A role of neuropsychological test in the patients with chronic liver disease / 대한내과학회지

BACKGROUND: Minimal (subclinical) hepatic encephalopathy (mHE) currently diagnosed by psychometric tests or neurophysiological test adversely affects daily functioning. In view of its sociomedical relevance, simple and reproducible tests for routine diagnosis are required. The aims of this study are to evaluate cognitive function of patients with chronic liver disease by computerized neuropsychological test (STIM), and the difference of cognitive function according to Child classification. METHODS: Between June, 2002 and February, 2003 We enrolled 61 randomized consecutive patients diagnosed with chronic liver disease by biochemical tests, ultrasonographic finding or histology. This study used finger tapping, visual CPT, spatial memory test, Wisconsin card sorting test chosen from Neuscan and STIM system (Neurosoft company, U.S.A) and global-local processing test. RESULTS: In the present study, significant correlation was found between neurologic abnormalities and the degree of liver disease. The result of neuropsychological test showed that cognitive function was decreased according to the severity of chronic liver disease, especially liver cirrhosis. Cirrhotic patients, especially Child C group, exhibited selective deficits in complex attentional and fine motor skills, visuospatial perception, with preservation of memory. CONCLUSION: The STIM in this study is simple, objective and reproducible method because it can subdivide evaluation of cognitive function and computerize the measurement of response. We assume that STIM may be used early detection method of mHE if the study will be in a large scale. Because psychomotor deficits found in mHE could have a disadvanting influence on daily functioning of patients, e.g., driving abilty of a car or performance at work, we concluded early detection of mHE and aggressive treatment of mHE in clinically asymptomatic cirrhotic patients is necessary for improvement of their quality of life.

Changes of Propranolol Pharmacokinetic Parameters According to Hepatic Fibrotic Severity in CCl4-Treated Rats / 대한간학회지

BACKGROUND/AIMS: This study was designed to determine the effect of hepatic fibrotic severity on pharmacokinetics of propranolol in CCl4-treated rats. METHODS: 1 mL/kg of 10% CCl4 in olive oil was injected intramuscularly to rats twice weekly for 4, 6, 8 and 10 weeks, respectively (n=6). Control (n=6) was a sham-injected equal dose of olive oil for 10 weeks. After intravenous bolus injection of 2 mg/kg propranolol to rats, the serum propranolol concentrations were analyzed for 4 hours at various time points by a HPLC-fluorimetric system, and pharmacokinetic parameters such as C0, MRT, AUC, Vdss, t1/2( ) and CLp were determined. Then, a small amount of hepatic tissue was obtained and subjected to determination of the hepatic 4-hydroxyproline content, which confirmed the hepatic fibrotic severity. RESULTS: The serum concentrations of propranolol at 0.5, 1, 2 and 4 hours were significantly increased in CCl4-treated rats (p<0.01). In proportion to the duration of CCl4 treatment, C0 and AUC were significantly increased, and Vdss and CLp were significantly decreased (p<0.001). But MRT and t1/2( ) were not significantly changed. The hepatic 4-hydroxyproline content was gradually increased in CCl4-treated rats (p<0.001). CONCLUSION: Gradual changes in pharmacokinetic parameters of propranolol were seen to be dependent on the hepatic fibrotic severity. We suggest that gradual dosage modification, according to their hepatic fibrotic severity, is necessary for many drugs administered to patients with chronic liver disease.

Assessment of malnutrition in patients with liver cirrhosis / 대한내과학회지

BACKGROUND: Malnutrition frequently occurs in patients with liver cirrhosis independently for its etiology and can modify prognosis of the disease. Since malnutrition was observed at all clinical stages, but more frequently seen at advanced stages, early and detailed nutritional assessment in all patients with liver cirrhosis is important. The aims of this study are to define the nutritional status and the difference of nutritional index according to etiology and Child classification in patients with liver cirrhosis in Korea. METHODS: A total 138 cirrhotic patients (41 alcoholic cirrhosis, 97 virus-related cirrhosis) were studied. The diagnosis of cirrhosis was based on clinical, laboratory and ultrasonographic criteria and liver biopsy. The patients were divided into three groups according to the severity of their liver disease as assessed by the Child-Pugh classification. Nutritional parameter of protein (serum albumin, serum transferrin, total lymphocyte count) were measured. RESULTS: The patients with protein malnutrition are as follows: albumin 55, transferrin 68, total lymphocyte count 8. The frequency of moderate to severe protein malnutrition was high in alcoholic cirrhosis.: albumin (<2.9 g/dL) (26.8% vs 17.5%), transferrin (<180 mg/dL) (48.5% vs 24.8%), total lymphocyte count (<1200 number/L) (2.4% vs 2.0%). The mean value of nutritional index correlated with the degree of liver function impairment. (Child C showed the lowest value). CONCLUSION: In spite of limitation of nutritional index in this study, our study showed that severe protein-energy malnutrition was rare in Korea, and protein-energy malnutrition was not only more common in alcoholic cirrhosis but related to the severity of liver disease. Therefore, our data suggests that clinician should understand the importance of not imposing unnecessary restrictions and supplementation on protein intake for fear of imbalance of nutrition.

A Case of Microscopic Polyangiitis with Peripheral Neuropathy / 대한류마티스학회지

Microscopic polyangiitis (MPA) is a systemic necrotizing vasculitis of small-sized vessels (capillary, venule, or arterioles) whose clinical manifestations are very similar to those of PAN (polyarteritis nodosa), but it is characterized by the presence of rapidly progressive glomerulonephritis (RPGN), which is nearly constant, and pulmonary involvement usually absent in PAN. Peripheral neuropathy occurs in only 14~36% of the patients with MPA, distinctly less frequent than in those with classic PAN. While PAN may be considered a self-limiting disease which tend not to recur once remission is acquired, relapse occurs frequently in MPA. Prognosis has been transformed by corticosteroids and immunosuppressive drugs, especially cyclophosphamide. We reported a 72-year-old woman with subacute sensorimotor polyneuropathy involving peroneal and sural nerve accompanied by focal segmental glomerulonephritis which was proven by renal biopsy.

A Case of Delayed Hemolytic Transfusion Reaction with Acute Renal Failure Caused by Anti-E Antibody / 대한수혈학회지

A delayed hemolytic transfusion reaction (DHTR) is the result of delayed anamnestic alloantibody response four to fourteen days after transfusion of apparently compatible blood. Most DHTRs are very mild and may not be recognized clinically. Some are manifested only by anemia. Only a few cases are severe enough to induce a massive hemolytic reaction followed by frank renal failure. Recently, we experienced a case of DHTR with acute renal failure (ARF) due to anti-E. A 21-year-old woman received compatible four units of packed red cells after right artificial total hip replacement arthroplasty due to juvenile rheumatoid arthritis. She had a history of transfusion 4 years ago. Fourteen days after the transfusion, she showed a fall in hematocrit, hemoglobinuria and a positive indirect antiglobulin test, and accompanied by ARF. Anti-E was identified in the patient's serum by antibody screening and identification test at that time. She recovered from ARF after hemodialysis with conservative management. However, eventually, she died due to disseminated intravascular coagulopathy.