Membranous Nephropathy Relapsed after 20-year of Complete Remission / 대한내과학회지

Membranous nephropathy is the most common pathologic lesion in adult patients with nephrotic syndrome. The cause is idiopathic, and the pathogenesis is believed to involve the deposition of immune complexes in the subepithelial tissue of the glomerular capillaries. After a period of 5 to 10 years, one-third of patients with membranous nephropathy will develop spontaneous remission, one-third will develop sustained proteinuria, and one-third will experience progression to chronic renal disease. Proteinuria may recur in patients who are in complete remission; this has been reported in approximately 26% of patients during an average of 89 months. To date, however, recurrence of membranous nephropathy has not been reported in patients who have been in complete remission for ≥ 20 years. We report herein such a case. Membranous nephropathy may recur in adult patients who are currently in the remission stage. Ongoing follow-up is therefore required, even after several years of complete remission.

A Patient with IgA Nephropathy: 5 Years after Complete Remission of Minimal Change Nephrotic Syndrome / 이화의대지

A 37-year-old male patient was admitted with generalized edema as the main symptom. A blood test confirmed hypoalbuminemia and hyperlipidemia, and a urine test confirmed severe albuminuria. A renal biopsy was conducted, which revealed a diagnosis of minimal change disease. Although the patient experienced complete remission of minimal change nephrotic syndrome after oral prednisolone and cyclophosphamide treatment, he is readmitted due to bilateral leg edema 5 years later since minimal change nephrotic syndrome was completely cured. The patient is diagnosed with IgA nephropathy. Although the exact mechanisms of IgA nephropathy in this patient remain unclear, this case represents an extremely rare development, and is separate from the remission of minimal change nephrotic syndrome.

Clinical Study of a Newly Diagnosed Case of Gitelman Syndrome in a Patient Monitored for Liddle Syndrome

A 55-year-old man who had been monitored for Liddle syndrome in the nephrology division for 15 years visited again Inje University Sanggye Paik Hospital for a newly developed electrolyte disorder. Because his blood pressure was normal and he showed hypomagnesemia and hypokalemia, a renal clearance test and renal biopsy were conducted for suspected Gitelman syndrome. The patient was diagnosed with Gitelman syndrome, which has been previously reported 12 cases in South Korea. The renal clearance test revealed a disorder of the Na-Cl cotransporter (NCCT) in the distal tubule, while the renal biopsy revealed partial expression of NCCT, typical of Gitelman syndrome. Currently, the patient is being monitored, and is receiving oral administration of calcium and magnesium.

A Case of Acute Tubular Necrosis and Hearing Loss Induced by Intravenous Administration of Ciprofloxacin / 대한내과학회지

Ciprofloxacin is a broad-spectrum antibiotic used to treat a variety of infections. However, acute kidney injury is a rarely reported side effect. Ciprofloxacin-related nephrotoxicity typically manifests as acute tubulointerstitial nephritis. To the best of our knowledge, few cases of acute tubular necrosis as a complication of ciprofloxacin have been reported to date. We herein describe a case involving a 41-year-old woman treated with intravenous ciprofloxacin at 200 mg twice daily for gastroenteritis. One day after initiation of treatment, her serum creatinine level increased from 0.95 to 3.83 mg/dL and she experienced impaired hearing. Five days later, renal biopsy demonstrated acute tubular necrosis. The acute tubular necrosis encountered in this patient resolved; however, short-term hemodialysis was required. This is the first reported case of acute kidney injury associated with ciprofloxacin use in Korea.

A Case of Chronic Renal Failure after Exposure to Oral Sodium Phosphate Bowel Purgatives / 대한내과학회지

Renal failure due to nephrocalcinosis after large-bowel cleansing with sodium phosphate preparations before endoscopic procedures is an easily overlooked diagnosis. While it has been reported that acute renal failure can result from the use of oral sodium phosphate preparations, chronic renal failure has not yet been reported. We report a case of chronic renal failure due to oral sodium phosphate, in which a kidney biopsy was performed.

A Case of Dermatomyositis with Focal Segmental Glomerulosclerosis / 대한내과학회지

A 59-year-old man visited our hospital for facial edema and muscle weakness in both lower extremities. He was diagnosed with dermatomyositis (DM) about 1 year previously, and sudden development of proteinuria was noted. Renal biopsy revealed focal global and segmental glomerulosclerosis with slight mesangial expansion. Glomerulonephritis is rare in DM. According to our review of related literature, membranous nephropathy is the main type of DM, while mesangial proliferative glomerulonephritis is the most common type in polymyositis. The mechanism underlying the association between DM and glomerulonephritis remains to be elucidated. We herein report a case of DM associated with focal segmental glomerulosclerosis, which has not been reported previously.

A Case of Systemic Thrombolysis in the Membranous Glomerulonephritis Presenting as Acute Inferior Vena Cava and Renal Vein Thrombosis / 대한신장학회지

Thromboembolism is one of the common complications in nephrotic syndrome. The incidence of renal vein thrombosis in the setting of nephrotic syndrome varies from 5% to 62%. Membranous glomerulonephritis (MGN) has been rarely manifested as inferior vena cava (IVC) and/or renal vein thrombosis. We report a case of acute IVC and left renal vein thrombosis as initial manifestation of MGN. The renal vein thrombosis was successfully treated with systemic thrombolysis with temporary IVC filter insertion. After 4 months, MGN was diagnosed by renal biopsy.

A Case of Multiple Venous Thrombosis as the First Manifestation of Lupus Nephritis / 대한신장학회지

Kidney involvement in systemic lupus erythematosus (SLE) is common. The incidence of venous thrombosis in SLE ranges from 5-15%, and venous thrombosis in lupus nephritis associated with nephritic syndrome or antiphospholipid antibody syndrome is reported in 30-35%. Lupus nephritis with nephrotic syndrome is not infrequently encountered at the point of diagnosis of SLE, but venous thrombosis as the first manifestation of SLE is rare. Herein we present our clinical experience with a case of multiple venous thrombosis with nephrotic-range proteinuria as the first manifestation of lupus nephritis.

Contrast-induced Nephropathy in Patients Undergoing Percutaneous Coronary Angiography and its Clinical Characteristics / 대한신장학회지

PURPOSE: Contrast media-induced nephropathy (CIN) following coronary angiography is associated with an increased mortality and morbidity. We investigated the incidence of nephrotoxicity, clinical characteristics, laboratory characteristics and risk factors of CIN in patients undergoing coronary angiography. METHODS: We retrospectively evaluated the medical records of 555 patients who had undergone coronary angiography at the Sanggye Paik Hospital, from January 2004 to December 2005. We defined CIN as any increase in the creatinine value of more than 0.5 mg/dL or 50% of baseline value. RESULTS: Among 555 patients, CIN developed in 10 of 48 patients (20.8%) with renal insufficiency (serum creatinine > or =1.4 mg/dL) and in 7 of 507 patients (1.4%) without renal insufficiency (p or =65 years were the significant predictors of CIN. There were no statistical differences in contrast type and volume according to the development of CIN. CONCLUSION: Our data supported the assumption that renal insufficiency, congestive heart failure, hyperuricemia and anemia may be the risk factors of developing CIN.

Strangulated Umbilical Hernia Misdiagnosed as CAPD Peritonitis / 대한신장학회지

Abdominal wall hernias are a common problem in patients treated with continuous peritoneal dialysis. Although most patients with abdominal wall hernia are asymptomatic, some patients may present with abdominal pain or, if the hernia is incarcerated or strangulated, with signs and symptoms of peritonitis. It is often difficult to differentiate abdominal catastrophe such as peritonitis secondary to strangulated hernia from CAPD peritonitis. Because their clinical manifestations are similar, several biochemical markers including amylase and lactic acid have been recently used as an indicator of abdominal catastrophe. We report a case of strangulated umbilical hernia with perforation misdiagnosed as CAPD peritonitis. The patient was operated 36 hours after the first inspection but expired due to overwhelming sepsis, 257 days after the admission to hospital.

Clinical evaluation of hemochromatosis with end-stage renal disease / 대한내과학회지

Hemochromatosis is almost always a consequence of treatment for anemia in long term hemodialysis patients who have undergone frequent blood transfusions and iron therapy. Clinically, iron overload may be a serious problem for some maintenance hemodialysis patients and it may be manifested as organ dysfunctions. So, it is important to diagnose iron overload early and restrict blood transfusions and the administration of iron agents in these patients. We recently experienced one case of suspected primary hemochromatosis in a long term hemodialysis patient, and we evaluated the patient by checking the serum ferritin level and performing liver biopsy. Treatment with desferrioxamine was started with recombinant erythropoietin. We report on this case with a brief review of the literature.

Effect of Cyclophosphamide as the Treatment of Recurrent Membranoproliferative Glomerulonephritis after Renal Transplantation / 대한이식학회지

The treatment of recurrent type 1 membranproliferative glomerulonephritis (MPGN) after renal transplantation is undetermined yet. We report a case with a recurrent type 1 MPGN with ascites after renal transplantation that had a favorable outcome. A woman aged 50 was diagnosed recurrent type 1 MPGN in 2002. Afterwards she took cyclosporine, prednisolone and mycophenolate mofetil. Since August 2003, Her urine output was reduced and she suffered from abdominal distention. Serum creatinine was elevated to 2.5 mg/dL and physical examination and abdominal CT scan showed large amount of ascites. So, we substituted cyclophosphamide for mycophenolate mofetil. She was 55 kg before the substitution of cyclophosphamide but 12 months later, she weighed 44 kg and her creatinine decreased to 1.5 mg/dL. Therefore, it seems a good idea to use cyclophosphamide for the treatment of recurrent glomerulonephritis with ascites after renal transplantation.

A case of minimal change nephropathy with malignant thymoma / 대한내과학회지

It is the first case that nephrotic syndrome with malignant thymoma reported in Korea. A 56-year-old man have had generalized edema, weight gain, dyspnea, oliguria for 10 days. At that time, a full blown nephrotic syndrome developed, with minimal change glomerulopathy, A mediastinum mass was shown by the chest X-ray. Thymectomy and palliative radiotherapy was done. In the treatment of nephrotic syndrome, firstly diuretics and prednisolone were given. but the response was poor, so additionally cyclophosphamide and azathioprine were given. After 1 year passed, the patient died of the respiratory failure with pulmonary fibrosis of complication of radiotherapy, without improvement in nephrotic syndrome.

A clinical consideration about clinical manifestations of the Bromate poisoning / 대한내과학회지

Bromate which is an oxidant exists as a form of potassium bromate (KBrO3) and sodium bromate (NaBrO3) and has been primarily used as a permanent neutralizer in a household. In 1985, that has been reported for clinical course of bromate poisoing. After 1985, many variable clinical manifestation of the bromate poisoning were reported in Korea. In 2003, three patients of the bromate poisoing admited in Sanggye Paik hospital,Inje university school of medicine, Korea. In this work, the bromate poisoning was investigated based on 3 cases experienced previously 8 cases reported in Korea and compared with the case report of foreign country.

The difference of complications and overall survival according to the types of vascular access in hemodialysis / 대한내과학회지

BACKGROUND: The vascular access in hemodialysis is the most important procedure, so has been developed to many methods. In other countries, some centers were reported for vascular access in hemodialysis, but few studies in Korea. This review has researched the difference of complications and overall survival according to the type of vascular asccess in hemodialysis, and compared with other reports. METHODS: A total 157 patients (M:F=88:69) who newly underwent hemodialysis with vascular catheter insertion in Sanggye Paik hospital were enrolled into this study by review of hemodialysis database. We analyzed indication, site and numbers of catheter insertion, reason for removal of catheter, hemodialysis duration with catheter and complications based on the route of vascular access. We performed the survival analysis for the disease, gender and the methods of access according to type of catheter. RESULTS: The mean patient age was 58.3 +/- 10.5 years and 83.4% of patients received the catheter insertion for renal replacement therapy in end stage renal disease (ESRD). The site and duration of catheter insertion for internal jugular vein were 76.9% and 26.3 +/- 7.3 days, for subclavian vein were 8.9% and 38.0 +/- 12.6 days and for femoral vein were 6.1% and 8.7 +/- 3.2 days. The duration of tunneled cuffed catheter was 237.0 +/- 103.2 days. The most common indication of removal was obtaining permanent vascular access route such as arteriovenous fistula or vascular graft anastomosis (70.8%). Complications related to catheter insertion included infection, catheter occlusion and hemorrhage. The infection occurred in 30 of 213 catheter insertion (14.1%). The infection occurred in 84.6% of patients with femoral catheter, 42.1% of subclavian catheter and 6.7% of internal jugular catheter. The most common site of catheter occlusion was subclavian vein in 15.8%, femoral vein in 7.7% and jugular vein in 2.4%. The most common organism was MRSA, cultured 30.0% in tip and blood. And reinsetion for reinfected cases, MRSA was also most common cause of infection growed 42.8% in tip culture. The survival analysis according to access revealed the jugular access was excellent method for complications and overall survival. No significant difference between diabetes and non-diabetes patients in internal jugular catheter (p=0.042). The subclavian catheter significantly higher survival rate of non-diabetes patients (p=0.036). In femoral catheter, diabetes patients showed higher survival rate (p=0.029). In internal jugular and femoral catheter, survival rate between gender was not significantly different (p=0.200). The survival rate of female was significantly higher than male in subclavian catheter (p=0.037). CONCLUSION: This study revealed internal jugular approach is safe and popular access in according to complications and overall survival. No difference of survival rate was demonstrated between diabetics and non-diabetics in internal jugular catheter. In subclavian catheter, the survival rate was higher in non-diabetics than diabetics and female than male. Incidence of complication was associated with duration of indwelling and the type of vacular access.

The cause of death of chronic renal failure patients before renal replacement therapy / 대한내과학회지

BACKGROUND: Long-term survival rate of chronic renal failure patients has been increasing gradually since the development of renal replacement therapy. At present, death cause of patients under the renal replacement therapy is well known, however, there is few clinical research on that of patients before starting the therapy and the referral time to a nephrologist. We have analyzed the death cause of patients before starting the renal replacement therapy and to investigate if the death has associated with the referral time to a nephrologist. METHODS: We investigated chronic renal failure patients who had been admitted Sanggye Paik Hospital from January 1997 to December 2000. Specific target was the deceased among the chronic renal failure patients who had not undergone renal replacement therapy. Our research was done in a retrograde study. We divided the target group into diabetic group and non-diabetic group. RESULTS: Among 29 expired patients, male patients were 17 and female were 12, and their average age was 61+/-12.3 years. As the cause of chronic renal failure, diabetes was 15, hypertension was 8, glomerular disease was 4, and unidentified was 2. Diabetic group were 15(51.7%) and non-diabetic group were 14(48.3%). Average age was 57.3+/-9.5 years in the diabetic group and 58.9+/-10.2 years in the non-diabetic group. The rate of male and female was 9:6 in the diabetic group and 8:6 in the non-diabetic group, so the rate seems similar in both of groups. BUN and creatinine in blood was compared at the hospital admission, the diabetic group had an average BUN of 54.3+/-12.4 mg/dL and average creatinine of 7.1+/- 2.5 mg/dL and the non-diabetic group had an average BUN 98.9+/-10.6 mg/dL and average creatinine of 9.3+/-3.0 mg/dL. Albumin in blood was 3.4+/-0.6g/dL in the diabetic and 3.6+/-0.8g/dL in the non-diabetic. As the death cause, sepsis was 17(58.6%), cardiovascular disease 5(17.5%), intracranial hemorrhage 4(13.8%), and liver disease was 3(10.1%). As the cause of sepsis, pneumonia was 9(52.9%), catheter infection 5(29.4%), peritoneum 2(11.7%) and urinary track infection was 1(6.0%). The initial meeting with a nephrologist prior to dialysis occurred as follow; in the diabetic group, early refer was 4(26.6%) and delay refer was 11(73.4%), and in the non-diabetic early refer was 2(14.2%) and delay refer was 12(85.8%). CONCLUSION: As for chronic renal failure patients before starting the renal replacement therapy, a physician should give an continual attention to the patients and refer them to a nephrologist promptly for the renal replacement therapy. In addition, a nephrologist should not lose the time for dialysis by analyzing the patient's condition thoroughly and starting the renal replacement therapy at the opportune moment, which could be helpful to reduce patients' medical expense and death rate.

A case of nephrotic syndrome in a patient with scleroderma / 대한내과학회지

Scleroderma is a connective tissue disorder characterized by fibrosis of the skin, vessels and internal organs (gastrointestinal tract, lung, heart, and kidney etc.). Renal involvement in scleroderma has a clinical manifestation from subnephrotic proteinuria to renal crisis accompanied by hypertension, and shows a typical histology of intimal proliferation and fibrinoid necrosis of blood vessel without primary glomerular pathology. We experienced a case of nephrotic syndrome in a 31-old-female patient with sclerodema. But the patient has not showed a clinical feuture of hypertension or renal crisis, moreover, renal biopsy of the patient showed global sclerosis and crescent formation in the glomeruli without vessel involvement. We report this case with a brief review of literature.

Comamonas Acidovorans Peritonitis in a CAPD Patient Managed with Preservation of the Catheter / 대한신장학회잡지

To date, only one case of peritonitis with exit site infection in peritoneal dialysis caused by this micro- organism has been reported. In spite of its apparently benign clinical course, which distinguished it from peritonitis caused by Pseudomonas, this peritonitis relapsed and Comamonas could not be eliminated from the peritoneal liquid, probably due to the persistence of the micro-organism in the exit site. Consequently, peritoneal catheter was removed. In this case, a 68-year-old man was admitted with fever, abdominal tenderness and cloudy peritoneal effluent and empirically treated with antibiotics(cefazolin, tobramycin), intraperitoneally(IP) for 7 days. The first culture was positive for Comamonas acidovorans, sensitive to ceftazidime, cefotetan, ceftriaxone, ciprofloxaxin and imipenem and the perotoneal effluent remained cloudy after 7 days. He was treated with ceftazidime IP, oral ciprofloxacin and nystatin for 26 days. 4 days after the antibiotics treatment, the patient was asymptomatic and the cell count of peritoneal effluent was 50 WBC/mm3 with negative culture. 25 days after the treatment, the patient remained asymptomatic and with 5 WBC/mm3 in peritoneal effluent. Consequently, We experienced a case of peritonitis due to Comamonas acidovorans in a patient on CAPD without exit site infection and managed with preservation of the catheter.

A Case Report of Acute Encephalopathy by Aluminum Intoxication with Subdural Hematoma in End Stage Renal Failure / 대한신장학회잡지

Despite of the improved water purification system, the decreased use of aluminum based phosphate binding gels and periodic determination of serum aluminum levels, aluminum accumulation cannot be eliminated. We experienced a case of acute encephalopathy in aluminum intoxication with subdural hematoma presenting myoclonic jerk and mental change in a end stage renal failure. She was treated succesfully with low dose DFO treatment for 3 month.

A Case of Central Diabetes Insipidus in a Patient with Systemic Lupus Erythematosus / 대한류마티스학회지

Central diabetes insipidus is caused by the insufficient secretion of vasopressin and has been reported in great variety of disorder of brain tumor, systemic infiltrative disease such as histiocytosis, amyoidosis and vasculitis, leukemia, and other autoimmune diseases. But there has been reported only 3 cases of systemic lupus erythematosus (SLE) associated with central diabetes insipidus. The exact pathophysiologic process of pituitary gland involvement in SLE has been unknown, although there are some evidence that vascular impairment and autoantibodies to pituitary gland may be contributory factors. Here, we report a case of central diabetes insipidus complicated by neuropsychiatric systemic lupus erythematosus.