Uremic Pericarditis Accompanying Cardiac Tamponade after Emergency Hemodialysis / 계명의대학술지

Although the incidence of uremic pericarditis was high in the past, it has decreased in recent decades with early and appropriate dialysis. However, cardiac tamponade caused by uremic pericarditis is still a life-threatening emergency and it requires urgent management. Herein we report a case of 38-year-old man with chronic renal disease who represented critical uremic pericarditis followed by cardiac tamponade despite of appropriate hemodialysis. Careful consideration of risk factors and aggressive treatment are very important for effective and safe treatment of uremic pericarditis and cardiac tamponade.

A Carcinoid Tumor Arising from a Normal Kidney in a Young Man / 대한내과학회지

Carcinoid tumors are low-grade malignant tumors arising from neuroendocrine cells. Primary renal carcinoid tumor is very rare due to the absence of neuroendocrine cells in the kidney and ureter. Therefore, little is known about the management and prognosis of renal carcinoid. Here, we report a case of a primary renal carcinoid tumor arising from a normal kidney in a 21-year-old man. He presented with a left renal mass, which was found accidentally. Abdominal computed tomography (CT) showed a 5.5 x 5.0-cm cystic mass with calcification. We suspected a cystic renal cell carcinoma and performed a laparoscopic radical nephrectomy. However, the histology revealed a well-differentiated neuroendocrine tumor. We concluded that it was a primary renal carcinoid tumor with no distant metastasis and did not administer chemotherapy or radiation therapy. He is recurrence-free after 8 months.

Retraction: Compliance and Impact of an ID Physician's Advisory Consults on the Use of Restricted Antimicrobial Agents / 감염과화학요법

No abstract available.

Retraction: Compliance and Impact of an ID Physician's Advisory Consults on the Use of Restricted Antimicrobial Agents / 감염과화학요법

No abstract available.

Change of Parathyroid Hormone and Markers of Bone Metabolism after Renal Transplantation / 대한신장학회지

PURPOSE: The aims of this retrospective study were to evaluate the sequential changes of parathyroid hormone (iPTH) and calcium metabolism after renal transplantation (RTP) and to identify risk factors for hypertension (HPT). METHODS: Biochemical bone parameters were reviewed in 264 patients at pre-transplant, 6, 12, 36 and 60 months after RTP. RESULTS: iPTH levels fell significantly during the first six months after RTP and remained substantially stable thereafter. The mean total serum calcium level showed significant increase during the first six months and progressive and significant decline after the first year. The mean serum phosphorus level returned to the normal range during the first six months and remained normal thereafter. The serum alkaline phosphatase (ALP) level increased during the first year and gradually decreased after then. The prevalence of persistent HPT was 17.8%. Patients with persistent HPT had significantly elevated serum levels of iPTH at the time of RTP and had spent a longer time on dialysis. Significant positive correlations were observed between the serum iPTH levels on the one hand and the pre-transplant iPTH, serum ALP, and creatinine levels on the other hand. CONCLUSION: The prevalence of persistent HPT after RTP is not uncommon. The patients with long duration of dialysis showing high serum level of iPTH at the time of transplantation are at risk for persistent HPT.

Clinicopathologic Study on Adults Idiopathic Nephrotic Syndrome in Korea / 대한신장학회잡지

PURPOSE: We examined the clinical characteristics and incidence of adults idiopathic nephrotic syndrome (NS) according to pathologic diagnosis, age, sex. METHODS: We retrospectively reviewed the clinical and pathological characteristics of primary glomerular lesions in adults idiopathic NS taken a renal biopsy from 1978 to 2005 at the Dongsan Medical Center. We compared the prevalence of adults idiopathic NS according to the pathologic diagnosis between two time intervals 1978 to 1990 and 1991 to 2005. RESULTS: The patients had mean age of 36.7+/-16.3 years and male to female ratio was 1.7:1 with male predominance. The frequency of histopathologic diagnoses were minimal change nephrotic syndrome (MCNS) 51.6%, membranous glomerulonephritis (MGN) 21.3%, focal segmental glomerulosclerosis (FSGS) 12.1%, IgA nephropathy 9.1%, membranoproliferative glomerulonephritis (MPGN) 4.2% in decreasing order of frequency. The mean age was youngest in MCNS (32.9+/-15.1) and oldest in MGN (46.2+/-16.6). Between 1978 to 1990 period and 1991 to 2005 period, the prevalence of MGN was significantly increased, whereas the prevalence of MPGN was decreased significantly. The prevalence of MCNS had a tendency to decrease and that of IgA nephropathy had a tendency to increase, however, both didn't reach statistical significance. The incidence of FSGS didn't show a significant change during the both study periods. CONCLUSION: MCNS was the most common disease among adults idiopathic NS. MGN was the most frequent etiology in patients older than 45 years. The incidence of MGN was increased over the 28-year period, and that of MPGN decreased significantly. There was no change in the frequency of FSGS.

Peritonitis by Chryseobacterium indologenes and Sphingomonas paucimobilis in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD) / 대한신장학회지

Bacterial peritonitis is a well-recognized complication of continuous ambulatory peritoneal dialysis (CAPD) in patients with end-stage renal failure. Chryseobacterium indologenes is a non-fermentative Gram-negative bacillus that is a rare pathogen in humans and Sphinomomas paucimobilis has rarely been reported as an opportunistic human pathogen. We present a case of peritonitis due to unusual pathogens, C. indologenes and S. paucimobilis, unresponsive to the standard antibiotics therapy. A 51-year-old diabetic man undergoing CAPD for 45 days developed the first peritonitis due to C. indolegenes. Although he had received intraperitoneal antibiotics with good in vitro activity against organism, the signs of peritonitis persisted. S. paucimobilis was isolated from dialysate sample. The Tenckhoff catheter was finally removed on 19th day of hospitalization and the fever and abdominal pain subsided.

A Case of Posttransplant Lymphoproliferative Disorder in the Duodenum after Kidney Transplantation / 대한신장학회지

Posttransplant lymphoproliferative disorder (PTLD) is an uncommon but life-threatening complication of immunosuppressive therapy following solid organ transplantation. It encompasses a heterogeneous group of lymphoproliferative disorders ranging from reactive, polyclonal hyperplasia to aggressive non- Hodgkin's lymphoma. The majority of PTLD is of B-cell origin and associated with Epstein-Barr virus (EBV) infection. Gastrointestinal involvement, especially small bowel and colon, is common in patients with PTLD, but the duodenum is rarely involved. We have experienced a case of PTLD involving the duodenum eight years after kidney transplantation in 50-year-old man. Two weeks before admission, he had complained of epigastric pain, and was diagnosed as pangastritis and duodenal ulcer by upper gastrointestinal endoscopy. He was admitted due to aggravated epigastric pain despite anti-ulcer medication. On the seventh hospital day, we found a new mass-like lesion in the pyloric area of antrum and diffuse ulceration in the duodenum by follow-up endoscopy. Histologic findings revealed diffuse large B-cell lymphoma. During reduction in immunosuppressive regimens, his conditions deteriorated rapidly. He died of sepsis associated with duodenal ulcer perforation, 18 days after diagnosis.

Successful Treatment of Severe Lactic Acidosis by Continuous Venovenous Hemodiafiltration / 대한신장학회잡지

Lactic acidosis is often associated with a strikingly high mortality. The effective therapy involves treatment of the underlying cause and correction of acidemia by infusion of sodium bicarbonate. When lactic acidosis is accompanied by oliguric renal failure, bicarbonate therapy becomes more complex with volume overload and hypernatremia. Hemodialysis against a bicarbonate-buffered dialysate will achieve this. However, it is generally tolerated poorly by hemodynamically unstable patients. We report here three hemodynamically unstable patients with severe lactic acidosis, which was treated successfully by the use of continuous venovenous hemodiafiltration with bicarbonate based dialysate and replacement solution. We would suggest that continuous renal replacement with bicarbonate buffer should be indicated in the treatment of severe lactic acidosis.

Kidney Transplantation in Patients with Focal Segmental Glomerulosclerosis / 대한이식학회지

Purpose: Kidney transplantation (KT) is one of the important treatment modality for the patients with focal segmental glomerulosclerosis (FSGS), but high recurrence rate and resulting graft failure is still a great obstacle. In order to compare the results of transplantation for recipient with FSGS, we reviewed our cases retrospectively. Methods: Thirty-six biopsy proven FSGS were reviewed and compared their clinical characteristics according to their recurrence status, retrospectively. Patient with significant proteinuria after KT was re-biopsied and light- and electron-microscopic study were done to confirm the recurrence of original disease. Results: Recurrence of FSGS was confirmed histologically in 13 (36%) recipients. Among 15 failed grafts, 9 grafts lost their function by recurrence of FSGS. Higher rate of acute rejection associated in recurred group (53% vs 39%). Five-year graft survival of recurred group was significantly lower than non-recurred group (65% vs 78%, P=0.0071). Cyclosporin group showed more frequent recurrence of FSGS after transplantation than tacrolimus group but no statistical significance (P>0.05). Plasmapheresis (PP) was done in 8 patients with early recurred FSGS and was effective in reducing the grade of proteinuria. Their long-term graft survival, however, was poor even though half of the recurred patients maintain their graft function until 5 years after PP. Conclusion: Our data showed that the recurred FSGS group showed higher rate of graft loss and poor graft survival. Since the FSGS recurrence is directly related with graft survival, large data analysis will be necessary to analyze the risk factor of recurrence and prevent adverse effect of recurrence of FSGS after KT.

Peritoneal Equilibration test (PET) in Korean Patients - Single Center Experience / 대한신장학회잡지

BACKGROUND: Peritoneal solute transport rate, assessed by PET, varies widely among patients and has been shown to differ significantly among different ethnic groups. The aim of the present study is to investigate the peritoneal transport characteristics in Korean peritoneal dialysis (PD) patients and factors that predict peritoneal transport status. METHODS: Between May 2001 and February 2006, 141 patients on PD performed a standard 4-hour PET within the first 6 months after initiation of PD therapy. RESULTS: Of these 141 patients, there were 71males and 70 females. The mean age of the patients was 51.2+/-12.5 years and the etiology of renal failure was diabetes in 67 patients (47.5%). The mean 4-hour D/P creatinine ratio was 0.68+/-0.11. Compared with a mean of 0.65+/-0.15 as determined by Twardowski et al, our patients have significantly higher mean solute transport rate (p<0.05). Numbers of low (L), low-average (LA), high-average (HA), and high (H) transporters were 15 (10.6%). 68 (48.2 %), 53 (37.6%) and 5 (3.5%), respectively. However, according to our own data, the number of L, LA, HA and H were 18 (12.8%), 42 (29.8%), 64 (45.4%) and 17 (12.1%), respectively, significantly different from those classified by Twardowski et al. In univariate analysis, older age, hypoalbuminemia and lower BMI were predictive of high transport status. Using multiple linear regression, only hypoalbuminemia was independently predictive of higher 4-hour D/Pcr (p=0.000). CONCLUSION: Korean PD patients have a higher mean solute transport rate than Twardowskis data, and serum albumin is an independent predictor of high transport status. Further prospective studies with a large number of patients are needed for evaluating the diversity of peritoneal transport characteristics in different ethnic populations.

Peritoneal Equilibration test (PET) in Korean Patients - Single Center Experience / 대한신장학회잡지

BACKGROUND: Peritoneal solute transport rate, assessed by PET, varies widely among patients and has been shown to differ significantly among different ethnic groups. The aim of the present study is to investigate the peritoneal transport characteristics in Korean peritoneal dialysis (PD) patients and factors that predict peritoneal transport status. METHODS: Between May 2001 and February 2006, 141 patients on PD performed a standard 4-hour PET within the first 6 months after initiation of PD therapy. RESULTS: Of these 141 patients, there were 71males and 70 females. The mean age of the patients was 51.2+/-12.5 years and the etiology of renal failure was diabetes in 67 patients (47.5%). The mean 4-hour D/P creatinine ratio was 0.68+/-0.11. Compared with a mean of 0.65+/-0.15 as determined by Twardowski et al, our patients have significantly higher mean solute transport rate (p<0.05). Numbers of low (L), low-average (LA), high-average (HA), and high (H) transporters were 15 (10.6%). 68 (48.2 %), 53 (37.6%) and 5 (3.5%), respectively. However, according to our own data, the number of L, LA, HA and H were 18 (12.8%), 42 (29.8%), 64 (45.4%) and 17 (12.1%), respectively, significantly different from those classified by Twardowski et al. In univariate analysis, older age, hypoalbuminemia and lower BMI were predictive of high transport status. Using multiple linear regression, only hypoalbuminemia was independently predictive of higher 4-hour D/Pcr (p=0.000). CONCLUSION: Korean PD patients have a higher mean solute transport rate than Twardowskis data, and serum albumin is an independent predictor of high transport status. Further prospective studies with a large number of patients are needed for evaluating the diversity of peritoneal transport characteristics in different ethnic populations.

Clinical characteristics of idiopathic membranoproliferative glomerulonephritis / 대한내과학회지

BACKGROUND: Idiopathic membranoproliferative glomerulonephritis (MPGN) is a chronic primary glomerular disease that occurs in both children and adults, with generally progressive course. We have examined the clinical and long-term outcome of patients with idiopathic MPGN at Keimyung University Dongsan Medical Center. METHODS: Of the total 1,971 patients with biopsy-proven glomerulonephritis over the 21-year period from June 1982 and June 2003, there were 51 cases of idiopathic MPGN of whom 49 had type I and two type II. RESULTS: Of the total 51 idiopathic MPGN, male to female ratio was 1.7:1, a mean age at diagnosis was 32 +/- 17 years (range; 6-70) and 50% of the patients were under the age of 30. The clinical presentations at the time of diagnosis were nephrotic syndrome (70%), asymptomatic urinary abnormality (18%), acute nephritic syndrome (6%), and recurrent gross hematuria (6%). Of the 40 patients who followed more than 6 months, with a mean follow-up of 71months, 10 patients progressed to end-stage renal disease. The renal survival at 5 and 10 years after diagnosis were 86 and 52%, respectively. Eight (20%) patients obtained a complete remission and none of them progressed to end-stage renal failure. The quantity of proteinuria at the time of biopsy was much more prominent in deteriorating group, though not significant (p=0.05) and young age and female seemed associated with the complete remission (p<0.05). CONCLUSION: Idiopathic MPGN remains a disease with a poor prognosis. Age, gender and quantity of proteinuria at the time of diagnosis were associated with the prognosis. Further prospective study with larger number of patients would be necessary to assess the prognostic factors and effective therapy for idiopathic MPGN.

Compliance and Impact of an ID Physician's Advisory Consults on the Use of Restricted Antimicrobial Agents / 감염과화학요법

BACKGROUND: Many strategies have been developed to guide more appropriate and cost-effective antibiotic use in hospitals. This study was done to evaluate compliance and short-term impact of targeted antibiotic advisory consult implemented in our hospital since October 2002. Materials and METHODS: A total of 339 prescriptions in 187 patients were retrospectively reviewed and antimicrobial utilization density was compared quarterly from January 2002 through June 2003. RESULTS: Overall, 85.6% of prescriptions were inappropriate, with 73.7% being inappropriate for therapeutic regimens and 100% for prophylactic regimens. Overall compliance was 46.5%. The compliance was higher in the medical services than in the surgical services (64.2% vs. 43.1%, P=0.005) and for therapeutic use than for prophylactic use (54.7% vs. 36.5%, P=0.001). From 1Q 2002 to 2Q 2003, use of aminoglycosides was reduced from 269.1 AUD to 171.8 AUD, and that for antipseudomonal cephalosporins from 112.1 AUD to 64.5 AUD (both, P<0.01). Overall, inpatient use of parenteral antibiotics was decreased from 770.8 AUD to 626.8 AUD (P<0.01). CONCLUSION: Targeted antibiotic advisory consult resulted in substantial reduction in antibiotic use despite relatively poor compliance. This type of antibiotic control program can be an alternative for hospitals with limited human resources trying to implement an antibiotic policy.

Compliance and Impact of an ID Physician's Advisory Consults on the Use of Restricted Antimicrobial Agents / 감염과화학요법

BACKGROUND: Many strategies have been developed to guide more appropriate and cost-effective antibiotic use in hospitals. This study was done to evaluate compliance and short-term impact of targeted antibiotic advisory consult implemented in our hospital since October 2002. Materials and METHODS: A total of 339 prescriptions in 187 patients were retrospectively reviewed and antimicrobial utilization density was compared quarterly from January 2002 through June 2003. RESULTS: Overall, 85.6% of prescriptions were inappropriate, with 73.7% being inappropriate for therapeutic regimens and 100% for prophylactic regimens. Overall compliance was 46.5%. The compliance was higher in the medical services than in the surgical services (64.2% vs. 43.1%, P=0.005) and for therapeutic use than for prophylactic use (54.7% vs. 36.5%, P=0.001). From 1Q 2002 to 2Q 2003, use of aminoglycosides was reduced from 269.1 AUD to 171.8 AUD, and that for antipseudomonal cephalosporins from 112.1 AUD to 64.5 AUD (both, P<0.01). Overall, inpatient use of parenteral antibiotics was decreased from 770.8 AUD to 626.8 AUD (P<0.01). CONCLUSION: Targeted antibiotic advisory consult resulted in substantial reduction in antibiotic use despite relatively poor compliance. This type of antibiotic control program can be an alternative for hospitals with limited human resources trying to implement an antibiotic policy.

Clinical Observation on Hyperkalemic Distal Renal Tubular Acidosis / 대한신장학회잡지

PURPOSE: Renal tubular aicdosis (RTA) is a disorder of renal acidification out of porportion to the reduction in glomerular filtration rate. Type IV RTA refers to hyperkalemic metabolic acidosis resulting from aldosterone deficiency or resistance. The incidence of each type RTA has not been reported exactly, however reports on type IV RTA have been recently increasing. METHODS: A retrospective clinical analysis was performed in 50 patients with hyperkalemic distal renal tubular acidosis diagnosed between Jan. 1984 and Feb. 2003 at Department of Internal Medicine, Keimyung University, Dongsan Medical Center. RESULTS: From 1984 to 2003, 50 cases of hyperkalemic distal renal tubular acidosis were diagnosed. The mean age was 50.8+/-19.5 years. The two most common conditions were posttransplantation (28%), and diabetes mellitus (22%), which were followed by hypertension (12%), systemic lupus erythematosus (12%), chronic renal failure (12%), and others (26%). Asymptomatic hyperkalemia (34%), and muscle weakness (28%) were the two most common clinical presentations. All patients demonstrated normal anion gap acidosis with positive urine anion gap. The mean creatinine clearance was 25.6+/-16.4 mL/min. The mean baseline PRA and aldosterone levels were 3.82+/-7.16 ng/mL/hr and 110.02+/-108.2 ng/mL, respectively. Hyperkalemia was well responded to 9-alpha-fludrocortisone, furosemide, K-exchane resin, and combinations of these regimens. CONCIUSION: Type IV RTA is the most common type of RTA in children and adults, and can be an important cause of asymptomatic hyperkalemia. Therefore, type IV RTA should be included in the diffrential diagnosis of unexplained hyperkalemia in various clinical settings.

Prognosis of Idiopathic Membranous Nephropathy after Complete Remission of Proteinuria / 대한신장학회잡지

BACKGROUND: The natural history of idiopathic membranous nephropathy is often benign, but approximately 30% of the patients develop renal insufficiency and progress to end-stage renal failure over 5 to 15 years. Several retrospective analyses have been performed to identify favorable factors influencing the long-term prognosis of idiopathic membranous nephropathy. However, little attention has been paid to the significance of remission of proteinuria in this disease. METHODS: Forty-six patients with biopsy-proven idiopathic membranous nephropathy who achieved complete remission (CR) of proteinuria between 1982 and 2003 were enrolled. We retrospectively analyzed the clinical and laboratory data between persistent remission group and relapsing group after CR of proteinuria. RESULTS: Complete remission of proteinuria was seen in 46 patients (31%) and was obtained 7-170 months (mean 38 months) after discovery of the disease. During mean 89 months follow-up, 74% of the patients remained in remission and 26% relapsed. However, proteinuria disappeared again spontaneously in some patients so that at last follow-up 83% of the patients are in CR. The probability of remaining free of proteinuria at 5 and 10years after CR was 0.73 and 0.60, respectively. 5 and 10years renal survival in patient with CR were 100%, respectively, whereas those of patient without remission were 89 % and 75%, respectively, which was significantly different (p<0.05). We could not find any specific clinical factors favored maintenance of remission, except serum level of creatinine and serum cholesterol during remission, which are significantly less in patients with persistent remission. CONCLUSION: In conclusion, CR of proteinuria is a strong predictor of long-term favorable outcome in patients with idiopathic membranous nephropathy.

Senior Medical Students' Attitudes toward and Knowledge about Breastfeeding / 예방의학회지

OBJECTIVES: This study surveyed medical students attending clerkship to assess their attitude toward and knowledge about breastfeeding, and self-confidence to manage common breast-feeding problems. METHODS: A self-report questionnaire was administered to the 323 medical students at four medical colleges in Taegu in May 1997. The response rate was 92.9%, but the respondents used in the final data analysis were 245 (75.8%) due to missing variables. RESULTS: Overall, respondents showed equivocal attitudes toward breastfeeding (mean score 2.9 on a 6-point scale). Knowledge about breastfeeding was substantially low with the median % correct 39.2%. Of nine knowledge areas, weak areas were especially "contraindications and barriers to breastfeeding", "use of breastfeeding aids", "expression and storage of breast milk". Those reported to be confident to manage common breastfeeding problems were only 25.7%. Correlations between knowledge and self-confidence were not statistically significant except in college A (r=0.35, p<0.05). Correlations between knowledge and attitude were not significant. CONCLUSIONS: These results suggest that medical students attending clerkship in Taegu show equivocal attitudes toward breastfeeding, low self-confidence to manage common breastfeeding problems and have substantially limited level of knowledge. There should be more concerted efforts to improve this situation on the part of those involved in breastfeeding education.