Korean clinical practice guidelines for preventing transmission of coronavirus disease 2019 (COVID-19) in hemodialysis facilities

Coronavirus disease 2019 (COVID-19) is a highly contagious viral disease that is caused by the novel virus Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). COVID-19 has become pandemic since December 2019, when the first case developed in Wuhan, China. Patients receiving hemodialysis are more vulnerable to viral transmission because their immune functions are impaired and they receive treatment within a narrow space. Calling on previous experience with Middle East Respiratory Syndrome during the 2015 outbreak, the joint committee of the Korean Society of Nephrology and the Korean Society of Dialysis Therapy quickly formed a COVID-19 task force team to develop a manual before the first index case was diagnosed in the hemodialysis unit. This special article introduces clinical practice guidelines to prevent secondary transmission of COVID-19 within hemodialysis facilities, which were developed to protect patients, healthcare workers, and caregivers from this highly transmissible virus. The areas of infection control covered by these guidelines include standard precautions, performing dialysis therapy for confirmed or suspected cases, performing cohort isolation for contact patients, and disease monitoring and contact surveillance. We hope these guidelines help healthcare workers and hemodialysis patients around the world cope with the COVID-19 pandemic.

High serum C-reactive protein level predicts mortality in patients with stage 3 chronic kidney disease or higher and diabetic foot infections

BACKGROUND: Diabetic patients are predisposed to foot infections because of vascular insufficiency and peripheral neuropathy. Diabetic foot infection is a common cause of mortality and lower extremity amputations (LEAs) in patients with chronic kidney disease (CKD). We evaluated the risk factors for mortality and LEAs in patients with stage 3 CKD or higher with diabetic foot infections. METHODS: We retrospectively evaluated a cohort of 105 CKD patients with diabetic foot infections between July 1998 and December 2011. We reviewed their demographic characteristics and laboratory parameters to evaluate the risk factors for mortality and amputations at 24 weeks after diagnosis of a diabetic foot infection. RESULTS: The mortality of the 105 enrolled CKD patients was 21% at 24 weeks after the diagnosis of a diabetic foot infection. Cox proportional regression analyses revealed that age 60 years or older [odds ratio (OR) 3.03, 95% confidence interval (CI) = 1.02-9.02, P = 0.047] and initial serum C-reactive protein (CRP) level > or = 3 mg/dL (OR 3.97, 95%CI = 1.17-13.43, P = 0.027) were independent risk factors for mortality at 24 weeks.Twenty-four patients (23%) underwent LEAs. On Cox proportional regression analyses, peripheral vascular disease (OR=4.49,95% CI=1.98-10.17, P=0.01) and cerebrovascular accident (OR 2.42, 95%CI=1.09-5.39, P=0.03) were independently associated with LEAs. CONCLUSION: This study showed that age and serum CRP level, were independent risk factors for mortality at 24 weeks in patients with stage 3-5 CKD with diabetic foot infections. Peripheral vascular disease and cerebrovascular accident were significantly associated with LEAs.

Risk factors for mortality in patients with acute kidney injury and hypotension treated with continuous veno-venous hemodiafiltration

BACKGROUND: Continuous veno-venous hemodiafiltration (CVVHDF) is a preferred treatment modality in hemodynamically unstable acute kidney injury (AKI) patients, because it has advantages over intermittent dialysis in terms of hemodynamic stability. However, this patient group still shows a significantly high mortality rate. To aid in the management of these high-risk patients, we evaluated the risk factors for mortality in CVVHDF-treated hypotensive AKI patients. METHODS: We studied 67 patients with AKI and hypotension who were treated with CVVHDF from February 2008 to August 2010. We reviewed patient characteristics and laboratory parameters to evaluate the risk factors for 90-day mortality. RESULTS: Of the 67 enrolled patients (male:female=42:25; mean age=69+/-14 years), 18 (27%) survived until 90 days after the initiation of CVVHDF. There was no significant difference in survival rates according to the etiology of AKI [hypovolemic shock 2/10 (20%), cardiogenic shock 4/20 (20%), septic shock 12/37 (32%)]. Univariate analysis did show significant differences between survivors and non-survivors in the frequency of ventilator use (44% vs. 76%, respectively; P=0.02), APACHE II score (29+/-7 vs. 34+/-7, respectively; P=0.01), SOFA score (11+/-4 vs. 13+/-4, respectively; P=0.03), blood pH (7.3+/-0.1 vs. 7.2+/-0.1, respectively; P=0.03), and rate of urine output <500mL for 12hours (50% vs. 80%, respectively; P=0.03). A multivariate Cox proportional hazards model showed that a urine output <500mL for 12hours was the only significant risk factor for 90-day mortality following CVVHDF treatment (odds ratio=2.1, confidence interval=1.01-4.4, P=0.048). CONCLUSION: A urine output <500mL for 12hours before the initiation of CVVHDF is an independent risk factor for 90-day mortality in hypotensive AKI patients treated with CVVHDF.

A case of chinese herb nephropathy induced by aristolochia fangchi / 대한내과학회지

Chinese herb nephropathy (CHN) is characterized by progressive tubulointerstitial nephritis and development of renal failure in a couple of years after diagnosis. Aristolochic acid (AA) is believed to be associated with the development of CHN. The authors report a case of CHN in which AA in the herb regimen was identified by high-performance liquid chromatography (HPLC). A 32-year-old female presented with nausea, vomiting and generalized weakness. She had been taking Chinese herbs for symptomatic care. Clinical and laboratory examinations revealed Fanconi syndrome, renal failure, and severe anemia. Renal biopsy showed severe tubulointerstitial nephritis with moderate tubular atrophy and interstitial fibrosis. She developed end-stage renal failure 4 months after diagnosis. The herb she had been taking was Aristolochia fangchi. HPLC technique was used to identify AA and to measure its concentration in the herb. From the clinical and laboratory data, the patient was diagnosed with CHN caused by aristolochic acid.

A case of intraductal papillary mucinous tumor of pancreas associated with liver metastasis / 대한내과학회지

Intraductal papillary mucinous tumor has been reported with increasing frequency these days. It can be malignant (adenocarcinoma) or premalignant (adenoma). This tumor, even when malignant, is often resectable and has a favorable prognosis as compared with pancreatic ductal adenocarcinoma. We report a case of intraductal papillary mucinous tumor with liver metastasis in a 63-year-old male patient. He presented with recurrent epigastric pain, which had developed 3 months ago. Abdominal computed tomography showed the diffusely dilated pancreatic duct, 3 cm-sized low-attenuated mass in the body and multiple liver metastasis. During endoscopic retrograde pancreatography, patulous orifice of papilla, mucin secretion and diffusely dilatedpancreatic duct were noted. Cytologic examination during ERCP revealed mucinous material with atypical columnar cells. Metastatic adenocarcinoma was confirmed by sono-guided liver biopsy. Only supportive care has been done and he died at 3 months after the diagnosis.

Prognostic Factors of Diffuse Proliferative Lupus Nephritis / 대한신장학회잡지

Diffuse proliferative lupus nephritis(DPLN) is the most severe form in lupus nephritis. We retrospectively analyzed 90 DPLN patients who were confirmed by kidney biopsy and treated at least for 12 months to compare the effectiveness of treatment modalities and to investigate the prognostic factors of DPLN. The patients were categorized as intravenous cyclophosphamide pulse(CY) group and oral corticosteroid(with or without cytotoxic drug; PO) group. When CY group(69pts) and PO group(21pts) were compared, there was no differences between two groups in sex, age, follow-up months, chronicity index(CI, 4.55 vs 3.76; CY vs PO, respectively), complications of treatment, mortality rate(4.3% vs 0%), remission rate of nephritis(at 3 year; 59.1% vs 75.5%) and renal survival rate(at 5 years; 88.0% vs 91.7%), b ut significant differences in frequency of nephrotic syndrome(66.7% vs 33.3%) and azotemia (30.4% vs 0%), activity index(7.14 vs 4.33) and relapse rate(2.9% vs 42.9%). When remission group (49pts) and nonremission group(41pts) were compared, the CI, initial azotemia, tubular atrophy, glomerular sclerosis, sex and duration of nephritis were prognostic factors for remission in univariate analysis, and CI(OR, 9.89) and sex(OR, 10.99) in multivariate analysis. When remission group(35pts) and nonremission(34pts) group were compared in CY group, the CI, initial azotemia and tubular atrophy were the prognostic factors in univariate analysis, and CI(OR, 7.69) in multivariate analysis. The initial azotemia was the only prognostic factor for renal survival. We concluded that the CI, sex and initial azotemia were the prognostic factors for renal remission and survival, but the treatment modality was not in DPLN. Therefore it is necessary to evaluate the prognostic factors before decision of treatment modality.

Localization of HBsAg and Hepatitis B Virus DNA in Renal Tissues from HBsAg Positive Patients with the Membranoproliferative Glomerulonephritis / 대한신장학회잡지

Hepatitis B virus(HBV) infection has been suggested as the etiologic agent in membranoproliferative glomerulonephritis(MPGN), but the mechanism by which HBV infection leads to MPGN in human has not been established. To localize the HBV antigen and HBV-DNA in the kidney tissue, we examined paraffin sections of kidney biopsies which were positive for HBsAg by immunohistochemical study from 13 HBV carriers with MPGN (HBV-MPGN). Polymerase chain reaction(PCR) and in situ PCR(ISP) were used for the HBV DNA amplification and localization in kidney tissues. Primers used in PCR and ISP were from the S, C, and X HBV-DNA regions. Immunohistochemical study showed HBsAg deposits on the mesangium and glomerular capillaries. Arteriolar deposits were also occasionally observed. PCR for the S, C, and X regions were positive in 11 patients(85%), 11 patients(85%), and 9 patients (69%), respectively. The PCR findings were further confirmed by direct sequencing of PCR products and the amplification of HSP70 gene as a control. ISP showed the amplified HBV-DNA at the glomeruli and renal tubules. For S region, ISP was positive in 7 patients. For C and X regions, ISP was positive in 8 patients, respectively. 5 patients showed the positive signals for both the glomeruli and tubules, while 4 patients were positive at the tubules only. These 4 patients seemed to have the longer disease durations when compared to the other 5 patients (52.8 months vs. 11.8 months), but it was not statistically significant. In conclusion, the detection and the localization of HBV antigen and DNA in renal tissues indicate the presence of the complete virion in the kidney. These results suggest that HBV may infect the kidneys of HBV carriers with MPGN.

Nucleotide Sequence and phylogenetic Analysis of Hantaviruses Isolated from Patients with Hemorrhagic Fever with Renal Syndrome (HFRS) in Korea

Eleven hantavirus isolates were obtained by innoculation of viremic blood, urine, or autopsy tissue specimens from ten HFRS patients, and sera were obtained from five patients with HFRS. The disease was diagnosed by clinical manifestations and indirect immunofluorescent antibody technique. We obtained 6 hantaviruses from gene bank. So, we analyzed 22 hantavirus samples to elucidate the genetic diversity. The hantaviral RNAs were extracted and 365 base-pair complementary DNAs of M segment were obtained by reverse transcriptase polymerase chain reaction (RT-PCR) and 326 base-pair by nested PCR. The nucleotide sequences of amplified cDNA fragments were determined by the direct sequencing method using automatic DNA sequence analyzer. We got full M segment sequences of 28 reported hantaviruses with medline searching, and aligned them with our 22 samples, and the phylogenetic analysis for nucleotide and amino acid sequences were done by the Clustal method. The nucleotide and amino acid sequences of Hantaan virus 17 samples showed high (above 90%) homology with 76-118 strain, but 2 samples showed significant differences with 76-118 strain and with other 17 samples. The 3 Seoul virus samples showed high intraspecies differences in 1 sample, and showed singnificant differences with SR-11 strain. In phyogenetic tree analysis, Puumala virus and Hantavirus pulmonary syndrome viruses showed high homology, but Hantaan and Seoul viruses showed significant genetic diversity among strains. In conclusion, hantaviruses isolated from HFRS patients showed genetic diversity compared with those isolated from rodent hosts.

The Prevalence of Proteinuria and Hematuria at a Tertiary Referral Hospital / 대한신장학회잡지

Urinalysis is one of the basic laboratory tests in patient care and routine examinations. But few studies have been carried out about the prevalence of proteinuria and hematuria in Korea, especially in tertiary referral hospital, and the meanings of them are not clear until now. So we performed a cross- sectional study to find out the prevalence of proteinuria and hematuria at a tertiary referral hospital, Seoul National University Hospital. From Jan. 1. 1995 to Dec. 31. 1995, there were 35,361 adults (17,123 males and 18,238 females) in whom urinalyses were carried out. The age of them ranged from 15 to 96 years and the average was 49 years with the distribution of 2.3% in 15-19 years, 10.6% in 20-29 years, 16.0% in 30-39 years, 19.6% in 40-49 years, 24.3% in 50-59 years, 19.2% in 60-69 years, and 8.0% in 70 years or older. The degree of proteinuria was classified to '-', '+/-', '+', '++', '+++' by dipstick method. In males, 80.0% were '-', 6.3% '+/-, 6.8% '+', 3.7% '++', 3.2% '+++', and 5.0% '+/-', 5.1% '+', 2.8% '++', 2.1% '+++' in females. Proteinuria of degree '+/-' or higher was defined as significant and found in 19.9% of males and 14.9% of females. According to the age groups, 17.0% in 15 to 19 years, 17.3% in 20 to 29 years, 16.3% in 30 to 39 years, 15.2% in 40 to 49 years, 16.8% in 50 to 59 years, 18.6% in 60 to 69 years, 23.6% in 70 years or older had significant proteinuria. Hematuria was classified by the number of erythrocytes per 400X high-power field, to grade 1 (30), 6 (many). In males, 62.9% were grade 1, 23.5% grade 2, 5.3% grade 3, 3.9% grade 4, 1.9% grade 5, 2.6% grade 6, and 47.4% grade 1, 32.6% grade 2, 8.8% grade 3, 5.3% grade 4, 2.4% grade 5, 3.4% grade 6 in females. Hematuria of grade 3 or higher was defined as significant and found in 13.6% of males and 20.0% of females. According to the age groups, 11.1% in 15 to 19 years, 13.7% in 20 to 29 years, 16.8% in 30 to 39 years, 17.4% in 40 to 49 years, 16.7% in 50 to 59 years, 18.0% in 60 to 69 years, 19.9% in 70 years or older had significant hematuria.

Churg-Strauss Syndrome with Acute Renal Failure in a Patient without Asthma / 대한신장학회잡지

Churg-Strauss syndrome(allergic granulomatosis and angiitis) is a distinct entity composed of fever, eosinophilia, systemic vasculitis of multiple organ systems, and pathologically eosinophilic infiltration, granuloma and necrotizing vasculitis. In most cases it develops in patients with asthma, and renal involvement is characteristically mild and acute renal failure is rare in contrast to other systemic vasculitides. We report an unusual case of Churg-Strauss syndrome manifested by acute renal failure as well as fever, rash, eosinophilia, and nonfixed pulmonary infiltrates in a patient without history of asthma but with that of allergic contact dermatitis. Renal biopsy revealed interstitial eosinophil infiltration, glomerular, vascular and perivascular granulomas containing giant cells. Fever, eosinophilia, and acute renal failure improved immediately after prednisolone 1mg/kg/day demonstrating good response to steroid as in previous reports.

Correlation of Liver and Kidney Pathologic Features in Patients Presented with Glomerular Disease and Positive Serum HBsAg / 대한신장학회잡지

No abstract available.

Recombinant Alfa-interferon Therapy in HBGN with HBe Antigenemia / 대한신장학회잡지

Recently the results of alpha-interferon treatement in hepatitis B virus associated glomerulonephritis showed a reduction of proteinuria and a loss of HBeAg in some treated patients. But, alpha- interferon therapy was mainly tried in membranous nephropathy of children. So, we treated 13 adults patients with recombinant alpha-interferon who were diagnosed as HBV associated membranous nephropathy(2) and membranoproliferative GN(11) at Seoul National unversity hospital. All of them had nephrotic range proteinuria and HBe antigenemia for more than 6 months, normal serum creatinine level and had no other systemic disease. Three million units of recombinant alpha-interferon was given six times a week for 16 weeks intramuscularly and the therapeutic effect was analyzed during treatment periods, especially in terms of changes in urine protein excretion and serum HBeAg. And we compared them with 14 control patients who had received conservative therapy only. As a results, at the end of interferon therapy, serum HBeAg disappeared in 4 of 13 treated patients, and serum HBsAg disappeared in 1 of 4. At the end of therapy, proteinuria diminished to non-nephrotuc range in 6 of 13 treated patients and decrement of proteinuria was accompanied with disappearance of serum HBeAg in 3 patients. And proteinuria diminished in 5 of 11 MPGN patients and serum HBeAg disappread in 3 of them. But in 14 controls there were no significant changes in 24 hour urine protein excretion and serum HBeAg. During interferon therapy, mild febrile reaction was developed in 8 patients, anemia in 3 patients, and cytopenia in 7 patients, but most of these adverse effects resolved spontaneously after discontinuation of interferon therapy. During follow up periods over 1 years, proteinuria relapsed to nephrotic range in 3 of 6 patients and serum HBeAg reappreared in 2 of them. In conclusion, the alpha-interferon at the dose induced a clearance of HBeAg and the decrement of the proteinuria in some adult MN and MPGN patients. And these results suggested the possibilities that HBeAg might be involved in the pathogenesis of HBV associated MPGN and alpha-interferon might be effective in some HBV associated MPGN.

Clinical and Pathological Characteristics of Membranoproliferative Glomerulonephritis in Korean Adults / 대한신장학회잡지

We performed a retrospective study to find out the frequency, clinical and pathological characteristics of membranoproliferative glomerulonephritis (MPGN) in Korean adults. Of the total 1,893 adults with biopsy-proven glomerulonephritis over the 13-year period from 1979 to 1991 in Seoul National University Hospital, there were 212 cases of MPGN of whom 22 had primary MPGN and 190 secondary MPGN. Secondary MPGN was composed of 64 cases of hepatitis B virus- associated glomerulonephritis(HBV-GN), 121 cases of lupus nephritis(LN) and 5 cases associated with other conditions. Age at diagnosis(median and range in years) was higher in primary MPGN(31, 16-67) and in HBV-GN (39, 16-60) than in LN(28, 16-44)(P<0.05). Male-to- female ratio was 1.2:1 in primary MPGN, 7.5:1 in HBV-GN and 1:13 in LN. At the time of diagnosis, nephrotic syndrome and azotemia were more frequent in primary MPGN(72%, 50%) and in HBV-GN (50%, 42%) than in LN(25%, 15%)(P<0.05). Decreases of C3 and CH50 were more common in LN(59%, 77%) than in primary MPGN(24%, 41%) or in HBV-GN(12%, 32%)(P<0.05). On light microscopic exams, tubular atrophy was more frequently observed in primary MPGN(96%) than in HBV-GN(57%) or in LN(69%)(P<0.05). Under immunofluorescence microscopy, mesangial deposition of IgM was more common in HBV-GN (50%) and in LN(59%) than in primary MPGN(6%) (P<0.05). The prognosis was better in LN(13 remission, 15 persistence, 1 end stage) than in primary MPGN(1 remission, 8 persistence, 4 deterioration, 6 end stage) or in HBV-GN(18 persistence, 4 deterioration, 2 end stage)(P<0.05). Conclusively, in Korea considering much higher incidence of secondary MPGN than that of primary MPGN contrary to western countries and the difference in prognosis between the primary and secondary forms, one should consider the possibility of secondary MPGN, especially hepatitis B virus- associated glomerulonephritis and lupus nephritis in adult patients diagnosed as MPGN by kidney biopsy in Korea.

Rifampin Induced Rapidly Progressive Glomerulonephritis / 대한신장학회잡지

Most cases of acute renal failure induced by rifampin are due to acute tubulointerstitial nephritis and usually resolve spontaneously after discontinuation of rifampin. But there were a few reports that rifampin could cause crescentic glomerulonephritis. We present a 67 year-old male patient who has suffered from pulmonary tuberculosis and taken antituberculosis drugs including rifampin. The medication was interrupted two times because of anorexia and nausea. Azotemia, lower extremity edema and palpable purpura on both legs developed after administering antituberculosis drugs for two months. We performed the skin and kidney biopsy. The skin biopsy showed necrotizing vasculitis and kidney biopsy showed crescentic IgA nephropathy. He was tentatively diagnosed as rifampin induced rapidly progressive glomerulonephritis and underlying Henoch-Sch nlein purpura. The antituberculosis regimen was switched excluding rifampin and prednisolone was administered orally. His renal function was improved slowly over 4 months.

Membranous nephropathy associated with small cell lung cancer and recurrent multiple arterial thromboses in the lower extremities / 대한신장학회잡지

No abstract available.

Transplant kidney diseases confirmed by biopsy / 대한신장학회잡지

No abstract available.

Evaluation of urine acidification by urine anion gap in chronic metabolic acidosis / 대한내과학회지

No abstract available.