Diagnosis of Osteoporotic Spinal Fractures

STUDY DESIGN: Literature review. OBJECTIVES: To present updated information on the diagnosis of osteoporotic spinal fractures (OSFs). SUMMARY OF LITERATURE REVIEW: Conventional modalities including simple radiographs, bone mineral density (BMD) tests, and bone scans are sufficient for diagnosis of OSFs. However, other clinical and radiographic clues should be considered for prediction of the prognosis and differential diagnosis. MATERIALS AND METHODS: Review of the relevant literature. RESULTS: Clinical clues including morphometric changes in the vertebral body are sufficient for diagnosis of OSFs. BMD testing is helpful for diagnosis of osteoporosis. However, simple radiographs and BMD tests do not present sufficient information on the prognosis of OSFs. The location of the involved segments, morphological characteristics, and other co-morbidities should be taken into consideration in the initial management of OSFs. Moreover, pathologic conditions leading to spinal fractures should be taken into account in some clinical situations. CONCLUSIONS: With increasing reports of complicated OSFs or other pathologic fractures, other diagnostic modalities and clinical factors should be considered in predicting the prognosis of OSFs and differentiating OSFs from other pathologic conditions.

The Use of Tunneled Cuffed Catheter(Permcath(R)) in ESRD Patients / 대한신장학회잡지

BACKGROUND: Mortality and morbidity of ESRD patients depend on a maintenance of vascular access for dialysis. Polyurethane teflon double lumen catheters have been used for a temporary vascular access for hemodialysis. But, their use has a high rate of complications and a limited duration. Recently developed tunneled cuffed catheter(Permcath(R)) have lesser complications and longer durability and it could be an alternative for double lumen polyurethan catheter. This study evaluated the usefulness and complications of a tunneled cuffed catheter as a long-term vascular access at the Korea University Medical Center. METHODS: The study was done retrospectively through medical chart review and telephone interview to investigate age, sex, the absence or presence of diabetes mellitus, catheter performance, indications for a insertion, complications, causes of catheter removal. 101 catheters were inserted in 86 ESRD patients(80 jugular, 21 subclavian) from February, 1995 to August, 1999. The complication rates and it's association with diabetes mellitus and the location of catheter insertion were reviewed. RESULTS: The mean age of patients was 58 years (49 men, 37 women). 35 patients were diabetics. The purpose of catheters insertion were : 1) waiting for the maturation of an arteriovenous fistula(46%), 2) no other available vascular access(31%), 3) after a removal or insertion of peritoneal dialysis catheters (15%), 4) waiting for the better vascular access operation(5%). Catheters were removed because of mechanical obstructions(8%), infections(12%), deaths of patients(16%). 51% of patients had catheter related complications. Local bleeding(70%) was the most common complication. Bacteremia and exit site infection rate were 30% and 14% respectively. The complication rates had no association with age, sex, the absence or presence of diabetes mellitus and the location of catheter insertion. However, a subcalvian catheter was more vulnerable to exit site infection than an internal jugular catheter. CONCLUSIONS: A tunneled cuffed catheter is safer, and more durable than a polyurethane teflon double lumen catheter. It could be used for a short-term vascular access, or for a permanent vascular access in person otherwise with no other alternatives.

Polymorphisms of Angiotensin Converting Enzyme and Plasminogen Activator Inhibitor-1 Genes in Diabetic Nephropathy and Macroangiopathy in NIDDM Patients / 대한신장학회잡지

BACKGROUND: Although development of DM nephropathy in NIDDM patients is associated with poorly controlled blood sugar level and hypertension, relationship of genetic factor is also emphasized. Recent studies showed that an insertion or deletion (I/D) polymorphism in the ACE gene and a 4/5- guanine tract polymorphism in the promotor region of the PAI-1 gene are associated with the myocardial infarction. The aim of this study were to determine the relationships of these polymorphism and substance activities to DM nephropathy and macroangiopathy. METHODS: 72 NIDDM patients who suffered from DM more than 6 years and 62 non-diabetic healthy control were evaluated. After extraction of DNA from peripheral blood, ACE and PAI-1 gene polymorphisms were determined by polymerase chain reac tion, SSCP electrophoresis and silver stain. Serum PAI-1 level was dctected by Immulyse PAI-1 ELISA kit(Bipool Sweden). RESULTS: Total 134 samples were evaluated and ACE genotype were DD 27(20%), ID 88(66%), and II 19(14%). PAI-1 genotype were 4G4G 26(19%), 4G5G 73(55%), and 5G5G 35(26%). The distribution of ACE and PAI-1 polymorphism according to presence or absence of nephropathy were DD 10, ID 32, II 8, 4G4G 9, 4G5G 31, and 5G5G 10 in DM nephropathy group and DD 3, ID 17, II 2, 4G4G 5, 4G5G 12, and 5G5G 5 in non-nephropathy group. There were no significant differences in the distribution of ACE and PAI-1 gene between the two groups. The distribution of ACE and PAI-1 polymorphism according to macroangiopathy were DD 6, ID 16, II 3, 4G4G 5, 4G5G 15, and 5G5G 5 in macroangiopathy group and DD 7, ID 33, II 7, 4G4G 9, 4G5G 28, and 5G5G 10 in non-macroangiopathy group. There were no significant differences in the distribution of ACE and PAI- 1 gene between macroangiopathy and non-macroangiopathy groups. Serum PAI-1 level according to PAI-1 gene and ACE gene polymorphism were 4G4G 47.99+/-19.73, 4G5G 40.19+/-18.49, 5G5G 40.37+/-20.99 ng/mL, DD 37.99+/-16.64, ID 44.80+/-20.35, and II 31.92+/-12.98 and had a tendency that is higher in 4G4G genotype. CONCLUSION: From the above results, we cannot define the relationships of ACE and PAI-1 gene polymorphism and PAI-1 activities to DM nephropathy and macrovascular complications of NIDDM patients, but prospective studies including more patients population will be required.

Effect of High Glucose, Angiotensin ll and Aniotenisn Converting Enzyme Inhibitor on the Expression of PC alpha1(IV) mRNA in Cultured Human Mesangial Cells / 대한신장학회잡지

OBJECTIVE: Diverse glomerular disorders leadsing to progressive glomerulosclerosis share the common features of increased mRNA expression for extra- cellular matrix protein and growth factors. The precise role of angiotensin II in contributing to these disturbances is currently unknown. ACE inhibitors have been proved to be beneficial in protecting against glomerular injury in animal models and many of human glomerular diseases. Type IV collagen is a main component of extracellular matrix in the mesangium : its increased accumulation is a common pathologic finding in the glomerulosclerosis. There are some evidences that the beneficial effect of ACE inhibitor does not solely depend on the hemodynamic effect, but may be mediated by other effect. The purpose of this study is to evaluate the effects of high glucose, angiotensin II and angiotensin converting enzyme inhibitor on the expression of PC alpha1(lV) in mesansial cells(MCs). METHODS: Human mesangial cells were cultured with standard method. To investigate the effect of each drug and high glucose condition, MCs were cultured in the normal-glucose medium(100mg/dl) and high-glucose medium(450mg/dl), respectively. An- giotensin II and angiotensin converting enzyme inhibitor(captopril) were added to culture medium at final concentration of 10 M which is the physiologic dose in vivo. MCs were cultured in each condition for 3days, when the maximal effect of high glucose on MCs, and harvested for mesurement of the expression of PC alpha1(IV) mRNA. To quantitate the PC alpha(1V) mRNA levels in each condition, semiquantitatine RT-PCR was done with co-amplification of house keeping gene. RESULTS: PCa1(IV) mRNA expression was significantly increased in high-glucose medium(30mM) compared to normal-glucose medium(5.5mM)(2.28+/-0.34 vs 0.96+/-0.08, p(IV) mRNA expression to 4.64+/-0.28(p<0.05). Angiotensin II in the normal-glucose medium increased the PC alpha1(lV) mHNA expression as 2.69+/-0.23 control(p<0.05). Addition of angiotensin converting enzyme inhibitor(Capopril, 10(-6)M) in high- glucose culture medium significantly suppressed the PC alpha1(IV) mRNA expression as 0.690.11(p<0.05). CONCLUSION: High glucose concentration in culture medium significantly increases the mRNA expression of procollagen alphal(IV) than normal glucose concentration. Angiotensin II increases the collagen mRNA expression directly and this effect was significantly prevented by ACE inhibitor. This result suggests that hyperglycemia in diabetic millieu can directly increase collagen production, and ACE inhibitor may inhibit progressive glomerulosclerosis by decreasing collagen production as well as reducing intraglomerular pressure.

Comparison between Cuprophane and Polysulfone Membrane in Biocompatibility / 대한신장학회잡지

OBJECTIVE: It has been proposed that the contact between blood and dialysis membrane during hemodialysis therapy induces harmful reactions to patients. Membrane biocompatibility is the characteristic that makes less adverse reaction. We tried to compare the biocompatibility between Cuprophane and Polysulfone membranes. MRTHODS: Nine chronic renal failure patients who have undergone maintenance hemrodialysis therapy with Hemophan membrane three times per week were included in this study. Cuprophane membranes were used in the first week: Hemophan membranes in the second week; Polysulfone membranes in the third week. Each membrane was used three times a week. On the day of third dialysis with the Cuprophane membrane(first week) and Polysulfone membrane(third week), serial blood sampling was obtained from the afferent line at hemodialysis initiation, 15 minutes, 30 minutes, 60 minutes, 120 minutes and 30 minutes to measure serum complement activity(C3a, C5a), blood polymorphonuclear leukocyte and platelet count, and arterial oxygen pressure which have been regarded as biocompatibility parameters. The parameters measured during the first week(Cuprophane) and the third week(Polysulfone) were compared to evaluate the difference in biocompatibility of both membranes. RESULTS: 1) C3a desArg In both groups, the level of C3a desArg increased significantly from basal level and the Cuprophane group showed significantly higher level of C3a desArg than that of Polysulfone group. 2) C5a desArg : In both groups, the level of C5a desArg did not increased sigpificantly from basal level. Only at 30 minute after hemodialysis, Cuprophane group showed significantly higher level of C5a desArg than that of Polysulfone group(p=0.037). 3) Polymorphonuclear leukocyte : In both groups, the polymorphonuclear leukocyte counts decreased significantly at 15 minutes and 30 minutes from basal level. The polymorphonuclear leukocyte count was lower in Cuprophane group than that of Polysulfone group at 15 minute after hemodialysis(p=0.001). 4) Platelet: In Cuprophane group, the platelet count was decreased significantly at 15 minute(p=0.004) but there were no difference in platelet counts between the two groups. 5) Arterial oxygen pressure Both group showed no consistent pattern of variation of oxygen pressure and there was no significant difference between the two groups. CONCLUSION: The biocompatibility of Polysulfone membrane was superior to the Cuprophane membrane with respect to the increased activation of complement C3a. decrease of polymorphonuclear leukocyte and decrease of platelet count.

The Effects of High Glucose, Angiotensin II and ACE Inhibitor on the Expression of TGFbeta mRNA in Cultured Human Mesangial Cells / 대한신장학회잡지

OBJECTIVE: Diabetic nephropathy is an important cause of end stage renal disease in Korea and associated with major morbidity and mortality. The precise pathogenic mechanism of this disease is still controversial, but it has been considered that multiple factors are contribute to the development and progression of diabetic nephropathy. One of these factors, renin-angiotensin system has been proven to be a major mediator of this disease via activation of angiotensin II, which has multiple functions such as induction of production of extracellular matrix protein and various intraglomerular cells, tubulointerstital component and increment of intraglomerular pressure. Transforming growth factor(TGFbeta) is a multifunctional cytokine with major profibrotic character, which stimulates the production of extracellular matrx(ECM) protein, inhibit the degradation of ECM and induce the interaction of mesangial cells with ECM via integrin receptors. This study was done to evaluate the role of angiotensin II and angiotensin converting enzyme inhibitor in expression of TGFbeta mRNA which is a main mediator in the pathogenesis of diabetic nephropathy. METHODS: Human mesangial cells(MCs) were cultured by standard culture techniqne. For this study, cells in the 5th to 7th passage were used. To make a different glucose concentration in culture medium, normal(100mg/dl) or high glucose(450mg/dl) concentrations of D-glucose were added, and cultured in 17% heat inactivated fetal bovine serum. Angiotensin II and ACE inhibitor(captopril) were administered to the culture medium at final concentration of 10-6M. After 72 hours, MCs were harvested to measure the expression of TGFbeta mRNA. To measure the mRNA expression of TGFbeta in each condition, semi quantitative PCR was done and all results were corrected by beta-actin gene. RESULTS: mRNA expression of TGFbeta was significantly increased in the high glucose medium(30 mM) compared to normal glucose medium(5.5mM) (3.82+/-0.465 vs 2.27+/-0.13, p<0.05). Administration of angiotensinII(10-6M) in high glucose medium induced a further increase in the TGFbeta expression to 4.29+/-0.476(p<0.05). AngiotensinII(10-6M) in normal glucose medium also showed a significant increase in TGFbeta expression as 3.40+/-1.88(p<0.05). Administration of ACE inhibitor(Captopril, 10-6M) in high glucose medium prevented the increse of TGFbeta expression(1.20+/-0.18 vs 3.82+/-0.465, p<0.05). CONCLUSION: From these findings, it suggest that angiotensinII is an important mediator in the pathogenesis of diabetic nephropathy. ACE inhibitor may have a role in the progress of this disease via direct suppression of TGFbeta system as well as beneficial intraglomerular hemodynamic effect.

Clinicopathologic Correlation in IgA Nephropathy with Haas' Subclassification / 대한신장학회잡지

OBJECTIVES: IgA nephropathy is a common type of primary glomerulonephritis and may present with a wide variety of histologic patterns on renal biopsy. IgA nephropathy may progress to end stage renal disease. But it is difficult to predict the prognosis of IgA nephropathy. METHODS: In an attempt to identify prognostic indicators in this disease, the clinical data from 158 patients with IgA nephropathy were analyzed and compared to the pathologic subclassification proposed by Haas. RESULTS: 1)The mean age of 158 patients with IgA nephropathy was 31.5 yrs(M:F=1:1.04) and there were 17 patients in subclass I, 5 patients in subclass II, 80 patients in subclass III, 34 patients in subclass IV, 22 patients in subclass V. 2)The significant correlation between renal survival rate and histologic subclass in 114 patients who were followed-up for more than 12 months was showed in order of I, II>III, IV>V. 3)Active crescents were a significant negative prognostic indicator in renal survival in subclass III, but not in subclass IV. 4) The presence of immune complex deposits in the glomerular capillary loops in addition to the deposits in mesangial areas was associated with poor prognosis in progression to end stage renal disease of IgA nephropathy 5)With a respect to clinical presentation, hypertension, serum creatinine of>=1.5mg/dL, and proteinuria of>=2.0g/day were significant negative prognostic indicators for renal survival but the presense of gross hematuria was not associated with increased renal survival rate by an univariate analysis. CONCLUSION: These results suggest that histologic subclassification proposed by Haas may be a useful prognostic indicator for the clinical outcome of IgA nephropathy, as well as the amount of proteinuria, serum creatinine level and hypertension at the time of initial renal biopsy