for evaluating H. pylori status after H. pylori eradication.

The Lymphocyte Dependent Bactericidal Assay of Human Monocyte and Alveolar Macrophage for Mycobacteria / 결핵

BACKGROUND: Though mononuclear phagocytes serve as the final effectors in killing intracellular Mycobacterium tuberculosis, the bacilli readily survive in the intracellular environment of resting cells. The mechanisms through which cellular activation results in the intracellular killing is unclear. In this study, we sought to explore an in vitro model of a low-level infection of human mononuclear phagocytes with MAC and H37Ra and determine the extent of the lymphocyte dependent cytotoxicity of human monocytes and alveolar macrophages. METHOD: The peripheral monocytes were prepared using the Ficoll gradient method from PPD positive healthy people and tuberculosis patients. The alveolar macrophages were prepared from PPD positive healthy people via a bronchoalveolar lavage. The human mononuclear phagocytes were infected at a low infection rate (bacilli:phagocyte 1:10) with MAC(Mycobacterium avium) and Mycobacterium tuberculosis H37Ra. Non-adherent cells(lymphocyte) were added at a 10:1 ratio. After 1,4, and 7 days culture in 37degrees C, 5% CO2 incubator, the cells were harvested and inoculated in a 7H10/OADC agar plate for the CFU assay. The bacilli were calculated with the CFU/1 X 10(6) of the cells and the cytotoxicity was expressed as the log killing ratio. RESULTS: The intracellular killing of MAC and H37Ra within the monocyte was greater in patients with tuberculosis compared to the PPD positive controls (p<0.05). Intracellular killing of MAC and H37Ra within the alveolar macrophage appeared to be greater than that within the monocytes of the PPD positive controls. There was significant lymphocyte dependent inhibition of intracellular growth of the mycobacteria within the monocytes in both the controls and tuberculosis patients and within the macrophages in the controls(p<0.05). There was no specific difference in the virulence between the MAC and the H37Ra. CONCLUSION: This study is an in vitro model of a low-level infection with MAC and H37Ra of human mononuclear phagocytes. The intracellular cytotoxicity of the mycobacteria within the phagocytic cells was significantly lymphocyte dependent. During the 7 days culture after the intracellular phagocytosis, the actual confinement of the mycobacteria was observed within the monocytes of tuberculosis patients and the alveolar macrophages of the controls as in the case of adding lymphocytes.

The Change of Cholesterol Level and IL-6, CRP in Unstable Angina Patients with Hypercholesterolemia after Low Dose Simvastatin Therapy

BACKGROUND AND OBJECTIVES: Cardiovascular mortality in patients with atherosclerosis can be reduced by treatment with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors. This proven effect is probably due, not only to the cholesterol lowering effect, but also to the non-lipid-lowering mechanisms elicited by the action of statins. These results, however, were achieved with high or usual doses of statin therapy, whereas similar results with low dose statins are rare. The aims of this study wereas to investigate the changes ofin cholesterol level and the inflammatory markers, Interleukin-6(IL-6), and C-Reactive protein (CRP), in unstable angina patients with hypercholesterolemia, using low dose simvastatin therapy. SUBJECTS AND METHODS: Eighteen unstable angina patients (55+/-6 years, M : F=10 : 8, Baunwald class IIIb) with hypercholesterolemia (a LDL -cholesterol level over 100 mg/dL) were evaluated. A Llow dose of simvastatin (5 mg) was administrated for 4 weeks. The changes of total cholesterol, LDL-cholesterol, triglyceride, HDL-cholesterol and the inflammatory markers, IL-6, and CRP, were all elevated from the baseline following 4 weeks of treatment. RESULTS: The baseline mean values of total cholesterol, LDL-cholesterol, triglyceride, and HDL-cholesterol were 237.1+/-56.9 mg/dL, 131.9+/-39.0 mg/dL, 168.3+/-20.4 mg/dL, and 50.0+/-3.8 mg/dL, respectively. The baseline mean values of IL-6 and hs CRP were 6.842+/-6.661 pg/mL, and 0.866+/-1.083 mg/dL, respectively. Following the 4 weeks of simvastatin treatment, the levels of total cholesterol, LDL- cholesterol, triglyceride, and HDL-cholesterol were 200.8+/-47.5 mg/dL, 101.6+/-35.4 mg/dlL, 155.8+/-18.6 mg/dL, and 47.0+/-2.3 mg/dL, respectively, giving percentage changes of -17.6% (p0.05), and -2.1% (p>0.05), respectively. Following the 4 weeks of treatment, the levels of IL-6 and hs CRP were 6.955+/-5.555 pg/mL, and 0.753+/-0.571 mg/dL, respectively, giving percentage changes of 51.8 (p>0.05), and 36.5% (p>0.05), respectively. There was no significant correlation between the level of LDL-cholesterol and the levels of IL-6, or hs CRP at the baseline, or post-treatment. There was also no significant correlation between the change of LDL-cholesterol and the changes of IL-6 or hs CRP levels during the simvastatin therapy. There was no significant correlation between the levels of IL-6 and hs CRP at the baseline or ost-treatment. CONCLUSION: Our data showed that in patients with unstable angina patients with coupled with hypercholesterolemia, low dose statin therapy has a cholesterol lowering effect, but no effect on inflammation.

A Case of Primary Gastric Choriocarcinoma Presenting with Amenorrhea / Journal of the Korean Cancer Association, 대한암학회지

Primary gastric choriocarcinomas are very rare, and their prognosis is extremely poor. A 37-year-old woman presented with amenorrhea, vaginal spotting and severe nausea, which mimicked a pregnancy and gestational trophoblastic disease. The serum level of the beta-subunit of human chorionic gonadotrophin (beta-hCG) was significantly increased. An endoscopic biopsy of the stomach mass showed the features of a choriocarcinoma, with marked anaplasia and necrosis. Immunohistochemical staining for beta-hCG showed positive results in the choriocarcinoma. Chemotherapy for the choriocarcinoma was administered, but she died 8 months following diagnosis.