Greater Severity of Steatosis Is Associated with a Higher Risk of Incident Diabetes: A Retrospective Longitudinal Study

Background@#Fatty liver is associated with increased risk of developing type 2 diabetes. We aimed to evaluate whether the severity of hepatic steatosis is associated with incident diabetes. @*Methods@#We conducted a longitudinal analysis using data from 1,798 participants who underwent a comprehensive health checkup and abdominal computed tomography (CT). We assessed the association between baseline liver attenuation value on non-contrast CT images and risk of incident diabetes. All the participants were categorized into three groups based on the baseline liver attenuation value on non-contrast CT images: without hepatic steatosis (>57 Hounsfield unit [HU]), mild hepatic steatosis (41–57 HU), and moderate to severe hepatic steatosis (≤40 HU). @*Results@#During a median follow-up period of 5 years, 6.0% of the study participants progressed to diabetes. The incidence of diabetes was 17.3% in the moderate to severe hepatic steatosis group, 9.0% in the mild steatosis group, and 2.9% in those without hepatic steatosis. In a multivariate adjustment model, as compared with participants without hepatic steatosis, those with moderate to severe steatosis had a hazard ratio (HR) of 3.24 (95% confidence interval [CI], 1.64 to 4.2) for the development of diabetes, and those in the mild steatosis group had a HR of 2.33 (95% CI, 1.42 to 3.80). One standard deviation decrease in mean CT attenuation values of the liver was associated with a 40% increase in the development of diabetes (multivariate adjusted HR, 1.40; 95% CI, 1.2 to 1.63). @*Conclusion@#We found a positive association between severity of hepatic steatosis and risk of incident diabetes. Greater severity of steatosis was associated with a higher risk of incident diabetes.

Value of Doppler evaluation of physically abnormal fistula: hemodynamic guidelines and access outcomes

BACKGROUND/AIMS: The strategy of access care at out center involves the use of ultrasound (USG) in case of physical examination (PE) abnormality. USG determines the need of angiography. This study investigated the possible association between the need for percutaneous transluminal angioplasty (PTA) and hemodynamic parameters of USG. The study also assessed the effects of this monitoring strategy on outcomes in comparison with a historical control. METHODS: A retrospective study of the medical records of 127 patients (65 PTA, 62 non-PTA) was conducted. Data were analyzed using logistic regression analysis and receiver operating characteristic curve. Fistula outcomes and intervention rates were calculated and compared with 100 historic controls. RESULTS: Logistic regression analysis showed that brachial artery flow volume (FV) 0.63 was independently associated with the need for PTA. This monitoring strategy showed an a reduction in thromboses (0.02 ± 0.11 events/arteriovenous fistula [AVF]-year vs. 0.07 ± 0.23 events/AVF-year, p = 0.046), reduction in central venous catheter placement (0.01 ± 0.05 events/AVF-year vs. 0.06 ± 0.22 events/AVF-year, p = 0.010), reduction in access loss (0.02 ± 0.13 events/AVF-year vs. 0.19 ± 0.34 events/AVF-year, p = 0.015), and increase in access selective repair (0.49 ± 0.66 events/AVF-year vs. 0.21 ± 0.69 events/AVF-year, p = 0.003), compared to historic control. CONCLUSIONS: There was significant stenosis if brachial artery FV was 0.63 for PE abnormality. These parameters should be used as markers for assessing PTA risk in hemodialysis patients. Addition of USG to determine the need of angiography after detection of PE abnormality leads to decreases in access thrombosis, catheter placement, and access loss despite increasing access intervention rates compared to clinical monitoring.

Differing Associations between Fatty Liver and Dyslipidemia According to the Degree of Hepatic Steatosis in Korea

OBJECTIVE: Fatty liver is associated with insulin resistance-related diseases, such as dyslipidemia, obesity, and type 2 diabetes. The aim of this study was to evaluate the association of dyslipidemia with fatty liver and assess the differences in these associations according to the degree of hepatic steatosis. METHODS: A total of 2,462 subjects (1,679 men and 783 women) who underwent a comprehensive health check-up (including abdominal computed tomography) from January 2010 to December 2013 were enrolled at Samsung Changwon Hospital Healthcare Center. The liver attenuation index (LAI), defined as the difference between mean hepatic and splenic attenuation, was used to assess the degree of hepatic steatosis. An LAI below 5 Hounsfield units was defined as fatty liver. RESULTS: We found that 32.2% of the study subjects had fatty liver. Serum low-density lipoprotein cholesterol (LDL-C) and triglyceride (TG), and fasting blood glucose concentrations and glycated hemoglobin (HbA1c percentage) were significant greater in the fatty liver group compared with the non-fatty liver group, while serum high-density lipoprotein cholesterol (HDL-C) was significantly lower in the fatty liver group. Subjects with fatty liver had 1.7-fold greater risk of dyslipidemia than those without fatty liver after adjusting for age, sex, body mass index (BMI), and HbA1c. When individuals with fatty liver were analyzed by tertiles of LAI values, LDL-C, TG, fasting glucose, BMI, and HbA1c concentrations increased while HDL-C decreased with decreasing LAI tertiles. Compared with LAI tertile 3, the risk for dyslipidemia significantly increased with adjusted odds ratios of 1.42, and 1.81 in tertiles 2 and 1, respectively. CONCLUSION: Fatty liver was significantly associated with dyslipidemia and this association varied according to the degree of hepatic steatosis.

Clinical experience with ultrasound guided angioplasty for vascular access

BACKGROUND: The use of ultrasound guided percutaneous transluminal angioplasty (UG-PTA), which use ultrasound as an imaging modality, is an evolving strategy. But, in Korea, this method is rarely used. We report our experiences with UG-PTA with respect to technical success rates and complication rates compared to conventional PTA (C-PTA), performed between 2010 and 2015 at Samsung Changwon Hospital, Korea. METHODS: In our series, 53 cases of UG-PTA and 90 cases of C-PTA were reviewed, respectively. Cases of central vein stenosis, cephalic arch stenosis, arterial stenosis and thrombosis were excluded. However, cases of juxta-anastomotic stenosis and outflow vein stenosis were included. RESULTS: Technical success was achieved in 96.2% (51 of 53) of cases in the UG-PTA group and in 93.3% (84 of 90) of cases in the C-PTA group, respectively (P = 0.710). Technical failure was experienced in a total 8 cases (UG-PTA group: 2/53, 3.8%; C-PTA group: 6/90, 6.7%). No differences were observed in complications. CONCLUSION: Duplex ultrasound-guided angioplasty for dialysis access in the outpatient setting is feasible, safe, and effective for peripheral venous stenotic lesions. It offers many advantages over conventional angiographic procedures, and, in the future, it has great potential to play a significant role in the management of these challenging patients.

Hypocitraturia-related Ureteral Steinstrasse in a Renal Transplant Recipient / 이화의대지

Urolithiasis is an uncommon complication in renal transplantation. We report a case of hypocitraturia-related ureteral steinstrasse which was spontaneously formed in a renal transplant recipient. The patient who underwent renal transplantation was admitted with acute pyelonephritis. Hydronephrosis in the transplanted kidney and multiple stones (steinstrasse) in the distal ureter were incidentally found on computed tomography scanning. After a failed attempt of ureteroscopic removal of stones, the patient underwent open ureterolithotomy and ureteroureterostomy. On stone analysis, carbonate apatite was confirmed. Urinary citric acid levels were decreased to 127.6 mg/day. Potassium citrate was administered to prevent stone recurrence by increasing urinary citrate excretion. No recurrence of stones was shown six months later. Urolithiasis in renal transplant recipients requires a high index of suspicion. Hypocitraturia can increase the risk for urolithiasis. Rapid recognition by careful surveillance, prompt removal of stones, and precautionary efforts to prevent recurrence are needed.

The Effects of Preoperative Practice Patterns on Hemodialysis Vascular Access Outcomes / 대한신장학회지

To evaluate the effects of specialty of the operator and of preoperative ultrasonic mapping at the time of AVF creation on access outcomes, we studied 224 patients who received AVF surgery by nephrologist with preoperative sonographic mapping (Group 1, n=112) or by vascular surgeon with only physical examination (Group 2, n=112) from January 2008 to December 2009. We compared the rate of autogenous fistula formation, primary failure rate (immediate failure, maturation failure) and patency rate between two groups. Group 1 had more autogenous fistula (97.4 vs. 63.0%, p<0.05), more mid-arm fistula (20.7 vs. 0%, p<0.05) compared to group 2. Immediate failure was more common in group 2 (1 vs. 9, p<0.05). Maturation failure was not different between two groups (10 vs. 10, p=ns). Group 1 had higher primary patency rate at 1 year (74.40 vs. 68.27%, p<0.05) and also had higher secondary patency rate at 1 year (87.33 vs. 81.63%, p<0.05) compared to group 2.

Clinical Experience of Proximal Radio-Cephalic Fistula / 대한신장학회지

PURPOSE: The first choice of vascular access is a distal radiocephalic fistula (dRCF) at the wrist. In patients with a failed dRCF or with vessels unsuitable for dRCF, the recommendation is to place a brachiocephalic fistula (BC) in the upper arm. Proximal forearm radiocephalic fistulas (pRCF) are created infrequently, but may permit a second forearm fistula before proceeding to the upper arm BC. The goal of the present study was to evaluate the effect of pRCF in hemodialysis patients. METHODS: We included 80 patients who received arteriovenous fistula operation between December, 2008 and July, 2010. The type of arteriovenous fistula (dRCF, pRCF, BC) was determined according to preoperative vascular mapping using doppler ultrasonography. The fistula operation was performed by one surgeon. We compared the non-maturation rates, primary and secondary patency rates among dRCF, pRCF, and BC. RESULTS: The numbers of patients that underwent dRCF, pRCF, and BC operation were 27, 27, and 26, respectively. Only 33.8% of patients needed creation of a dRCF potentially. Non-maturation rates were similar among the patients that underwent dRCF, pRCF and BC (11.1%, 7.4%, and 3.8%, respectively, p>0.05). The primary patency rates of dRCF, pRCF, and BC were 81.5%, 92.6%, 80.8%, respectively (p>0.05). The secondary patency rates of dRCF, pRCF, and BC were 92.3%, 96.3%, and 92.3%, respectively (p>0.05). CONCLUSION: pRCF had non-maturation rate, primary and secondary patency rate, comparable to those of a dRCF and, a BC. pRCF may be an attractive alternative to a BC in patients who do not have vessel suitable for creation of a dRCF.

Erratum to "Assessment of Deceased Donor Kidneys Using a Donor Scoring System" by Bang K, et al. (Yonsei Med J 2010;51:870-876)

No abstract available.

Erratum to "Assessment of Deceased Donor Kidneys Using a Donor Scoring System" by Bang K, et al. (Yonsei Med J 2010;51:870-876)

No abstract available.

Characteristics and Survival of Dialysis Patients due to Type 2 Cardiorenal Syndrome / 대한신장학회지

PURPOSE: We evaluated clinical outcomes in patients with type 2 cardiorenal syndrome who were treated with peritoneal dialysis (PD) or hemodialysis (HD). METHODS: A retrospective database of PD or HD patients with type 2 cardiorenal syndrome from January 1, 2002 to December 31, 2010 was established. We evaluated the mean survival on dialysis, days of hospitalizations and NYHA class changes. RESULTS: Thirty-two patients with mean age at the start of dialysis of 68.4+/-10.8 years had mean survival on dialysis of 20.5+/-14.4 months (median survival 17.8 months). Survival after starting dialysis is highly variable, but long term survival was proved possible. The days of hospitalization for cardiovascular causes were reduced (25.1+/-17.7, predialysis vs. 9.5+/-32.8 days/patient/month, postdialysis, p=0.013). All patients showed improvement in NYHA functional class. Kidney function stabilized, while significant improvement in hemoglobin (+16.5%, p<0.001) were achieved. CONCLUSION: After starting dialysis for Type 2 cardiorenal syndrome, the chances of hospitalization for cardiovascular causes were reduced for all patients. Survival on dialysis in these patients was highly variable.

Assessment of Deceased Donor Kidneys Using a Donor Scoring System

PURPOSE: Marginal grafts should be used more actively in Asian countries where deceased donor transplantation is unpopular. We modified a quantitative donor scoring system proposed by Nyberg and his colleagues and developed a donor scoring system in order to assess the quality of deceased donor grafts and their prognostic value as an initial effort to promote usage of marginal donors. MATERIALS AND METHODS: We retrospectively evaluated 337 patients. RESULTS: A scoring system was derived from six donor variables [age, 0-25; renal function, 0-4; history of hypertension, 0-4; Human Leukocyte Antigen (HLA) mismatch, 0-3; body weight, 0-1; cause of death, 0-3 points]. Donor grafts were stratified by scores: grade A, 0-10; grade B, 11-20; grade C, 21-30; and grade D, 31-40 points. Donor grades significantly correlated with estimated glomerular filtration rate (eGFR) at 6 months (A, 64.0 mL/min/1.73 m2; B, 57.0 mL/min/1.73 m2; C, 46.8 mL/min/1.73 m2; p < 0.001). The five-year graft survival rate was also lower in grade C than grade A (74% vs. 93%, p = 0.002). Donors in grade C and D were regarded as marginal donors. The proportion of marginal donors was much lower in Korea, compared with data from the United Network for Organ Sharing (15.2% vs. 29%). CONCLUSION: Considering the scarcity of deceased donor kidneys and the relatively better graft outcome with lower grade-donors in Korea, it is worth increasing the usage of marginal grafts.

The current status of diabetic nephropathy in Korea / 대한내과학회지

The number of patients beginning renal replacement therapy (RRT) in Korea has grown exponentially over the past two decades. Patients with end-stage renal disease attributed to diabetes accounted for most of this increase (45% of new patients requiring RRT). The estimated prevalence of diabetic nephropathy in diabetics in Korea is 30% or more. The early detection and effective treatment of nephropathy in diabetics would prevent or delay the progression of chronic kidney disease. Therefore, comprehensive health intervention to control the increasing prevalence of diabetes and promote early awareness and aggressive management of diabetic nephropathy are needed.

A Case of Idiopathic Retroperitoneal Fibrosis Associated with Rapidly Progressive Glomerulonephritis with Anti-myeloperoxidase Antineutrophil Cytoplasmic Antibodies / 대한신장학회지

Idiopathic retroperitoneal fibrosis is a rare disease characterized by the presence of retroperitoneal fibroinflammatory tissue, which often surrounds the abdominal aorta, the ureters, or other abdominal organs. There have been sporadic reports of an association with autoimmune diseases, although the pathogenesis of idiopathic retroperitoneal fibrosis is unclear. However, there are very few reports ofidiopathic retroperitoneal fibrosis associated with rapidly progressive glomerulonephritis. We report a case with idiopathic retroperitoneal fibrosis associated with rapidly progressive glomerulonephritis, and anti-myeloperoxidase antineutrophil cytoplasmic antibodies (anti MPO-ANCA), that was improved by the combination therapy of steroids and cyclophosphamide.

Renal Recovery from Severe Acute Kidney Injury Requiring Renal Replacement Therapy / 대한신장학회지

PURPOSE: Acute tubular necrosis (ATN) is a serious complication in critically ill patients. This study investigated the renal outcome of severe ATN requiring RRT and prognostic factors for renal recovery. METHODS: Between January 2000 and May 2008, surviving patients with presumed ATN requiring dialysis were analyzed retrospectively. Patients with pre-existing chronic kidney disease and other causes of ARF rather than ATN were excluded. Primary outcomes were complete renal recovery (CR) and dialysis withdrawal. CR was defined as a return to basal serum creatinine level or creatinine <1.5 mg/dL (male) or <1.3 mg/dL (female) without dialysis. RESULTS: Of one hundred twenty two patients, 79 (65%) patients were male. The mean age was 54+/-16 years and 87 patients (71%) received continuous renal replacement therapy. 55% had ischemic ATN, 29% had septic ATN, and 16% had nephrotoxic ATN. Mean duration of dialysis was 12 (6-29) days. Dialysis withdrawal rate at 30 days and at 60 days after initiation of dialysis were 51% and 77 %, respectively. CR at 60 days after initiation was 50%. Multivariate analysis revealed that older age (per year, Hazard ratio (HR)=0.981, 95% Confidence interval (CI) 0.963 to 0.999), ischemic ATN (vs. toxic ATN, HR=0.481, 95% CI 0.238 to 0.974),and longer duration of oliguria (per day, HR=0.979, 95 % CI 0.962 to 0.996) were independent prognostic factors of renal recovery. CONCLUSION: Young age and short duration of oliguria were favorable factors for renal recovery from ATN requiring dialysis. The cause of ATN might be also an independent prognostic factor.

Acute Graft Pyelonephritis after Kidney Transplantation: Clinical Manifestations and the Impact on Long-term Allograft Outcome / 대한신장학회지

PURPOSE: The objective of this study was to investigate the clinical manifestations and risk factors associated with acute graft pyelonephritis (AGPN) and its impact on graft outcome. METHODS: We performed a retrospective study reviewing the medical records of 272 recipients with a graft survival of more than 1 year among 291 recipients that had undergone kidney transplantation between January 1995 and December 1999. RESULTS: Twenty eight (10.3%) patients had at least one episode of AGPN during a follow-up of 7.3 years, and 14 (50%) among them had recurrent episodes. 31.5% of total AGPN episodes had no any urinary signs and symptoms and only had a fever and leukocyturia. Escherichia coli and Klebsiella, the most common pathogens isolated, were susceptible to ciprofloxacin in 48.6% of cases and to ceftriaxone in 94.3% of cases. Acute rejection was not associated with the occurrence of AGPN. However, female gender was a risk factor for acute rejection (risk ratio 7.11, p<0.001). Vesicoureteral reflux in allograft was found in 72.7% of the recipients with an episode of AGPN (16/22). There was a trend toward more frequent development of vesicoureteral reflux in recipients with recurrent AGPN episodes (54.6% in patients with a single episode vs 90.9% in patients with recurrent episodes, p= 0.074). On Cox regression/Time-dependent covariate analysis, AGPN had no significant association with the graft or patient survival. CONCLUSION: AGPN is common after kidney transplantation, especially in women. However, AGPN was not associated with a poor long-term graft outcome.

The Patency Rate of Hemodialysis Vascular Access and the Analysis of Patency-related Factors: Comparision of Native Arteriovenous Fistula with Arteriovenous Graft, Single Center Study / 대한신장학회지

PURPOSE: As the proportion of patients with diabetes and old age increases, the use of arteriovenous graft (AVG) is increasing. However, there are few data about the comparison of the patency rate of native arteriovenous fistula (AVF) to that of AVG in Korea. We compared the outcome of native AVF to that of AVG with analysis of the factors affecting the patency of the permanent vascular access in use. METHODS: A retrospective database of all vascular access related procedures performed from January 1, 2003 to December 31, 2003 was established. We evaluated the primary unassisted and cumulative access patency rate with analysis of patency-related factors. We also evaluated the primary failure rate of AVF and AVG. RESULTS: 196 new vascular access surgeries were performed during the period. 14 cases were excluded due to loss of follow-up. 142 native arteriovenous fistulas (78%) and 40 grafts (22%) were constructed. The primary failure rate was similar between AVF and AVG group. The primary unassisted (78%, 72%, 68% vs. 62%, 41%, 22% at 1, 2, 3 year; p<0.001) and cumulative patency rate (93%, 88%, 85% vs. 84%, 74%, 73% at 1, 2, 3 year; p=0.087) were better in AVF group than in AVG group. The factors affecting the patency of vascular access were the type of vascular access and planned construction of permanent vascular access. CONCLUSION: Patency of native AVF as the permanent vascular access was better than that of AVG. Planned construction of permanent vascular access improved the patency of the access.

The Clinical Outcome of Acute Renal Failure Requiring Hemodialysis after Coronary Intervention in Patients with Chronic Kidney Disease / 대한신장학회지

PURPOSE: Acute renal failure requiring dialysis (ARFD) after coronary intervention is a rare but serious complication, and it is associated with poor prognosis. This study investigated the clinical characteristics and risk factors of ARFD after coronary intervention in patients with chronic kidney disease (CKD). METHODS: This study included 178 adult patients with CKD (baseline serum creatinine of >1.3 mg/dL) undergoing coronary intervention at Samsung Medical Center from April 2003 through June 2007. We retrospectively evaluated the incidence, clinical outcome, and risk factor of ARFD via medical records. ARFD was defined as a decrease in renal function necessitating hemodialysis in the first 7 days after percutaneous coronary intervention. The estimated glomerular filtration rate (eGFR) was obtained using the Levey Modification of Diet in Renal Disease (MDRD) formula. RESULTS: Ten of the 178 patients (5.6%) developed ARFD with a subsequent in-hospital mortality rate of 10% (n=1). According to CKD stage, incidence of ARFD was 0/136 patients (baseline eGFR 30 to 90 ml/min/1.73m2 4/32 (15 to 29,) and 7/10 (<15) respectively (0% vs 9.4% vs 70%, p<0.0001). Multivariate analysis found eGFR (OR=0.5, 95% CI 0.3 to 0.9, p=0.02) to be only independent predictor of ARFD. Of those who developed ARFD (n=10), 2 patients stopped dialysis, 8 had required permanent dialysis. CONCLUSION: Incidence of ARFD increased according to the severity of renal dysfunction. The majority of ARFD patients had required permanent dialysis.

A Case of Deep Vein Thrombosis and Pulmonary Thromboembolism after Intravenous Immunoglobulin Therapy

Although high-dose intravenous immunoglobulin (IVIG) is generally considered a safe medication for various immune-mediated diseases, thrombotic events have been reported as a complication of the therapy. We report a case who developed thrombotic complications after receiving IVIG. A 56-yr-old woman with idiopathic thrombocytopenic purpura received IVIG at a dose of 400 mg/kg/day for five days. Three days after the administration of IVIG, the patient developed painful edema in the left leg. Lower extremity doppler ultrasound revealed deep vein thrombosis in the left leg. Chest computed tomography (CT) scan demonstrated a filling defect indicating thromboembolism of the right pulmonary artery. After three weeks of enoxaparin therapy, her symptoms and pulmonary embolism on CT improved. This case suggests clinicians should be cautious in the development of thromboembolism by administration of IVIG, especially in patients with thrombophilia.

Identification of Brucella abortus using the sequencing of omp gene / 대한내과학회지

BACKGROUND: As the incidence of bovine brucellosis increases in Korea, the incidence of human brucellosis is also increasing since 2002. However, it is difficult to identify Brucella species by using the conventional methods. METHODS: Three strains of gram-negative coccobacilli were isolated from blood specimens of three patients with prolonged fever, which were not identified by using the conventional methods. After extracting total DNA from these isolates, PCR amplification of 16S rRNA and omp2 genes was performed. These sequences secured by PCR assay were compared with known sequences by using GenBank BLAST. RESULTS: DNA sequences were obtained from 3 isolates by using PCR amplification of 16S rRNA. These sequences had more than 99.9% similarities with Brucella species by using GenBank BLAST. In the second place, after comparing DNA sequences secured by PCR amplification of omp2a and omp2b by using GenBank BLAST, these isolates were confirmed as B. abortus. CONCLUSIONS: DNA sequence analysis is a rapid and accurate method for identification of uncommon microorganisms, such as Brucella species.

Regional Citrate Anticoagulation in Continuous Venovenous Hemodiafiltration: Report of Two Cases / 대한신장학회잡지

Continuous renal replacement therapy (CRRT) has been used increasingly for the management of renal failure in hemodynamically unstable and critically ill patients. CRRT requires anticoagulation, usually with heparin, to prevent clotting in the extracorporeal circuit. Systemic heparinization is associated with a high rate of bleeding when used during CRRT in critically ill patients. We applied regional citrate anticoagulation for CRRT to two critically ill patients with high bleeding risk using calcium containing commercial solutions. We conclude that regional citrate anticoagulation with commercial calcium containing solution can be used alternative to heparin for CRRT in patients with high bleeding risk.