A Case of Horseshoe Kidney with Focal Segmental Glomerulosclerosis / 대한신장학회지

An 18-year-old man presented as marked proteinuria on urinalysis. Abdominal ultrasonography and computed tomography indicated the presense of horseshoe kidney without any other abnormalities. A percutaneous computed tomography (CT) guided renal biopsy was done. Of 6 glomeruli obtained, global sclerosis was found in 2. Some segments of affected glomerulus showed peripheral solidifications and focal hyalinosis, which are Periodic acid-Schiff and Masson Trichrome stain positive. The diagnosis of horseshoe kidney with focal segmental glomerulosclerosis (FSGS) was made by clinical and pathological findings. The authors report here a case of FSGS occurring in horseshoe kidney which has not yet been reported in Korea.

SIADH Associated with Prostate Cancer

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common disease leading to hyponatremia, and it is characterized by an inappropriately elevated serum ADH level relative to serum osmolality. This syndrome may occur in a variety of clinical settings including malignancies. However, it is rarely observed in association with prostate cancer. Moreover, its pathogenesis and clinical characteristics have not been completely understood. We report a case of SIADH associated with prostate cancer in a 64-year-old male patient with a literature review.

Clinical Characteristics of Uremic Pruritus in Chronic Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Pruritus is a common, unpleasant symptom in patients on maintenance hemodialysis (HD), however its pathogenesis remains unclear. The aim of this study was to evaluate the prevalence of pruritus in chronic renal failure patients on hemodialysis and to correlate its presence with several clinical and laboratory parameters. METHODS: One hundred seventy patients on maintenance HD were enrolled, Some relevant clinical and laboratory parameters (age, sex, duration of dialysis, type of membrane, underlying renal disease, medications, erythropoietin (EPO) and laboratory findings including hematocrit, creatinine, urea, calcium, phosphorus, parathyroid hormone (PTH), erythrocyte sediment rate (ESR), albumin, beta2-microglobulin (beta2MG) and lipid profile as well as parameters of adequate dialysis (Kt/Vurea, URR) were evaluated. RESULTS: Total 170 patients (80 males) were enrolled and pruritus was found in 60 patients (Group I, M:F=29:31). One hundred ten patients did not complain pruritus (Group II, M:F=51:59). Mean age was significantly higher in Group I (59.6+/-14.8 vs. 54.3+/-13.6 years, p<0.05). There was no difference in sex, type of membrane, primary renal disease, serum beta2MG, ESR, EPO dose, duration of dialysis and serum albumin level. The mean value of Kt/V was higher in Group II (1.39+/- 0.36 vs. 1.51+/-0.27, p<0.035). CONCLUSION: Pruritus was more common in older patients and low Kt/V, but other clinical characteristics and laboratory findings were not correlated with uremic pruritus.

Clinical Characteristics of Uremic Pruritus in Chronic Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: Pruritus is a common, unpleasant symptom in patients on maintenance hemodialysis (HD), however its pathogenesis remains unclear. The aim of this study was to evaluate the prevalence of pruritus in chronic renal failure patients on hemodialysis and to correlate its presence with several clinical and laboratory parameters. METHODS: One hundred seventy patients on maintenance HD were enrolled, Some relevant clinical and laboratory parameters (age, sex, duration of dialysis, type of membrane, underlying renal disease, medications, erythropoietin (EPO) and laboratory findings including hematocrit, creatinine, urea, calcium, phosphorus, parathyroid hormone (PTH), erythrocyte sediment rate (ESR), albumin, beta2-microglobulin (beta2MG) and lipid profile as well as parameters of adequate dialysis (Kt/Vurea, URR) were evaluated. RESULTS: Total 170 patients (80 males) were enrolled and pruritus was found in 60 patients (Group I, M:F=29:31). One hundred ten patients did not complain pruritus (Group II, M:F=51:59). Mean age was significantly higher in Group I (59.6+/-14.8 vs. 54.3+/-13.6 years, p<0.05). There was no difference in sex, type of membrane, primary renal disease, serum beta2MG, ESR, EPO dose, duration of dialysis and serum albumin level. The mean value of Kt/V was higher in Group II (1.39+/- 0.36 vs. 1.51+/-0.27, p<0.035). CONCLUSION: Pruritus was more common in older patients and low Kt/V, but other clinical characteristics and laboratory findings were not correlated with uremic pruritus.

Serum homocysteine concentration in kidney transplant recipients / 대한내과학회지

BACKGROUND: Cardiovascular disease (CVD) after kidney transplantation is a major cause of both graft loss and patient death in kidney transplant recipeints. There are several well known risk factors of CVD, such as hyperlipidemia, hypertension, diabetes melitus, old age and smoking. Non-classic risk factors are acute rejection episode, LVH, C-reactive protein and hyperhomocysteinemia. Homocysteine is an amino acid filtered through the glomerulus and hyperhomocysteinemia is considered as a risk factor of CVD in end-stage renal disease (ESRD) and kidney transplant patients. So homocysteine lowering trials, such as folic acid and vitamine supplement therapy, are being made. We evaluated the prevelance and determinants of hyperhomocysteinemia in kidney transplant recipients. METHODS: We measured serum total homocysteine concentration (tHcy) and its determinants in 21 normal persons, 37 chronic renal failure (CRF) patients with conservative treatment (predialysis) and 48 kidney transplant patients. RESULTS: The prevalence of hyperhomocysteinemia was 4.8%, 83.8% and 45.8% among normal persons, predialysis and kidney tranplant patients, respectively. Among the kidney transplant recipients the prevelence of hyperhomocysteinemia was 18.8% in normal renal function (serum creatitine concentration male: below 1.2 mg/dL, female: below 1.1 mg/dL) group and 59.4% in abnormal renal function group. The tHcy values in kidney transplant patients are significantly lower than those in predialysis patients (16.38+/-6.48 nmol/L vs. 24.68+/-9.01 nmol/L, p < 0.01), but higher than those in normal persons (16.38+/-6.48 nmol/L vs. 8.80+/-2.07 nmol/L, p < 0.01). Among the kidney transplant recipients the tHcy values in normal creatinine group are significantly lower than those in abnormal creatinine group (12.02+/-3.68 nmol/L vs. 18.57+/-6.51 nmol/L, p < 0.01). Using muliple regression analysis, this study showed increased serum creatinine concentration is a major determinant of tHcy concentrations in kidney transplant recipients and hyperhomocysteinemia is not correlated with whole blood trough level of cyclosporin (mean 126.26+/-62.19 ng/mL, range: 26~322 ng/mL) or vitamines supplement therapy. CONCLUSION: In this study the serum homocysteine values in kidney transplant recipients were higher than in normal control group but significantly lower than in CRF patients with conservative treatment. The major determinant for serum homocysteine concentration is a serum creatinine concentration.

Serum CRP level is positively correlated with the cardiovascular disease in dialysis patients / 대한내과학회지

BACKGROUND: Atherosclerosis, a major problem in patients undergoing chronic dialysis treatment, has been characterized as an inflammatory disease. Cardiovascular disease is the major cause of mortality, accouting for approximately half of all deaths in this population. The present study was aimed whether CRP, an important inflammatory marker, might be associated with cardiovascular risk in dialysis patients. METHODS: We performed retrospective study in 77 dialysis patients. Patients were divided into the elevated CRP group (>8 mg/L, n=11) and the normal CRP group (8 mg/L) showed significant higher cardiovascular events (by chi-squre test, p=0.032). BMI, smoking, alcohol, dialysis modality, lipid parameters, BUN, serum creatinine, serum protein, serum albumin and seurm TIBC did not show significant difference between two groups. Correlation between CRP and other biochemical parameters was analysed. Only ESR was positively correlated with CRP. In a subsequent analysis, elevated CRP group had significantly higher cardiovascular risk (by stepwise logistic regression method, odd ratio = 6.59;95% CI, 1.13 to 38.28). CONCLUSION: These results suggest that CRP level is correlated with cardiovascular risk in dialysis patients.

Relationship between the Serum Parathyroid Hormone and Magnesium Levels in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients using Low-magnesium Peritoneal Dialysate

BACKGROUND: Patients on continuous ambulatory peritoneal dialysis (CAPD) have increased risk of low-turnover bone disease and relative hypoparathyroidism. Recently, it has been believed that magnesium plays an important role in regulating secretion of parathyroid hormone (PTH). The aim of this study was to evaluate the relationship between serum PTH and serum magnesium as a factor increasing the frequency of relative hypoparathyroidism. METHODS: We analyzed the data of 56 patients who had been on CAPD for more than 6 months without any significant problems. No patient had been previously treated with vitamin D or aluminum hydroxide. The patients had used peritoneal dialysate with the magnesium concentration of 0.5 mEq/L. Biochemical parameters, such as BUN, creatinine, alkaline phosphatase bony isoenzyme, total protein, albumin, total calcium, ionized calcium and intact parathyroid hormone level were measured. RESULTS: The mean serum magnesium level was 1.99 +/- 0.36 mEq/L. Among total 56 patients, 15 patients (26.8%) showed hypermagnesemia (serum magnesium > 2.2 mEq/L) and 5 patients (8.9%) showed hypomagnesemia (serum magnesium < 1.6 mEq/L). Among all 56 patients, serum iPTH (intact PTH) level was not correlated with serum magnesium level. However, it was inversely correlated with serum total calcium and ionized calcium levels, respectively (r=-0.365, p=0.006; r=-0.515 p < 0.001). Among 49 patients whose serum iPTH level was less than 300 pg/mL, serum iPTH level was inversely correlated with serum magnesium level (r=-0.295, p=0.039) and inversely correlated with serum total calcium and ionized calcium levels, respectively (r=-0.546, p < 0.001; r=-0.572 p < 0.001). Among 49 patients whose serum iPTH level was less than 300 pg/mL, lower iPTH group (serum iPTH < 120 pg/mL) showed higher serum magnesium level (p=0.037), higher serum total calcium level (p < 0.001) and lower bone isoenzyme of alkaline phosphatase level (p < 0.001) than those of higher iPTH group (120 pg/mL

Dialysis Adequacy and Nutritional Status in Patients with Continuous Ambulatory Peritoneal Dialysis(CAPD) / 대한신장학회잡지

PURPOSE: Malnutrition is common in CAPD patients and depends on many factors such as dialysis-related and nondialysis-related factors. The present study aimed to assess nutritional status, dialysis adequacy and their relationships with overall mortality and morbidity. METHODS: We studied 102 patients who had been receiving CAPD for at least 6 months. Dialysis adequacy was assessed by parameters derived from urea kinetic modeling(UKM) and nutritional status was assessed by serum biochemical measurement, normalized protein catabolic rate(nPCR), normalized protein equvalent of total nitrogen appearance(nPNA) and urea kinetic studies. Spearman's simple correlation and multiple linear stepwise regression analysis were used to assess correlation between dialysis adequacy and nutritional status in CAPD patients. We compared the differences between patients who suf fered morbid events, defined as either an infectious complication or hospitalization, and patients who remained well. RESULTS: The results showed that the total dialysis dose(total weekly Kt/Vurea) has statistically significant correlation with nPCR(r=0.234, p=0.028), nPNA (r=0.246, p=0.021), total weekly creatinine clearance (WCC)(r=0.479, p=0.0001), serum albumin levels(r= 0.233, p=0.029), serum cholesterol(r=0.266, p=0.013), serum BUN(r=-0.290, p=0.006) and serum creatinine levels(r=-0.408, p=0.0001). nPNA was positively correlated with serum cholesterol(r=0.217, p=0.045), serum transferrin(r=0.218, p=0.042) and serum ferritin levels(r=0.220, p=0.043). Patients who suffered morbid events had an old age(p=0.001), long duration of CAPD(p=0.0001), higher CRP(p=0.021), lower serum albumin level(p=0.020), lower hematocrit(p=0.049) and lower WCC(p=0.017). Conclusions : These results indicate that adequate dialysis is very important for the maintenance of adequant nutrition because nutritional status positively correlated with dialysis dose, which is best assessed by UKM. In addition, assessment of nutritional status and dialysis adequacy are important in predicting clinical outcomes in CAPD patients.

Hyperhomocysteinemia in Patients with Chronic Renal Failure / 대한신장학회잡지

OBJEVTIVE: It has been reported that hyperhomocysteinemia is an independent risk factor for atherosclerotic complications, although the mechanisms remain unclear. The major determinents of total fasting plasma homocysteine(tHcy) concentrations have been recently reported but there are still conflicting data on the influence of those in peritoneal and hemodialysis patients. Therefore, we evaluated the prevalence and association of vascular complications and the determinents of hyperhomocysteinemia in chronic renal failure patients receiving conservative treatment(predialysis), peritoneal dialysis(PD) and hemodia- lysis (HD) patients. METHODS: We measured the factors, including fasting plasma vitamine levels(folate, vitamin B6 and vitamin B12), serum creatinine concentration, dialysis adequacy-related varibles as well as associated risk factors for vascular diseases that might affect tHcy concentrations in 37 predilysis, 30 PD, 34 HD patients and 21 normal persons. Continuous variables were compared using independent sample t-test. Spearman's correlation was used to determine the strength of association between tHcy and other predictive variables. Percentages were compared using Pearson's chi-square test or Fisher's exact test, depending on the frequencies. Independent determinents of tHcy concentration and atherosclerotic vascular complications were identified using multiple regression analysis. RESULTS: The prevalence of hyperhomocysteinemia was 83.8, 72, 88% among predialysis, PD and HD patients,respectively(Odds ratio was 103.33, 81.43, 150.0 vs. controls, respectively). tHcy values in predialysis, PD and HD patients are significantly higher than those in controls(24.68+/-9.01, 21.04+/-8.82, 23.62+/-9.46 vs. 8.80+/-2.07 mumoL/L, repectively, p<0.01). Predialysis, PD and HD patients with atherosclerotic vascular complications had higher tHcy concentrations than did predialysis, PD and HD patients without vascular complications(21.93+/-8.71 vs. 32.09+/-4.71 mumoL/L, p<0.01, 17.57+/-5.85 vs. 28.74+/-9.70 mumoL/L, p<0.01, 19.00+/-4.29 vs. 33.28+/-10.13, p<0.01 respectively). We also observed increasing odds ratios of vascular events with increasing tHcy concentrations. For predialysis, PD and HD patients, fasting plasma folate level had negative correlation with tHcy concentrations by spearman's simple correlaltion. And using muliple regression analysis, we recognized hyperhomocysteinemia is an independent risk factor for atherosclerosis and fasting plasma folate is a major determinent of tHcy concentrations in predialysis, PD and HD patients. CONCLUSIONS: Hyperhomocysteinemia in predialysis, PD and HD patients was more prevalent than that in normal controls. Risk of atherosclerotic vascular complications increased with increasing tHcy concentrations. Hyperhomocysteinemia is an independent risk factor for atherosclerosis and fasting plasma folate is a major determinent of tHcy concentrations in predialysis, PD and HD patients.

Relationship between the serum parathyroid hormone and magnesium levels in continuous ambulatory peritoneal dialysis (CAPD) patients using low-magnesium peritoneal dialysate / 대한내과학회지

BACKGROUND: One of the most common complications in patients with end stage renal disease is renal osteodystrophy and parathyroid hormone (PTH) plays a key role in the pathogenesis of renal osteodystrophy. It is known that patients undergoing CAPD (continuous ambulatory peritoneal dialysis) have increased risk of low turnover bone disease and relative hypoparathyroidism is related to its pathogenesis. Factors related to relative hypoparathyroidism are increased in extracellular calcium level, accumulation of aluminum, vitamin D treatment, good control of serum phosphate, diabetes mellitus, and old age. Recently it has been believed that magnesium plays an important role in regulating secretion of PTH. The aim of this study was to evaluate the relationship between serum PTH and serum magnesium as a factor increasing the frequency of relative hypoparathyroidism. METHODS: Author studied 56 patients who had undergone CAPD for more than 6 months without any significant problems and had been followed by Chonnam National University Hospital. No patient had been previously treated with vitamin D or aluminum hydroxide. The patients had used peritoneal dialysate with the magnesium concentration of 0.5 mEq/L. Biochemical parameters were checked. RESULTS: 1. The mean serum magnesium level was 1.99+/-0.36 mEq/L. Among total 56 patients, 15 patients (26.8%) showed hypermagnesemia (serum magnesium > 2.2 mEq/L), and 5 patients (8.9%) showed hypomagnesemia (serum magnesium < 1.6 mEq/L)2. On all 56 patients, serum iPTH level was not correlated with serum magnesium level. But, it was inversely correlated with serum total calcium and ionized calcium levels, respectively (r=-0.365, p=0.006; r=-0.515 p<0.001).3. Among the 49 patients whose serum iPTH level was less than 300 pg/mL, serum iPTH level was inversely correlated with serum magnesium level (r=-0.295, p=0.039), and inversely correlated with serum total calcium and ionized calcium levels, respectively (r=-0.546, p<0.001; r=-0.572 p<0.001).4. Among the 49 patients whose serum iPTH level was less than 300 pg/mL, lower iPTH group (serum iPTH<120 pg/mL) showed higher serum magnesium level (p=0.037), higher serum total calcium level (p<0.001), and lower bone isoenzyme of alkaline phosphatase level (p<0.001) than those of higher iPTH group (120 pg/mL serum< or =iPTH<300 pg/mL). CONCLUSION: Among the CAPD patients whose serum iPTH level was less than 300 pg/mL, there was a significantly inverse correlation between serum iPTH level and serum magnesium level. This study indicates that not only serum calcium level, but also serum magnesium level are important in the regulation of serum iPTH levels of CAPD patients who have been dialyzed by low-magnesium peritoneal dialysate.

An analysis of fatigue among outpatients

BACKGROUND: Up to the present, there has been little study on chronic fatigue or chronic fatigue syndrome, and there is equally sparse relevant statistical data For this reason, we attempted to investigate the present status of fatigue, particularly its incidence and actual conditions. METHODS: The study subjects were 12,152 outpatients who visited family practice in hospitals all over Korea between July 24 and September 21, 1997. They were given a questionnaire which included questions reflecting the (U.S.) Center for Disease Control criteria defining chronic fatigue syndrome. RESULTS: Among the subjects, 861 people complained of fatigue in their response to the questionnaire and they became the focus of the study. Of this fatigue group, 426 people(49.4%) had rnanifested fatigue for more than 6 manths, and the male/female ratio was 54%/46%, respectively. People who re ported that fatigue impaired their ability to function on a daily basis made up 35.8% of the fatigue group and the percentage of people who had considered visiting a clinic duen to fatigue wasa unexpectedly high 52.8%. The reported causes of fatigue, in decreasing order, were. social interactio(mals 68.5%/ femals 45.1%); sleep disturbance(mals 26.8%/ femals 21.8%); and physical maladies(mals 24.2%/femals 26.5%). There were significant gender differences in social interaction relating to domestic problems(mals 4.7%/femals 16.7%) and emotional problems(mals 12.2%/femals 21.4%). Among 33 chronic fatigue syndrome patients who indicated what they thought were the causes of their problems, 68.8% reported physical maladies, 65.6% social life, 31.3% emotional problems, 21.9% sleep disturbance, and 21.9 % domestic problems. The associated symptoms of fatigue reported in both males and females, in decreasing order, included: myalgia, headache and neurologic symptoms. The prevalence of chronic fatigue was 0.27%. CONCLUSIONS: Our study showed that 7.1% of family practice outpatients complained of fatigue and that their daily activities or occupational life were disturbed as a result. This group demanstrates is serious need for medical assistance. Therefore, doctors should have more interest in fatigue, particularly in chronic fatigue syndrome, so as to provide real and versatile care.