Association between Chronic Kidney Disease or Acute Kidney Injury and Clinical Outcomes in COVID-19 Patients

Background@#A population-based study would be useful to identify the association between chronic kidney disease (CKD) or acute kidney injury (AKI) and prognosis of coronavirus disease 2019 (COVID-19) patients. @*Methods@#This retrospective study utilized the claim data from Korea. Patients who underwent COVID-19 testing and were confirmed to be positive were included and divided into the following three groups based on the presence of CKD or requirement of maintenance dialysis: Non-CKD (participants without CKD), non-dialysis CKD (ND-CKD), and dialysisdependent CKD (DD-CKD) patients. We collected data on the development of severe clinical outcomes and death during follow-up. Severe clinical outcomes were defined as the use of inotropics, conventional oxygen therapy, high-flow nasal cannula, mechanical ventilation, or extracorporeal membrane oxygenation and the development of AKI, cardiac arrest, myocardial infarction, or acute heart failure after the diagnosis of COVID-19. AKI was defined as the initiation of renal replacement therapy after the diagnosis of COVID-19 in patients not requiring maintenance dialysis. Death was evaluated according to survival at the end of follow-up. @*Results@#Altogether, 7,341 patients were included. The median duration of data collection was 19 (interquartile range, 11–28) days. On multivariate analyses, odds ratio (OR) for severe clinical outcomes in the ND-CKD group was 0.88 (95% confidence interval [CI], 0.64–1.20;P = 0.422) compared to the Non-CKD group. The DD-CKD group had ORs of 7.32 (95% CI, 2.14–33.90; P = 0.004) and 8.32 (95% CI, 2.37–39.21;P = 0.002) compared to the Non-CKD and ND-CKD groups, respectively. Hazard ratio (HR) for death in the ND-CKD group was 0.79 (95% CI, 0.49–1.26; P = 0.318) compared to the Non-CKD group. The DD-CKD group had HRs of 2.96 (95% CI, 1.09–8.06; P = 0.033) and 3.77 (95% CI, 1.29–11.06; P = 0.016) compared to the Non-CKD and ND-CKD groups, respectively. DD-CKD alone was associated with severe clinical outcomes and higher mortality. There was no significant difference in frequency of severe clinical outcomes or mortality rates between the Non-CKD and ND-CKD groups. In patients not requiring maintenance dialysis, AKI was associated with old age, male sex, and high Charlson's comorbidity index score but not with the presence of CKD. HRs for patients with AKI were 11.26 (95% CI, 7.26–17.45; P < 0.001) compared to those for patients without AKI in the multivariate analysis. AKI was associated with severe clinical outcomes and patient survival, rather than underlying CKD. @*Conclusion@#CKD requiring dialysis is associated with severe clinical outcomes and mortality in patients with COVID-19; however, the development of AKI is more strongly associated with severe clinical outcomes and mortality.

Association between Chronic Kidney Disease or Acute Kidney Injury and Clinical Outcomes in COVID-19 Patients

Background@#A population-based study would be useful to identify the association between chronic kidney disease (CKD) or acute kidney injury (AKI) and prognosis of coronavirus disease 2019 (COVID-19) patients. @*Methods@#This retrospective study utilized the claim data from Korea. Patients who underwent COVID-19 testing and were confirmed to be positive were included and divided into the following three groups based on the presence of CKD or requirement of maintenance dialysis: Non-CKD (participants without CKD), non-dialysis CKD (ND-CKD), and dialysisdependent CKD (DD-CKD) patients. We collected data on the development of severe clinical outcomes and death during follow-up. Severe clinical outcomes were defined as the use of inotropics, conventional oxygen therapy, high-flow nasal cannula, mechanical ventilation, or extracorporeal membrane oxygenation and the development of AKI, cardiac arrest, myocardial infarction, or acute heart failure after the diagnosis of COVID-19. AKI was defined as the initiation of renal replacement therapy after the diagnosis of COVID-19 in patients not requiring maintenance dialysis. Death was evaluated according to survival at the end of follow-up. @*Results@#Altogether, 7,341 patients were included. The median duration of data collection was 19 (interquartile range, 11–28) days. On multivariate analyses, odds ratio (OR) for severe clinical outcomes in the ND-CKD group was 0.88 (95% confidence interval [CI], 0.64–1.20;P = 0.422) compared to the Non-CKD group. The DD-CKD group had ORs of 7.32 (95% CI, 2.14–33.90; P = 0.004) and 8.32 (95% CI, 2.37–39.21;P = 0.002) compared to the Non-CKD and ND-CKD groups, respectively. Hazard ratio (HR) for death in the ND-CKD group was 0.79 (95% CI, 0.49–1.26; P = 0.318) compared to the Non-CKD group. The DD-CKD group had HRs of 2.96 (95% CI, 1.09–8.06; P = 0.033) and 3.77 (95% CI, 1.29–11.06; P = 0.016) compared to the Non-CKD and ND-CKD groups, respectively. DD-CKD alone was associated with severe clinical outcomes and higher mortality. There was no significant difference in frequency of severe clinical outcomes or mortality rates between the Non-CKD and ND-CKD groups. In patients not requiring maintenance dialysis, AKI was associated with old age, male sex, and high Charlson's comorbidity index score but not with the presence of CKD. HRs for patients with AKI were 11.26 (95% CI, 7.26–17.45; P < 0.001) compared to those for patients without AKI in the multivariate analysis. AKI was associated with severe clinical outcomes and patient survival, rather than underlying CKD. @*Conclusion@#CKD requiring dialysis is associated with severe clinical outcomes and mortality in patients with COVID-19; however, the development of AKI is more strongly associated with severe clinical outcomes and mortality.

Effects of tranilast on the epithelial-to-mesenchymal transition in peritoneal mesothelial cells

BACKGROUND: We investigated the effects of tranilast on epithelial-to-mesenchymal transition (EMT) in an animal model and on the EMT signaling pathway in human peritoneal mesothelial cells (HPMCs).METHODS: We performed in vitro studies (cytotoxicity, cell morphology, and western blot analyses) on HPMCs from human omenta, along with in vivo studies (peritoneal membrane function and morphometric and immunohistochemical analyses) on Sprague Dawley rats. Thirty-two rats were divided into three groups: control (C) group (peritoneal dialysis [PD] catheter but not infused with dialysate), PD group (4.25% glucose-containing dialysate), and PD + tranilast group (4.25% glucose-containing dialysate along with tranilast).RESULTS: In in vitro experiments, transforming growth factor-beta 1 (TGF-β1) increased α-smooth muscle actin and Snail expression and reduced E-cadherin expression in HPMCs. TGF-β1 also reduced cell contact, induced a fibroblastoid morphology, and increased phosphorylation of Akt, Smad2, and Smad3 in HPMCs. Tranilast significantly inhibited TGF-β1-induced EMT and attenuated these morphological changes in HPMCs. In in vivo studies, after 6 weeks of experimental PD, the peritoneal membrane was significantly thicker in the PD group than in the C group. Tranilast protected against PD-induced glucose mass transfer change and histopathological changes in rats.CONCLUSION: Tranilast prevented EMT both in HPMCs triggered with TGF-β1 and in rats with PD-induced peritoneal fibrosis. Thus, tranilast may be considered a therapeutic intervention that enables long-term PD by regulating TGF-β1 signaling pathways.

The Effect of Mycophenolate Mofetil versus Cyclosporine as Combination Therapy with Low Dose Corticosteroids in High-risk Patients with Idiopathic Membranous Nephropathy: a Multicenter Randomized Trial

BACKGROUND: Appropriate immunosuppressive therapy for patients with idiopathic membranous nephropathy (MN) remains controversial. The effect of mycophenolate mofetil (MMF) versus cyclosporine (CsA) combined with low-dose corticosteroids was evaluated in patients with idiopathic MN in a multi-center randomized trial (www.ClinicalTrials.gov NCT01282073). METHODS: A total of 39 biopsy-proven idiopathic MN patients with severe proteinuria were randomly assigned to receive MMF combined with low-dose corticosteroids (MMF group) versus CsA combined with low-dose corticosteroids (CsA group), respectively, and followed up for 48 weeks. Complete or partial remission rate of proteinuria and estimated glomerular filtration rate (eGFR) at 48 weeks were compared. RESULTS: The level of proteinuria at baseline and at 48 weeks was 8.9 ± 5.9 and 2.1 ± 3.1 g/day, respectively, in the MMF group compared to 8.4 ± 3.5 and 3.2 ± 5.7 g/day, respectively, in the CsA group. In total, 76.1% of the MMF group and 66.7% of the CsA group achieved remission at 48 weeks (95% confidence interval, −0.18 to 0.38). There was no difference in eGFR between the two groups. Anti-phospholipase A2 receptor Ab levels at baseline decreased at 48 weeks in the complete or partial remission group (P = 0.001), but were unchanged in the no-response group. There were no significant differences between the two groups in changes in the Gastrointestinal Symptom Rating Scale and Gastrointestinal Quality of Life Index scores from baseline to 48 weeks. CONCLUSION: In combination with low-dose corticosteroids, the effect of MMF may not be inferior to that of CsA in patients with idiopathic MN, with similar adverse effects including gastrointestinal symptoms. Trial registry at ClinicalTrials.gov (www.ClinicalTrials.gov NCT01282073).

Complete atrioventricular block during tunneled cuffed hemodialysis catheter insertion in a patient with pre-existing left bundle branch block / 영남의대학술지

Arrhythmias are complications of tunneled cuffed hemodialysis catheter insertion. Most complications associated with arrhythmias occur during guide-wire access, where the guide wire can cause traumatic damage to the conduction system of the heart. Conducting system injury in tunneled cuffed hemodialysis catheter insertion often involves the right bundle, causing right bundle branch block (RBBB). Transient RBBB with sinus rhythm is not usually accompanied by abnormal vital signs. However if patients already have left bundle branch block (LBBB), new onset RBBB can cause complete atrioventricular block (AVB), which can lead to fatal complications requiring invasive treatment. We report on a patient with LBBB who developed complete AVB during hemodialysis catheter insertion.

Immunoglobulin E-mediated hypersensitivity reaction after intraperitoneal administration of vancomycin

Intraperitoneal (IP) vancomycin is widely used to treat Gram-positive peritonitis associated with peritoneal dialysis. There have been two cases of red man syndrome (RMS), a vancomycin-specific nonimmunologic reaction, associated with IP vancomycin. However, immune-mediated hypersensitivity reaction to IP vancomycin has not yet been reported. A 49 year old woman on continuous ambulatory peritoneal dialysis developed her first peritonitis episode. The patient was treated with IP vancomycin once/wk for 4 weeks. She experienced mild itching and flushing throughout her body for 1 day after the second treatment. Whenever vancomycin was administered, generalized urticaria and a prickling sensation developed, and the intensity increased gradually; however, these symptoms improved after vancomycin was discontinued. An allergic skin test was performed 6 weeks after the previous urticarial episode, and an intradermal skin test revealed a positive response to vancomycin. To our knowledge, this is the first case report of immunoglobulin E-mediated hypersensitivity reaction to IP vancomycin administration.

Whole blood versus serum ionized calcium concentrations in dialysis patients

BACKGROUND/AIMS: The aim of this study is to measure the difference of ionized calcium between heparinized whole blood and serum. METHODS: We recruited 107 maintenance hemodialysis (HD) patients from our hospital HD unit. The clinical and laboratory data included ionized calcium in serum and in whole blood (reference, 4.07 to 5.17 mg/dL). RESULTS: The level of ionized calcium in serum was higher than that in whole blood (p < 0.001). Bland-Altman analysis showed that difference for ionized calcium was 0.5027. For the difference, the nonstandardized beta was -0.4389 (p < 0.001) and the intercept was 2.2418 (p < 0.001). There was a significant difference in the distribution of categories of ionized calcium level between two methods (kappa, 0.279; p < 0.001). CONCLUSIONS: This study demonstrates that whole blood ionized calcium is underestimated compared with serum ionized calcium. Positive difference increases as whole blood ionized calcium decreases. Therefore, significant hypocalcemia in whole blood ionized calcium should be verified by serum ionized calcium.

Recovery of Delayed Graft Function after Calcineurin Inhibitor Sparing Regimen in a Renal Transplant Patient with Calcineurin Inhibitor Toxicity: A Case Report / 대한이식학회지

The recipient candidate was a 51-year-old male with end-stage renal disease owing to diabetes mellitus. The initial immunosuppressive regimen included basiliximab for induction and tacrolimus, mycophenolate mofetil, and steroids. Urine output was 413 mL/day on the operative day and 100 mL/day on the postoperative day (POD) 1. There was no definite stenosis of the ureter or vessels. He had anuria on POD 2~4 and he had undergone hemodialysis. His serum creatinine level did not decrease. Therefore, a graft biopsy was performed on POD 4. The pathologic finding was consistent with acute calcineurin inhibitor (CNI) toxicity. There was no evidence of rejection or acute tubular necrosis. Anuria continued on POD 6; therefore, we started sirolimus instead of a CNI based regimen. Graft function was gradually recovered 1 day after reduction of CNI dose and hemodialysis was stopped. The serum creatinine level was normalized on POD 10. He was discharged on POD 21.

Toxoplasmosis after Kidney Transplantation / 대한이식학회지

Toxoplasmosis is an infection caused by Toxoplasma gondii. It can be lethal in immunocompromised hosts, such as a transplant recipients or patients infected with human immunodeficiency virus. In solid organ transplant recipients, toxoplasmosis results mainly from transmission of the parasite with an allograft in cases of serological mismatch. Toxoplasmosis in an immunocompromised host is associated with high mortality. Thus, early diagnosis and treatment is very important. We report on a case of toxoplasmosis in a 51-year-old male patient who had undergone deceased donor kidney transplantation. He suffered from fever of unknown origin. He was finally diagnosed with toxoplasmosis, and treated successfully with trimethoprim-sulphamethoxazole.

Obstructive uropathy after inguinal herniorrhaphy with a mesh in a renal transplant patient

A 67-year-old male renal transplant patient presented with a right inguinal bulging mass, and was diagnosed with a right indirect inguinal hernia. The day following inguinal herniorrhaphy, serum creatinine became elevated. The patient was oliguric and had abdominal pain on the first day after inguinal herniorrhaphy with a mesh. We diagnosed him with acute renal failure and subsequently performed acute hemodialysis. The kidney computed tomography showed hydronephroureter, with distal ureter obstruction. With urgent percutaneous nephrostomy, we were able to relieve the obstructive uropathy with distal ureteral stenosis. Subsequently, hernia repair was performed with removal of the mesh, followed by the antegrade ureteral stent insertion. Renal function was recovered after ureteral stent insertion. This case shows that acute renal failure can occur due to ureteral obstruction, complicated by an inguinal hernia repair, and this can be successfully treated with percutaneous nephrostomy and inguinal hernia repair with mesh removal.

Onodera's Prognostic Nutritional Index as a Risk Factor for Mortality in Peritoneal Dialysis Patients

The aim of this study was to evaluate the clinical relevance and usefulness of the Onodera's prognostic nutritional index (OPNI) as a prognostic and nutritional indicator in peritoneal dialysis (PD) patients. Patients were divided into 3 groups based on the initial OPNI score: group A (n = 186, 45). Group A was associated with a higher grade according to the Davies risk index than the other groups. Serum creatinine and albumin levels, total lymphocyte count, and fat mass increased with an increase in OPNI. According to the edema index, the correlation coefficient for OPNI was -0.284 and for serum albumin was -0.322. Similarly, according to the C-reactive protein (CRP), the correlation coefficient for OPNI was -0.117 and for serum albumin was -0.169. Multivariate analysis adjusted for age, Davies risk index, CRP, and edema index revealed that the hazard ratios for low OPNI, serum albumin, and CRP were 1.672 (P = 0.003), 1.308 (P = 0.130), and 1.349 (P = 0.083), respectively. Our results demonstrate that the OPNI is a simple method that can be used for predicting the nutritional status and clinical outcome in PD patients.

Onodera's Prognostic Nutritional Index as a Risk Factor for Mortality in Peritoneal Dialysis Patients

The aim of this study was to evaluate the clinical relevance and usefulness of the Onodera's prognostic nutritional index (OPNI) as a prognostic and nutritional indicator in peritoneal dialysis (PD) patients. Patients were divided into 3 groups based on the initial OPNI score: group A (n = 186, 45). Group A was associated with a higher grade according to the Davies risk index than the other groups. Serum creatinine and albumin levels, total lymphocyte count, and fat mass increased with an increase in OPNI. According to the edema index, the correlation coefficient for OPNI was -0.284 and for serum albumin was -0.322. Similarly, according to the C-reactive protein (CRP), the correlation coefficient for OPNI was -0.117 and for serum albumin was -0.169. Multivariate analysis adjusted for age, Davies risk index, CRP, and edema index revealed that the hazard ratios for low OPNI, serum albumin, and CRP were 1.672 (P = 0.003), 1.308 (P = 0.130), and 1.349 (P = 0.083), respectively. Our results demonstrate that the OPNI is a simple method that can be used for predicting the nutritional status and clinical outcome in PD patients.

Rhabdomyolysis Induced Acute Kidney Injury in a Patient with Leptospirosis / 영남의대학술지

Leptospirosis is a spirochetal infectious disease caused by Leptospira interrogans, and may vary in degree from an asymptomatic infection to a severe and fatal illness. The kidney is one of the principal target organs of Leptospira. Renal disorders caused by Leptospira infection vary from an abnormality in urinalysis to acute kidney injury (AKI). Incidence of AKI in severe leptospirosis varies from 40% to 60%. AKI reflects the severity of leptospirosis and is generally accompanied by cholestatic jaundice. The pathophysiology of AKI in leptospirosis consists of hypovolemia, direct tubular toxicity, and rhabdomyolysis. Most patients with acute leptospirosis experience severe myalgias, and show laboratory evidence of mild rhabdomyolysis. However, occurrence of severe rhabdomyolysis is rare. We report here on a patient with leoptospirosis, who had severe rhabdomyolysis and acute kidney injury without jaundice.

A Case of Exit-Site Infection and Abscess by Mycobacterium Abscessus in a CAPD Patient / 영남의대학술지

Nontuberculous mycobacterial infections are a rare, but clinically important cause of infections in continuous ambulatory peritoneal dialysis (CAPD) patients. This is typically suspected when a patient does not respond to treatment with the usual antibiotics. We describe here a case of Mycobacterium abscessus exit site infection with abdominal wall abscess formation that was associated with CAPD, which required peritoneal catheter removal, surgical debridement of the abscess and long term antibiotic therapy.

The Factors Influencing Peritoneal Membrane Transport Characteristics Within 4 Weeks in CAPD Patients / 대한신장학회잡지

BACKGROUND: To get stability and reproducibility of peritoneal membrane transport characteristics of peritoneal dialysis patients, peritoneal equilibration test (PET) is usually recommended at least 1 month after initiation of peritoneal dialysis. But there has been controversy about the exact mechanism. The aim of this study was to compare peritoneal membrane transport characteristics at 2nd and 4th week after initiation of peritoneal dialysis and analyze associated factors. METHODS: From May 2001 to March 2002, 60 new CAPD patients in our hospital were enrolled (male: 31, mean age: 52.6 years old, DM: 23). PET, body weight, body surface area (BSA), blood hemoglobin, serum albumin, hs-CRP(high sensitivity C reactive protein), 24 hours dialysate volume and 24 hours dialysate albumin amount, weekly Kt/Vurea, weekly CCr, residual renal function (RRF) were checked at 2nd and 4th week. Paired t-test, independent t-test, Pearson correlation and multiple regression analysis (GEE by STATA, version 7.0) were used. RESULTS: We can summarize the RESULTS: D/P4Cr and hemoglobin level were significantly increased with time (0.66+/-0.13 g/dL vs. 0.69+/-0.11 g/dL and 9.38+/-1.12 g/dL vs. 9.82+/-1.09 g/dL, p<0.05, respectively) and body weight was significantly decreased with time (63.1+/-11.7 kg vs. 62.4+/-11.2 kg, p<0.05). Factors influencing D/P4Cr change were 24 hours dialysate volume, serum albumin and 24 hours dialysate albumin amount (Beta coefficients: -0.044/L, -0.062/g/dL and 0.028/g/day, p<0.01, respectively). Factors influencing serum albumin (g/dL) were D/ P4Cr, 24 hours dialysate volume and hemoglobin level (Beta coefficients: -0.129/0.1, -0.117/L and 0.133/g/ dL, p<0.01, respectively). There was positive correlation between delta changes of D/P4Cr and delta changes of hs CRP (r=0.297, p=0.02) CONCLUSION: The change of D/P4Cr within 1 month was reciprocally correlated with the change of serum albumin (negatively) and hs CRP (positively). The change of serum albumin, 24 hours dialysate volume and 24 hours albumin loss via dialysate influenced the change of D/P4Cr within 1 month after initiation of peritoneal dialysis.

Analysis of renal biopsies performed in 208 patients with asymptomatic urinary abnormalities / 대한내과학회지

BACKGROUND: Asymptomatic urinary abnormalities are one of the most frequent abnormalities in clinical nephrology. However, there are few large-scaled studies about the clinical manifestations and the pathologic findings of the disease. The aim of present study was to evaluate the clinicopathologic nature of the patients with asymptomatic urinary abnormality proven by renal biopsy. METHODS: Between January 1998 and July 2002, two hundred and eight patients with asymptomatic urinary abnormality at three hospitals in Daegu were studied for age, sex, initial urinary findings, serum creatinine, daily urine protein and pathologic findings by renal biopsy. RESULTS: Mean age was 28.0 years (range 14-60 years) at diagnosis of 208 patients and sex ratio of male to female was 141:67. One hundred and two patients (49.0%) had hematuria and proteinuria, 94 (45.2%) had pure microscopic hematuria and the remaining 12 (5.8%) had isolated proteinuria. Pure microscopic hematuria was the dominant urinary abnormality in younger patients. In pathologic findings, 120 patients (57.7%) were IgA nephropathy, 35 (16.8%) thin glomerular basement membrane disease, 8 (3.8%) minimal change disease, 6 (2.9%) membranous glomerulonephropathy and 22 (10.6%) showed no histologic abnormality. The most common pathologic diagnosis in all three groups was IgA nephropathy. In pure microscopic hematuria group, 38 patients (40.4%) were IgA nephropathy and 27 patients (28.7%) were thin glomerular basement membrane disease. There were no significant difference in pathologic findings depending on the severity of proteinuria (p>0.05). CONCLUSION: In our study, the most common cause of asymptomatic urinary abnormalities was IgA nephropathy. In patients with pure microscopic hematuria, IgA nephropathy and thin glomerular basement membrane disease were two leading causes.

The Changes of Body Compositions and Associated Factors in CAPD Patients During First One Year / 대한신장학회잡지

PURPOSE: CAPD is an important treatment modality along with hemodialysis and kidney transplantation in end stage renal disease. Malnutrition is very common and associated with increased morbidity and mortality in CAPD patients. The cause of malnutrion in CAPD patients might be multifactorial. This prospective study was carried out to investigate nutritional changes for 1 year after initiation of peritoneal dialysis by measurement body composition, especially lean body mass (LBM) using bioelectrical impedance analysis (BIA) and dual energy X-ray absorptiometry (DEXA) and to evaluate the factors associated with malnutrition in CAPD patients. METHODS: Among new CAPD patients from May, 2001 to Dec, 2002 in our hospital, 25 patients were enrolled. Body weight, LBM, LBM percen t (%LBM), fat mass, fat mass percent (%fat mass), ECF volume and ECF/TBW were compared between 1st month and 12th month after initiation of PD. The biochemical parameters, Urea kinetic modeling, Peritoneal equilibration test, the amounts of glucose absorption through the dialysate, the amounts of protein and albumin loss through the dialysate were measured at the same time point with measurement of the body composition. RESULTS: There were significantly decreased LBM (46.3+/-9.1 kg to 44.7+/-9.0 kg in BIA, 45.7+/-9.3 kg to 42.1+/-7.9 kg in DEXA, p< 0.05, respectively) but significantly increased fat mass (16.3+/-6.2 kg to 20.2+/-7.9 kg in BIA, 15.7+/-6.6 kg to 20.1+/-7.4 kg in DEXA, p<0.01, respectively) during first one year. Mean weekly Kt/V were significantly correlated with the changes of LBM (r=-0.64 in BIA, r=-0.81 in DEXA, p<0.01, respectively). With the multiple regression test, 1st month weekly Kt/V in BIA and DEXA were significant predictors of the changes of LBM for 1 year (beta-coefficients: -0.573 in BIA, -0.773 in DEXA, p<0.01, respectively). CONCLUSION: Adequate dialysis, especially 1st month adequacy, is very important for maintaining good nutritional status for one year after initiation of peritoneal dialysis.

Correlation Between Cyclosporine Trough Levels and 2-Hour Postdose Blood Levels and Target C2 Levels in Patients after 12 Months Post Kidney Transplantation / 대한신장학회잡지

BACKGROUND: Cyclosporine dosing is traditionally based on trough levels(C0 level) rather than area under the concentration-time curve(AUC), although AUC correlates better with post transplantation acute rejection and acute toxicity. It is reported that C2 levels(2-hour postdose blood levels) are single sampling point that best reflects AUC0-4. But there has been no recommended C2 levels for patients after 12 months post kidney transplantation. The purpose of this study was to evaluate the correlation between C0 levels and C2 levels and define recommended target C2 levels in patients after 12 months post kidney transplantation. METHODS: Seventy three patients after 12 months post transplantation were studied. 83 data were obtained from 73 renal transplant patients. Blood C0 levels, blood C2 levels, body weight and serum creatinine level were measured. Blood cyclsporine levels were measured by monoclonal fluorescence polarization immunoassay(mFPIA)(TDX, Abbot). The data of C0 levels were divided into three groups : low group (mean+SD, 197.1 ng/mL). RESULTS: There was a positive correlation between C0 levels and C2 levels, but no correlation between C0 levels and C2 levels when C0 levels were divided into three groups. There was a positive correlation between cyclosporine/body weight and C2 levels in normal C0 group. Recommended C2 levels in normal C0 group is 724.7+/-210.1 ng/mL. CONCLUSION: It is assumed that cyclosporine doses can be individualized by using C2 levels rather than C0 levels in renal transplant patients. However, prospective study may be needed to confirm the improvement of longterm renal allograft survival by individualizing cyclosporine doses based on C2 levels.

Analysis of the Factors Determining the Changes of Serum Albumin in Stable Patients on Peritoneal Dialysis / 대한신장학회잡지

BACKGROUND: Hypoalbuminemia is the most important risk factor for death in dialysis patients. But, it is not well known the factors determining the changes of serum albumin with time. The present study attempts to address the changes of serum albumin with time and the factors determining the changes of serum albumin in stable patients on peritoneal dialysis. METHODS: Fifty-four peritoneal dialysis patients in stable condition were included. Serum albumin, peritoneal equilibration test, weekly urea clearance (Kt/V), weekly creatinine clearance(CCr) and normalized protein catabolic rate(nPCR) were determined two times(mean 5.8+/-2.3 months and 31.3+/-6.5 months after initiation of peritoneal dialysis). RESULTS: Initially lower serum albumin group patients(below 3.7 g/dL) showed significantly increased serum albumin level with time(3.2+/-0.43 g/dL vs 3.57+/-0.52 g/dL, p=0.006) and initially higher serum albumin group patients(above 3.7 g/dL) showed decreased serum albumin level with time(4.07+/-0.32 g/dL vs 3.97+/-0.3 g/dL, p=0.15). Serum albumin changes(delta) were significantly higher in initially lower serum albumin group than higher serum albumin group(0.37+/-0.6 g/dL vs -0.11+/-0.3 g/dL, p < 0.01). There were negative correlations between delta serum albumin and delta D/PCr with time in initially lower and initially higher serum albumin groups(0.37+/-0.56 g/dL vs -0.02+/-0.11, -0.11+/-0.33 g/dL vs 0.05+/-0.12, respectively, r=-0.308, p=0.008). The group which increased serum albumin level with time showed significantly lower initial serum albumin(3.32+/-0.51 g/dL vs 3.98+/-0.46 g/dL, p < 0.001) and significantly decreased D/P(Cr) changes(-0.03+/-0.09 vs 0.06+/-0.10, p= 0.02) than the group which decreased serum albumin level with time. With multiple regression analysis, initial serum albumin level and the change of D/P(Cr) were significant predictors of the change of serum albumin with time. CONCLUSION: Initial serum albumin and the change of D/PCr were identified as the predictors of the change of serum albumin in stable peritoneal dialysis patients.

A Study on the Complications of Renal Transplant Recipients / 대한이식학회지

PURPOSE: The purpose of this study was to analyze the complications in renal transplant recipients and analyze the factors that affect the survival rate of transplant kidney and patients. METHODS: Between March 1985 and April 2000, 380 cases of renal transplantation were performed at Yeungnam University Hospital. The results were analyzed retrospectively. RESULTS: Infectious complications occurred 612 times in 215 cases and non-infectious complications occurred 200 times in 143 cases. The region of infection was in the order of urinary tract infection (461 times) and pulmonary infection (44 times). Non-infectious complications were as follows; hyperglycemia in 44 cases, de novo hypertension in 27 cases out of 35 previously normotensive patients, nephrotoxicity caused by CsA in 15 cases, myelosuppression in 14 cases, avascular necrosis in 10 cases, and malignancy in 9 cases. Surgical complications were as follows; renovascular bleeding in 15 cases, ureteral obstruction in 5 cases, lymphocele in 4 cases, ureteral leak in 3 cases, and intestinal obstruction in 3 cases. Out of total 380 cases of renal transplant, 113 times of acute rejection occurred in 99 cases. CONCLUSION: Infectious complications were most frequent complication. There were significant differences in graft survival for living non-related donor kidney transplantation by immunosuppressive regimen. CsA+PD+MMF group results in highest graft survival in living non-related donor kidney transplantation and was followed by CsA+PD group, CsA+PD+AZA group. But CsA+PD+MMF regimen has been used in recent years and it needs to be studied prospectively.