Spontaneous Intracranial Hemorrhage in Children: Analysis of Clinical Characteristics

OBJECTIVE: Spontaneous intracranial hemorrhage in children is not common and very different compared to adults. We analyze the etiology, hemorrhagic type, clinical features, and outcome of spontaneous intracranial hemorrhage in children. METHODS: Twenty-nine patients under 17years of age with nontraumatic intracranial hemorrhage were analyzed retrospectively. Neonates were excepted. We reviewed their medical records in regard to their age, symptoms, radiologic findings, treatment, and prognosis. RESULTS: Among 29 patients, there were 17boys and 12girls. The average age was 10.2years. The most common presenting symptom was mental deterioration, and the most common cause was arteriovenous malformation. Spontaneous intracranial hemorrhage in children showed a better prognosis than in adults. CONCLUSION: Spontaneous intracranial hemorrhage in children resulted mainly from vascular malformation and the prognosis is relatively good. More careful follow-up studies and active management are needed for better outcomes.

Clinical Utility of Random Spot Urine Protein to Creatinine Ratio Modified by Estimated Daily Creatinine Excretion / 대한신장학회잡지

BACKGROUND: The urinary protein to creatinine ratio in a single voided random urine sample has been widely used as an estimation of 24 hour urine protein excretion because of inconvenience and frequent collection errors during timed collection of 24 hour urine. But the protein to creatinine ratio also showed frequent estimating error, overestimation or underestimation. We thought that protein to creatinine ratio adjusted by daily creatinine excretion estimated by Cockroft-Gault equation can be more accurate than protein to creatinine ratio and compared them as follows. METHODS: This study consisted of 81 patients whose 24 hour urine protein excretion and random spot urine protein to creatinine ratio were measured concomitantly. There was no significant change of body weight or serum creatinine change around the study day. The modified protein to creatinine ratio could be estimated from the measured protein to creatinine ratio in a random spot urine sample by multiplying the ratio by the expected daily creatinine excretion estimated by Cockroft-Gault equation. These results were compared with well collected 24 hour urine protein. RESULTS: The difference between protein to creatinine ratio and 24 hour urine protein was 0.87+/-1.13, on the other hand, the difference between modified protein to creatinine ratio and 24 hour urine protein was 0.52+/-0.65 (p<0.05). Correlation coefficients between protein to creatinine ratio, modified protein to creatinine ratio and 24 hour urine protein were 0.877, 0.957 respectively. CONCLUSION: The protein to creatinine ratio modified by the expected daily creatinine excreation rate calculated by Cockfort-Gault equation was more accurate than simple protein to creatinine ratio.

Comparison of Safety and Efficiency of Hemodialysis Using Heparin-bound Hemophan with those of Saline Flushing Hemodialysis and Hemodialysis Using Low Dose Heparin in Patients at Risk of Bleeding / 대한신장학회잡지

OBJECTIVE: Although hemodialysis using heparin bound Hemophan (HBH-HD) has been reported to be a possible modality in patients at risk of bleeding, the efficiency and safety of HBH-HD is not certain. Therefore, we prospectively compared the safety and efficiency of HBH-HD with those of saline flushing HD (SF-HD) and HD using low dose heparin (LDH-HD) in 13 HD patients at risk of bleeding in a cross-over design. METHODS: The safety and efficiency were evaluated by measuring activated partial prothrombin time (aPTT) before and during HD, hemostasis time after needle removal, total blood compartment volume (TBCV) loss of dialyzer, urea clearance (K) and Kt/V. RESULTS: There was no difference in compression time needed to achieve hemostasis at puncture site after needle removal between HBH-HD, SF-HD and LDH-HD. During HBH-HD, there was a slight increase in aPTT at 15 min (50.6+/-4.5 sec), compared to predialysis levels (40.9+/-4.7 sec). In this cross- over study, aPTT during dialysis session was markedly higher in LDH-HD than those in HBH-HD or SF-HD (p<0.05). The loss of TBCV of the dialyzer was greater in SF-HD than HBH-HD or LDH-HD (17.4+/-1.9% vs. 12.4+/-1.4% vs. 10.1+/-1.8%). However, there was no difference in K (212.0+/-30.7 vs. 217.2+/-36.9 vs. 221.6+/- 29.5 mL/min) and Kt/V (1.22+/-0.12 vs. 1.24+/-0.16 vs. 1.26+/-0.18). CONCLUSION: We concluded that the safety and efficiency of HBH-HD are not different compared to SF-HD or LDH-HD and HBH-HD could an alternative hemodialysis method in patients at risk of bleeding.

Estimation of GFR Using Iohexol Plasma Clearance in Korean without Renal Disease / 대한신장학회잡지

BACKGROUND: Plasma clearance of iohexol (Omnipaque(r)) which used widely in radiologic procedure is considered as useful method for estimation of GFR because iohexol is neither reabsorbed nor secreted from tubule after filtered as inulin and its extrarenal clearance is negligible. Plasma clearance of iohexol can be calculated from two compartment model or one compartment model with Brochner-Mortensen (B-M) modification which convenient and reliable. But there were controversies about sufficient sampling numbers and times for B-M modification of iohexol clearance. METHODS: Nineteen healthy Korean without renal disease underwent measurement of iohexol clearance. Iohexol was given as a single iv dose, and 14 blood sample were drawn up to 300 min. A reference GFR was iohexol clearance calculated from two-compartment model using 14 samples (CL-T). From 8, 3 and 2 samples clearances were calculated by B-M modification (CL-M8, 3 and 2 respectively). The accuracy of estimates was evaluated as percent of estimates falling within 10% above or below the reference GFR. Accuracy of CCr and equations for GFR estimation were also compared. RESULTS: CL-T, CL-M8, CL-M3 and CL-M2 were not different (101.9+/-24.0, 101.9+/-18.7, 101.7+/-18.6, 101.9+/-19.5 mL/min/1.73 m2 respectively). Accuracy of CL-M8, 3 and 2 were not different (74%, 84% and 79% respectively, p>0.05). MDRD equation had higher accuracy (47%) compared with other equations. CONCIUSION: These results indicate that sampling number for measuring iohexol plasma clearance using simplified method might be reduced to only two without accuracy loss in Korean without renal disease.

A Case of Systemic Vasculitis with Intraperitoneal Aneurysmal Rupture / 대한신장학회잡지

Though systemic vasculitidis are a group of diseases with extremely low incidence and prevalence, vessels with diverse size from aorta to capillaries are involved. It has been argued how to classify and define systemic vasculitidis, especially how to discriminate poly arteritis nodosa (PAN) and microscopic polyangiitis (MPA). Since there are lots of overlapping between them, clinical manifestations, antineuclear cytoplasmic antibody (ANCA) and angiographic findings besides pathologic findings should be considered altogether. We report a case of systemic vasculitis in which crescentic necrotizing glomerulonephritis with positive perinuclear-type ANCA occurred with intraperitoneal aneurysmal rupture simultaneously. Our case can be a typical one that shows definite overlapping between PAN and MPA.

A Case of Postinfectious Glomerulonephritis Following Meningococcal Meningitis / 대한신장학회잡지

A 21-year-old male was presented with sudden headache, fever, petechiae and neck stiffness. The diagnosis of meningococcal meningitis was confirmed by examination of cerebrospinal fluid. The clinical symptoms of the illness were improved after treatment of antibiotics. However the patient developed generalized edema, oliguria, azotemia, and heavy proteinuria in the recovery phase of illness. Low serum C3 level was also noted. A kidney biopsy was performed and showed the features of postinfectious glomerulonephritis and typical subepithelial humps on electron-microscopic examination. His symptoms and laboratory findings were improved, and C3 level returned to normal range after conservative treatment. We suggest that a complement deficiency should be ruled out in patients of glomerulonephritis developed during the recovery phase of meningococcal meningitis. C3 nephritic factor detection and renal biopsy should be carefully considered in these patients.

Hemodialysis Using Heparin Bound Hemophan Hemodialysis in ESRD Patients at High Risk for Bleeding: A Seven-Year Experience / 대한신장학회잡지

OBJECTIVE: Positively charged N, N-diethyl-aminoehtyl groups on Hemophan enable negative charged heparin to be bound with the dialyzer membrane and hemodialysis using heparin bound Hemophan (HBH- HD) could be a hemodialysis modality in patients at risk of bleeding. We designed simplified heparin binding technique and evaluated the bleeding risk and efficiency of HBH-HD in chronic renal failure patients at risk of bleeding. METHODS: During the period from April 1995 through April 2002, 159 patients at high bleeding risk received 1057 HBH-HD (dialyzer: GFS plus 11, Gambro). The duration of each HBH-HD was standardized to 4 hours at blood-flow rate of 200-250 mL/min. To evaluate safety of HBH-HD, we measured serum heparin concentration (HC) and activated partial thromboplastin time (aPTT) at baseline, 15, 60, 120 minutes and endpoint (240 minutes) (n= 40). To evaluate the dialysis efficiency, HBH-HD and routine hemodialysis with systemic heparinization (R-HD) were compared for total blood compartment volume (TBCV) loss, dialyzer urea clearance (K) and Kt/V in same study group patients (n=20). RESULTS: Clotting of dialyzer necessitating termination of dialysis occurred in 11 (1.0%) out of 1, 057 dialyses at 150 minutes, and clotting requiring change of blood line occurred in 64 dialyses (6.1%) between 150 and 230 minutes. There was a slight increase in the aPTT (mean+/-SD, 49.8+/-10.5 sec) and HC (0.14+/-0.06 U/mL) at 15 min, compared to predialysis levels of 44.3+/-12.9 sec and 0.11+/-0.06 U/ mL, respectively (p>0.05). But no increase in aPTT, HC was observed in measurements at 60 min, 120 min, and at the endpoint. TBCV loss was significantly higher in HBH-HD (mean+/-SD, 17.2+/-9.6%), compared to R-HD (2.8+/-1.2%) (p0.05). CONCLUSION: HBH-HD could be a safe and efficient HD technique in patients at high risk of bleeding. Extracorporeal clotting, however, should be observed carefully during HBH-HD.

Peritoneal Transport Characteristics and Peritoneal Clearance of beta2-microglobulin / 대한신장학회잡지

In addition to CAPD, various modalities of peritoneal dialysis such as CCPD and NIPD have been introduced recently. The adequacy in these peritoneal dialysis has been evaluated by clearance of small molecular weight solutes such as creatinine(molecular weight 113 Dalton) and urea(molecular weight 60 Dalton). The middle molecular weight solutes(molecular weight 3,000 to 12,000 Dalton) have been regarded as one of the uremic toxins. Relatively larger clearance of middle molecular weight solutes is one of the advantages of CAPD compared with HD. Although peritoneal transport of middle molecular solutes can be different from that of small molecular weight solutes because of its size, there are a few reports about peritoneal transport characteristics and clearance of middle molecular weight solutes in various modalities of PD. We wanted to analyze peritoneal transport characteristics and clearances of middle molecular weight solute in various modalities of peritoneal dialysis in comparison with small molecular weight solutes. To evaluate the potential differences in peritoneal transport characteristics and clearances of middle and small molecules in CAPD, CCPD and NIPD, we compared transport characteristics and clearance of beta2-MG and creatinine. 35 CAPD patients, 9 CCPD patients, 7 NIPD patients were included in the study, who were clinically stable for at least one month without peritonitis. he beta2-MG concentrations in serum and dialysate as measured by radioimmunoassay. Standard peritoneal equilibration test and a weekly peritoneal clearance for creatinine and beta2-microglobulin were used. The results were as follows: 1)Dialysate to plasma ratio of beta2-MG were 0.11+/-0.03, 0.13+/-0.05, 0.10+/-0.02, 0.08+/-0.03, respectively in high(N=6), high average(N=13), low average(N= 14), low(N=7) group according to PET. There were significant differences between high average and low average, high average and low group(p<0.05). Correlation between D/Pbeta2-MG ratio and D/Pcr ratio was significant(spearman's p=0.453, p<0.05). 2)In 35 CAPD patients, peritoneal creatinine and beta2-MG clearance were 48.9, 8.2L/wk, respectively and there was a weak correlation between them (Spearman's p=0.294, p<0.05). 3)The peritoneal creatinine clearance were 48.9, 41.0, 35.9L/wk and beta2-MG clearance were 8.2, 5.5, 4.1L/wk, respectively in CAPD, CCPD and NIPD. The ratio of peritoneal beta2-MG clearance to creatinine clearance were 0.16, 0.14, 0.11, respectively in CAPD, CCPD and NIPD. Peritoneal beta2-MG clearance in APD such as CCPD and NIPD is lesser than that in CAPD. In conclusion, peritoneal transport characteristics for beta2-MG differ from that for creatinine, although peritoneal clearnce for beta2-MG corrleated with that for creatinine. Perioneal clearance for beta2-MG was better in CAPD than in APD.

Two Cases of Liver Abscess Caused by Group G beta-Hemolytic Streptococcus / 감염

Group G beta-hemolytic Streptococcus is a normal flora of skin, pharynx, female genital tract, and intestine. Group G beta-hemolytic Streptococcus has been reported to cause a variety of human infections, such as pharyngitis, soft tissue infection, arthritis, osteomyelitis, respiratory infection, endocarditis, meningitis, puerperal infection, neonatal sepsis and peritonitis. But liver abscess caused by group G beta-hemolytic Streptococcus has not been reported to date. We report two cases of liver abscess caused by group G beta-hemolytic Streptococcus. One patient with underlying neurofibromatosis presented with fever and diarrhea; the other patient presented with fever and pain on the right upper quadrant of abdomen. Hepatic abscess was diagnosed by computerized tomography and confirmed by percutaneous needle aspiration. Cultures of pus obtained by aspiration revealed group G beta-hemolytic Streptococcus, which were susceptible all tested antibiotics, including penicillin.

Estimation of Kidney Size by Ultrasonography in Normal Korean Adults / 대한신장학회잡지

BACKGROUND: The kidney size is important in differentiating many renal diseases. Some studies have been reported about the normal kidney size in the foreign countries. However, no studies were performed by using ultrasonography in Korea. Therefore, we investigated the normal kidney length, the factors affecting the kidney length and the relationship of each other. METHODS: One thousand three hundred eighty eight healthy Koreans were scanned for the kidney length by ultrasonography and were measured for their body index(height, weight, body surface area, total body water, and fat free mass). We analyzed the association between kidney length and body index. RESULTS: Eight hundred four male and five hundred eighty four female were involved in this study and their mean age was 47.8+/-10.3 in male, 48.1+/-9.5 in female. 1) The average value of left and right kidney was 10.65+/-0.80cm, 10.50+/-0.78cm respectively, and the left kidney was greater than right one(P<0.01). 2) The difference between male and female was 10.77+/-0.79cm, 10.49+/-0.78cm respectively in the left kidney and 10.66+/-0.76cm, 10.27+/-0.75cm in the right kidney(P<0.01). 3) The aging process nearly does not affects the kidney size from 4th decade to 7th decade. However, the kidney size is getting smaller after 8th decade. 4) The correlation coefficient between the kidney size and height, weight, body surface area, total body water, fat free mass was 0.37, 0.41, 0.43, 0.37, 0.38(P<0.01) respectively. CONCLUSION: The kidney length showed normal distribution in normal Korean adult and the length greater than 12.36cm, smaller than 8.76cm means out of its range of normal(+/-2SD) irrespective of sex and position. The body surface area has the largest correlation with kidney size in both sex(r=0.38/0.44; left/right, P<0.01).

Estimation of Creatinine Clearance with Serum Creatinine in Korean Patients / 대한신장학회잡지

Cockcroft and Gault's formula is frequently used to estimate creatinine (Ccr) in clinical practice. To determine the accuracy of such estimation in Korean patients, we measured simultaneously, serum creatinine and 24-hour urinary creatinine excretion in 696 Korean patients (male:350, female:346). Measured Ccr was significantly different from estimated Ccr in several age groups and the decrease of creatinine excretion with age is less than Cockcroft and Gault's estimation. We assumed that this difference can be due to difference of the body habitus and difference of urinary creatinine excretion per body weight between different races. So we divided the sample population into two groups and derived the new formula in one group with regression analysis between age and 24 hour urinary creatinine excretion per body weight for estimation of Ccr as Cockcroft and Gault derived their formula and applied it to another group to compare the new formula with Cockcroft and Gault's formula in Korean patients. The new formula was Ccr (mL/min)=[ (260-age)x weight (kg)]/[160 x serumCr (mg/dL)] for male and Ccr (mL/min)-[ (236-age) x weight (kg)]/[180 x serum Cr (mg/dL)] for female. Predictive accuracy of the new formula was significantly better than the Cockcroft and Gault's formula in the other sample population and also in subgroup of the patients with azotemia.

The Effect of Dialysate Dwelling on Gastric Emptying Time in Patients with Continuous Ambulatory Peritoneal Dialysis (CAPD) / 대한신장학회잡지

We evaluated gastric emptying time (GET) by using Tc99m-sulfur colloid gastric emptying scintigraphy in 11 patients with CAPD (6 male, 5 female) and 14 healthy volunteers. We investigated the effect of dialysate dwelling on GET by studying twice, once without dialysate in the abdomen (drained) and once with 2 L of dialysate in the abdomen (full), and the relationship between body surface area (BSA) and delayed gastric emptying. 1) The mean of gastric emptying rate in 120 minute in patients with CAPD when drained (67.8+/-13.4%) was not different from that in healthy volunteers (65.4+/-8.6%) 2) The mean of gastric emptying rate in 120 minute when full (55.6+/-14.6%) was significantly lower than that when drained (67.8+/-13.4%) (P<0.05). In four of the 11 patients (36.4%), gastric emptying was extremely delayed from normal to abnormal range when full. 3) The BSA (1.5+/-0.11m2)of patients who had extremely delayed GET from normal to abnormal range was smaller than that (1.74+/-0.22m2) of patients who had minimal delayed or unchanged GET when full. This study showed the patient with CAPD had normal gastric emptying when drained, and that gastric emptying was delayed by dialysate dwelling, especially in the patients who has less than 1.5m2 of body surface area. Therefore, we suggest that intermittent nocturnal peritoneal dialysis or a small volume of dialysate may be considered for the patient with small body surface area based on the adequacy.

Evaluation of disabled patients with 10 ADLs

No abstract available.