Laparoscopic internal fixation is a viable alternative option for continuous ambulatory peritoneal dialysis catheter insertion / 대한외과학회지

PURPOSE: One of the major drawbacks of peritoneal dialysis (PD) is catheter migration and dysfunction. Preventing catheter migration is one of the main concerns. We compared laparoscopic internal fixation method with open surgical method for catheter migration rates. METHODS: From January 2008 to August 2009, PD catheters were inserted by laparoscopic fixation (LF) method in 22 patients and by open surgery (OS) in 32 patients. Clinical data were reviewed retrospectively. The frequency of migration, peritonitis, and other complications were compared. Catheter and patient survival rates were also compared. RESULTS: The mean age and sex ratio were not different between groups. Mean follow-up duration was 29.1 months in LF group and 26.1 months in OS group. More patients in LF group (27.3%) had history of laparotomy than in OS group (3.1%) (P = 0.01). The mean operation time was significantly longer in LF group (101.6 +/- 30.4 minutes) than in OS group (72.4 +/- 26.03 minutes) (P = 0.00). The cumulative incidence of catheter migration was 65.6% in OS group and 13.6% in LF group (P = 0.00). Migration-free catheter survival was higher in LF group (P = 0.001). There were no differences in complication rates between groups. Overall catheter survival was similar (P = 0.93). Patient survival rate at 2 years was not different (P = 0.13). CONCLUSION: Laparoscopic internal fixation of continuous ambulatory peritoneal dialysis catheter significantly reduces migration rates without any addition of complications. Also, laparoscopic technique did not incur patient morbidity or mortality despite the requirement for general endotracheal anesthesia and longer operation time. Therefore, internal fixation can be afforded safely in patients with previous abdominal surgery as either a salvage or preventive measure in patients with repeated catheter migration.

The Usefulness of Urinary Angiotensinogen as a Biomarker of Renal Progression in Autosomal Dominant Polycystic Kidney Disease / 대한신장학회지

PURPOSE: The renin-angiotensin-aldosterone system activation has been suggested as a potential risk factor for renal progression in autosomal dominant polycystic kidney disease (ADPKD). This study was performed to evaluate urinary angiotensinogen as a biomarker of renal progression in ADPKD. METHODS: Patients with estimated glomerular filtration rate (eGFR) > or =30 mL/min/1.73m2 were enrolled in the study. Specimens (blood and urine) and computed tomography (CT) were taken from each subject. The eGFR was calculated by 4-variable MDRD equation and total kidney volume (TKV) was measured from CT images by modified ellipsoid method. Urinary angiotensinogen (AGT) and neutrophil gelatinaseassociated lipocalin (NGAL) were measured by ELISA. The concentration of AGT was adjusted with random urine creatinine (Cr). The association between urinary biomarkers, TKV and eGFR were evaluated. RESULTS: A total of 59 (M:F=31:28) subjects were enrolled in the study and their mean age was 46 years. The eGFR and TKV at the enrollment were 77.3+/-15.6 mL/min/1.73m2 and 1389.8+/-925.1 mL, respectively. Log AGT/Cr was associated with TKV (r2=0.117, p=0.01) in the earlier stage of disease (TKV<3,000 mL). However, it did not show significant correlation with eGFR. Log NGAL was not associated with either TKV or eGFR. Urinary AGT/Cr was closely related to the number of anti-hypertensive medication, TKV, and the presence of albuminuria, although there was no correlation with plasma renin activity or aldosterone level. CONCLUSION: Urinary angiotensinogen may be a useful biomarker of disease progression in ADPKD patients.

Concurrent renal and hepatic angiomyolipoma with pulmonary involvement in two patients with tuberous sclerosis / 대한내과학회지

Tuberous sclerosis (TS) involves multiple organs. Angiomyolipoma of the liver or kidney is one of the clinical manifestations of TS. However, coexistent renal and hepatic angiomyolipoma associated with TS is a rare condition. Pulmonary involvement is extremely rare, and occurs in only 0.1~1% of TS. We report two cases of concurrent renal and hepatic angiomyolipomas with pulmonary involvement in patients with TS. The first case was a 35 year-old woman who showed multiple angiomyolipomas in the liver and both kidneys and cystic parenchymal changes in the lungs. The other case was a 27-year-old woman who showed multiple angiomyolipomas in the liver and both kidneys, and multinodular pulmonary shadows. To the best of our knowledge, this is the first reported case of renal and hepatic angiomyolipomas associated with pulmonary involvement in Korea.

A Case of Peritonitis due to Comamonas testosteroni in a Patient on Continuous Ambulatory Peritoneal Dialysis / 대한신장학회지

Comamonas testosteroni has rarely been implicated as a human pathogen. We here present a case of peritonitis due to this organism in a patient on continuous ambulatory peritoneal dialysis (CAPD). A 32-year-old woman was admitted with abdominal pain and cloudy peritoneal effluent. Empirical intraperitoneal (IP) treatment with cefazolin and ceftazidime was started. The culture was positive for C. testosteroni and antibiotic was changed to ceftazidime IP. Four days after the ceftazidime treatment, the patient became asymptomatic. The follow-up culture from peritoneal effluent at 7th day was negative. This treatment was maintained for 21 days. After that, culture negative peritonitis occurred twice for 2 months in this patient, so CAPD catheter had to be removed. This is the first reported case of CAPD peritonitis caused by C. testosteroni. It is important for clinicians to recognize that CAPD peritonitis is caused by this organism which has been largely overlooked as a potential pathogen.

Kaposi's Sarcoma in a Patient on Hemodialysis / 대한신장학회지

Kaposi's sarcoma (KS) is an unusual multifocal neoplasm of vascular endothelial cell origin. The trunk, arms, head, and neck are the most common sites. It is common in men and has four distinct variants: classic, Africa-endemic, immunosuppressive drug-associated, and acquired immunodeficiency syndrome-associated KS. KS appears to develop immunosuppressed patients, but is uncommon in patients on dialysis. A 79-year-old man on hemodialysis for 2 months presented with pruritus over the entire body and multiple, discrete, variable-sized, dark blue papulonodules (papuloplaques, maculopapules) on the left arm and shoulder. A biopsy specimen form the left arm showed spindle cells with slit-like spaces and extravasated red blood cells. The specimen was positive for CD 34 antigen, and human herpesvirus 8 was detected. We report a case of KS that occurred in a 79-year-old patient on hemodialysis.

Association of Angiotensin II Type 2 Receptor Gene A1818T Polymorphism with Progression of Immunoglobulin A Nephropathy in Korean Patients

We determined the relationship between the progression of immunoglobulin A nephropathy (IgAN) and the A1818T polymorphism in intron 2 of Angiotensin II type 2 receptor (AT2R) gene, which might play protective roles in the pathogenesis of IgAN. Patients with biopsy-proven IgAN were recruited from the registry of the Progressive REnal disease and Medical Informatics and gEnomics Research (PREMIER) which was sponsored by the Korean Society of Nephrology. A1818T polymorphism of AT2R gene was analyzed with PCR-RFLP method and the association with the progression of IgAN, which was defined as over 50% increase in baseline serum creatinine level, was analyzed with survival analysis. Among the 480 patients followed for more than 10 months, the group without T allele had significantly higher rates of progression of IgAN than the group with T allele (11.4% vs. 3.9%, p=0.024), although there were no significant differences in the baseline variables such as initial serum creatinine level, the degree of proteinuria, and blood pressure. In the Cox's proportional hazard model, the hazard ratio of disease progression in the patients with T allele was 0.221 (95% confidence interval for Exp(B): 0.052-0.940, p=0.041) compared to that of without T allele. In conclusion, A1818T polymorphism of AT2R gene was associated with the progression of IgAN.

A case of Tsukamurella tyrosinosolvens peritonitis associated with continuous ambulatory peritoneal dialysis / 대한내과학회지

A case of Tsukamurella peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD) in a 54-year-old woman is described. Peritonitis is a common complication of peritoneal dialysis in patients with end-stage renal disease. Tsukamurella has been reported to cause rare opportunistic infections in humans, and most cases have been reported in immunocompromised patients or patients with indwelling foreign bodies. This organism is difficult to identify and has been mistaken for Corynebacterium and atypical Mycobacteria. Here, we describe the first case of CAPD-related peritonitis caused by Tsukamurella tyrosinosolvens in Korea. It was treated with CAPD catheter removal.

A case of spontaneous ureteral rupture in a patient on hemodialysis / 대한내과학회지

Spontaneous ureteral rupture is rare, and refers to leakage in the absence of prior ureteral manipulation, external trauma, previous surgery, or any destructive kidney disease. It presents a major diagnostic challenge due to the diversity at presentation. Here, we present a rare case of spontaneous ureteral rupture in a 62-year-old man with a history of fungal pyonephrosis (Candida) on maintenance hemodialysis, causing a large infected urinoma and abscess and a review the literature.

Peritonitis due to Leclercia adecarboxylata in a Patient Receiving Automated Peritoneal Dialysis / 대한신장학회지

Peritonitis in patients undergoing peritoneal dialysis is a major complication and the leading cause of peritoneal dialysis failure. Leclercia adecarboxylata is a motile, gram-negative, facultative anaerobic bacillus of the Enterobacteriaceae family. These bacteria are uncommon pathogen, and rarely isolated from environmental and clinical specimens. Some cases have been reported about peritonitis due to Leclercia adecarboxylata in a patient receiving continuous ambulatory peritoneal dialysis (CAPD). However, there has never been any report about peritonitis in a patient receiving automated peritoneal dialysis (APD). We have isolated Leclercia adecarboxylata from peritoneal fluid in a patient receiving APD, and the patient completely recovered with 14-day treatment of intraperitoneal antibiotics without catheter removal.

Clinical Manifestations of Mycobacterium Tuberculosis Infection after Renal Transplantation / 대한이식학회지

PURPOSE: Transplant patients under immunosuppression are susceptible to mycobacterium tuberculosis infection. We analyzed renal transplant recipients, to evaluate the risk factors, clinical characteristics, and long-term outcomes of post- transplant tuberculosis (TB). METHODS: This study is based on the records of renal allograft recipients from October 1991 to June 2006 in two transplant centers in Korea. The demographic data, clinical manifestations, and long-term outcomes of this cohort of patients were retrospectively analyzed. RESULTS: Total 617 patients were enrolled in this study. Eighteen cases of TB (2.92%) occurred with a mean interval from transplant to diagnosis of TB of 33.1 (range: 1~121) months. Most of post-transplant TB were pulmonary TB (including pleural) (13/18), and extrapulmonary TB occurred in 5/18. There was no difference in the prevalence of diabetes mellitus, hepatitis B or C, and immunosuppressive agents between the patients who had developed post- transplant TB and who had not. However, there was higher incidence of acute rejection in post-transplant TB group (0.9+/-1.1 vs. 0.4+/-0.6, P=0.043), and post-transplant TB group had a tendency toward more past history of TB infection (P=0.096). Thirteen patients were successfully treated, 2 patients have been under treatment and 3 patients died. The patient survival was significantly reduced by post- transplant TB in multivariate analysis (relative risk=3.355, P=0.038). CONCLUSION: Post-transplant TB is a serious problem, which is associated with poor outcomes in renal transplant patients. Therefore, high index of suspicion is warranted to ensure early diagnosis and prompt initiation of treatment.

A Case of Primary Hepatic Angiosarcoma after Renal Transplantation / 대한신장학회지

Malignancy is one of the important complications after renal transplantation, and decreases both patient survival and graft survival. Hepatic angiosarcoma is the most common sarcoma in liver, but a rare malignant tumor which occupies about 2% of all hepatic malignancies. We report a case of primary hepatic angiosarcoma after renal transplantation, the first case of post-transplantation angiosarcoma in Korea. A 27-year old man had received a living related renal transplantation. He was admitted due to clinical manifestations of liver cirrhosis such as ascites, spontaneous bacterial peritonitis, and varix bleeding at 8 months after transplantation. Whole liver was infiltrated with angiosarcoma; therefore, he was managed only by supportive care. Considering the poor prognosis of hepatic angiosarcoma, both careful screening of malignancy before transplantation and periodic surveillance of malignancy after transplantation are essential.

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

No abstract available.

MCP-1 and RANTES Polymorphisms in Korean Diabetic End-Stage Renal Disease

Macrophage infiltration has been observed in the renal biopsy specimens of diabetic nephropathy (DN), and hyperglycemic state stimulates the renal expression of RANTES (regulated upon activation, normal T-cell expressed and secreted) and MCP-1 (monocyte chemoattractant protein-1). Upregulation of RANTES and MCP-1 with infiltrating macrophages may play a crucial role in the development and progression of DN. Genetic polymorphisms of RANTES and its receptors were reported to be independent risk factors for DN. We genotyped single nucleotide polymorphism (SNPs) in the MCP-1 G-2518A, CCR2 G46295A, RANTES C-28G and G-403A in 177 diabetic end-stage renal disease (ESRD) patients and 184 patients without renal involvement (controls) in order to investigate the effects of these SNPs on DN in Korean patients with type 2 DM. There were no differences in the frequencies of SNPs and the distribution of haplotypes of RANTES promoter SNPs between two groups. In conclusion, there were no associations of MCP-1, CCR2 and RANTES promoter SNPs with diabetic ESRD in Korean population. Prospective studies with clearly-defined, homogenous cohorts are needed to confirm the effect of these genetic polymorphisms on DN.

Significance of Peritoneal Albumin Excretion in New Peritoneal Dialysis Patients / 대한신장학회지

PURPOSE: High peritoneal transport status is known to be related with the cardiovascular risk. One of the hypotheses that explain the relationship between peritoneal permeability and atherosclerosis is chronic inflammation and endothelial dysfunction. Microalbuminuria is a well-known marker of endothelial dysfunction and a predictor of cardiovascular disease (CVD). We hypothesized that peritoneal albumin excretion, like microalbuminuria, may be related to the cardiovascular events and chronic inflammation in peritoneal dialysis (PD) patients. METHODS: We enrolled eighty-five patients who started PD. Pre-existing CVD was defined as angina, history of MI, cerebrovascular disease, or peripheral arterial disease. Modified peritoneal equilibration test was performed within 2 months. At that time, peritoneal albumin excretion, serum and dialysate IL-6, CRP were measured. RESULTS: The age was 49.5+/-14 years and male-to-female ratio was 1 to 3. Diabetes mellitus and CVD were present in 40% and 28%, respectively. The dialysate-to-plasma albumin (D/Palb) was correlated with D/P4 Cr (r= 0.552, p<0.001), and was higher in HA/H group than in LA/L group (0.19+/-0.008 vs. 0.12+/-0.005, p<0.001). D/Palb was closely correlated with the dialysate IL-6 (r=0.432, p< 0.001), but not with the serum IL-6 and CRP. There were no differences in the peritoneal albumin excretion with respect to the diabetic status or pre-existing CVD. CONCLUSION: The peritoneal albumin excretion was associated with peritoneal small solute transport and dialysate IL-6 in the new PD patients. Prospective studies will follow in order to verify the role of peritoneal albumin excretion as a predictor of cardiovascular events.

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

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

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

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

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

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

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

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

Factors Related to Baseline Peritoneal Solute Transport Rate in Incident Peritoneal Dialysis Patients:Results from Modified Peritoneal Equilibration Test Using 3.86% Glucose Solution / 대한신장학회잡지

BACKGROUND:The present study was designed to determine factors related to baseline peritoneal small solute transport rate (PSTR) from incident Korean peritoneal dialysis (PD) patients using modified peritoneal equilibration test (PET). METHODS:Incident PD patients whose duration of PD is between 4 weeks and 6 months were enrolled from four major university hospitals in Seoul. Modified PET with 3.86% glucose solution and adequacy test were performed. RESULT: 1) Our PET result from incident Korean PD patients showed results similar to that from the Caucacian patients. 2) The patients were divided into four groups based on the PSTR:serum albumin at time of PET, dip dialysate/plasma sodium, dialysate/plasma albumin ratio and peritoneal albumin excretion were significantly different among the four transport types (p<0.05). 3) D/PAlb was significantly higher in the high transport group than in the low transport. Serum albumin concentration before the onset of PD was not different among the four groups but was significantly different at the time of PET. 4) There was no difference of D/PCr4 between the diabetic (0.72+/-0.10) and the non-diabetic (0.72+/-0.11) groups. 5) PSTR in incidental PD patients was correlated with D/PAlb and dip D/P(Na). CONCLUSION:Our PET results from incidental Korean PD patients turned out to be showed results similar to those from Caucacian patients. There were no differences in age, BSA, BMI, nutrition index, CRP, residual renal function among four transport types in incidental PD patients. PSTR in incidental PD patients was correlated with D/PAlb and dip D/P(Na).

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

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