Glycemic Control and Adverse Clinical Outcomes in Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus: Results from KNOW-CKD

Background@#The optimal level of glycosylated hemoglobin (HbA1c) to prevent adverse clinical outcomes is unknown in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM). @*Methods@#We analyzed 707 patients with CKD G1-G5 without kidney replacement therapy and T2DM from the KoreaN Cohort Study for Outcome in Patients With Chronic Kidney Disease (KNOW-CKD), a nationwide prospective cohort study. The main predictor was time-varying HbA1c level at each visit. The primary outcome was a composite of development of major adverse cardiovascular events (MACEs) or all-cause mortality. Secondary outcomes included the individual endpoint of MACEs, all-cause mortality, and CKD progression. CKD progression was defined as a ≥50% decline in the estimated glomerular filtration rate from baseline or the onset of end-stage kidney disease. @*Results@#During a median follow-up of 4.8 years, the primary outcome occurred in 129 (18.2%) patients. In time-varying Cox model, the adjusted hazard ratios (aHRs) for the primary outcome were 1.59 (95% confidence interval [CI], 1.01 to 2.49) and 1.99 (95% CI, 1.24 to 3.19) for HbA1c levels of 7.0%–7.9% and ≥8.0%, respectively, compared with <7.0%. Additional analysis of baseline HbA1c levels yielded a similar graded association. In secondary outcome analyses, the aHRs for the corresponding HbA1c categories were 2.17 (95% CI, 1.20 to 3.95) and 2.26 (95% CI, 1.17 to 4.37) for MACE, and 1.36 (95% CI, 0.68 to 2.72) and 2.08 (95% CI, 1.06 to 4.05) for all-cause mortality. However, the risk of CKD progression did not differ between the three groups. @*Conclusion@#This study showed that higher HbA1c levels were associated with an increased risk of MACE and mortality in patients with CKD and T2DM.

Quality of life in patients with diabetic nephropathy: findings from the KNOW-CKD (Korean Cohort Study forOutcomes in Patients with Chronic Kidney Disease) cohort

Diabetic nephropathy (DN) can affect quality of life (QoL) because it requires arduous lifelong management. This study analyzed QoL differences between DN patients and patients with other chronic kidney diseases (CKDs). Methods: The analysis included subjects (n = 1,766) from the KNOW-CKD (Korean Cohort Study for Outcomes in Patients with Chronic Kidney Disease) cohort who completed the Kidney Disease Quality of Life Short Form questionnaire. After implementing propensity score matching (PSM) using factors that affect the QoL of DN patients, QoL differences between DN and non-DN participants were examined. Results: Among all DN patients (n = 390), higher QoL scores were found for taller subjects, and lower scores were found for those who were unemployed or unmarried, received Medical Aid, had lower economic status, had higher platelet counts or alkaline phosphatase levels, or used clopidogrel or insulin. After PSM, the 239 matched DN subjects reported significantly lower patient satisfaction (59.9 vs. 64.5, p = 0.02) and general health (35.3 vs. 39.1, p = 0.04) than the 239 non-DN subjects. Scores decreased in both groups during the 5-year follow-up, and the scores in the work status, sexual function, and role-physical domains were lower among DN patients than non-DN patients, though those differences were not statistically significant. Conclusion: Socioeconomic factors of DN were strong risk factors for impaired QoL, as were high platelet, alkaline phosphatase, and clopidogrel and insulin use. Clinicians should keep in mind that the QoL of DN patients might decrease in some domains compared with non-DN CKDs.

Effect of urinary angiotensinogen and high-salt diet on blood pressure in patients with chronic kidney disease: results from the Korean Cohort Study for Outcome in Patients with Chronic Kidney Disease (KNOW-CKD)

Background/Aims@#This study aimed to investigate whether urinary angiotensinogen (UAGT) excretion was associated with elevated blood pressure in patients with chronic kidney disease (CKD) and to evaluate the relationship among blood pressure, intra-renal renin-angiotensin system (RAS) activity, and dietary sodium in patients with CKD. @*Methods@#Participants from the Korean Cohort Study for Outcome in Patients with Chronic Kidney Disease (KNOW-CKD) were included. Of the total cohort of 2,238 individuals with CKD, we included 1,955 participants who underwent complete 24-hour urinary sodium (24-hour UNa) analysis. They were categorized into three groups according to three tertiles of their 24-hour UNa, reflecting daily salt intake. To measure intra-renal RAS activity, the UAGT excretion was assayed with an enzyme-linked immunosorbent assay. @*Results@#Elevated 24-hour UNa levels, logarithm of UAGT-to-creatinine ratio (UAGT/Cr), increased waist-to-hip ratio, and decreased estimated glomerular filtration rate were the risk factors for increased systolic blood pressure. Systolic blood pressure showed a positive correlation with 24-hour UNa levels and logarithm of UAGT/Cr. @*Conclusions@#UAGT and urinary sodium excretion are independent determinants of systolic blood pressure in patients with CKD. These findings suggest that increased systolic blood pressure in CKD patients is associated with both increased dietary sodium levels and intra-renal RAS activity. The risk of elevated systolic blood pressure in the 3rd tertile of both the UAGT/Cr and 24-hour UNa groups was about 2.3 times higher than that in the reference group.

Effect of urinary angiotensinogen and high-salt diet on blood pressure in patients with chronic kidney disease: results from the Korean Cohort Study for Outcome in Patients with Chronic Kidney Disease (KNOW-CKD)

Background/Aims@#This study aimed to investigate whether urinary angiotensinogen (UAGT) excretion was associated with elevated blood pressure in patients with chronic kidney disease (CKD) and to evaluate the relationship among blood pressure, intra-renal renin-angiotensin system (RAS) activity, and dietary sodium in patients with CKD. @*Methods@#Participants from the Korean Cohort Study for Outcome in Patients with Chronic Kidney Disease (KNOW-CKD) were included. Of the total cohort of 2,238 individuals with CKD, we included 1,955 participants who underwent complete 24-hour urinary sodium (24-hour UNa) analysis. They were categorized into three groups according to three tertiles of their 24-hour UNa, reflecting daily salt intake. To measure intra-renal RAS activity, the UAGT excretion was assayed with an enzyme-linked immunosorbent assay. @*Results@#Elevated 24-hour UNa levels, logarithm of UAGT-to-creatinine ratio (UAGT/Cr), increased waist-to-hip ratio, and decreased estimated glomerular filtration rate were the risk factors for increased systolic blood pressure. Systolic blood pressure showed a positive correlation with 24-hour UNa levels and logarithm of UAGT/Cr. @*Conclusions@#UAGT and urinary sodium excretion are independent determinants of systolic blood pressure in patients with CKD. These findings suggest that increased systolic blood pressure in CKD patients is associated with both increased dietary sodium levels and intra-renal RAS activity. The risk of elevated systolic blood pressure in the 3rd tertile of both the UAGT/Cr and 24-hour UNa groups was about 2.3 times higher than that in the reference group.

Effect of Dialysis on Aryl Hydrocarbon Receptor Transactivating Activity in Patients with Chronic Kidney Disease

Sub-morbid dehydration-associated glomerular hyperfiltration: An emerging reality?

BACKGROUND: Severe dehydration decreases renal perfusion. However, it is unclear whether sub-morbid dehydration affects kidney function similarly. Although there have been numerous animal and human studies that have suggested mild dehydration is associated with glomerular hyperfiltration, it has not been confirmed on a large-scale in the general population. Therefore, we aimed to identify the relationship between hydration status and kidney function. METHODS: We reviewed the data of 28,342 adults who participated in the Korea National Health and Nutrition Examination Surveys. Urine specific gravity unit (SGU) was the primary variable that indicated hydration status, and the estimated glomerular filtration rate (eGFR) was used as the primary outcome. RESULTS: Multivariate linear regression analysis showed urine SGU was positively associated with eGFR, which was J-shaped in the multivariate generalized additive model plot. In the penalized spline curve analysis, the odds ratio for high eGFR was steadily increased. Although increased urine SGU was associated with decreased blood pressure and pulse rate, it had no effect on increased fasting glucose and total cholesterol, suggesting conflicting cardio-metabolic dehydration effects. CONCLUSION: Dehydration, presumably sub-morbid in an ambulatory community-dwelling general population, is associated with higher kidney function. The clinical significance of sub-morbid dehydration-associated glomerular hyperfiltration needs further investigation.

Successful Pregnancy in a Patient with Autosomal Dominant Polycystic Kidney Disease on Long-Term Hemodialysis

Recent advances in dialysis and a multidisciplinary approach to pregnant patients with advanced chronic kidney disease provide a better outcome. A 38-yr-old female with autosomal dominant polycystic kidney disease (ADPKD) became pregnant. She was undergoing hemodialysis (HD) and her kidneys were massively enlarged, posing a risk of intrauterine fetal growth restriction. By means of intensive HD and optimal management of anemia, pregnancy was successfully maintained until vaginal delivery at 34.5 weeks of gestation. We discuss the special considerations involved in managing our patient with regard to the underlying ADPKD and its influence on pregnancy.

First Case of Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis Caused by Cryptococcus arboriformis

No abstract available.

Subcutaneous sarcoidosis presenting as a suprapubic mass, acute kidney injury, and hypercalcemia

No abstract available.

A Rare Case of Primary Hyperparathyroidism Associated with Primary Aldosteronism, Hurthle Cell Thyroid Cancer and Meningioma

Multiple endocrine neoplasia type 1 (MEN1) syndrome includes varying combinations of endocrine and non-endocrine tumors. There are also a considerable number of atypical MEN1 syndrome. In this case, a 68-yr-old woman was referred to the Department of Endocrinology for hypercalcemia. Five years ago, she had diagnosed as primary hyperaldosteronism and now newly diagnosed as parathyroid hyperplasia with laboratory and pathologic findings. Hurthle-cell thyroid cancer was also resected during the parathyroid exploration and small meningioma was found on brain MRI. Her general condition has markedly improved and her adrenal mass and meningioma are being closely observed now. We could find the loss of heterozygosity of the MEN1 locus in parathyroid glands, suggesting a MEN1-related tumor, but not a germline mutation. Considering a variety of phenotypic expression and a limitation of current molecular analysis, periodic follow up will be needed in patients with a MEN1-like phenotype.

A Case of Delftia acidovorans Peritonitis in a Peritoneal Dialysis Patient Managed with Preserving the Dialysis Catheter / 대한신장학회지

Delftia acidovarans is aerobic, nonfermentative Gram-negative rod commonly found in soil and water. Generally it is nonpathogenic but it unusually can cause bacteremia in immunocompromised patients. We present a case of peritonitis due to D. acidovorans in a patient on continuous ambulatory peritoneal dialysis. A 75-year-old woman was admitted with abdominal pain and cloudy peritoneal effluent. She was empirically treated with intraperitoneal (IP) cefazolin and ceftazidime, and then IP ceftazidime and oral ciprofloxacin, but peritonitis did not improve. Seven days after admission, D. acidovorans was identified from the peritoneal effluent, which was sensitive to amikacin, ceftazidime, ciprofloxacin and imipenem. Catheter removal was considered with regard to poor response to adequate antibiotics; however, 4 days after changing to IP imipenem/cilastatin, abdominal pain, the leukocyte count of peritoneal effluent and C-reactive protein decreased. She was treated with imipenem/cilastatin for two weeks and discharged with the dialysis catheter intact.

Bleeding Complications Associated With the Use of Low Molecular Weight Heparin According to the Degree of Renal Impairment / 대한신장학회지

PURPOSE: Low molecular weight heparin (LMWH) is safe and effective in the treatment of acute coronary syndrome (ACS) and venous thromboembolism. Compared with unfractionated heparin (UFH), it is known to have less bleeding tendency in the general population. However, it is not certain whether bleeding complications are decreased by LMWH in patients with renal failure. We postulated that the use of LMWH may lead to increase in bleeding tendency in patients with renal dysfunction. METHODS: We conducted a retrospective study in 486 hospitalized patients who were diagnosed as cerebral infarction or ACS, and treated with enoxaparin or nadroparin from January 2008 to December 2009. Bleeding complications were compared in 3 groups according to estimated glomerular filtration rate (GFR> or =60, 30-59, and <30 mL/min/1.73m2). Age, hypertension (HTN), diabetes mellitus (DM), smoking and usage of antithrombotics were examined and the relationship of these variables with bleeding tendency was analyzed. RESULTS: Compared with group I, the frequency of total bleeding complications increased in patients with group II (p=0.002) and III (p=0.005) regardless of adequate dose reduction. Multiple logistic regression analysis after adjustment for age, HTN, DM, and usage of antithrombotics revealed that decreased GFR groups [odds ratio (OR) of group II was 5.79 (95% confidence interval (CI), 1.23-29.97; p=0.042), OR of group III 5.92 (95% CI, 1.22-27.61; p=0.029)] and DM [OR of DM 7.88 (95% CI; 1.46-46.32, p=0.026)] were two independent factors which affect major bleeding. CONCLUSION: These findings suggest that renal insufficiency, even if it is mild, could affect major bleeding complications in the use of LMWH.

Central Venous Stenosis Caused by Traction of the Innominate Vein due to a Tuberculosis-Destroyed Lung

We report a case of central venous stenosis due to a structural deformity caused by a tuberculosis-destroyed lung in a 65-year-old woman. The patient presented with left facial edema. She had a history of pulmonary tuberculosis, and the chest X-ray revealed a collapsed left lung. Angiography showed leftward deviation of the innominate vein leading to kinking and stenosis of the internal jugular vein. Stent insertion improved her facial edema.

Waldenstrom Macroglobulinemia with CD5+ Expression Presented as Cryoglobulinemic Glomerulonephropathy: A Case Report

Waldenstrom macroglobulinemia (WM) is a B-cell lymphoproliferative disorder associated with bone marrow involvement of lymphoplasmacytic lymphoma (LPL) and an IgM monoclonal gammopathy. Generally B-lymphocytes in LPL do not express CD5 that is important for differential diagnosis of B-cell lymphoproliferative disorders. In WM, various renal diseases and type I cryoglobulinemia are well described separately, but cryoglobulinemic glomerulonephropathy is very rarely reported. A 61-yr-old woman complained of generalized edema, cyanosis of the extremities in cold weather, visual disturbance, and pancytopenia. Bone marrow and renal biopsy showed CD5+ expressing B-cells and cryoglobulinemic glomerulonephropathy. With the diagnosis of WM, she received cyclophosphamide, doxorubicin, vincristine and prednisolone chemotherapy and got complete remission. Here, we report a rare case of WM associated with unusual expression of CD5+ B-lymphocytes and cryoglobulinemic glomerulonephropathy, and emphasize the importance of the clinical features in differentiating CD5+ B-cell lymphoproliferative disorders.

A Case of Continuous Ambulatory Peritoneal Dialysis Related Peritonitis Caused by Ochrobactrum anthropi / 대한신장학회지

Ochrobactrum anthropi is a ubiquitous gram-negative bacillus and currently thought to be an opportunistic pathogen. We experienced a 66-year-old male patient with continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis caused by O. anthropi. Susceptible antibiotic therapy including amikacin and ciprofloxacin improved the patient's clinical status. However, peritoneal effluent showed sustained leukocytosis, thus CAPD catheter was removed. After 2 weeks of temporary hemodialysis, CAPD was successfully restarted with reinsertion of catheter. This is, to our knowledge, the first case of CAPD-related peritonitis caused by O. anthropi in Korea.

An Infrarenal Aortic Hypoplasia Presented with Claudication

We describe a case of infrarenal aortic hypoplasia in a 52-yr-old woman who presented with claudication. Computed tomographic angiography revealed an abrupt absence of the infrarenal aorta, with collateral flow reconstituting the iliofemoral systems. After a polytetrafluoroethylene graft was interposed between the aortic stump and the iliac bifurcation, the patient's claudication resolved.

Rapid Extension of Renal Angiomyolipoma to Perinephric Space: A Case Report / 대한신장학회지

Angiomyolipoma is a benign neoplasm composed of fat, smooth muscles and blood vessels. We report a case of a 64-year-old man with a renal angiomyolipoma which rapidly extended to perinephric space. He had been diagnosed of having a small renal angiomyolipoma, and seven years later, a large perinephric mass was newly detected. Right nephrectomy with mass excision revealed an exophytic mass in the lower pole of right kidney which extended to perinephric space. A histological examination showed large angiomyolipomatosis. Clinicians who follow the renal angiomyolipoma should be aware of the unusual perinephric progression.

Diagnostic value of cystatin C for predicting acute kidney injury in patients with liver cirrhosis / 대한간학회지

BACKGROUND/AIMS: The present study aimed to determine the role of cystatin C as a prognostic factor for acute kidney injury and survival in cirrhotic patients. METHODS: The study investigated 53 liver cirrhosis patients. The renal function was evaluated by serum creatinine, serum and urine cystatin C, and 24-hour creatinine clearance on admission. Acute kidney injury was defined as a serum creatinine level exceeding the normal range (>1.2 mg/dl) and an increase of at least 50% from the baseline value. Multivariate analysis, receiver operating characteristic curve, and survival analysis were used to investigate prognostic factors for acute kidney injury and survival. RESULTS: Nine of the 53 cirrhotic patients (17.0%) developed acute kidney injury within 3 months. Both serum creatinine and cystatin C were predictive factors for acute kidney injury in univariate analysis, with a diagnostic accuracy of 0.735 (95% confidence interval (CI), 0.525-0.945; p=0.028) for serum cystatin C and 0.698 (95% CI, 0.495-0.901, p=0.063) for creatinine. In multivariate analysis, only serum cystatin C was an independent risk factor for acute kidney injury. The sensitivity and specificity of a serum cystatin C level of >1.23 mg/L to acute kidney injury were 66% and 86%, respectively. Serum cystatin C was positively correlated with the Model for End-Stage Liver Disease (MELD) and MELD-Na scores (r=0.346 and p=0.011, and r=0.427 and p=0.001, respectively). Comparison of the survival rates over the observation period revealed that a serum cystatin C level of >1.23 mg/L was a useful marker for short-term mortality (p1.23 mg/L than for the serum creatinine concentration in patients with cirrhosis.

Vancomycin Dosing in Critically Ill Patients Receiving Continuous Renal Replacement Therapy / 대한신장학회지

No abstract available.

A case of spontaneous bladder rupture after a bout of heavy drinking / 대한내과학회지

Spontaneous urinary bladder rupture is uncommon, but is associated with significant morbidity and mortality because of delayed diagnosis. A 65-year-old man was admitted to the emergency room because of low abdominal pain and abdominal distention of sudden onset. The previous night, he had consumed a bottle of alcohol and fallen asleep. Diagnosed as peritonitis of unknown origin, he was prescribed antibiotics empirically. However, the ascites progressed and oliguric acute renal failure developed. On the fifth day, we measured the creatinine level in the ascitic fluid and performed retrograde cystography. He was diagnosed as idiopathic spontaneous bladder rupture and underwent a primary repair successfully. When a patient presents with acute abdominal pain, ascites, and oliguric acute renal failure without definite causes, physicians should consider idiopathic spontaneous bladder rupture, measure the creatinine level in the ascitic fluid immediately, and perform retrograde cystography to obtain an early diagnosis.