Why should we focus on high-volume hemodiafiltration?

Though noticeable technological advances related to hemodialysis (HD) have been made, unfortunately, the survival rate of dialysis patients has yet to improve significantly. However, recent research findings reveal that online hemodiafiltration (HDF) significantly improves patient survival in comparison to conventional HD. Accordingly, the number of patients receiving online HDF is increasing. Although the mechanism driving the benefit has not yet been fully elucidated, survival advantages are mainly related to the lowering of cardiovascular mortality. High cardiovascular mortality among HD patients is seemingly attributable to the cardiovascular changes that occur in response to renal dysfunction and the HD-induced myocardial stress and injury, and online HDF appears to improve such secondary cardiovascular changes. Interestingly, patient survival improves only if the convection volume is supplied sufficiently over a certain level during online HDF treatment. In other words, survival improvement from online HDF is related to convection volume. Therefore, there is a growing interest in high-volume HDF in terms of improving the survival rate. The survival improvement will require a minimum convection volume of 23 L or more per 4-hour session for postdilution HDF. To obtain an optimal high convection volume in online HDF, several factors, such as the treatment time, blood flow rate, filtration fraction, and dialyzer, need to be considered. High-volume HDF can be performed easily and safely in routine clinical practice. Therefore, when the required equipment is available, performing high-volume HDF will help to improve the survival rate of dialysis patients.

Safety and Efficacy of Tolvaptan in Korean Patients with Hyponatremia Caused by the Syndrome of Inappropriate Antidiuretic Hormone

BACKGROUND: The aim of this multicenter study was to evaluate the safety and efficacy of tolvaptan (TLV) in Korean patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). METHODS: Of 51 enrolled patients with SIADH, 39 patients (16 female patients, aged 70.8 ± 11.3 years) were included in an intention to treat analysis. All patients received 15 mg/day as the initial dose, and the dose was then increased up to 60 mg/day (as needed) until day 4. RESULTS: Serum sodium increased significantly from baseline during the first 24 hours (126.8 ± 4.3 vs. 133.7 ± 3.8 mmol/L, P < 0.001), rose gradually between days 1 and 4 (133.7 ± 3.8 vs. 135.6 ± 3.6 mmol/L, P < 0.05), and then plateaued until day 11 (136.7 ± 4.5 mmol/L). The correlation between the change in serum sodium for the first 24 hours and initial serum sodium concentration was significant (r = −0.602, P < 0.001). In severe hyponatremia (< 125 mmol/L), the change was significantly higher (11.1 ± 4.8 mmol/L) than in moderate (6.4 ± 2.5 mmol/L, P < 0.05) or mild hyponatremia (4.3 ± 3.3 mmol/L, P < 0.01). In addition, logistic regression analysis showed that body weight (odds ratio [OR], 0.858; 95% confidence interval [CI], 0.775–0.976; P = 0.020) and body mass index (BMI) (OR, 0.692; 95% CI, 0.500–0.956; P = 0.026) were associated with rapid correction. No serious adverse events were reported, but in 13% of patients hyponatremia was overcorrected. CONCLUSION: TLV is effective in correcting hyponatremia and well-tolerated in Korean patients with SIADH. However, those with low body weight, low BMI or severe hyponatremia, could be vulnerable to overcorrection with the initial dose of 15 mg TLV.

A Personalized and Learning Approach for Identifying Drugs with Adverse Events

PURPOSE: Adverse drug events (ADEs) are associated with high health and financial costs and have increased as more elderly patients treated with multiple medications emerge in an aging society. It has thus become challenging for physicians to identify drugs causing adverse events. This study proposes a novel approach that can improve clinical decision making with recommendations on ADE causative drugs based on patient information, drug information, and previous ADE cases. MATERIALS AND METHODS: We introduce a personalized and learning approach for detecting drugs with a specific adverse event, where recommendations tailored to each patient are generated using data mining techniques. Recommendations could be improved by learning the associations of patients and ADEs as more ADE cases are accumulated through iterations. After consulting the system-generated recommendations, a physician can alter prescriptions accordingly and report feedback, enabling the system to evolve with actual causal relationships. RESULTS: A prototype system is developed using ADE cases reported over 1.5 years and recommendations obtained from decision tree analysis are validated by physicians. Two representative cases demonstrate that the personalized recommendations could contribute to more prompt and accurate responses to ADEs. CONCLUSION: The current system where the information of individual drugs exists but is not organized in such a way that facilitates the extraction of relevant information together can be complemented with the proposed approach to enhance the treatment of patients with ADEs. Our illustrative results show the promise of the proposed system and further studies are expected to validate its performance with quantitative measures.

Effect of low-dose valsartan on proteinuria in normotensive immunoglobulin A nephropathy with minimal proteinuria: a randomized trial

BACKGROUND/AIMS: Immunoglobulin A nephropathy (IgAN) is a generally progressive disease, even in patients with favorable prognostic features. In this study, we aimed to investigate the antiproteinuric effect and tolerability of low-dose valsartan (an angiotensin II receptor blocker) therapy in normotensive IgAN patients with minimal proteinuria of less than 0.5 to 1.0 g/day. METHODS: Normotensive IgAN patients, who had persistent proteinuria with a spot urine protein-to-creatinine ratio of 0.3 to 1.0 mg/mg creatinine, were recruited from five hospitals and randomly assigned to either 40 mg of valsartan as the low-dose group or 80 mg of valsartan as the regular-dose group. Clinical and laboratory data were collected at baseline, and at 4, 8, 12, and 24 weeks after valsartan therapy. RESULTS: Forty-three patients (low-dose group, n = 23; regular-dose group, n = 20) were enrolled in the study. Proteinuria decreased significantly not only in the regular-dose group but also in the low-dose group. The change in urine protein-to-creatinine ratio at week 24 was -41.3% +/- 26.1% (p < 0.001) in the regular-dose group and -21.1% +/- 45.1% (p = 0.005) in the low-dose group. In the low-dose group, blood pressure was constant throughout the study period, and there was no symptomatic hypotension. In the regular-dose group, blood pressure decreased at weeks 8 and 12. No significant change in glomerular filtration rate, serum creatinine level, or serum potassium level was observed during the study period. CONCLUSIONS: Our results suggest that low-dose valsartan can significantly reduce proteinuria without causing any intolerability in normotensive IgAN patients with minimal proteinuria.

A Case of Thymic Carcinoma with Behcet's Disease Combined with Immunoglobulin A Nephropathy

Behcet's disease is a systemic inflammatory disorder of unknown etiology, characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Renal involvement is rare in patients with Behcet's disease particularly immunoglobulin A (IgA) nephropathy. Other autoimmune diseases have been associated with increased risk of malignancy, but not Behcet's disease. Some cases of Behcet's disease accompanied by bladder cancer, thyroid cancer, stomach cancer, or hematologic malignancies have been reported. However, to the best of our knowledge, co-occurrence of Behcet's diseases with thymic carcinoma has not yet been reported. We experienced a 49-year-old male patient who had been treated for Behcet disease and IgA nephropathy, who presented with a large mediastinal mass on chest x-ray. After thymectomy, he was diagnosed with thymic carcinoma with complete resection.

A randomized crossover study of single biweekly administration of epoetin-alpha compared with darbepoetin-alpha in chronic kidney disease patients not receiving dialysis

BACKGROUND: Recent evidence demonstrates that high doses of epoetin-alpha (EPO-alpha) can be administrated at extended intervals, despite its relatively short serum half-life. However, no prospective randomized trials on the effects of extended dosing intervals of EPO-alpha compared with darbepoetin-alpha (DA-alpha) have been performed. This study was designed to investigate whether a single biweekly (Q2W) administration of a high dose of EPO-alpha is as effective as DA-alpha for anemia in chronic kidney disease (CKD) patients not receiving dialysis. METHODS: Sixty non-dialysis CKD patients were equally randomized to either Q2W subcutaneous EPO-alpha (10,000 unit) or DA-alpha (50microg) therapy groups for the first 6 weeks. After a 6-week washout period, the participants of the EPO-alpha and DA-alpha treatment groups switched to the alternate regimen for 6 weeks. The mean hemoglobin (Hb) levels after erythropoiesis stimulating agent (ESA) therapy and percentage change in Hb levels from baseline to the end of the study were analyzed. RESULTS: The mean Hb levels of postESA therapy increased significantly compared with those of preESA therapy in both ESA regimens. The percentage increase in Hb levels and erythropoietin resistance index did not show a significant difference between the different ESA regimens. No difference was observed between the regimens regarding mean Hb levels after ESA therapy. Additionally, there were no serious adverse effects leading to withdrawal from treatment. CONCLUSION: Biweekly high doses of EPO-alpha therapy may be equally as effective as Q2W DA-alpha therapy in maintaining target Hb levels in non-dialysis CKD patients.

Serum calcium and phosphorus levels in patients undergoing maintenance hemodialysis: A multicentre study in Korea

BACKGROUND: In many countries, nephrologists follow clinical practice guidelines for mineral bone disorders to control secondary hyperparathyroidism (SHPT) associated with abnormal serum calcium (Ca) and phosphorus (P) levels in patients undergoing maintenance hemodialysis (MHD). The Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines have long been used in Korea, and this study was undertaken to investigate the current status of serum Ca and P control in MHD patients. METHODS: Data were collected from a total of 1,018 patients undergoing MHD without intercurrent illness, in 17 hemodialysis centers throughout the country. Serum levels of Ca, P, and intact parathyroid hormone (iPTH) were measured over 1 year, and the average values were retrospectively analyzed. RESULTS: Serum levels of Ca, P, and the CaxP product were 9.1+/-0.7mg/dL, 5.3+/-1.4mg/dL, and 48.0+/-13.6mg2/dL2, respectively. However, the percentages of patients with Ca, P, and Ca x P product levels within the KDOQI guideline ranges were 58.7%, 51.0%, and 70.7%, respectively. Of the 1,018 patients, 270 (26.5%) had iPTH >300pg/mL (uncontrolled SHPT), whereas 435 patients (42.7%) showed iPTH <150pg/mL. Patients with uncontrolled SHPT had significantly higher values of serum Ca, P, and CaxP product than those with iPTH < or =300pg/mL. CONCLUSION: Despite the current clinical practice guidelines, SHPT seems to be inadequately controlled in many MHD patients. Uncontrolled SHPT was associated with higher levels of serum Ca, P, and Ca x P product, suggestive of the importance of SHPT management.

Nephron Numbers in Patients with Minimal Change Nephrotic Syndrome (MCNS) and Focal Segmental Glomerulosclerosis (FSGS) / 대한신장학회지

PURPOSE: It has been proposed that a decreased nephron number may be associated with the increased risk of glomerulosclerosis. In order to test the hypothesis that a reduced number and an increased volume of glomeruli may contribute to the pathogenesis of focal segmental glomerulosclerosis (FSGS), we compared the number and volume of glomeruli between 9 patients with FSGS and 8 with minimal change nephrotic syndrome (MCNS). METHODS: Mean glomerular volume was measured using the method of Weibel and Gomez. An estimate of glomerular number (index) was obtained by multiplying the cortical volume of a kidney by the fraction of renal cortex made up of glomeruli and dividing this by the mean glomerular volume for that kidney x 10(6). We determined kidney volume from ultrasonographic measurement. RESULTS: Patients with FSGS had significantly greater glomerular volume than patients with MCNS [2.02+/-0.36 (x10(6) micrometer3) vs. 1.57+/-0.27 (x10(6) micrometer3)] (p<0.025). However, there was no significant difference in the index of glomerular number (estimated glomerular number) between FSGS & MCNS patients (2.8+/-1.4 vs. 3.0+/-0.8). CONCLUSION: The glomerular volume was greater in FSGS patients than MCNS patients. But there was no significant difference in the index of glomerular number between patients with FSGS and MCNS.

Successful Treatment of Vancomycin-Resistant Enterococcal Peritonitis with linezolid in a Patient on CAPD / 대한신장학회지

Peritonitis is one of the major complications of CAPD (continuous ambulatory peritoneal dialysis). Among its causative organisms, vancomycin-resistant enterococcus (VRE) is rare, but serious causative organism, because it is refractory to antibiotics commonly used for CAPD peritonitis. Some drugs such as linezolid and dalfopristin have been introduced for VRE infections nowadays, but reports about usefulness of those drugs in VRE peritonitis are rare. We experienced a case of CAPD peritonitis caused by VRE, which was treated successfully with removal of CAPD catheter and use of linezolid. We report our experience with review of the literature.

Affecting Factors on Endothelial Dysfunction in Diabetic End Stage Renal Disease Patients on Hemodialysis / 대한신장학회잡지

BACKGROUND: Non-traditional risk factors of cardiovascular disease such as endothelial dysfunction, inflammation and malnutrition may be significant contributors to the excessive cardiovascular mortality in end stage renal disease (ESRD) patients. This study was undertaken to evaluate endothelial function in diabetic ESRD patients on hemodialysis and correlation between endothelial dysfunction and clinical, biochemical parameters. METHODS: Twenty eight stable diabetic ESRD patients (M: F=1.3: 1, average age: 60.1+/-1.0 yr) on hemodialysis were included. flow-mediated dilation (FMD) of brachial artery was measured using Doppler ultrasonography with 10 MHz transducer. Subjective global assessment (SGA) was used to assess the nutritional status of patients. RESULTS: The FMD (%) (% change of brachial artery diameter between before and after cuff inflation) was 5.1+/-1.0%. Serum albumin and C-reactive protein (CRP) were independent factors influencing SGA. When the patients were divided into groups according to history of ischemic heart disease (IHD), systolic pressure was significantly higher and FMD (%) was significantly lower in the group of patients with IHD compared with the group of patients without IHD. The FMD (%) showed significant positive correlation with SGA, serum albumin, and significant negative correlation with CRP. On multiple regression analysis, however, only CRP was an independent factor affecting FMD (%). CONCLUSION: These findings suggest that CRP influenced the nutritional status of diabetic ESRD patients on hemodialysis, and endothelial dysfunction, estimated by FMD, was significantly correlated with CRP. Therefore, CRP can be a modifiable risk factor for endothelial dysfunction in diabetic ESRD patients on hemodialysis.

A case of renal arterial embolization using 99% ethanol and lipiodol mixture for autosomal dominant polycystic kidney disease in a hemodialysis patient / 대한내과학회지

Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder characterized by innumerable bilateral renal cysts. It has an prevalence rate of one in 200~1,000 individuals and is a relatively common cause of renal failure. As renal function deteriorates, overall renal size usually diminish in patients with chronic renal failure. However, renal size of patients with ADPKD usually continues to increase, even after the initiation of dialysis therapy, because numerous cysts replace renal mass. Attempted methods to reduce the size of enlarged kidneys have included needle aspiration and sclerotherapy, cyst decompression surgery, laparoscopic and surgical nephrectomy. The outcome of these therapy frequently has been suboptimal, and there is a need to develop a more effective therapy. We report a case of renal arterial embolization using 99% ethanol and lipiodol mixture for ADPKD in a hemodialysis pathient, which has not been previously reported.

Clinical Characteristics of Peritoneal Fluid Eosinophilia in Patients on CAPD / 대한신장학회잡지

BACKGROUND: The clinical characteristics and significance of peritoneal fluid eosinophilia (PFE) in patients on continuous ambulatory peritoneal dialysis (CAPD) in Korea were uncertain. The present study was performed to clarify the clinical characteristics of PFE in our CAPD patients. METHODS: Between January 2000 and December 2001, we analyzed retrospectively the clinical data of 112 patients on CAPD at two renal centers. RESULTS: The mean period of the observation was 12.6+/-6.7 months, and the total number of peritoneal effluent sampling was 1, 024 (10.5/patient-year). PFE was found in 4.4% of patients. The incidence of PFE was 4.25 per 100 patients/year. Sixty percent of patients with PFE experienced within 2 weeks of initiation of dialysis. The duration of PFE episode varied from 1 to 4 days with the mean value of 2.8 days. All PFE episodes except one patient with abdominal pain treated by oral prednisolone had no symptoms and was spontaneously resolved. The only distinction between the patients with PFE and those without was concomitant peripheral blood eosinophilia (80.0% vs. 15.8%, p=0.0027). Other factors such as age, sex, primary renal disease, bacterial peritonitis, previous use of heparin or antibiotics, blood in peritoneal fluid, and allergic history were not significantly different between the two groups. CONCLUSION: The majority of PFE episode in CAPD patients developed within 2 weeks of initiation of dialysis and spontaneously resolved without treatment. Peripheral blood eosinophilia was a good predictor of PFE.

Changes of the Thyroid Function in Continuous Ambulatory Peritoneal Dialysis Patients / 대한신장학회잡지

BACKGROUND: In peritoneal dialysis patients, altered thyroid function was reported but the frequncy and pathophysiology were not well understood. The object of this study is to evaluate the effect of continuous ambulatory peritoneal dialysis (CAPD) on thyroid function by observing the frequency of primary thyroid dysfunction and the sequential change of thyroid function after CAPD. METHODS: In a cross-sectional study, thyroid function test (TFT) was done for 192 CAPD patients between Jan. 2001 and Jan. 2002. For another 38 CAPD patients, we observed the sequential change of thyroid function by performing TFT before and 6, 12, 24 months after CAPD. Thyroid hormones were quantitated after 200 mL sample of 24-hour dialysate effluent was lyophilized. TFTs were interpreted as subclinical hypothyroidism (sbhypo) when TSH is over 5 uIu/mL, mild hypothyroidism (mhypo) when TSH is between 5 and 10 uIu/mL with decreased fT4, and overt hypothyroidism (ohypo) when TSH level is over 10 uIu/mL with decreased fT4. RESULTS: Frequencies of normal thyroid function, sbhypo, mhypo and ohypo were 81.2%, 11%, 5.2%, and 2.6% respectively. Serum levels of TSH before and 6, 12, 24 months after CAPD were 2.6 +/- 0.1, 3.8 +/- 0.3, 4.2 +/- 0.5, 4.1 +/- 0.5 uIu/mL respectively and the frequencies of thyroid dysfunction including subclinical hypothyroidism were 6.4, 23.6, 26.3, 28.8% respectively, which showed the increasing tendency. Peritoneal loss of TSH was 11, 067 +/- 1, 776 uIu/day, and that of TT4 was 11.68 +/- 2.7 microgram/day. These were approximately 7%, and 10% of daily production rate. CONCLUSION: TSH increased after start of CAPD and thyroid dysfunction including subclinical hypothyoidism was observed in significant proportion of CAPD patients. Thyroid hormones were eliminated by peritoneal dialysis. It can be suggested that CAPD affects thyroid function. Clinical significance of the above observation needs further well-controlled study.

Effect of Dialysis and Residual Renal Function on Olfactory Function in Patients with Chronic Renal Failure / 대한신장학회잡지

PURPOSE: The object of the present study were to clarify the effect of dialysis treatment and residual renal function on olfactory function of patients with chronic renal failure and to assess the correlations between the Cross Cultural Smell Identification Test (CC-SIT) scores and various clinical variables. METHODS: Ninety subjects were studied and divided four groups; age- and sex-matched healthy controls (Control, n=20), patients with varying degree of renal insufficiency but not on dialysis (Pre- dialysis, n=20), patients on CAPD (PD, n=22), and patients on hemodialysis (HD, n=28). We performed olfactory function test using the CC-SIT kit and compared the CC-SIT scores of each of the groups. RESULTS: The CC-SIT scores of each of the groups were; Control : 8.6+/-1.5, Pre-dialysis : 7.2+/-2.0, PD : 8.1+/-1.2, HD : 8.5+/-1.4. In Pre-dialysis group, the CC-SIT scores were significantly lower than Control group (p=0.01). But, no significant difference was observed in the CC-SIT scores between HD and PD group and control group (p>0.05). Creatinine clearance was positively correlated with the CC-SIT scores in control and Pre-dialysis group (r=0.58, p= 0.0001). Total Kt/V was positively correlated with the CC-SIT scores only in HD group (r=0.39, p= 0.03). But, no correlation was found between Kt/ Vurea, URR or residual renal function and the CC- SIT scores in HD and PD group (p>0.05). Age was negatively correlated with the CC-SIT scores only in Control group (r=-0.76, p=0.0001). CONCLUSION: Our results indicate that smell disturbance in patients with chronic renal faliure can be recovered by adequate dialysis treatment.

The Effect of Hemodialysis on the Olfactory Function in Chronic Renal Failure Patients / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The sense of smell plays an important role in the quality of life. Loss of smell is common in the elderly and it results from respiratory diseases, certain disease states (Alzheimer disease, chronic renal failure (CRF), multiple sclerosis), medications, and surgical interventions. Many studies have shown a declining odor perception in the CRF patients. The objectives of the present study were to test odor identification ability in patients with CRF and the effect of hemodialysis on olfactory recognition, and to examine the possible correlations between smell identification test score and various clinical parameters. MATERIALS AND METHOD: We performed a case-control study comparing the Cross- Cultural Smell Identification Test (CC-SIT) scores of CRF patients with hemodialysis, and those without hemodialysis, and age-sex matched healthy controls. RESULTS: Healthy controls had significantly high CC-SIT scores compared to those of CRF patients without hemodialysis. No significant differences were observed in the CC-SIT scores between CRF patients with hemodialysis and healthy controls and in CRF patients before and after the hemodialysis session. No significant positive correlation was found between CC-SIT score and creatinine clearance in the dialysis group. CONCLUSION: Acute removal of uremic toxins by hemodialysis does not correct olfactory disturbances. Odor perception is severly impaired in patients with CRF and is related to the degree of renal impairment.

The prevalence and associated risk factors of renal artery stenosis in patients undergoing cardiac catheterization

Renal artery stenosis may be a cause of hypertension and a potential contributor to progressive renal insufficiency. However, the prevalence of renal artery disease in a general population is poorly defined. The purposes of this study were to evaluate the prevalence of angiographically-determined renal artery narrowing in a patient population undergoing routine cardiac catheterization, and to identify the risk factors for renal artery stenosis. After left ventriculography, abdominal aortography was performed to screen for the presence of renal artery stenosis. A total of 427 patients (274 males, 153 females) were studied and the mean age was 59 years. Renal artery narrowing was identified in 10.5% of patients. Significant (> or = 50% diameter narrowing) renal artery stenosis was found in 24 patients (5.6%) and insignificant stenosis was found in 21 patients (4.9%). Significant unilateral stenosis was present in 4.2% of patients and bilateral stenosis was present in 1.4%. The stem of the renal artery was a more common site of stenosis in 62.2% of patients than in the ostium (37.8%), but the severity of stenosis was not significantly different according to the site of stenosis. By univariate and multivariate logistic regression analysis, the association of clinical variables with renal artery stenosis was assessed. Multivariable predictors included age, hypertension and peripheral vascular disease (p < 0.05). The variables such as sex, smoking history, hyperlipidemia, renal insufficiency, as well as the presence of obesity, severity of coronary heart disease and D.M., were not associated. In conclusion, the prevalence of angiographically-determined renal artery narrowing in a patient population undergoing cardiac catheterization is 10.5%. Old age, hypertension and evidence of peripheral vascular disease represent the predictors of renal artery stenosis.

Phase IV Study on the Antihypertensive Effect and Safety of Irbesartan in Patients with Mild to Moderate Hypertension and Renal Disease / 대한신장학회잡지

Irbesartan is a new selective angiotensin II subtype 1 receptor antagonist. We evaluated the efficacy and tolerability of irbesartan in patients with mild to moderate hypertension and renal disease. On 24 hypertensive patients, oral irbesartan 150mg a day was administered. In cases whose seated diastolic blood pressure did not decrease to 85mmHg after treatment for 4 weeks, the dose of irbesartan was increased to 300mg per day. Every 4 weeks, blood pressure, heart rates, and adverse effects were monitored. And we assessed WBC counts, hemoglobin, hematocrits, platelets, creatinine, BUN, total protein, albumin, fasting blood sugar, total cholesterol, AST, ALT, alkaline phosphatase, total bilirubin, sodium, potassium, calcium, uric acid and urine protein/creatinine ratio to evaluate the change of renal and hepatic function and other adverse effects. Seated systolic blood pressure was decreased from 157.1+/-3.1mmHg to 135.5+/-3.7mmHg, and seated diastolic blood pressure was also decreased from 99.2+/-1.7mmHg to 84.3+/-2.5mmHg. Irbesartan was effective in lowering blood pressure in 20 among 24 patients, and the effective rate of this drug was 83.3%. After treatment, a non clinically significant increase of heart rates and statistically significant decrease of total cholesterol level were noted. There was no dose-related adverse effect. We conclude that irbesartan is a safe and effective angiotensin II subtype 1 receptor antagonist for lowering blood pressure in patients with mild to moderate hypertension and renal disease.

Study on the Prevalence of Coronary Heart Disease and Albuminuria in Type 2 Diabetic Patients / 대한신장학회잡지

There are opinions that microalbuminuria acts as an independent risk factor for cardiovascular diseases, related to other risk factors such as endothelial cell dysfunction, hypertension, insulin resistance, obesity, hyperlipidemia and platelet aggregation dysfunction in diabetic and non-diabetic patients. We examined the prevalence of microalbuminuria and macroalbuminuria and the relationship of microalbuminuria and macroalbuminuria to coronary heart disease in type 2 diabetic patients. Out of 798 type 2 diabetic patients who were hospitalized at Yonsei medical center from Oct. 1997 to Feb. 1999, we studied 181 patients who had normal renal function and were examined 24 hour urine albumin excretion. According to the amount of urine albumin excretion, 181 patients were categorized into three groups; normoalbuminuria(less than 30mg/24hour), microalbuminuria(30-300mg/24hour) and macroalbuminuria (more than 300mg/24hour). Patients were tested using treadmill test, stress thallium scan, echocardiography, and coronary angiography for the evaluation of coronary heart disease. The freguency of normoalbuminuria, microalbuminuria, and macroalbuminuria in our patients were 50.3%(91/181), 30.9%(56/181), and 18.3%(34/181), respectively. In each group, the prevalence of hypertension were 42.5%, 78.5%, and 82.3%, respectively and the prevalence of cardiovascular disease were 24.7%, 50.0%, and 46.0%, respectively. Microalbuminuria and macroalbuminuria groups showed statistically significant differences in the prevalence of hypertension and coronary heart disease compared with normoalbuminuria group(p<0.05). In addition, the prevalence of diabetic retinopathy were 37.3%, 58.9%, and 55.8%, respectively and microalbuminuria and macroalbuminuria groups showed statistically significant differences in the prevalence of diabetic retinopathy compared with normoalbuminuria group(p<0.05). We conclude that microalbuminuria and macroalbuminuria is a strong predictor of coronary heart disease in patients with type 2 diabetes.

The Efficacy and Safety of Cyclosporin A(Cipol-N(R) soft capsule) in Adult Nephrotic Syndyrome: 16 Weeks, Open Label, Multicenter Study(Phase III Clinical Trial / 대한신장학회잡지

A multicenter prospective study was done in four-university hospital to evaluate the efficacy and safety of cyclosporin A(CyA, Cipol-N(R)) in 64 patients with adult nephrotic syndrome mean age 34.8 years, male:female 2.4:1, duration of disease 38.0+/-40.9months, 31 patients with MCD, 33 patients with Non-MCD (8 FSGS, 14 MGN, 7 MPGN, 2 lupus nephritis, 1 HBsAg associated GN)]. The prior steroid responses of these patients were 17 steroid dependent, 9 frequent relapser, 4 steroid resistant and 1 other in MCD patients, and 5 steroid dependent, 5 frequent relapser, 22 steroid resistant and 1 other in Non-MCD patients. After a 2-week steroid (predni-solon 10mg/day or deflazacort 12mg/day) run-in period, CyA 5mg/kg/day and prednisolone 10mg/day (or deflazacort 12mg/day) were administered for up to 16 weeks. Of the 64 patients enrolled, ll patients were dropped out prematurely due to adverse events or protocol violation. Of the 53 patients who completed the study, 27 had MCD and 26 had Non- MCD. High response (CR and PR) rate of 68% (36/53) were obtained with CyA treatment in all patients. Although the response rate in MCD was significantly higher than that in Non-MCD (89 vs. 46%, p<0.05) and response rates were significantly different according to the previous steroid responses by univariate analysis, only previous steroid responses affected the response to CyA significantly by Logistic multiple regression analysis (p=0.03, RR 7.08); responses were 84% (27/32) in steroid dependent and frequent relapser patients, and 37% (7/19) in steroid resistant patients. 24-hr proteinuria significantly decreased after 2 weeks and serum albumin and cholesteroi increased significantly after 4 weeks of treatment compared to baseline level. The serum creatinine level was not changed during the study. No serious and unexpected side event was observed. In conclusion, cyclosporine therapy is a safe and effective mode of treatment in patients with ne-phrotic syndrome, especially in those who need prolonged administration of steroids with resulting in unavoidable steroid complications such as frequent relapser and steroid dependent type. The patients with steroid resistant type and contraidications of steroid administration such as DM, aseptic bone neerosis etc. can also be candidates for this treatment.

Comparison between Oral Pulse and Daily Calcitriol (Calcio(R)) Therapy in Continuous Ambrlatory Peritoneal Dialysis (CAPD) Patients with Secondary Hyperparathyroidism / 대한신장학회잡지

The most widely used method for treatment of secondary hyperparathyroidism(SH) in CAPD patients has been the administration of calcitriol by oral route. In this study, we compared the efficacy and safety of daily low dose calcitriol therapy with those of intermittent high dose pulse therapy. The study group consisted of 38 patients undergoing CAPD with serum intact PTH level of more than 200pg/ mL. Twenty patients were randomly administered daily low dose calcitriol(0.25 microgram/day for 1 month followed by 0.5 microgram daily dose for the next 3 mon-ths) while 18 patients were given intermittent pulse therapy (0.5 microgram-0.5 microgram-0.75 microgram 3 times a week for 1 month, increased to 1.0 microgram-1.25 microgram-1.25 microgram 3 times a week for the next 3 months). Thirty five patients completed the study : 17 on daily oral calcitriol (M: F=0.7:1, mean age=47.3+/-10.6 years, mean duration of CAPD=48.9+/-41.1 months), and 18 on oral pulse calcitriol (M:F=1.6:1, mean age=41.5+/-12.7 years, mean duration of CAPD=49.2+/-41.6 months). The baseline serum levels of calcium, phosphorus, i-PTH, alkaline phosphatase, and total CO2 were not different between daily and pulse group(9.5+/-0.8 vs 9.3+/-0.9mg/dL, 5.8+/-1.3 vs 5.1+/-1.2mg/dL, 443.1+/-162.5 vs 546+/-385.9pg/mL, 91.8+/-47.7 vs 108.9+/-66.5IU/L, 23.7+/-1.9 vs 25.5+/-2.0mEq/L, p>0.05, respectively). The i-PTH level decreased significantly in daily calcitriol group after 1 month (332.8+/-214.8pg/mL, p0.05). The serum calcium increased similarly in both groups after treatment (daily=10.6+/-0.8 vs pulse=l0.1+/-1.0mg/dL, p>0.05). Hypercalcemia(>11.0mg/dL) was rarely observed in all patients (daily=5, pulse=8 episodes). In conclusion, both daily and pulse calcitriol therapy were similarly effective and safe in control of SH.