A Case of Paradoxical Renal Embolism through Patent Foramen Ovale / 대한신장학회지

Paradoxical embolism is a kind of stroke caused by embolism of thrombus of venous origin through a lateral opening in the heart, such as a patent foramen ovale (PFO). Although the most frequent manifestation of paradoxical embolism is cryptogenic stroke, noncerebral paradoxical embolism is also associated with PFO. We experienced a case of cryptogenic renal infarction in a previously healthy 70-year-old man. He had no cardiac thrombus on transthoracic echocardiography and electrocardiogram revealed a normal sinus rhythm. Because it was cryptogenic renal infarction, we performed transesophageal echocardiography with microbubble test. Microbubble test using agitated saline proved the presence of right-to-left shunt and patent foramen ovale was diagnosed. We also performed lower leg doppler ultrasonogram, but there was no evidence of deep vein thrombosis. Although only the presence of a right-to-left shunt is not enough to establish the diagnosis of paradoxical embolism, it is uncommon for the source of the embolism to be identified. In this case, we concluded that paradoxical embolism is the cause of renal embolism. We report paradoxical renal embolism through PFO with review of relevant literatures.

A Case of Rhabdomyolysis and Acute Renal Failure Associated with Mitochondrial Myopathy / 대한신장학회잡지

Mitochondrial myopathies are diseases caused by defects in metabolic pathway of mitochondria. Mitochondrial myopathy is known as one of the causes of recurrent myoglobinuria, while clinically, rarely causes acute renal failure requiring medical treatments. We report a case of rhabdomyolysis and acute renal failure associated with mitochondrial myopathy. A 58-year-old male was presented with dyspnea and hypotensive shock. The patient had a history of recurrent dark colored urine and cramping leg pain after prolonged fasting. Laboratory findings showed hyperkalemia, azotemia, metabolic acidosis, and elevated AST, ALT, and creatinine kinase. He had no history of trauma or medication. Muscle biopsy showed "ragged red fibers" in modified Gomori staining. On electron microscope, increased number of mitochondria and abnormal mitochondria were seen. He received hemodialysis and his renal function recovered after 1 month.

Effect of Salicylate on the Monocyte Chemoattractant Protein-1 Expression and Intracellular Reactive Oxygen Species Formation in Human Mesangial Cells / 대한신장학회잡지

BACKGROUND: Monocyte chemoattractant protein-1 (MCP-1) and reactive oxygen species (ROS) play an important role during glomerular inflammation. We investigated the effect of aspirin metabolite, salicylate on the pro-inflammatory cytokine-induced MCP-1 expression and lysophosphatidylcholine -induced intracellular ROS formation in human mesangial cells. METHODS: Cells were pretreated with salicylate, and then stimulated with tumor necrosis factor-alpha (TNF-alpha) or interleukin-1beta (IL-1beta). The expression of MCP-1 mRNA and MCP-1 protein were measured by Northern blot analysis and enzyme-linked immunosorbent assay, respectively. Nuclear factor-kappa B (NF-kappaB) activity was measured by electrophoretic mobility shift assay. Degradation of Ikappa B-alpha was assessed by Western blot analysis. Intracellular ROS production was monitored by flow cytometry using 2'7'-dichlorofluorescin diacetate. RESULTS: Salicylate inhibited the TNF-alpha- or IL-1beta- induced MCP-1 mRNA expression in a dose dependent manner (1-20 mM) and also suppressed the MCP-1 protein expression. Its effect was not attributable to de novo synthesis of intermediary proteins. Salicylate inhibited the TNF-alpha- or IL-1beta-induced NF-kappa B binding activity and also suppressed the TNF-alpha-induced Ikappa B-alpha degradation. Low concentration of salicylate (0.01-1 mM) suppressed the lysophosphatidylcholine-induced ROS formation. CONCLUSION: Milimolar concentration of salicylate inhibited the MCP-1 expression at least in part, via suppression of NF-kappaB by reducing the degradation of Ikappa B-alpha. On the other hand, lower concentration of salicylate could suppress the lysophosphatidylcholine-induced intracellular ROS formation.

Effect of Enalapril or Lovastatin on Tubulointerstitial Injury Induced by Protein-overload Proteinuria in Rats / 대한신장학회잡지

BACKGROUND: Previous studies have demonstrated that enalapril or lovastatin seems to ameliorate the renal injury in several animal models with glomerulonephritis. The aim of this study was to examine whether enalapril or lovastatin was still beneficial in tubulointerstitial injury induced by protein-overload proteinuria in rats. METHODS: Enalapril(200mg/L in the drinking water) or lovastatin(16mg/kg, subcutaneously) was administered to uninephrectomized rats which received a daily intraperitoneal injections of bovine serum albumin(BSA, 1/100g body weight)(each n=6). Six rats were served as normal control. After 2 weeks, renal cortical pathologic findings, including immunohistochemistry for macrophage were examined and renal cortical osteopontin, MCP-1, endothelin-1, TGF-beta and procollagen alpha1(I) mRNA expression were examined by Northern blot analysis. RESULTS: Renal cortex in rats with protein-overload proteinuria showed infiltration of inflammatory cells including macrophages, tubular dilatation and atrophy. Renal cortical mRNA expression of osteopontin, MCP-1 and endothelin-1 were increased in rats with protein-overload proteinuria. There were no changes in TGF-beta and procollagen alpha1(I) mRNA expression. Enalapril decreased the macrophage infiltration significantly and inhibited the mRNA expression of osteopontin, MCP-1 and endothelin-1. However, lovastatin had no significant effects on the macrophage infiltration and cortical mRNA expression. CONCLUSION: Enalapril showed beneficial effects in tubulointerstitial injury induced by protein-overload proteiuria in rats by inhibition of macrophage infiltration and the cortical mRNA expression of osteopontin, MCP-1 and endothelin-1. However, lovastatin had no significant effects.

Effect of Enalapril or Lovastatin on Tubulointerstitial Injury Induced by Protein-overload Proteinuria in Rats / 대한신장학회잡지

BACKGROUND: Previous studies have demonstrated that enalapril or lovastatin seems to ameliorate the renal injury in several animal models with glomerulonephritis. The aim of this study was to examine whether enalapril or lovastatin was still beneficial in tubulointerstitial injury induced by protein-overload proteinuria in rats. METHODS: Enalapril(200mg/L in the drinking water) or lovastatin(16mg/kg, subcutaneously) was administered to uninephrectomized rats which received a daily intraperitoneal injections of bovine serum albumin(BSA, 1/100g body weight)(each n=6). Six rats were served as normal control. After 2 weeks, renal cortical pathologic findings, including immunohistochemistry for macrophage were examined and renal cortical osteopontin, MCP-1, endothelin-1, TGF-beta and procollagen alpha1(I) mRNA expression were examined by Northern blot analysis. RESULTS: Renal cortex in rats with protein-overload proteinuria showed infiltration of inflammatory cells including macrophages, tubular dilatation and atrophy. Renal cortical mRNA expression of osteopontin, MCP-1 and endothelin-1 were increased in rats with protein-overload proteinuria. There were no changes in TGF-beta and procollagen alpha1(I) mRNA expression. Enalapril decreased the macrophage infiltration significantly and inhibited the mRNA expression of osteopontin, MCP-1 and endothelin-1. However, lovastatin had no significant effects on the macrophage infiltration and cortical mRNA expression. CONCLUSION: Enalapril showed beneficial effects in tubulointerstitial injury induced by protein-overload proteiuria in rats by inhibition of macrophage infiltration and the cortical mRNA expression of osteopontin, MCP-1 and endothelin-1. However, lovastatin had no significant effects.

Dissociation between Clearances of Small and Middle Molecules in Incremental Peritoneal Dialysis / 대한신장학회잡지

OBJEVTIVE: To evaluate the peritoneal clearance of the middle molecule compared with that of the small molecule in incremental peritoneal dialysis(PD). METHODS: Peritoneal clearances of the creatinine and beta2-microgloblulin were compared in 57 continuous ambulatory PD patients with full dose 4 times exchange and in 54 incremental PD patients with 2 or 3 times exchange over 24 hours. The clearances were also compared when there were changes in the peritoneal dialysis regimen such as in the number of exchanges and dwelling time. RESULTS: Peritoneal creatinine clearance increased almost linearly along with the increase in the number of exchanges. In contrast, peritoneal clearance of beta2-microglobulin was 9.1+/-3.6 L/week, 8.8+/-4.4 L/ week, and 7.9+/-2.5 L/week respectively with 2, 3 and 4 exchanges per day, not different from each other. Peritoneal clearance of beta2-microglobulin did not change when there was an increase in the number of exchange from 2 to 3 times and 3 to 4 times over a period of 24 hours, whereas the peritoneal clearance of creatinine increased. Peritoneal clearance of beta2-microglobulin almost doubled from 5.4+/-2.7 L/ week with 2 times exchange over 12 hours per day, to 9.5+/-4.4 L/week with 2 times exchange over 24 hours, whereas the creatinine clearance did not change. CONCLUSION: In contrast to peritoneal clearance of small molecule which depends on the number of dialysate exchange, peritoneal clearance of middle molecule depends mainly on the total dwelling hours rather than the number of exchange per day in incremental PD. This can be another advantage of incremental PD since peritoneal clearance of middle molecules in incremental PD over 24 hours is comparable to that in full dose PD.

A Magnetic Resonance Angiographic Diagnosis and Successful Thrombolytic Therapy in The Thrombosis of Renal Vein Complicated from Nephroitc Syndrome / 대한신장학회잡지

The nephrotic syndrome has been considered a hypercoagulable state since it may be complicated by thromboembolic events of the venous or the arterial circulations. Diverse pathogenetic factors leading to the hypercoagulable state in nephrotic syndrome have been recognized. Renal vein thrombosis is a serious complication, which might lead to either renal failure or to secondary thromboembolic processes like pulmonary thromboembolism. Although it may present acutely with flank pain and macroscopic hematuria, the majority of cases run an indolent course. Until relatively recently, the diagnosis could only be confidently confirmed or excluded with selective renal venography but, more recently, computerized tomography and magnetic resonance imaging have been used. Anticoagulant therapy with heparin and warfarin apparently halts the natural progression of the disease and allowing for slow recovery. The possibility of more rapid and complete resolution with thrombolytic agents warranted their application. We described a case of bilateral renal vein thrombosis diagnosed by the new technique of magnetic resonance angiography and successful treatment by thrombolytic agent.

Involvement of Macrophage Migration Inhibitory Factor(MIF) in Experimental Uric Acid Nephropathy / 대한신장학회잡지

Chronic deposition of uric acid in the kidney can lead to progressive tubulointerstitial injury with granuloma formation. We hypothesized that uric acid crystal deposition may induce granuloma formation by stimulating local expression of macrophage migration inhibitory factor(MIF), which is a known mediator of delayed type hypersensitivity(DTH). A model of acute uric acid nephropathy was induced in rats by the administration of oxonic acid (an inhibitor of uricase) together with uric acid supplements. Kidney tissue examined at 35 days showed widespread tubulointerstitial damage with intratubular uric acid crystals deposition and granuloma formation. Tubules within the areas of granuloma showed a six-fold increase in MIF mRNA compared to uninvolved areas by in situ hybridization. Moreover, the areas of increased MIF mRNA expression correlated with sites of dense accumulation of macrophages and T cells. Control rats fed a normal diet had no discernible evidence of renal disease by routine light microscopy and minimal tubular expression of MIF mRNA and protein. These data suggest that intrarenal granulomas in urate nephropathy may be the consequence of a crystal induced DTH-like reaction mediated by MIF.

A Case of Adult Fanconi Syndrome and Osteomalacia associated with x-Light Chain Monoclonal Gammopathy / 대한내분비학회지

The Fanconi syndrome is a complex tubulopathy, which is characterized by urinary hyperexcretion of amino acids of all classes, phosphate, glucose, bicarbonate, calkium, potassium, and otherions, and proteins with molecular weights under 50,000 daltons. This metabolic disease leads to hypophospatemia, hypokalemia, growth failure, metabolic acidasis, and rickets/osteomalacia. Fanconi syndrome may be inherited or acqulred. Most cases of adult Fanconi syndrome are acquired, and the acquired syndrome is associated with thermal burns, exposure to heavy metals or drugs, vitmnin D deficiency, renal transplantation, or light chain deposition. The most common cause of adult Fanconi syndrome is multiple myeloma. We ribe here a case of adult Fanconi syndrome and osteomalacia associated with x-light chain monoclonal gammopathy. A 47-year-old woman presented with multiple bane pain and proximal muscle weakness for 2 years. Laboratory findmgs showed hypophosphatemia, mild hypocalcemia, marked elevation of serum alkaline phosphatase, metabolic acidosis, low 25-OH- vitamm D level and secondary hyperparathyroidism. Urinary excretion of protein, uric acid, phosphate, and glucose was mcreased, and tubular reabsorption of phosphate was decreased to 50%. Protein immunofixation electrophoresis of serum and urine showed x-light chain type monoclonal gammopathy. Bone marrow examination was normal except moderate elevation of plasma cell component(8.8%). The skeletal radiography showed fractures of both lower ribs and pseudofracture in right femoral lesser trochanter. We treated the patient with calcium, 1.25-(OH)2-vitamin D, phosphorus, bicarbonate, and potassium, and her clinical symptoms were gradually relieved.

Endoscopic Stenting with Minor PapilIa Sphincterotomy in a Patient with Pancreas Divisum and Recurrent Pancreatitis / 대한소화기내시경학회지

A 50-year-old woman presented with recurrent pancreatitis and pancreas divisum. Minor papilla sphincterotomy and endoscopic stent placement were done for the drainage of dorsal pancreatic duct. After stenting of the minor papilla, abdominal pain has disappeared and pancreatitis has not developed during 9 month follow-up.