Comparison of Icodextrin and 2.5% Glucose in Potassium Metabolism by Acute K+oad via Dialysate in Continuous Ambulatory Peritoneal Dialysis Patients

This study aimed to compare the increment in plasma potassium concentration ([K+]) as well as the role of internal K+ balance for its changes following acute K+ supplementation between conventional 2.5% glucose (GD) and non-glucose containing dialysate (icodextrin, ID) in continuous ambulatory peritoneal dialysis (CAPD) patients. A total of 9 stable CAPD patients (5 men and 4 women; age, 56+/-13 years; 7 type-2 diabetics and 2 non-diabetics) on daily 4 exchanges of 2 L of glucose dialysate underwent the 6-hr dwell on fasting in the morning with 2 L of 2.5% glucose mixed with 20 mEq/L of KCl, and then the same regimen was repeated with icodextrin after 1-wk interval. The degree of intraperitoneal absorption was comparable, 65+/-2% in GD and 68+/-2% in ID, respectively (p=NS). However, despite the similar plasma K+ levels at the baseline of both regimens, its increment was significantly less in GD than ID, which was accompanied by more marked increase in the calculated intracellular K+ redistribution (68+/-3% vs. 52+/-3%, p<0.05). The basal levels of insulin were similar between the GD and ID groups. However, the change, checked up after 2 hours' dwell, from the basal insulin levels was much lower on ID. ID with a lesser degree of transcelluar K+ shift by the decreased secretion of insulin is more effective than the conventional glucose solution for acute K+ repletion via dialysate during CAPD. Furthermore, these results suggested that the role of insulin for the internal K+ balance was intact even in type-2 diabetic patients on CAPD

Add-on Therapy of Potassium-exchange Resin for Hrkalemia in Chronic Kidney Disease Patients on Renin-angiotensin System Blockers / 대한신장학회지

PURPOSE: This prospective study aimed to evaluate the safety and efficacy of potassium-exchange resin (PER, Kalimate(R) or Argamate(R)) for managing hyperkalemia induced by Renin-Angiotensin System (RAS) blockers in chronic kidney disease (CKD) patients without their discontinuation. METHODS: Besides conservative remedies including low-potassium diet, all hyperkalemic CKD patients (n=21, [K] > or =5.6 mEq/L) received PER added on angiotensin-converting enzyme inhibitor (Moexipril, n=2) or angiotensin-receptor blocker (Irbesartan, n=19) with, at least, weekly monitoring of serum [K] if its level remains more than 5.5 mEq/L for more than 2 months (mean+/-SD, 6.8+/-5.9 mon; range, 2-26 mon). RESULTS: Baseline serum [K] on RAS blocker alone (5.1+/-0.4 mEq/L; 4.2-6.3 mEq/L) increased to 6.0 +/-0.4 mEq/L (p<0.05) before adding PER, and then it was significantly decreased to 5.3+/-0.6 mEq/L at the first clinic visit (p<0.05) and to 5.0+/-0.7 mEq/L at the last clinic visit (p<0.05) following the administration of PER added on RAS blocker. During the study period, GFR, serum creatinine and urinary protein excretion didn't change significantly. CONCLUSION: The development of hyperkalemia on RAS blockers in CKD patients doesn't necessarily lead to withdrawal of RAS blockers when the cautious add-on therapy of potassium-exchange resin with other conservative remedies launches, unless severe refractory hyperkalemia persists.

Prevalence of Hypertension and Impact of Predialysis Systolic Blood Pressure on Cardiovascular Mortality in Chronic Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Hypertension is very common in chronic hemodialysis patients. But impact of predialysis systolic blood pressure on cardiovascular mortality is not clear and it's investigation is not thoroughgoing enough in Korea. METHODS: We assessed the prevalence and control rate of hypertension in a cross sectional study of 81 clinically stable hemodialysis patients who had been treated with regular hemodialysis sessions in the Hanyang University Guri Hospital. To investigate the impact of predialysis systolic blood pressure on cardiovascular mortality, we retrospectively reviewed in May 2001 predialysis blood pressure and covariable factors of 115 hemodialysis patients who were monitored from the start of hemodialysis for more than 2 months between May 2001 and May 2004 in the Hanyang University Guri Hospital and local dialysis centers. Exclusion criteria were as follows: change to CAPD, transplantation, transfer to another dialysis center, non compliant, death due to accident and self withdrawal and hemodialysis for less than 2 months. RESULTS: The majority of hemodialysis patients (83%) take antihypertensive medications. Pre and post dialysis mean blood pressure was 153.2+/-14.5/86.9+/-4.7 mmHg, 145.5+/-17.1/84.2+/-5.2 mmHg respectively. Predialysis systolic blood pressure that was higher than 140 mmHg documented in 83% of patients. On the other side, predialysis diastolic blood pressure that was higher than 90 mmHg was only seen in 23 % of patients. Predialysis systolic hypertension was not associated with an increase in short term cardiovascular mortality. On the other hand, hypoalbuminemia and diabetes mellitus were associated with an increase in short term cardiovascular mortality. CONCLUSION: The present study suggests that control of hypertension, particularly systolic hypertension, in chronic hemodialysis patients, is insufficient, despite the use of antihypertensive drugs. The overall impact of predialysis systolic hypertension on cardiovascular mortality tends to be increased, but it was not associated with short term cardiovascular mortality.

A Case of Idiopathic Retroperitoneal Fibrosis with Acute Renal Failure / 대한신장학회잡지

Retroperitoneal fibrosis is proliferation of fibrous tissue with inflammatory process in retroperitoneal cavity. It is relatively rare disease that has been reported less than 20 cases in Korea until now. Idiopathic type is more frequent but secondary type is increasing nowadays. Secondary causes include drugs, infections, and leakage of blood or urine, malignancies, connective tissue diseases, etc. Recent studies suggest the relationship between retroperitoneal fibrosis and autoimmunity to own vascular or lipoid tissue. It can cause compression and obstruction of ureter, abdominal aorta, hypertension and finally collapse of renal function. Surgical procedure and immunosuppressive therapy consist of mainstay of management. Corticosteroid therapy may reduce inflammation and reverse fibrosis. Retroperitoneal fibrosis is thought to have some reVersible components in early stage. Corticosteroid may be used as initial therapy but more studies should be performed. We report a case of idiopathic retroperitoneal fibrosis with acute renal failure improved with ureter stent insertion and steroid therapy.

Propylthiouracil-associated p-ANCA Positive Vasculitis with Focal Segmental Glomerulosclerosis / 대한신장학회잡지

Antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis has been reported in Graves' disease patients treated with propylthiouracil (PTU). In most cases, it's renal involvements has been known as crescentic glomerulonephritis. A 41-year-old female patient with hyperthyroidism has been treated with PTU for 3 years. The patient had developed isolated hematuria and polyarthralgia with p-ANCA positivity, 6 months and 10 months after PTU treatment, respectively. She had been continuously treated with PTU until she was admitted at our hospital. Three months before admission, polyarthralgia was aggravated and purpura in both lower legs and hands was developed. Urinalysis revealed hematuria, proteinuria. Serologic evaluation showed p-ANCA positive. Skin biopy showed leukocytoclastic vasculitis and renal biopsy showed focal segmental glomerulosclerosis (FSGS). She was diagnosed as PTU-associated vasculitis with FSGS. Polyarthralgia and purpura were improved after discontinuing the PTU with prednisolone treatment but hematuria, proteinuria were not changed. We suggest that progression of PTU-associated focal segmental necrotizing glomerulonephritis to FSGS over two years might be due to continued PTU medication.

Cerebral Infarction as a Complication of Nephrotic Syndrome: A Case Report with a Review of the Literature

Arterial thrombosis is relatively rare compared with venous thrombosis in nephrotic syndrome. However, the assessment of its pathogenesis and risk factors in individual patient with nephrotic syndrome is necessary to allow appropriate prophylactic management because it is a potentially serious problem. Hereby, with review of the literature, we report a case of a 53 yr-old man with cerebral infarction associated with nephrotic syndrome due to focal segmental glomerulosclerosis during the course of treatments with diuretics and steroid. It reveals that the hypercoagulable state in nephrotic syndrome can be associated with cerebral infarction in adults. Prophylactic anticoagulants can be considered to reduce the risk of serious cerebral infarction in nephrotic patients with risk factors such as severe hypoalbuminemia and on diuretics or steroid treatment, even in young patients regardless of types of underlying glomerular diseases.

Hypercalciuria and Hyperuricosuria in Adults with Microscopic Hematuria / 대한신장학회잡지

PURPOSE: We investigated the prevalence of hypercalciuria and hyperuricosuria in adults with microscopic hematuria and whether specific underlying diseases were associated with it. METHODS: A total of 36 patients with microscopic hematuria were divided into hypercalciuria or normocalciuria and hypercalciuria or normouricosuria and compared between groups in their clinical characteristics and laboratory findings. RESULTS: Of the 36 patients, 27 patients (75%) had normocalciuria but 9 (25%) had hypercalciuria. Twenty-eight patients (78%) had normouricosuria but 8(22%) had hyperuricosuria. All 8 patients in the hyperuricosuric group were male but 6 were male and 3 female in the hypercalciuric group. Other basal parameters and clinical characteristics were comparable between hypercalciuric and normocalciuric groups as well as between hyperuricosuric and normouricosuric groups except for significantly higher proteinuria in the latter. Underlying or associated diseases were hypertension (11), nephrolithiasis (5), simple renal cysts (3), hepatitis B carrier (3), diabetes mellitus (2), poststreptococcal glomerulonephritis (1), and membranous nephropathy (1). The degrees of calciuria and uricosuria were not different between patients with or without specific underlying or associated diseases but relative hypercalciuria in diabetic patients and hyperuricosuria in hepatitis B carriers were noted. CONCLUSION: We found a high prevalence of hypercalciuria and hyperuricosuria in adults with microscopic hematuria. In view of relatively higher proteinuria in hyperuricosuric patients in addition to some differences in clinical characteristics of patients with hypercalciuria or hyperuricosuria, a simple cost- effective examination of the degree of calciuria and uricosuria would be helpful in the clinical evaluation of microscopic hematuria.

Histopathologic Studies on Crescentic Glomerulonephritis / 대한신장학회잡지

BACKGROUND: Crescentic glomerulonephritis is expressed pathologically by crescent formation in Bowman's capsule and clinically by rapidly progressive loss of renal function. The pathologic experience of crescentic glomerulonephritis in one institution was analyzed here. METHODS: We classified 25 cases of crescentic glomerulonephritis patients into 4 categories and reviewed the cases pathologically and clinically. RESULTS: We found no case with group I (anti- GBM disease), 8 cases in group II (immune complex glomerulonephritis) including 3 patients with IgA nephropathy, 2 patients with Henoch-Sch nlein purpura and 3 patients with APSGN, 12 cases in group III (ANCA-associated glomerulonephritis) including 7 patients with microscopic polyangitis, 4 patients with Wegener's granulmatosis and 1 patient with ANCA GN, and 5 cases in group IV (idiopathic crescentic glomerulonephritis). The mean ages of patients with group II, III, and IV were 32.0, 59.3 and 39.0 years old, respectively, and mean serum creatinine levels at the time of biopsy were measured as 9.1, 5.2, 8.8 mg/dL in each group. On light microscopic findings, the frequency of crescents in glomeruli was 64.4% in group II, 43.7% in group III, and 51.2% in group IV. The score of infiltration into tubules of inflammatory cells was 0.8 in group II, 0.4 in group III, and 0.6 in group IV and the score of fibrosis in interstitium was 1.0 in group II, 0.8 in group III and 1.2 in group IV. The score of atherosclerosis in arteries was 1.4, 0.9 and 1.6 in each group. CONCLUSION: We conclude that the precise diagnosis and classification of crescentic glomerulonephritis by an early renal biopsy and clinical assessments are important in the management of rapidly progressive (crescentic) glomerulonephritis. Since the number of the cases was not so enough, we could not analyze the statistical significance between morphologic differences of each group of crescentic glomerulonephritis, but if more cases were collected, acknowledgements of differences and prognostic factors in pathologic findings could be possible.

A Case of Fanconi's Syndrome Due to Chinese Herb Nephropathy: Differences between European and Asian CHN / 대한신장학회잡지

We encountered one case of Chinese Herb Nephropathy in Korea. But clinical feature of our case was different from those of CHN in Belgium. The purpose of this case report was clarified the features of CHN in Asia. The subjects consisted of a patient diagnosed as interstitial nephritis in Hanyang University Hospital and of those reported in the literature in Asia and Belgium. We investigated the clinical and histological features of CHN patients in Asia and compared them with the Belgian cases. The remarkable differences were as follows; (1) relatively high prevalence in males compared with Belgian cases, (2) digestion with multiple object and mode in Asia, (3) Most of renal failure in Asia were improved or were in stable status. (4) Fanconi's syndrome was found in most cases of Asia. In conclusion, CHN in Asia has some characteristics distinguished from Belgian Chinese Hreb Nephropathy. These findings could indicate that susceptibility to aristolochic acid may be different among races. Furthermore, it is likely that different components of AA could cause different features, that the amount of ingested AA, mode in digestion, or interaction with other components except nephrotoxic agent such as AA might reflect clinical pictures. Other hypothesis may be some other toxic substances affecting the clinical findings although they are not identified at present. Further studies must be undertaken to clarify these differences.

A Case of Pulmonary Leiomyoma in a Renal Transplanted Patient / 대한신장학회잡지

The overall incidence of malignancy in a renal transplanted patient is 3 to 5 times higher compared with general population. We report a very rare case of multiple leiomyoma originated from lung after renal transplantation. 33-year-old male underwent renal transplantation in November, 1989. A 5 mm sized pulmonary nodule was found in the left lower lobe incidentally in March, 2001. The size of pulmonary nodule increased and same lesion was found on the opposite side of the lung on chest roentgenogram after one year, so we proceeded with computed tomography of the chest. Variable sized multiple nodules in the whole lung field were noted, which were thought be metastatic lesions, and for detection of the primary site of malignancy, further study including esophagogastroduodenoscope, colon study, abdominal ultrasound, abdominal CT, bone scan and tumor marker were checked, but there was no evidence of primary cancer. After open lung biopsy low malignant potential smooth muscle tumor was noted, and Epstein-barr virus (EBV) DNA was detected. The patient had been maintained on immunosuppressive therapy with cyclosporine and mycophenolate mofetil (MMF), and after the diagnosis of leiomyoma administration of MMF was stoped, and cyclosporine dosage was reduced. With the reduction of immunosuppressants, intravenous immunoglobulin trial was done for the first cycle, but the efficacy of treatment is not clear.