Two cases of acute renal failure secondary to acute pyelonephritis / 대한내과학회지

Acute renal failure secondary to acute pyelonephritis is developed rarely. But acute pyelonephritis is considered in differential diagnosis of acute renal failure, particularly in elderly patient. Elderly patient showed subtle symptoms or signs of infections and can be missed easily. We experienced two cases of acute renal failure secondary to acute pyelonephritis. In first case, one patient complained fever, chilling and right flank pain for 10 days. Three repeated blood and urine cultures showed E. coli, respectively. At admission serum creatinine showed 2.4 mg/dL and thereafter increased to 4.5 mg/dL, and then decreased to 1.7 mg/dL with antibiotic therapy and hydration at 14 days of admission. In second case, patient complained right flank pain, costovertebral tenderness and urinary difficulty at admission. Two repeated blood culture showed no growth, two repeated urine culture showed > 105 ml/dL of E. coli. At admission serum creatinine level was 2.69 mg/dL and then decreased to 1.7 mg/dL with antibiotic therapy and hydration at 14 days of admission.Acute pyelonephritis should be considered in differential diagnosis of acute renal failure in the elder ages, although this developed rarely. Early recognition and appropriate antibiotic treatment helps recover acute renal failure secondary to acute pyelonephritis.

Two cases of scrub typhus complicating acute respiratory distress syndrome / 대한내과학회지

Scrub typhus is a zoonotic disease, caused by Orientia tsutsugamushi, and characterized by a typical primary lesion(eschar), rash and non-specific symptoms such as fever and chills, headache, myalgia. Although it is an acute febrile illness, severe complications of this disease are very rare since the introduction of specific antibiotic therapy. The authors report two cases of scrub typhus complicating acute respiratory distress syndrome. Although appropriate diagnosis and treatment were performed, all two patients expired. They were diagnosed as scrub typhus by travel history, clinical manifestations, eschars, serologic test and polymerase chain reaction(PCR).

Predictive Factors of Acute Renal Failure in Sepsis: APACHE III Prognostic System and Liano System / 대한신장학회잡지

Uncontrolled infection quite often 1eads to systemic inflammatory response syndrome and multi-organ dysfunction syndrome. Despite advances in medical knowledge and technology, the mortality of patient with sepsis is still 35-60%, and even reach up to 50-90% in septic patients having acute renal failure. The purpose of this study was to examine the characteristics and predictive factors of progression to acute renal failure(ARF) in sepsis. We analyzed the bacteriologic and laboratory data of 54 admitted patients with SIRS (systemic inflammatory response syndrome) at Pusan National University Hospital from July 1997 to July 1999 (ARF 23 vs non-ARF 31). Multiple factor which may influence mortality and progression to AEK in sepsis, were evaluated and measured on admission day. The following of results, 1) Of the 54 patients, 23 were ARF group and 31 were non-ARF group. Mean age were, 52 years and 51 years. The mortality of ARF group and non-ARF group were 78% and 23%, Urine output, albumin, cholesterol, mean arterial blood pressure and evidence of underlying disease were not statistically different in each group. 2) Although the sources of sepsis could not identified in 9% (ARF), 23% (non-ARF), the others had the primary site of infections: gastrointestinal tract (35% vs 29%), lung (30% vs 19%), genitourinary tract(9% vs 13%), skin (17% vs 16%). 3) Although statistically not different, gram-positive bacterial infection was more common in ARF group (mainly staphylococcus aureus). Culture negative results were 4 patients (ARF), 1 patient (non-ARF). 4) APACHE III score in ARF group was higher than non-ARF group (48.1+/-16.5 vs 30.2+/-15.6). Liafio score in ARF group was higher than non-ARF group (39.1+/-13.0 vs 28.9+/-8.3). 5) APACHE III score and Liailo score in non-survivors were higher than survivors(APACHE III score: 48.6+/-15.3 vs 28.1+/-14.0, Liaho score:37.9+/-12.0 vs 29.4+/-9.2) 6) APACHE lII system was positively correlated with Liaho system (r=0.512, p=0.001). In conclusion, APACHE III system and Liaho system were significant predictors of progression to ARF and mortality in sepsis. In the future, prospective and multicenter studies are required to improve the method of treatment and the prognosis in sepsis.

Gallium-67 Scintigraphy in Glomerular Disease / 대한내과학회지

OBJECTIVES: Gallium 67(Ga-67) scintigraphy has been used to diagnose inflammatory and neoplastic diseases. We undertook a study to determine the clinical value of Ga- 67 renal scan in patients with various glomerular diseases. METHODS: Ga-67 scintigraphy was performed in 48 patients with various biopsy proven forms of renal diseases. Renal uptake in 48 patients images was graded as follow: Grade 0 = not visualization at 48 hours: 1 = faintly visualize: 2 = equal to uptake in spine: 3 = greater than over the spine: 4 = greater than activity over the liver. RESULTS: 1) Of the 48 patients, 31 were male, and mean age was 32 years. 11 patients had hypertension and 29 patients had hematuria. 2) Positive scintigram were seen in 40 of 48(83%) cases. In results of renal biopsy, IgA nephropathy(IgAN) was 15 patients, minimal change disease(MCD) was 14, focal segmental glomerulosclerosis (FSGS) was 8, membranoproliferative glomerulonephritis (MPGN) was 3, lupus nephritis(LN) was 3, poststreptococcal glomerulonephritis(PSGN) was 3 and membranous glomerulonephritis(MGN) was 2. 3) In 26 patients (54%) with nephrotic-range proteinuria, Grade 2 or higher renal uptake was observed in 9 (75%) of MCD, 5(100%) of FSGS, 2(100%) of LN and 3(75%) of IgAN. 4) In comparision nephrotics with non-nephrotics at biopsy, renal Ga-67 uptake in who patients had nephrotic-range proteinuria was correlated with clinical severity determined by serum albumin, serum total cholesterol and 24 hours urine protein excretion. CONCLUSIONS: Renal Ga-67 scintigraphy may be able to be a predictor in the assessment for severity of nephrotic syndrome.

A Case of Cutaneous Panniculitis in Relapsing Polychondritis / 대한류마티스학회지

Relapsing polychondritis is a rare disease characterized by widespread destructive inflammatory lesions, involving cartilaginous tissue throughout the body. Commonly involved organs include the external ear, nose, joints, eyes, tracheobronchial tree, cardiovascular system and cutaneous tissues. Erythema nodosum or mesenteric panniculitis have sometimes been described in association with relapsing polychondritis, but cutaneous panniculitis is rarely reported in relapsing polychondritis. We report here a relapsing polychondritis patient who developed cutaneous panniculitis, which was resolved by corticosteroid therapy.

Aminoglycoside Nephrotoxicity Using 99mTc-DTPA Renal Scan / 대한신장학회잡지

Aminoglycoside has a broad-spectrum bactericidal activity and especially excellent effect on gram negative bacteria. But, its harmful effect is existed about kidney and ear. Among these, many studies were done about aminoglycoside nephrotoxicity. Until now, many authors have been reported its incidence was 4.45-45%. We needed parameters monitoring about nephrotoxicity. So, our study was done using 99mTc-DTPA renal scan to evaluate nephrotoxicity. We enrolled forty patients who admitted due to infection. 32 patients received Netilmicin and 8 patients Isepamicin. Mean duration and dosage were 8 days, 200mg daily. We accomplished 99mTc-DTPA renal scan, 24hr urine study and blood sampling before starting antibiotics. After mean 8 days, same procedure was repeated. Aminoglycoside nephrotoxicity(defined as 50% GFR reduction) was presented in only one patient. She didn't have risky factor, such as hepatic dysfunction, hypotension, previous renal problem. However, duration was longer than other patients(13 days). GFR was fallen by 25-50% in 6 patients. This finding represent nephrotoxic effects of aminoglycoside indirectly. Above 6 patients had not any characteristics compared to other 33 patients. In addition to renal scan, sodium excretion was increased compared to pre-antibiotics, and glomerular filtration rate using 99mTc-DTPA renal scan was positively correlated with 24hr urine creatinine clearance, GFR by Cockcroft & Gault equation. I conclude that aminoglycoside has nephrotoxic effect when used for longer period. Thus, I suggest that DTPA renal scan including other many renal monitoring method has usefulness in revealing aminoglycoside nephrotoxicity.

Clinical Characteristics and Prognostic Factors of Bacteremia and Sepsis / 대한내과학회지

OBJECTIVES: In spite of the improvement in therapeutic strategy, the mortality rate from sepsis is still high. The purpose of this study was to examine the clinical characteristics and prognostic factors of sepsis to get help in treatment and estimation of prognosis of sepsis. METHODS: We analyzed the clinical and bacteriologic data of 313 admitted patients with bacteremia at Pusan National University Hospital from Jan., 1996 to Dec., 1997 retrospectively and all patients were categorized into 4 groups (bacteremia, sepsis, severe sepsis, septic shock) by the definition from American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference, 1992. RESULTS: 1) Male to female ratio was 1.22: 1 and mean age was 52 years. 2) The overall mortality rate was 32.3% and the mortality rates of bacteremia, sepsis, severe sepsis and septic shock were 14.9%, 22.8%, 52.0%, and 95.2%, respectively. 3) Underlying diseases predisposing to bacteremia were diabetes mellitus(14.4%), solid cancer (13.1%), hematologic malignancy(10.2%) and liver cirrhosis(9.9%), but the most common was no underlying disease. 4) Among the total 80 species of isolated microorganisms, gram-positive organisms were responsible in 169 cases, gram-negative organisms in 218 cases. E. coli was isolated most frequently, followed by S. aureus, S. epidermidis, K. pneumoniae, Enterococcus spp., Enterobacter spp., Str. viridans group, CNS, P. aeruginosa and S. typhi. 5) Although the source of bacteremia could not be identified in 28.8% of the patients, the others had the primary site of infections ; skin(17.9%), gastrointestinal tract(16.9%), respiratory tract(12.5%), urinary tract(9.9%) and biliary tract(7.3%). 6) The mortality rate in patients with gram-positive bacteremia was 39.4%, with gram-negative bacteremia was 20.9% and with polymicrobial bacteremia was 33.3%. MRSA sepsis showed the highest mortality rate(58.8%), followed by Enterococcus spp.(50.0%), K. pneumoniae (35.0%), P. aeruginosa(27.3%) and E. coli(18.8%). 7) There was significant relation between etiologic organisms of bacteremia and the primary site of infections. 8) Using logistic regression analysis, mortality was predicted by disseminated intravascular coagulation, severity of sepsis and severity of underlying diseases. CONCLUSION: Sepsis occurred in 16 patients among 1,000 adult admitted patients and overall mortality rate was 32.3%, still high. The mortality rate had positive correlation with the severity of sepsis. Among 16 evaluated risk factors of mortality, mortality was predicted by disseminated intravascular coagulation, severity of sepsis and severity of underlying disease.

The Usefulness of DEXA about Nutritional Assesment in Chronic Renal Failure / 대한신장학회잡지

It has been considered that the nutrition affects the mortality of chronic renal failure patients. Thus, several studies reported the method of examination about nutritional status in chronic renal failure patients. The purpose of the present study was to evaluate the nutritional status of 32 chronic renal failure patients, and recommend DEXA as a objective method. Thirty two chronic renal failure patients and 24 disease-free persons on kidney(control group) were included in this syudy. There were no difference in mean age, sex, weight, height, body mass index between two groups. We measured % total body fat, fat-free mass, limb fat, trunl fat, limb fat/trunk fat ratio with Hologic QDR 4500. The results were as follows. 1)% Total body fat of chronic renal failure patients was 20.7+/-7.9%. That was lower than 26.3+/-7.9% of control group(P<0.05). 2)Fat-free mass of chronic renal failure patients revealed lower result compared with control group. Each result was 40.2+/-12.2kg, 46.2+/-9.1kg(P<0.05). 3)Despite of no significant difference between two groups in ratio of limb fat and trunk fat, limb fat and trunk fat were statistically different(Limb fat:CRF-5.6+/-2.4kg, Control-7.1+/-1.9kg, Trunk fat:CRF- 5.2+/-3.0kg, Control-7.7+/-2.7kg)(P<0.05). 4)Triceps skinfold thockness was positively correlated with % total body fat, limb fat, trunk fat, and negatively correlated with fat-free mass. Mid- arm muscle area circumference had inverse relationship above(P<0.05). 6)Severe malnurished patients(SGA-C group) had lower result compared to mild-moderate malnurished patients(SGA-B group) about %TBF, LF,TF, total lymphocyte count. In addition to DEXA, we examined triceps skinfold thickness and mid-arm muscle area circumference. The result showed significant comparison between two groups, too. But albumin, cholesterol, potassium level was no statistical significant difference, except lymphcyte count. In conclusion, as suggested by above results, chronic renal failure patients has protein-calorie malnutrition. This nutritional status affects long-term survival of chronic renal failure patients. DEXA can give objective data accompanied with simple anthropometric measurement in nutriti onal status. Thus, we recommend DEXA as objective method of nutritional examination. In future, more precise method will be discovered, and that contribute more long-term survival of chronic renal failure patients.

Two cases of acute renal failure complicated by the poisoning of amanita virosa / 대한내과학회지

Although the most of mushroom poisoning have a clinical menifestation of mild to moderate gastroenteritis, some mushroom may cause a serious illness; acute renal failure, hepatic necrosis. We experienced two cases of acute renal failure complicated by the poisoning of amanita virosa. Amanita virosa have a amatoxin. Amatoxin deteriorate hepatocytes, renal tubular cells, intestinal mucosal cells, and pancreas. They were transferred from local hospital for renal failure management. On admission, blood urea nitrogen and serum creatinine were highly elevated. We diagnosed acute renal failure complicated by poisoning of amanita virosa. In one case, renal function was further deteriorated compared with initial laboratory findings after creatinine was normalized at fifth day. Thus, we did a kidney biopsy. Light microscopy and EM showed interstitial inflammation and moderate tubular atrophy. They were recovered with the supportive management. We report two cases of mushroom poisoning-induced acute renal failure with review of literature.

Ulcerative colitis associated with seropositive rheumatoid arthritis / 대한내과학회지

We report a case of a 47 years old woman who had secondary renal amyloidosis due to rheumatoid arthritis. She admitted our hospital due to generalized edema, weakness and polyarthralgia, and had been diagnosed as having rheumatoid atrthritis and treated irregularly with anti-rheumatic drugs for 3 years. She had nephrotic range proteinuria (24 hour urine protein was 3.8 gm/day), hypoallbuminemia and pitting edema on both lowers. In kidney biopsy, amyloid (AA type) was deposited in renal glomerular, tubule and vessel walls. We diagnosed secondary renal amyloidosis.

A case of acute focal bacterial nephritis complicated by acute renal failure / 대한내과학회지

Acute focal bacterial nephritis is a part of urinary tract infection and a special form of acute pyelonephritis. In most cases, it is treated well by antimicrobial therapy without severe complications. Unusual cases have been reported that renal failure and or chronic granulomatous interstitial nephritis was combined with acute focal bacterial nephritis. We describe a case of acute reanl failure complicated by acute focal bacterial nephritis in 30-year-old male. He was admitted to this hospital owing to fever, chilling, right flank pain. On admission, BUN and creatinine were 29 mg/dl, 1.8 mg/dl. Urinalysis showed leukocyturia, & bactriuria. Urine culture revealed E. coli over us. Abdominal CT and ultrasonography was represented focal hypodense area and diffuse renal enlargement so we could diagnose acute focal bacterial nephritis. The patient was improved with antimicrobial therapy and hydration. In conclusion, this case shows the possibility that unusual complication such as acute reanl failure can be happensed in acute focal bacterial nephritis in continum with acute pyelonephritis

A case of myocardial infarction in the minimal change nephrotic syndrome / 대한내과학회지

The authors report the case of a 25 year old woman with a chronic corticosteroid-refractory nephrotic syndrome complicated by myocardial infarction. The thromboembolism, especially acute myocardial infarction, is the most serious complication of nephrotic syndrome. Until now many mechanisms have been studied about thromboem bolism including coronary artery disease in nephrotic syndrome, but not clear. Hypercoagulability and prolonged hyperlipidemia are known as the principal contributing factors in this complication. In addition, use of steroid as therapeutic trial and hypovolemic state induced by vigorous diuretics will affect the thromboembolism, too. In this case, several coagulation abnormality and prolonged hyperlipidemia are observed. On admission day, this patient had deep vein thrombosis and then was complicated by pulmonary thromboembolism. Despite of anticoagulant and thrombolytic therapy, she experienced acute myocardial infarction on fourth day after admission. After onset of myocardial infarction, by thrombolytics and prolonged anticoagulant therapy, this nephrotic patient was relieved and discharged without other serious complication. We recommend anticoagulant and antiplatelet agent therpy in risky patient of nephrotic syndrome. We present this case with review of literature.