Blood Volume Change and Side Effects during Various Sodium Ramping in Hemodialysis / 대한신장학회잡지

Chronic hemodialysis patients frequently experience hemodialysis(HD)-related side effects caused by excessive ultrafiltration and abrupt change of osmolality. Sodium ramping in HD is known to reduce ultrafiltration-related side effects, but it frequently induces symptoms related to sodium overload. We wanted to know the relationship between blood volume changes and the side effects related to ultrafiltration during hemodialysis and whether we can individualize various sodium ramping methods according to the effect of change in blood volume( BV) and side effects of sodium ramping. We studied 9 hypotension-prone patients during HD. The duration of the study lasted for 5 weeks, each week using different sodium ramping protocols: protocol 1; dialysate [Na+] of 140mEq/L, protocol 2; dialysate [Na+] same as the predialysis serum [Na+], protocol 3; dialysate [Na+] was 20mEq/L greater than that of the patient's serum for 1hr, 10mEq/L greater than patient's serum [Na+] for 2hr and then the same as patient's serum [Na+] for the last 1hr, protocol 4; at the beginning of dialysis, dialysate sodium was ramped to 20mEq/L above the patient's serum sodium and then on a straight linear fashion lowered to the predialysis serum [Na+] at the end of dialysis, protocol 5; sodium was constantly ramped to 10 mEq/L above serum [Na+]. We measured the BV with Crit-Line IIR(In-Line Diagnostics, Corp., Riverdale, USA), the blood pressure during each HD and interdialytic weight gain. We documented subjective symptoms which occurred during the 5 treatment protocols by patient's questionnaire after each HD. The results were as follows. 1) The mean age of the patients(M:F=3:6) was 54.1years and 6 patients were diabetics. 2) There was no significant difference in the BV among the 5 protocols in both whole study population and individual. Neither was there a statistically significant difference in the BV with respect to hypotension during HD. 3) There were no episodes of hypotension(P value <0.001) with protocols 3, 4, 5 compared to protocols 1 and 2. 4) Three patients during protocols 4 and 5 experienced more thirst after HD than during protocol 1 and one patient during protocol 4, 5 had more interdialytic weight gain than the protocol 1. As a whole, patients while on protocol 4 & 5 experienced more thirst than protocol 1 but patients during protocol 3 experienced the same degree of thirst as protocol 1. In summary, sodium ramping reduced HD-related side effects but this benefit could not be explained on the basis of blood volume change measured by the Crit-Line IIR. Protocol 3 may be more appropiate sodium ramping method in 4 of the 9 patients. These data suggest that protocol 3 may be used before protocol 4, 5 when we apply sodium ramping to the patients who frequently have hypotension during HD.

Cystoscopy in the Evaluation of Hematuria / 대한신장학회잡지

Hematuria is a common presentation of bladder cancer. As medical examinations for health screening are becoming more popular, increasing number of patients are found to have hematuria. When to refer these patients to urologists for cystoscopy is a common problem to nephrologists and a matter of debate as well. In fact, many authors differ in their opinions on this issue, especially in cases of microscopic hematuria. Given the fact that the incidence of bladder cancer varies between countries, it will be reasonable that the investigation strategy for Koreans should be determined according to the studies on Korean people. In the present study, we retrospectively analyzed 349 patients who underwent cystoscopic examinations in our institution to investigate causes of microscopic or gross hematuria. Bladder cancer was detected on cystoscopy in 35(15.9%) of 220 patients with gross hematuria, in contrast to patients with microscopic hematuria in whom 2(1.6%) of 129 patients were found to have bladder cancer. Eighty nine percents of cancer patients were male. Bladder cancer was detected even in relatively young patients with gross hematuria, while no bladder cancer was found in patients with microscopic hematuria below 60 years of age. Urine cytology was revealing in 59.5% of cancer patients. Bladder cancer was detected in 71.4% and 76.2% of cancer cases by sonography and IVP, respectively. Urine protein by dipstick was unreliable in predicting the presence of cancer. In conclusion, decision on cystoscopy in patients with asymptomatic microscopic hematuria younger than 50-60 years of age should be made conservatively, while more aggressive diagnostic work up is necessary in patients with gross hematuria regardless of their age.

The Effect of ACE Inhibitors on the Gene Expression of Various Cytokines in Peripheral Blood Mononuclear Cells from Patients with Glomerular Diseases: TGF-beta, IL-6, IL-10 and TNF-alpha / 대한신장학회잡지

Angiotensin II(ANG II) has been known to induce systemic and glomerular hypertension, which leads to renal tissue injury and progressive fibrosis of kidney. Some effects of ANG II may be mediated by its effect on the cytokine synthesis. In the present study, we investigated the effect of ANG II inhibition on the expression of various cytokines implicated in the pathogenesis and progression of the kidney disease. Blood samples of 11 patients with glomerulonephritis were obtained before the ACE inhibitor therapy and then while they were taking ACE inhibitors. Using peripheral blood mononuclear cells(PBMC) harvested from the samples, RT-PCR was performed to evaluate the changes in mRNA expression of TGF-beta1, IL-6, TNF-alpha and IL-10. The ratios of target cytokines and beta-actin were calculated. TGF-beta1 mRNA expression was decreased in five pat ients after ANG II inhibition with ACE inhibitors, while it was increased in the remaining six patients. ACE inhibitors consistently decreased IL-6 mRNA expression in all 11 patients. IL-10 expression was decreased in 4 patients, and increased in 3 patients after ANG II inhibition. It was not expressed in 4 patients. TNF-alpha expression was increased in 8 patients, and decreased in only 1 patient. In two patients, it was not changed while on ACE inhibitors. Conclusion: ACE inhibitors attenuate IL-6 expression consistently in all 11 patients. This is the first-time demonstration of the in vivo inhibitory effect of ACE inhibitors on IL-6 mRNA expression in humans. The lack of significant suppression of TGF-beta1 in PBMC suggests that the in vivo attenuating effect of ACE inhibitors on TGF-beta1 may be derived from renal hemodynamic changes. The tendency of heightened expression of TNF-alpha confirms the previous investigations in which IL-6 was shown to down regulate TNF-alpha expression