Erratum: Bone scan appearance and biochemical markers of the bone metabolism in hemodialysis patients / 대한내과학회지

No abstract available.

Bone scan appearance and biochemical markers of the bone metabolism in hemodialysis patients / 대한내과학회지

BACKGROUND: The gold standard for a diagnosis of ROD is performing a bone biopsy. We need other non-invasive diagnostic techniques because of this procedure's invasiveness. In this study, we evaluated the value of a radionucleotide bone scan and the various biochemical markers for determining the bone metabolism in hemodialysis patients . METHODS: This study evaluated 118 hemodialysis patients who underwent 99mTc-MDP bone scanning and blood tests for such biochemical markers as osteocalcin and c-terminal telopeptide of type I collagen. Two nuclear medicine physicians read the bone scan images semi-quantitatively for six bone areas and the soft tissue, and they assigned a score of 0, 1 or 2 to the findings. RESULTS: The patients were categorized into 3 classes: iPTH or =200 pg/mL. For the group with a iPTH > or =200 pg/mL, the Ca, P product, alkaline phophatase and osteocalcin levels were increased, and the serum aluminum level was decreased compared to the other groups. When the bone scans were analyzed, the sum of the bone uptake scores was higher in the group with an iPTH > or =200 pg/mL while the soft tissue uptake score was higher in the group with an iPTH <50 pg/mL. The most common type of patient was a patient with an iPTH <50 pg/mL, and adynamic bone disease may be the most prevalent type of ROD. CONCLUSIONS: The bone scan findings correlated with the iPTH level in hemodialysis patients. Bone scans can provide additional information if this is combined with other biological markers. We stillneed to confirm its usefulness by conducting a comparative study with using bone biopsy.

A Case of Aloe-nduced Acute Interstitial Nephritis / 대한신장학회잡지

We report a case of aloe induced acute interstitial nephritis in a 66-year old man. He had been taken aloe as a healthy foodstuff for 6 weeks prior to admission. He complained poor oral intake and developed nonoliguric acute renal failure. Renal biopsy revealed focal tubular atrophy and interstitial infiltration of neutrophils, and lymphocytes. After discontinuation of aloe and high dose prednisolone therapy, acute renal failure of the patient improved and serum creatinine level decreased.

Henoch-Schonlein Purpura associated with Adenocarcinomas in Stomach and Colon / 대한신장학회잡지

There are a few reports about coexistence of Henoch-Schonlein purpura (HSP) and a variety of malignancy in adults. The accompanying malignancies, in order of frequency, were hematologic malignancy, lung cancer and prostate cancer. Gastrointestinal tract (GIT) cancer associated with HSP was rarely reported which includes 2 cases of stomach cancer, 1 case of small bowel cancer and 1 case of esophageal cancer. Malignancy is proposed to be a triggering factor in the development of HSP, however pathogenesis of HSP associated with malignancy remains obscure. Here, we report 2 cases of HSP associated with malignancy in GIT. One is an adenocarcinoma of the colon and the other is a stomach adenocarcinoma with signet ring cell component.

Clinical Characteristics in Patients with HELLP Syndrome Complicated with Acute Renal Failure / 대한신장학회잡지

BACKGROUND: The aim of this study was to exam the clinical features and the renal outcome of HELLP syndrome complicated with ARF. METHODS: Thirty-nine patients with HELLP syndrome were retrospectively analyzed on the basis of medical records. A serum creatinine level of >1.3 mg/dL was used as a criterion to define ARF for at least 48 hours. RESULTS: Of the 39 patients, HELLP syndrome with ARF developed in 17 patients. The ARF group had a higher incidence of primigravida (p<0.05) and a longer gestational age at the onset of HELLP syndrome (p<0.05) than those in the non-ARF group. The recovery time of HELLP syndrome in the ARF group was much longer than that in the non-ARF group (p<0.05). In the ARF group, the serum aspartate aminotransferase (AST) concentration was higher (p<0.05) and the nadir blood platelet counts were lower (p<0.05). The incidence of disseminated intravascular coagulation (DIC) was significantly higher in the ARF group than in the non-ARF group (p<0.01). There was no significant difference in the incidence of pulmonary edema, abruptio placenta, preeclampsia, and fetal death between the two groups. Only one patient in the ARF group required hemodialysis. In all ARF patients, the renal impairment fully recovered within a median of 5 days (range: 2-32 days) after the onset of ARF. CONCLUSION: The clinical factors associated with ARF in HELLP syndrome were primigravida, gestational age, serum AST level, blood platelet counts, and DIC. The ARF in HELLP syndrome fully recovered without progression to permanent renal impairment.

A Case of Idiopathic Sigmoid Colonic Perforation in a Hemodialysis Patient / 대한신장학회잡지

Many hemodialysis patients, because of low fiber diet, water restriction, phosphate binder and endocrine-metabolic disturbance, suffer from chronic constipation. In a state of chronic constipation, a large amount of hard fecal mass often results in fecal impaction. Megacolon, urinary obstruction and perforation of the large bowel rarely develop as a complication of fecal impaction. The authors experienced a case of idiopathic sigmoid colonic perforation, with fecal impaction, in a 66-year-old woman having undergone hemodialyis of 6 years duration. The clinical features of the case are presented, with a review of the literatures.

A Case of Anti-glomerular Basement Membrane Disease which Presented with Fever of Unknown Origin / 대한신장학회잡지

Anti-glomerular basement membrane disease is an autoimmune disorder characterized progressive renal failure and/or lung hemorrhage. Most of patients present with acute renal failure or acute nephritic feature such as hematuria, proteinuria, and leukocyturia in urinalysis. A part of patients present with pulmonary hemorrhage, anemia, tachypnea, and cyanosis. It is accompanied with transient fever and myalgia but fever of unknown origin (FUO) is very rare condition. We report the atypical case of anti-glomerular basement membrane mediated rapidly progressive glomerulonephritis which presented with FUO and shock after methylprednisolone pulse therapy.

Clinical Significance of Vesicoureteral Reflux in Renal Transplant Recipients / 대한신장학회잡지

BACKGROUND: We investigated the frequency and clinical impact on vesicoureteral reflux (VUR) in the transplanted kidney. METHODS: In this study 55 CsA - treated patients were enrolled who received kidney transplantation between 1993 and 1997. They survived for at least one year while taking Voiding cystourethrography. With the results, we divided into two classes, with and with out VUR, where we found such as graft survival, prevalence of hypertension, frequency of urinary tract infection (UTI), creatinine clearance (Ccr) and proteinuria (mg/day) at 1, 5, 7 years after transplantation. RESULTS: VUR was detected in 39 (71%) patients. Patients with no VUR, the prevalence of hypertension, graft failure, the number of UTI episodes/patient were 16 (100%), 1 (6.25%), 2.14+/-0.40 (mean+/-SEM) and patients with VUR were 33 (84.6%), 2 (5.12%), 1.37+/-0.26 respectively. There was no significant difference between the two groups (p>0.2). Patients with no VUR, Ccr (mean+/-SEM) at 1, 5, 7 years after transplantation were 69.9+/-9.1 (mL/ min), 59.4+/-3.6, 57.3+/-3.5 and proteinuria were 171+/-48.2 (mg/day), 188+/-74.5, 249+/-119.6 respectively. Patients with VUR, Ccr were 72.0+/-7.2, 55.5+/-2.6, 54.1+/-2.8 and proteinuria were 192+/-33.8, 148+/-29.0, 207+/-74.4 respectively. Also, there was no significant difference between the two groups (p>0.4). CONCLUSION: Our study showed that the presence of VUR did not harm graft function or survival.

Is the Angiodysplasia Significant as the Cause of Upper Gastrointestinal Hemorrhage in Patients with Chronic Renal Failure? / 대한신장학회잡지

PURPOSE: The role of angiodysplasia as a main cause of upper gastrointestinal hemorrhage (UGH) in patients with chronic renal failure (CRF) is controversial. We investigated the sources of UGH and the clinical characteristics of UGH in patients with CRF. METHODS: We reviewed the medical and endoscopic records of 574 patients who were admitted to Gil Medical Center from November 1999 to November 2004. UGH was defined as hematemesis, or nasogastric aspirate showing fresh or old blood, or melena associated with acute drop in hematocrit. CRF was defined as a serum creatinine clearance < or =59 mL/min for at least 3 months before and after the bleeding episode or the patients who have undergone dialysis or received renal transplantation. RESULTS: Thirty-two of 574 patients were CRF group. 19 of the CRF patients have received dialysis (18 paitents-hemodialysis; 1 patient-peritoneal dialysis). The mean age of CRF group was 56+/-13.65 years old and 16 patients were male. The causes of UGH in CRF patients, in order of frequency, was duodenal ulcer (37.5%), gastric ulcer (34.4%), unknown (12.5%). No angiodyplasia was found in CRF group. The sources of bleeding did not differ significantly between the two groups. The prevalence of taking ulcerogenic drugs in CRF patients was higher than that in control group (59.4% vs 29.7%, p=0.001). The prevalence of Helicobacter pylori (H. pylori) infection in CRF patients with peptic ulcer and gastritis was lower than that in control group (16.7% vs 42.3%, p=0.017). The mean length of hospital stay and the mean numbers of blood transfusions required were higher in the CRF group than control group. However, no differences were seen between the two groups in mortality, recurrent bleeding and surgery for control of bleeding. CONCLUSION: The common cause of UGH in patients with CRF was peptic ulcer disease and no angiodysplasia was found.

Analysis of factors affecting the delivered dose of hemodialysis in patients on conventional fixed dialysis regimen / 대한내과학회지

BACKGROUND: Although adequate removal of small solutes are essential for effective hemodialysis, many patients are suffering from inadequate delivery of hemodialysis, especially with the conventional fixed regimen of dialysis for 4 hours three times per week. We tried to evaluate actual delivered dose of hemodialysis in patients receiving 4 hours of low-flux hemodialysis, and to analyze factors affecting inadequate delivery of hemodialysis. METHODS: 97 stable maintenance hemodialysis patients who were undergoing 4 hours of hemodialysis thrice weekly were included for analysis. Prescribed dose of dialysis was calculated by Kt/V where K was in vitro urea clearance of dialyzer membrane and V was estimated according to the Watson's formula. Delivered dose of dialysis was calculated according to the Daugirdas equation. To find factors that may impair adequate delivery of hemodialysis, various clinical and technical parameters were analyzed. RESULTS: Prescribed dose of hemodialysis was 1.37+/-0.21, while delivered dose was 1.23+/-0.27, and thus, there was a significant difference (p <0.03). In 45% of the patients, delivered dose was less than 1.2. They were heavier and prescribed dose was low. delta Kt/V (Prescribed dose-Delivered dose) was significantly greater in patients who did not use heparin therapy compared to patients who used heparin. Other parameters such as hypotension, missed treatment, sex, type of vascular access and degree of recirculation were not associated with impaired delivery of hemodialysis.

A Case of Third Degree Complete Atrio-Ventricular Block During Catheterization of an Internal Jugular Vein for Hemodialysis / 대한신장학회잡지

Cardiac arrhythmias are a potential complication in the placement of central venous catheter for hemodialysis. These arrhythmias are typically benign and can be resolved by withdrawing the offending guide-wire or repositioning the catheter tip. We report a case of unusual arrhythmia, a complete 3rd degree atrioventricular block (3rd AVB). A 47-year-old man was admitted with clinical findings suggestive of end stage renal disease. His electrocardiography revealed a complete left bundle branch block. During the placement of the wire for a hemodialysis catheter via the right internal jugular vein, he developed 3rd AVB and hypotension. Despite the withdrawal of the wire, the hemodynamic instability and 3rd AVB had been sustained, leading to the insertion of a temporary pac emaker. On the 7th day after the insertion of the temporary pacemaker, the 3rd AVB was spontaneously resolved. To the best of our knowledge, a 3rd AVB related to the insertion of a hemodialysis catheter has not been reported in Korea.

Carpal Tunnel Syndrome caused by tuberculous tenosynovitis in a patient on long-term hemodiaysis / 대한내과학회지

Carpal Tunnel Syndrome (CTS) in patients undergoing long-term hemodialysis is caused by a variety of etiologic factors. Especially deposition of dialysis-related amyloidosis has been regarded as one of important etiologic factors. Although tuberculosis (TB) of wrist is a rare form of extrapulomary TB occurring in approximately 1% of osteoarticular TB in nonuremic patients, occurrence of the CTS as a result of TB tenosynovitis in these patients has been previously reported. To our best knowledge, TB tenosynovitis in hemodialysis patients has not been reported in spite of high incidence of extrapulmonary TB. We report a case of CTS due to TB tenosynovitis in the 53-year-old male receiving hemodialysis for more than eighteen years, confirmed by biopsy in flexor tendon. Initially we made a hasty conclusion that CTS in the patient was caused by dialysis-related amyloidosis.

A Case of Acute Myocardial Infarction Due to Coronary Artery Thrombosis During the Relapse of Nephrotic Syndrome / 대한신장학회잡지

Vascular thrombosis is one of the most serious complications in patients with nephrotic syndrome, but thrombosis occurs mainly in venous system. Arterial thrombosis is much less common and coronary artery thrombosis is rarely reported worldwide. We experienced a case of an acute myocardial infarction due to coronary artery thrombosis in a young male with minimal change disease during nephrotic relapse. This 35 year-old male was diagnosed to have minimal change nephrotic syndrome 15 years before admission. Two days before admission, he was found to have heavy proteinuria and edema which led to impression of relapse of nephrotic syndrome. Acute myocardial infarction was developed one day before admission and emergency thrombolytic therapy was performed. After admission, coronary angiography was performed and multiple thrombi were identified in distal left anterior descending artery without marked atherosclerotic changes. The formation of intracoronary thrombi in this patient appeared to be due to the hypercoagulable state associated with the relapse of nephrotic syndrome.

Renal Cortex Thickness and Kidney Size by Ultrasonography in Normal Korean Adults and Chronic Renal Failure Patients / 대한신장학회잡지

BACKGROUND: The thickness of the renal cortex is useful in all aspects of nephrology but no normal range has been established. Therefore, we investigated the renal cortex thickness by ultrasonography in normal Korean adults and chronic renal failure (CRF) patients before renal replacement therapy. For the purpose of evaluating the normal range then, we are going to predict the threshold range of cortex thickness in irreVersible renal failure status. METHODS: In 243 healthy Korean adults and 57 CRF patients with the creatinine level, or =30 mL/min was 0.63+/-0.10 cm, 0.79+/-0.11 cm (p or =30 mL/min in CRF patients. But the cortex thickness alone is not a sufficient marker to predict reversibility. We should consider other invasive procedure such as kidney biopsy.

A Case of Hydronephrosis as a Complication of Pelvic Actinomycotic Abscess / 대한신장학회잡지

Pelvic actinomycosis is a chronic granulomatous suppurative disease caused by an anaerobic gram- positive organism Actinomyces israelii. It is commonly associated with an intrauterine device(IUD) and can mimick pelvic or intra-abdominal malignant neoplasm. Ureteral obstruction leading to hydronephrosis is a rare complication of tubo-ovarian abscess. We experienced a case of hydronephrosis as a complication of pelvic actinomycotic abscess. The patient was a 46-year-old women presenting with fever and right flank pain. Leukocytosis and pyuria were present and a hydronephrosis was diagnosed by intravenous pyelography. Ultrasonography and a computerised tomography revealed a mass in right adnexum compressing the right ureter. Removal of retroperitoneal abscess and salphingo-oophorectomy were done and the diagnosis of actinomycosis was made by pathologic finding of resected mass. Postoperatively, the patient was treated with second-generation cephalosporin successfully.

Effect of High Glucose on the Expression of MCP-1 and VCAM-1 in Cultured Human Peritoneal Mesothelial Cells / 대한신장학회잡지

BACKGROUND: High glucose in peritoneal dialysis solution has been implicated in the pathogenesis of peritoneal fibrosis. Macrophages in peritoneal cavity seem to participate in the process of peritoneal fibrosis through the production of various cytokines and growth factors. Monocyte chemoattractant protein-1(MCP-1) plays a key role in the recruitment of monocytes toward the peritoneal cavity. Vascular cell adhesion molecule-1(VCAM-1) is assumed to be important in the transmigration of monocytes. MCP-1 and VCAM-1 can be induced by various cytokines and growth factors in human peritoneal mesothelial cells(HPMC). However, effect of high glucose on the expression of MCP-1 and VCAM-1 in HPMC has not been known well. METHODS: Cultured HPMC were conditioned with glucose(5-100mM) or mannitol for varying periods up to 7 days. Cell proliferation and mRNA expression of MCP-1 and VCAM-1 were assessed by MTT assay and Northern blot analysis respectively. MCP-1 protein was measured using ELISA. Chemotactic activity of high glucose-conditioned culture supernant were evaluated by chemotactic assay. Effect of protein tyrosine kinase(PTK) inhibitor on the high glucose-induced MCP-1 mRNA expression was examined. RESULTS: Glucose inhibited the cell proliferation in a time and dose dependent manner. Northern blot analysis showed that high glucose increased the MCP-1 mRNA expression in a time(2-7days) and dose(15-100mM) dependent manner, but not VCAM-1 mRNA expression. MCP-1 protein in cell culture supernant was also increased. Equivalent osmotic concentration of mannitol had no significant effect. High glucose-conditioned supernant had an increased chemotactic activity for monocyte, which was neutralized by specific anti-MCP-1 antibody. PTK inhibitors such as genistein and herbimycin A suppressed the high glucose-induced MCP-1 mRNA expression in a dose dependent manner. CONCLUSION: High glucose induced MCP-1 expression in HPMC partly via pathways involving PTK.

Bleeding from a Tuberculous Gastric Ulcer in a Hemodialysis Patient / 대한신장학회잡지

The incidence of Tuberculosis among the patients with end-stage renal disease(ESRD) has increased up to 16 times of that in the general population. The impairment of the cellular immunity in the ESRD patients may have a role in the pathogenesis. Extrapulmonary tuberculous manifestations such as lymph node, peritoneum, and pleura involvement are more frequent in the ESRD patients than in the general population. However, there has been no case of upper gastrointestinal(UGI) bleeding as a result of a gastric tuberculosis in the ESRD patient on hemodialysis. Here we report an unusual case of a hemodialysis patient with UGI bleeding secondary to a tuberculous gastric ulcer. A 31-year-old female on hemodialysis was admitted with melena. Endoscopy revealed a benign gastric ulcer with a visible bleeding vessel at the base, located in the anterior wall of the antrum. An exploratory laparotomy showed multiple, round, small and yellow nodules on the visceral peritoneum as well as a 1-cm sized gastric ulcer. After gastric resection, a histological examination including peritoneal nodules demonstrated chronic granulomatous inflamation with caseous necrosis and giant cells. The patient has been on antituberculosis medication and followed up in the outpatient department without any event for 8 months.

Two Cases of Combined Liver-kidney Transplantation in Patients with End Stage Renal Diseases Associated with Hepatitis B Related Liver Cirrhosis / 대한신장학회잡지

We here report two cases of combined liver-kidney transplantation in patients with both end stage renal disease and hepatitis B related liver cirrhosis. The first case was a 55-year-old man with hepatitis B related liver cirrhosis and chronic renal failure, who received cadaveric liver and kidney transplantation. Immunosuppressants were cyclosporine, prednisolone, and mycophenolate mofetil. Clinical course was uneventful except for hemolytic anemia due to alloimmunization that occurs after ABO-mismatched solid organ transplantation. Hemoglobin level became stable after plasmapheresis. His renal and hepatic function is maintained up to the present time. The second case was a 42-year-old man with nephrotic syndrome and liver cirrhosis. The patient underwent living related-combined liver-kidney transplantation. Donors were his son and brother. Blood type of the patient and donors were identical and the result of HLA crossmatch was negative. On the 14th postoperative day, stenosis at anastomotic site of hepatic artery was detected. After balloon angioplasty hepatic function was normalized. At 8 months after the transplantation, the patient is stable without adverse events.

C-reactive Protein, Coronary Heart Disease, and Mortality in CAPD Patients / 대한신장학회잡지

BACKGROUND: Atherosclerotic vascular disease is major cause of morbidity and mortality in dialysis patients. C-reactive protein(CRP) as a marker of inflammmation appears to be clinically useful in prediction of coronary heart disease and mortality. This study is designed to test whether plasma concentration of CRP correlates with coronary heart disease and mortality in CAPD patients. METHODS: A total of 137 end-stage-renal disease patients undergoing CAPD were included. The measurement of baseline CRP and stress thallium SPECT were performed in all patients. Patients were followed prospectively from initiation of dialysis to June 1999 for analysis of survival rate and cause of death. Coronary angiography performed in 16 of 32 patients showed all positive results. RESULTS: 32 patients showed positive results in thallium SPECT. The baseline CRP concentration were higher among patients with positive results in thallium SPECT than those with negative results(1.05 g/L vs 1.30mg/dL, p<0.001). The survival rate was significantly lower in lower CRP group than higher CRP group (44months vs 26 months, p<0.001). However, There was no difference in cause of death according to serum CRP level. Death from cardiac cause is significantly higher among patients with positive thallium SPECT than negative results. The most common cause of death are, in descending order of frequency, cardiac disease including acute MI, sepsis, cerebrovascular disease. CONCLUSION: The baseline level of inflammation as assessed by the plasma concentration of CRP independently predicts the risk of coronary heart disease and survival in CAPD patients.

Clinical Analysis on REnal Transplants at Asan Medical Center / 대한신장학회잡지

From June 1990 to December 1998, 792 kidney transplantations were performed at Asan Medical Center. 436 cases(55M) were from living-related donors, 139 cases(17.6%) were from living-unrelated donors and 217 cases(27.4%) were from cadaveric donors. The results of the trasnplantation were analyzed according to the various factors known to influence the outcome of transplantation. In living transplants, the overall patients survival rate was 98.2% at 1 year and 95.8% at 5 years, the corres-ponding allograft survival rate was 96.9 and 86.1N. In cadaveric transplants, the overall patients survival rate was 94.3% at 1 year and 94.3% at 5 years, the corresponding allograft survival rate was was 90.296 and 84.8%. In living transplants, donor age(>50yrs), recipient age(>50yrs), ABO compatability, pretrans-plant blood transfusion, diabetic history had no effect on allograft survival rate. But HLA DR cornpa-tability, serum creatinine(2.5mg/dL) at discharge and rejection history had effect on allograft survival(p50yrs), recipient age(>50yrs), ABO compatability, HLA DR match, diabetic history, pretransplant transfusion had no effect on allograft survival. But serum creatinine at discharge(>2.5mg/dL) and posttransplant rejection had effect on allograft survival.