Detecting Bacterial Growth in Continuous Ambulatory Peritoneal Dialysis Effluent Using Two Culture Methods

BACKGROUND/AIMS: The aim of this study was to evaluate the peritonitis-causing bacteria detected in peritoneal fluid using a blood culture bottle in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). METHODS: One-hundred and eleven dialysates from 43 patients suspected of peritonitis related to CAPD were retrospectively evaluated between May 2000 and February 2008. In all cases, 5 to 10 mL of dialysate was inoculated into a pair of BacT/Alert blood culture bottles, and 50 mL of centrifuged dialysate was simultaneously inoculated into a solid culture media for conventional culture. The results were compared to those of the conventional culture method. Isolated microorganisms were compared between the two methods. RESULTS: The blood culture method was positive in 78.6% (88 / 112) of dialysate specimens and the conventional culture method in 50% (56 / 112, p < 0.001). CONCLUSIONS: The blood culture method using the BacT/Alert system is useful for culturing dialysates and improves the positive culture rate in patients with suspected peritonitis compared to the conventional culture method.

Candida zeylanoides Peritonitis in a Continuous Ambulatory Peritoneal Dialysis Patient / 대한신장학회지

Despite the frequent occurrence of peritonitis in patients with continuous ambulatory peritoneal dialysis (CAPD), fungal peritonitis is uncommon and usually associated with antibiotics and immunodeficiency. Most of the fungal isolates are usually Candida albicans, Candida parapsilosis, Candida guilliermondii or Candida torulopsis. The authors report a case of fungal CAPD related peritonitis due to Candida zeylanoides that occurred in a patient with the absence of the usual risk factors for fungal peritonitis. Treatment with intravenous fluconazole was successful.

Kidney and Phosphate Metabolism

The serum phosphorus level is maintained through a complex interplay between intestinal absorption, exchange intracellular and bone storage pools, and renal tubular reabsorption. The kidney plays a major role in regulation of phosphorus homeostasis by renal tubular reabsorption. Type IIa and type IIc Na+/Pi transporters are important renal Na+-dependent inorganic phosphate (Pi) transporters, which are expressed in the brush border membrane of proximal tubular cells. Both are regulated by dietary Pi intake, vitamin D, fibroblast growth factor 23 (FGF23) and parathyroid hormone. The expression of type IIa Na+/Pi transporter result from hypophosphatemia quickly. However, type IIc appears to act more slowly. Physiological and pathophysiological alteration in renal Pi reabsorption are related to altered brush-border membrane expression/content of the type II Na+/Pi cotransporter. Many studies of genetic and acquired renal phosphate wasting disorders have led to the identification of novel genes. Two novel Pi regulating genes, PHEX and FGF23, play a role in the pathophysiology of genetic and acquired renal phosphate wasting disorders and studies are underway to define their mechanism on renal Pi regulation. In recent studies, sodium-hydrogen exchanger regulatory factor 1 (NHERF1) is reported as another new regulator for Pi reabsorption mechanism.

Blood glucose analysis in patients on continuous ambulatory peritoneal dialysis with Icodextrin / 대한내과학회지

BACKGROUND/AIMS: Icodextrin (glucose polymer) is metabolized by a-amylase to oligosaccharides such as maltose and maltotriose. The presence of these metabolites could have an effect on the enzymatic glucose measurement especially the glucose dehydrogenase pyrroloquinolinequinone (GDH-PQQ) based method. Patients treated with icodextrin are at risk for inaccurate blood glucose measurements. In this study we measured the blood glucose with different methods and analyzed the results to determine the test accuracy. METHODS: The blood glucose was measured, in seven outpatients and in seven inpatients using icodextrin, by the glucose hexokinase laboratory technique method as well as the GDH-PQQ method (Accu Chek Active)at the same time. To estimate an icodextrin residual effect, after discontinuing icodextin, the blood glucose was measured by the two methods after 48 hours in 4 inpatients. RESULTS: In seven outpatients the blood glucose was overestimated by the Accu Chek Active method (mean difference 68 mg/dL, p value 0.012). In seven inpatients the mean difference in the glucose was 56 mg/dL at 6am, 52 mg/dL at 11am, 52 mg/dL at 4pm, and 50 mg/dL at 9pm by the two different methods. In the four inpatients after changing their dialysate, the mean difference in the glucose was 58 mg/dL after 10 hours, 45 mg/dL after 24 hours, 24 mg/dL after 34 hours, and 26 mg/dL after 48 hours. CONCLUSION: Blood glucose was overestimated by the GDH-PQQ method and the inaccuracies were observed for more than 48 hours.

A Case of Idiopathic Fibrillary Glomerulonephritis with Hypocomplementemia / 대한신장학회지

A 72-year-old woman presented with generalized edema and proteinuria. Renal biopsy disclosed highly organized fibrillary deposits in subendothelial area by electron microscopy. The microfibrils were 14 nm in diameter and randomly arranged. They did not have a microtubular appearance. These materials were negative for Congo red staining. Cryoglobulinemia or paraproteinemia including light chains was not found. So we can diagnose her as fibrillary glomerulonephritis (GN). In fibrillary GN serum complement levels are usually normal except in rare cases with systemic disease. Here we present a rare case of fibrillary GN with unusual hypocomplementemia.

A Case of Renal Infarction with Arterial Thromboembolism / 대한이식학회지

Renal infarction in transplant kidney is an very uncommon post-transplant complication, and usually occurs in the early postoperative period. Thromboemboli to the renal arteries usually originate from the heart, e.g. atrial fibrillation. This paper reports a 64-year-old man who had total occlusion of transplanted renal artery after 9 years from transplantation. His medicines included cyclosporine, prednisolone, aspirin, clopidogrel, and propranlol. Our patient presented with fever, oliguria, and left costovertebral angle tenderness, three days ago. Abdominal computed tomography (CT) revealed total occlusion of transplanted renal artery and right common iliac artery. Preservation of renal function is inversely proportional to the period of renal ischemia. Our patient was treated with heparinization. Remnant renal function was lost, he has been treated with hemodialysis.

Relationship between serum cystatin C and glomerular filtration rate in renal transplant patients / 대한내과학회지

BACKGROUND: Serum cystatin C has been proposed to be a sensitive glomerular filtration rate (GFR) marker. This study was undertaken to evaluate correlation between serum cystatin C and GFR estimates in renal transplant recipients. METHODS: Serum cystatin C, serum creatinine and 24-hour creatinine clearance were measured in 40 adult renal transplant recipients. Three different GFR estimates were used: 24-hour creatinine clearance, Modification of Diet in Renal Disease (MDRD) equation, and Cockcroft-Gault formula. Linear regression analysis was performed to evaluate correlations between GFR estimates and serum cystatin C, and nonparametric receiver operating characteristic (ROC) analysis was carried out to compare the diagnostic accuracy of serum cystatin C with that of serum creatinine. RESULTS: Significant correlations were noted between each of the 3 different GFR estimates (from 24-hour creatinine clearance, MDRD equation and Cockcroft-Gault formula) and serum cystatin C. Serum cystatin C also correlated significantly with serum creatinine. In the ROC analysis, the areas under the curve for cystatin C and creatinine were not significantly different when using a cut-off GFR estimate at 60 mL/min/1.73 m2. CONCLUSIONS: Serum cystatin C is a useful marker for the assessment of GFR in renal transplant recipients, but it is not clear whether cystatin C is superior to creatinine in detection of a mild to moderate renal impairment.

Quinolone Resistance in Community-Acquired Acute Pyelonephritis / 대한신장학회잡지

BACKGROUND: Quinolone antibiotics are now frequently used for the empirical therapy of acute pyelonephritis (APN). However, failure of this empirical therapy is often encountered in clinical practice, and the emergence of quinolone resistance should be concerned. This study was undertaken to investigate the prevalence of quinolone resistance in community-acquired APN and to analyze the clinical characteristics of quinolone-resistant APN. METHODS: Clinical data were retrospectively analyzed from 367 patients who were admitted to Hanyang University Hospital for APN from January 2002 through December 2004. According to the result of urine culture, the patients were divided into quinolone-susceptible and quinolone-resistant groups, and clinical characteristics were compared. RESULTS: Urine culture was positive in 241 out of 367 patients, and E. coli was the most common (90%) isolate. The prevalence of quinolone resistance based on the in vitro ciprofloxacin susceptibility test was found to be 19.5%, and among the E. coli isolates the prevalence of quinolone resistance was 19.8 %. 91 patients had underlying diseases and they were more frequently complicated by urosepsis. The ages and the prevalence of azotemia were not significantly different between two groups. Quinolone-resistant group had a lesser frequency of urosepsis compared with quinolone-susceptible group. Diabetic patients were more frequently quinolone-susceptible than quinolone-resistant. CONCLUSION: Although the prevalence of quinolone resistance is rather high in community-acquired APN based on the in vitro susceptibility test, the choice of quinolone antibiotics seems to be valid for the empirical therapy.

A Case of Transplant Glomerulopathy Complicated by Crescent Formation / 대한이식학회지

Transplant glomerulopathy (TGP) is specified as thickening of capillary wall of glomerulus and clinically presented with proteinuria and progressive graft dysfunction. In contrast, crescent formation represents an extracapillary proliferative glomerular change and is clinically presented with rapidly progressive renal failure. Previously, in transplant kidneys, crescent formation was reported only in anti-GBM disease and ANCA- associated vasculitis. Here we report a case with a very unusual combination of transplant glomerulopathy and crescent formation. Ten years after the renal transplantation the patient was admitted due to proteinuria and progressive azotemia. Although his underlying renal disease was IgA nephropathy, the transplant kidney biopsy revealed typical findings of transplant glomerulopathy without specific immune deposits, but with extensive cellular crescents. Methylprednisolone pulse therapy was not successful, and he was switched to maintenance hemodialysis.

A Case of C4d-Positive Acute Humoral Rejection Treated with Rituximab and Plasma Exchange / 대한신장학회잡지

Although acute humoral rejection is a major cause of renal allograft loss, the diagnosis and treatment of acute humoral rejection have been very difficult because of lack of proper diagnostic tools and effective therapeutic modalities. Recently C4d deposition in peritubular capillaries of renal allografts has been demonstrated to be a sensitive and diagnostic in-situ marker of humoral rejection that correlates strongly with the presence of circulating donor-specific antibodies. Whereas conventional immunosuppressive agents are effective for the treatment of cellular rejection, specific therapeutic strategies targeting the humoral limb of immunosuppression should be necessary for the treatment of humoral rejection. Here we report a case of acute humoral rejection diagnosed with C4d immunostaining from transplant kidney biopsy and treated successfully with combination of plasma exchange, polyclonal rabbit anti-thymocyte globulin, and rituximab.

Association of posttransplantation proteinuria with allograft loss in transplant kidney biopsy-proven recipients / 대한내과학회지

BACKGROUND: Previous studies reported a poor prognosis in patients with persistent proteinuria later in the posttransplantation course, suggesting that posttransplantation proteinuria is a marker for graft failure. This study was undertaken to elucidate the role of proteinuria after renal transplantation in the pathogenesis and outcome of allograft dysfunction in transplant biopsy-proven recipients. METHODS: We retrospectively analyzed the data from 55 patients who underwent transplant renal biopsy for proteinuria and/or azotemia occurring beyond 1 year after transplantation. Proteinuria was considered as significant when >or=30 mg/dL, and the results of transplant biopsy were categorized according to the Banff 97 classification. Logistic regression was used to estimate odds ratios (OR) for graft loss associated with proteinuria and transplant pathology. RESULTS: The patients were followed for 86.0 +/- 32.8 (mean +/- SD) months after transplantation, and transplant biopsy was performed at 54.1 +/- 31.0 months. Proteinuria at 1 year after transplantation was noted in 29.1% of the patients, and it was not significantly associated with graft loss (OR=1.94, 95% CI 0.59-6.41). In addition, proteinuria at the time of transplant biopsy was not significantly associated with graft loss, and none of each category of transplant pathology was significantly associated with graft loss. Chronic allograft nephropathy was the most frequent transplant pathology, and only glomerulonephritis was significantly associated with proteinuria at the time of transplant biopsy. On the other hand, graft loss was significantly associated with the presence of proteinuria both at 1 year after transplant biopsy and at the final follow-up. CONCLUSION: These results suggest that posttransplantation proteinuria is an important marker of graft dysfunction but may not be predictive of graft loss in biopsy-proven cases. Appropriate management guided by the results of transplant biopsy may improve the outcome.

Outbreak of Posttransplant Lymphoproliferative Disorder (PTLD) in a Single Center / 대한이식학회지

Post transplant lymphoproliferative disorder is a serious complication after renal transplantation. Although the precise etiology is unknown, the Ebstein-Bar virus and immunosuppressive agents appear to be risk factors. The presentation of PTLD is diverse. Many patients develop symptoms in head and neck, which make diagnosis difficult. We experienced 3 cases of PTLD successively one or three months apart during year 2002. Before 2002, PTLD was very rare in our center. The incidence of PTLD in renal transplants in our center is 0.7% (5 out of 752), which is similar to that of other reports. But the incidence is very high during year 2002. This seems to be intensified immunosuppression recently adopted. EBV monitoring is necessary for early detection of PTLD in renal transplants.

A Case of Osteomalacia with Long Term Carbamazepine Therapy / 대한내분비학회지

Anticonvusant therapy with any of several agents, especially phenytoin, phenobarbital, and primidone causes disturbances in bone mineral metabolism. Anticonvulsants stimulate the hepatic microsomal mixed-oxidase enzymes and hence increase the rate of clearance of vitamin D and its metabolism. The severity of clinical manifestations in any given individual appears to be a function of the combined effects of variety of factors including drug type and total drug dose, dietary vitamin D intake, sunlight exposure, and physical activity level. We report a case of osteomalacia associated with long term carbamazepine therapy in a 21-year-old male with less exposure to sunlight.

Evaluation of Bartter-like Syndrome Associated with Aminoglycoside Micronomocin Sulfate Administration During Acute Pyelonephritis Treatment / 대한신장학회잡지

The aminoglycoside antibiotics is widely used in the treatment of infectious caused by gram-negative bacteria and for synergistic effect with(beta-lactam antibiotics. However, its therapeutic usefulness is limited by this potential nephrotoxicity and by disturbance of electrolyte homeostasis resulting in hypomagnesemia, hypokalemia, hypocalcemia such as Bartter-like syndrome. Many case repots have been reported on development of Bartter-like syndrome after aminoglycosides administration. But these reports had the many differences of such as types of aminoglycosides, age of patients, duration and total dose of treatment, combined antibiotics and baseline diseases. Therefore, the purpose of this study is to assess the effects of micronomocin sulfate on magnesium, calcium and potassium status of patients in acute pyelonephritis. Twenty one patients in acute pyelonephritis(18 female/3 male, ages 20-75) was treated with single or combined antibiotics. Eleven of twenty one patients as study group were treated with both micronomicin sulfate(aminoglycoside, 4mg/kg/day, during 5-8days) and flomoxef sodium (3rd cephalosporine, 2g/day, during 5-8days), and ten of twenty one patients as control group were treated only with flomoxef sodium(3rd cephalosporine. 2g/day. during 5-8days). Renal values, plasma and urinary electrolytes were measured before and at the end of IV antibiotic therapy. After micronomicin sulfate administrated for 6.4+/-1.5days, serum Mg, Ca, K, FEMg (fractional excretion of Mg), TTKG(transtubular K concentration gradient) and FECa(fractional excretion of Ca) did not significantly change(p>0.05). Therefore, those results suggest that micromonicin sulfate therapy within dose of 240mg/day(4mg/kg/day) for 6.4+/-1.5days may not cause disturbance of electrolyte homeostasis such as Bartter-like syndrome in acute pyelonephritis. Howerever, electrolyte disturbance is an important complication when aminoglycosides is given in larges doses over extended periods. Therefore, monitoring of blood concentration and urinary losses of electrolyte should be carried out along with careful observation of Bartter-like syndrome.

Total Protein, Albumin and IgG Analysis of Serum and Cerebrospinal Fluid in Control and Aseptic Meningitis

No abstract available.

Fibrous Dysplasia of the Skull

Fibrous dysplasia infrequently involves the cranium with wide range of variety. Recently, we have expierenced a case of diffuse sclerotic type of fibrous dysplasia which involves frontal and sphenoid bone with vault deformity. Furthermore, we stressed the diagnostic procedures such as carotid angiography, orbital venoraphy & C-T scan, are valuable in recognization of the extent of involvement and in differential diagnosis.

Brachial Plexus Injury by Gun-Shot

Disturbances of the surrounding vascular system and the severe cicatrical entrapment of the injured plexus should be considered, with its neural damage, in brachial plexus injury by Gun-Shot. Therefore, Subclavian arteriography and Subclavian venography before operation should be essential and the correction of the deficit of the vascular system may be a factor in the determination of prognosis in relation to pain control. We have reported 2 cases of the brachial plexus injury by Gun-shot and discussed the importance of Subcalvian arteriography and Subclavian venography. External neurolysis seems to be beneficial in Causalgia caused by brachial plexus injury.