Hand Grip and Leg Muscle Strength in Hemodialysis Patients and Its Determinants

Background@#Chronic kidney disease is associated with chronic inflammation and progressive loss of peripheral muscle strength and the ability to exercise, and these changes are highly pronounced in patients receiving hemodialysis (HD). We evaluated hand grip strength (HGS) and leg muscle strength (LMS) in patients receiving HD and attempted to identify factors associated with muscle strength. @*Methods@#We screened HGS (opposite the fistula side) and LMS (both sides) in HD patients at a single center (n = 112) by using digital hand and leg dynamometers (T.K.K. 5401 and 5710e/5715, Takei Scientific Instruments Co. Ltd., Niigata, Japan). @*Results@#The mean age of patients was 62.6 years, and 73.2% of the patients were male.Diabetes was the cause of kidney failure in 50% of the patients, and the median HD vintage was 34 months. A total of 77.7% of patients reported that they participated in regular home-based exercise, and 29.5% of patients regularly participated in hospital-based resistance exercise.HGS and LMS showed good correlation (r = 0.715, P < 0.001). HGS (25.1 vs. 17.0 kg) and LMS (30.1 vs. 20.4 kg) were greater in males (P < 0.001 and P < 0.001, respectively) than in females.Older patients (≥ 60 years) showed less LMS than younger patients in both males and females (P = 0.012 and P = 0.037, respectively), but HGS did not differ according to age. Patients performing regular home- or hospital-based exercise showed higher HGS than those who did not exercise (24.2 vs. 18.6 kg, P = 0.011), but LMS was not significantly different (29.3 vs. 23.6 kg, P = 0.185). Multiple linear regression analysis proved that male sex, younger age, and any type of exercise were factors associated with improved HGS and LMS. Groups of older age (≥ 60 years), male sex, and shorter duration of HD (< median) benefitted more from exercise. @*Conclusion@#Sex, age, and exercise were the most important determinants of muscle strength in HD patients. We need to encourage patients to engage in regular home or group exercise from the beginning of dialysis and introduce new feasible forms of exercise for HD patients.

Hand Grip and Leg Muscle Strength in Hemodialysis Patients and Its Determinants

Background@#Chronic kidney disease is associated with chronic inflammation and progressive loss of peripheral muscle strength and the ability to exercise, and these changes are highly pronounced in patients receiving hemodialysis (HD). We evaluated hand grip strength (HGS) and leg muscle strength (LMS) in patients receiving HD and attempted to identify factors associated with muscle strength. @*Methods@#We screened HGS (opposite the fistula side) and LMS (both sides) in HD patients at a single center (n = 112) by using digital hand and leg dynamometers (T.K.K. 5401 and 5710e/5715, Takei Scientific Instruments Co. Ltd., Niigata, Japan). @*Results@#The mean age of patients was 62.6 years, and 73.2% of the patients were male.Diabetes was the cause of kidney failure in 50% of the patients, and the median HD vintage was 34 months. A total of 77.7% of patients reported that they participated in regular home-based exercise, and 29.5% of patients regularly participated in hospital-based resistance exercise.HGS and LMS showed good correlation (r = 0.715, P < 0.001). HGS (25.1 vs. 17.0 kg) and LMS (30.1 vs. 20.4 kg) were greater in males (P < 0.001 and P < 0.001, respectively) than in females.Older patients (≥ 60 years) showed less LMS than younger patients in both males and females (P = 0.012 and P = 0.037, respectively), but HGS did not differ according to age. Patients performing regular home- or hospital-based exercise showed higher HGS than those who did not exercise (24.2 vs. 18.6 kg, P = 0.011), but LMS was not significantly different (29.3 vs. 23.6 kg, P = 0.185). Multiple linear regression analysis proved that male sex, younger age, and any type of exercise were factors associated with improved HGS and LMS. Groups of older age (≥ 60 years), male sex, and shorter duration of HD (< median) benefitted more from exercise. @*Conclusion@#Sex, age, and exercise were the most important determinants of muscle strength in HD patients. We need to encourage patients to engage in regular home or group exercise from the beginning of dialysis and introduce new feasible forms of exercise for HD patients.

Clinical Characteristics of COVID-19: Clinical Dynamics of Mild Severe Acute Respiratory Syndrome Coronavirus 2 Infection Detected by Early Active Surveillance

Background@#There is limited information describing the presenting characteristics and dynamic clinical changes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection diagnosed in the early phase of illness. This study is a case series of patients with coronavirus disease 2019 (COVID-19) admitted to 11 hospitals in Korea. @*Methods@#Patients with confirmed SARS-CoV-2 infection by positive polymerase chain reaction (PCR) testing of respiratory specimens by active surveillance that were finally discharged between February 20 and April 30, 2020 were included. Patients were classified into mild and non-mild groups on initial admission according to oxygen demand and Sequential Organ Failure Assessment score, and the mild group was followed up and subgrouped into non-aggravation and aggravation groups. @*Results@#A total of 161 patients with SARS-CoV2 infection were enrolled. Among the mild group of 136 patients, 11.7% of patients experienced clinical aggravation during hospitalization, but there was no initial clinical parameter on admission predicting their aggravation. Fever (odds ratio [OR], 4.56), thrombocytopenia (OR, 12.87), fever (OR, 27.22) and lactate dehydrogenase (LDH) > 300 U/L (OR, 18.35), and CRP > 1 mg/dL (OR, 11.31) significantly indicated aggravation in the 1st, 2nd, 3rd, and 4th 5-day periods, respectively.PCR positivity lasted for a median of 22 days and 32 days after the onset of illness in the nonaggravation and aggravation groups, respectively. @*Conclusion@#Old age was associated with early severe presentation. Clinical aggravation among asymptomatic or mild patients could not be predicted initially but was heralded by fever and several laboratory markers during the clinical course.

Characteristics of Faecal Microbiota in Korean Patients with Clostridioides difficile-associated Diarrhea

BACKGROUND@#The intestinal microbiota plays an important role in the pathogenesis of Clostridioides difficile-associated diarrhea, and regional and racial characteristics influence the microbiome composition and diversity. We investigated the intestinal microbiome characteristics of patients with C. difficile colitis (CD+) compared to those of patients with colitis not due to C. difficile (CD−), patients with vancomycin-resistant enterococci (VRE) colonization, and healthy controls, in Korea.@*MATERIALS AND METHODS@#We collected stool samples from 24, 18, 11 and 13 subjects within CD+, CD−, VRE and healthy control groups, respectively. The microbial communities were evaluated by 454-pyrosequencing of bacterial 16s rRNA.@*RESULTS@#The species richness and microbial diversity were significantly lower in the CD+ group compared to those in healthy controls, but not compared to those in CD− and VRE groups. Phylum-level analysis showed that the proportion of Actinobacteria in the CD+ group was significantly lower than in the healthy control, but was unchanged compared to that in CD− and VRE groups. At the genus level, compared to the healthy group, the CD+ group showed significantly lower proportions of Blautia, Bifidobacterium, Faecalibacterium et al. Compared to the VRE group, the CD+ group showed a significantly higher proportion of Anaerostipes.@*CONCLUSIONS@#We could identify the intestinal microbiome characteristics of Koreans with C. difficile colitis. It might help to develop microbiome based diagnostic and treatment modalities.

Long Pentraxin 3 as a Predictive Marker of Mortality in Severe Septic Patients Who Received Successful Early Goal-Directed Therapy

PURPOSE: Pentraxin 3 (PTX3) has been suggested to be a prognostic marker of mortality in severe sepsis. Currently, there are limited data on biomarkers including PTX3 that can be used to predict mortality in severe sepsis patients who have undergone successful initial resuscitation through early goal-directed therapy (EGDT). MATERIALS AND METHODS: A prospective cohort study was conducted among 83 severe sepsis patients with fulfillment of all EGDT components and the achievement of final goal. Plasma PTX3 levels were measured by sandwich ELISA on hospital day (HD) 0, 3, and 7. The data for procalcitonin, C-reactive protein and delta neutrophil index were collected by electric medical record. The primary outcome was 28-day all-cause mortality. RESULTS: 28-day all-cause mortality was 19.3% and the median (interquartile range) APHCH II score of total patients was 16 (13–19). The non-survivors (n=16) had significantly higher PTX3 level at HD 0 [201.4 (56.9–268.6) ng/mL vs. 36.5 (13.7–145.3) ng/mL, p=0.008]. PTX3 had largest AUC(ROC) value for the prediction of mortality among PTX3, procalcitonin, delta neutrophil index, CRP and APACHE II/SOFA sore at HD 0 [0.819, 95% confidence interval (CI) 0.677–0.961, p=0.008]. The most valid cut-off level of PTX3 at HD 0 was 140.28 ng/mL (sensitivity 66.7%, specificity 73.8%). The PTX3 and procalcitonin at HD 0 showed strong correlation (r=0.675, p<0.001). However, PTX3 at HD 0 was the only independent predictive marker in Cox's proportional hazards model (≥140 ng/mL; hazard rate 7.16, 95% CI 2.46–15.85, p=0.001). CONCLUSION: PTX3 at HD 0 could be a powerful predictive biomarker of 28-day all-cause mortality in severe septic patients who have undergone successful EGDT.

A Case of Community-Acquired Pneumonia Caused by Multidrug-Resistant Acinetobacter baumannii in Korea

Acinetobacter baumannii is an aerobic Gram-negative coccobacillus that causes nosocomial pneumonia in patients on mechanical ventilation or previously treated with broad-spectrum antibiotics. Nevertheless, community-acquired pneumonia (CAP) caused by A. baumannii, especially multi-drug resistant (MDR) strains, is rare. We experienced the first case of CAP caused by MDR A. baumannii in Korea in a 78-year-old man. This case shows that MDR A. baumannii can cause CAP in Korea.

Fecal Transplantation using a Nasoenteric Tube during an Initial Episode of Severe Clostridium difficile Infection

The incidence of Clostridium difficile infection is increasing worldwide, and its severity and resulting mortality are also on the rise. Metronidazole and oral vancomycin remain the treatments of choice, but there are concerns about treatment failure and the appearance of resistant strains. Furthermore, antibiotic therapy results in recurrence rates of at least 20%. Fecal transplantation may be a feasible treatment option for recurrent C. difficile infection; moreover, it may be an early treatment option for severe C. difficile infection. We report a case of severe C. difficile infection treated with fecal transplantation using a nasoenteric tube during an initial episode. This is the first reported case of fecal transplantation using a nasoenteric tube during an initial episode of C. difficile infection in Korea.

Risk Factors for Mortality in Patients with Serratia marcescens Bacteremia

PURPOSE: Over the last 30 years, Serratia marcescens (S. marcescens) has emerged as an important pathogen, and a common cause of nosocomial infections. The aim of this study was to identify risk factors associated with mortality in patients with S. marcescens bacteremia. MATERIALS AND METHODS: We performed a retrospective cohort study of 98 patients who had one or more blood cultures positive for S. marcescens between January 2006 and December 2012 in a tertiary care hospital in Seoul, South Korea. Multiple risk factors were compared with association with 28-day all-cause mortality. RESULTS: The 28-day mortality was 22.4% (22/98 episodes). In a univariate analysis, the onset of bacteremia during the intensive care unit stay (p=0.020), serum albumin level (p=0.011), serum C-reactive protein level (p=0.041), presence of indwelling urinary catheter (p=0.023), and Sequential Oran Failure Assessment (SOFA) score at the onset of bacteremia (p<0.001) were significantly different between patients in the fatal and non-fatal groups. In a multivariate analysis, lower serum albumin level and an elevated SOFA score were independently associated with 28-day mortality [adjusted odds ratio (OR) 0.206, 95% confidential interval (CI) 0.044-0.960, p=0.040, and adjusted OR 1.474, 95% CI 1.200-1.810, p<0.001, respectively]. CONCLUSION: Lower serum albumin level and an elevated SOFA score were significantly associated with adverse outcomes in patients with S. marcescens bacteremia.

Multicentric Type 3 Gastric Neuroendocrine Tumors

A 50-year-old woman with incidentally detected multiple gastric polyps and biopsy-proven neuroendocrine tumor (NET) was referred to our hospital. More than 10 polypoid lesions (less than 15 mm) with normal gastric mucosa were detected from the gastric body to the fundus. The serum level of gastrin was within the normal limits. There was no evidence of atrophic changes on endoscopy and serologic marker as pepsinogen I/II ratio. Computed tomography of the abdomen and pelvis revealed no evidence of metastatic lesions. She refused surgery, and we performed endoscopic polypectomy for almost all the gastric polyps that were greater than 5 mm. Although the histological examination revealed that all the removed polys were diagnosed as NET G1, three of them extended to the lateral or vertical resection margins, while two exhibited lymphovascular invasion. A follow-up upper endoscopy that was performed 6 months after the diagnosis showed multiple remnant gastric polyps that were suggestive of remnant gastric NET.

Effects of Dialyzer Reuse on Clearances of Blood Urea Nitrogen and beta2-Microglobulin in the Three Different Membranes / 대한신장학회잡지

BACKGROUND: We performed the study on the changes of beta2-microglobulin(beta2M) clearance and urea reduction ratio after reuse of dialyzers with three different membranes. METHODS: 9 patients who had received regular hemodialysis more than five years were enrolled. Three kinds of dialyzer membrane were used; i.e. : Two of them were high-flux and the other was low-flux. Dialyzer reprocessing was performed by an automated machine using glutaraldehyde and bleach. Each dialyzer was reused 10 times. Solute clearance was determined for each dialyzer after the 1st, 5th, 8th and 10th reuse. RESULTS: Urea clearance was well maintained after reuse with both high-flux and low-flux membrane but beta2M clearance was significantly greater with high-flux dialyzers than low-flux dialyzer. Effects of each dialyzer reuse on beta2M clearance showed no significant decrease until the 10th reuse and no significant difference in beta2M clearance between the two high-flux dialyzers(polyamide vs PEPA membrane, p= 0.197). CONCLUSION: Reuse of dialyzers was cost-effective. After reuse of dialyzer, clearance of solute was maintained in both small and large solutes until the 10 th reuse. Further study is needed regarding the maintenance of solute clearance with increased number of reuses.

A case of microscopic polyangiitis combined with pulmonary silicosis / 대한내과학회지

Microscopic polyangiitis (MPA) is a distinct type of systemic small vessel vasculitis affecting small sized vessels with few or no immune deposit and no granulomatous inflammation. Cause or pathogenetic mechanism of MPA has been unknown but association with silicon or silica exposure or pulmonary silicosis has been reported rarely and supports hypothesis that environmental factors are important modulating or triggering factors of the vasculitis in the indivisual who may be genetically predisposed. We report a case of microscopic polyangiitis with underlying pulmonary silicosis in 43 year-old male. He was admitted due to hemoptysis, dyspnea, fever and bilateral pulmonary infiltration with underlying small nodular densities in whole lung field and egg-shell calcification of both hilar areas. Laboratory findings showed hematuria, proteinuria and rapid deterioration of renal function. Renal biopsy revealed focal segmental necrotizing glomerulonephritis with early cellular crescents accompanied with membranous glomerulonephropathy and perinuclear-antineutrophil cytoplasmic antibody was positive. Under the diagnosis of MPA, he has been managed with high dose steroid, cyclophosphamide and hemodialysis. Chest infiltration decreased and hemoptysis and hypoxia was improved but renal function was not recoverd and he needed regular hemodialysis continuously.

A case of pan-dysautonomia associated with systemic lupus erythematosus / 대한내과학회지

Autonomic neuropathy can occur as a neurologic manifestation in patients with systemic lupus erythematosus (SLE). Its precise prevalence and pathogenesis were not fully evaluated. Recent studies reported that about half of patients with SLE had autonomic neuropathy. Autonomic neuropathies include cardiovascular, gastrointestinal, genitourinary, sudomotor, lacrimal, and pupillary dysfunction. Autonomic nerve dysfunction significantly affects clinical course of the disease, and especially cardiovascular autonomic dysfunction may cause arrhythmias increasing the risk of sudden death. Pan-dysautonomia has been rarely reported as a neurologic complication of SLE. We experienced a patient with SLE presenting pan-dysautonomic manifestations. A 23-year-old man was admitted due to dizziness and syncopal attack. He complained various autonomic symptoms, such as orthostatic syncope, dysphagia, severe constipation, indigestion, and anhidrosis. Autonomic nerve function tests and the clinical manifestations revealed that he had pan-autonomic dysfunction. During hospitalization, respiratory and cardiac arrest developed soon after syncopal attack. He recovered after prompt cardiopulmonary resuscitation. But his autonomic dysfunctions improved slightly after 7 months of therapy. Early detection and aggressive treatment are needed to prevent potentially fatal dysautonomic attack in patient with SLE.

Effect of Erythropoietin on Dialyzer Reuse, Dialysis Efficacy and Other Clinical Parameters / 대한신장학회잡지

The use of erythropoietin for correction of anemia in maintenance hemodialysis patients affects dialyzer reuse, dialysis efficacy and other clinical parameters. This study showed the change of Kt/Vurea, nPCR, pre-dialysis BUN, body weight, ultrafiltration volume, pre-dialysis blood pressure, heparin dosage, the number of dialyzer reuse caused by the administration of erythropoietin in reuse(n=11) and first use(n=9) patients who were started erythropoietin since January, 1995. 1) In 20 all patients, hematocrit increased significantly after EPO treatment 20.7+/-0.8%, 27.8+/-0.7%, ultrafiltration volume increased from 2.0+/-0.3L to 2.5+/-0.2L(P1.0/kg/ day) and then pretreatment versus posttreatment nPCR, pre-dialysis BUN and ultrafiltration volume were compared. In low baseline protein intake group, significant increases of ultrafiltration volume, nPCR were observed. However, pre-dialysis BUN were not changed significantly. In high protein intake group, nPCR, pre-dialysis BUN, ultrafiltration volume were changed without significance. In conclusion, EPO treatment did not affect Kt/Vurea, dialyzer reuse, nPCR, predialysis blood pressure, heparin dosage. But ultrafiltration volume increased significantly after EPO treatment. Maybe increased appetite in low baseline protein intake group caused the increased posttreatment ultrafiltration volume.

Differential Diagnosis between Dilated Cardiomyopathy and Ischemic Heart Failure with Post-Exercise Echocardiography

BACKGROUND: Ischemic cardiomyopathy and dilated cardiomyopathy may be clinically indistinguishable and cardiac catheterization is often required to differentiate between them. And many nonivasive methods including myocardial Thallium scan have showed nonspecific results in differentiating between them. METHODS: We studied the change of echocardiographic ejection fraction after exercise in 8 patients with ischemic heart failure and 9 patients with dilated cardiomyopathy and have assessed the usefulness of this noninvasive technique in distinguishing between the two groups. RESULTS: All patients with ischemic cardiomyopathy displayed the significant decrease of ejection fraction at 5 minutes after exercise(p28.75+/-7.89%-->34.38+/-8.50%). Respectively, all patients with dilated cardiomyopathy showed the significant increment of ejection fraction at 5 minutes(p46.33+/-11.93%-->35.00+/-5.68%). CONCLUSION: Our results suggest that echocardiographic ejection fraction at post-exercise 5 minutes, will be the adjunctive method to differentiate between ischemic cardiomyopathy and dilated cardiomyopathy.

A Study on the Urinary Metabolites and Sister Chromatid Exchanges of Peripheral Lymphocytes in Workers Exposed to the Organic Solvents / 대한산업의학회지

In order to know the possibility of utilizing the sister chromatid exchanges as an index which could evaliiate the effect of organic solvents on Lhe health in industrial workers, the authors Studied the effects of the inductivity of sister chromatid exchanges in peripheral lymphocyces from 90 female workers espoxed to organic solvents .and 20 lion-exposed female workers. The results obtained were as follows: 1. The frequency of sister chromatid exchanges in peripheral iympnocytes from 90 female workers exposed to organic solvents was significantly increased in comparison with 20 coatiol subiect. 2. The frequency of sister chromatid exchanges was significantly Increased in the workers who were employed in the manufacture of plastic materials than the other manufactures. 3. There were no significant differences in the frequency of sister chrornatid exchanges by carriera of the exposed workers. 4. The correlation between the frequency of sister chromatid exchanges and urinary hippuric acid was significant with the coefficient of 0.5902 showing Y=1.867X+15.188 in which Y indicate the frequency of sister chromatid exchanges per cell and X indicate the urinary hippuric acid concentration by g/l.