Removal of Kidney Stones by Extracorporeal Shock Wave Lithotripsy Is Associated with Delayed Progression of Chronic Kidney Disease

PURPOSE: This study aimed to elucidate whether stone removal by extracorporeal shock wave lithotripsy (ESWL) is associated with delayed chronic kidney disease (CKD) progression. MATERIALS AND METHODS: We conducted a retrospective analysis of 131 nephrolithiasis patients with stage 3 and 4 CKD. We collected baseline clinical and laboratory data, kidney stone characteristics, and history of receiving ESWL. We classified study patients into two groups according to whether they underwent ESWL or not (Non-ESWL group vs. ESWL group). We initially compared annual estimated glomerular filtration rate (eGFR) changes of Non-ESWL group with those of ESWL group before undergoing ESWL. In the next step, we sought to compare annual eGFR changes in the same patients before and after ESWL. Finally, we compared annual eGFR changes between success and failure groups among patients undergoing ESWL. RESULTS: The mean age of the patients was 62 years and 72.5% were male. The mean observation period was 3.2 years. Non-ESWL group and ESWL group before undergoing ESWL showed similar annual eGFR changes (-1.75+/-6.5 vs. -1.63+/-7.2 mL/min/1.73 m2/year, p=0.425). However, eGFR declined slower after undergoing ESWL than before ESWL (annual eGFR changes, -0.29+/-6.1 vs. -1.63+/-7.2 mL/min/1.73 m2/year, p<0.05). In addition, among patients in ESWL group, eGFR declined faster in the failure group than in the success group (annual eGFR change, -1.01+/-4.7 vs. -0.05+/-5.2 mL/min/1.73 m2/year, p<0.05). CONCLUSION: Our results suggest that stone removal by ESWL is associated with delayed deterioration of renal function in CKD patients with nephrolithiasis.

Immunoglobulin A Nephropathy Associated with Plasmodium falciparum Malaria

Glomerulonephritis occurs as a rare form of renal manifestation in Plasmodium falciparum malaria. Herein, we report a case of falciparum malaria-associated IgA nephropathy for the first time. A 49-yr old male who had been to East Africa was diagnosed with Plasmodium falciparum malaria. Microhematuria and proteinuria along with acute kidney injury developed during the course of the disease. Kidney biopsy showed mesangial proliferation and IgA deposits with tubulointerstitial inflammation. Laboratory tests after recovery from malaria showed disappearance of urinary abnormalities and normalization of kidney function. Our findings suggest that malaria infection might be associated with IgA nephropathy.

Estimating Average Glucose Levels from Glycated Albumin in Patients with End-Stage Renal Disease

PURPOSE: In patients with diabetic end stage renal disease (ESRD), glycated albumin (GA) reflects recent glycemic control more accurately than glycated hemoglobin (HbA1c). We evaluated the relationship between GA and average blood glucose (AG) level and developed an estimating equation for translating GA values into easier-to-understand AG levels. MATERIALS AND METHODS: A total of 185 ESRD patients, including 154 diabetic and 31 non-diabetic participants, were enrolled (108 hemodialysis, 77 peritoneal dialysis). Patients were asked to perform four-point daily self-monitoring of capillary blood glucose (SMBG) at least three consecutive days each week for four weeks. Serum levels of GA, HbA1c and other biochemical parameters were checked at baseline, as well as at 4 and 8 weeks. RESULTS: Approximately 74.3+/-7.0 SMBG readings were obtained from each participant and mean AG was 169.1+/-48.2 mg/dL. The correlation coefficient between serum GA and AG levels (r=0.70, p<0.001) was higher than that of HbA1c and AG (r=0.54, p<0.001). Linear regression analysis yielded the following equation: estimated AG (eAG) (mg/dL)=4.71xGA%+73.35, and with this formula, serum GA levels could be easily translated to eAG levels. Multivariate analysis revealed significant contributions of postprandial hyperglycemia (beta=0.25, p=0.03) and serum albumin (beta=0.17, p=0.04) in determining serum GA level, independent to other clinical parameters. CONCLUSION: Compared to HbA1c, serum GA levels were better correlated with AG levels. Using the estimating equation, an average blood glucose level of 155-160 mg/dL could be matched to a GA value of 18-19% in patients with ESRD.

Differences in Pathologic Findings and Gene Expressions of Renal Tissue according to Steroid Responsiveness in Adult-Onset Minimal Change Disease / 대한신장학회잡지

PURPOSE: Compared to children, adult MCD patients tend to have a slower response to steroids, however, little is known about the relationships between pathologic findings or the expression of certain gene and the response to steroid treatment in adult-onset MCD. This study was undertaken to investigate the differences in pathologic findings and the mRNA expression of nephrin and glucocorticoid receptor (GCR) in renal tissue according to steroid responsiveness in adult-onset MCD. METHODS: Twenty-eight adult patients who presented with idiopathic nephrotic syndrome at our institution and fulfilled the criteria for MCD clinically and pathologically were chosen for this study. Based on the response to steroid treatment, patients were divided into two groups: early responders (ER) in whom CR was achieved within 4 weeks of steroid treatment; late responders (LR) in whom CR was achieved after 4 weeks of steroid treatment. RESULTS: Of the 28 patients, ER consisted of 20 patients. Time to CR was significantly shorter in ER compared to LR (16.5+/-0.9 vs. 52.0+/-4.9 days, p<0.01). The proportion of patients with minimal IgM deposition on immunofluorescence was significantly higher in LR compared to ER (75.0% vs. 30.0%, p<0.01). On the other hands, the mRNA expression of GCR, assessed by real time-PCR, was significantly lower in LR than that in ER (p<0.005), whereas nephrin mRNA expression was not different between the two groups. CONCLUSION: The presence of glomerular IgM deposition and the amount of GCR in renal tissue may be useful predictors of steroid responsiveness in adult MCD patients.

Risk factors of gastrointestinal bleeding for end-stage renal disease patients / 대한내과학회지

BACKGROUDN: Gastrointestinal bleeding (GIB) is not a rare complication in end-stage renal disease (ESRD) patients on dialysis and the occurrence of GIB has also been associated with higher morbidity and mortality rates. However, reasons for the high incidence of GIB are not clear. This retrospective study was undertaken not only to analyze the clinical features of GIB but also to elucidate the independent risk factors for GIB in Korean ESRD patients. METHODS: One hundred thirty ESRD patients on dialysis at the Severance Hospital of Yonsei University College of Medicine from January 2000 to December 2005 were included in the study. The patients were divided into two groups: 65 patients with GIB (the GIB group) and 65 age-, sex-, and dialysis modality-matched patients without GIB (the C group). Clinical characteristics, medications, and laboratory findings were compared between the two groups. RESULTS: Compared to the C group, congestive heart failure (40.0% vs. 21.5%, p<0.05), coronary arterial occlusive disease (CAOD) (32.3% vs. 4.6%, p<0.005), and nonsteroidal anti-inflammatory drug (NSAID) use (18.4% vs. 1.5%, p<0.01) were significantly more common in the GIB group. The baseline serum albumin levels were significantly lower in the GIB group than in the C group (2.53+/-0.67 g/dL vs. 3.56+/-0.63 g/dL, p<0.005). Using logistic regression analysis, CAOD (OR=23.0), NSAID use (OR=12.5), and lower serum albumin levels (OR=2.9) were identified as independent risk factors for GIB (p<0.05). CONCLUSIONS: Careful attention must be paid to ESRD patients with CAOD, taking NSAIDs, or with low serum albumin levels in view of GIB.

Successful Treatment of Vancomycin-Resistant Enterococcal Peritonitis with linezolid in a Patient on CAPD / 대한신장학회지

Peritonitis is one of the major complications of CAPD (continuous ambulatory peritoneal dialysis). Among its causative organisms, vancomycin-resistant enterococcus (VRE) is rare, but serious causative organism, because it is refractory to antibiotics commonly used for CAPD peritonitis. Some drugs such as linezolid and dalfopristin have been introduced for VRE infections nowadays, but reports about usefulness of those drugs in VRE peritonitis are rare. We experienced a case of CAPD peritonitis caused by VRE, which was treated successfully with removal of CAPD catheter and use of linezolid. We report our experience with review of the literature.

Endothelial Dysfunction in ESRD Patients Starting Dialysis Treatment / 대한신장학회잡지

BACKGROUND:Patients with renal failure have increased cardiovascular risk due to accelerated atherosclerosis. Endothelial dysfunction (ED) appears to be an important initiating event in the process of atherogenesis. ED has been reported in patients receiving hemodialysis and peritoneal dialysis. However, there has been no study on ED in Korean ESRD patients starting dialysis treatment. In this study, ED was assessed in patients starting dialysis treatment and the risk factors of ED were analyzed. METHODS:Among the patients diagnosed as terminal-stage renal disease (ESRD) and started dialysis treatment at Severance Hospital of Yonsei University College of Medicine from January, 2005 to December, 2005, 35 patients (ESRD group) (51.7+/-12.6 years-old, M:F=22:13) underwent Doppler ultrasonography to have their endothelial functions assessed. Flow-mediated dilation (FMD) was used as an index of ED. For the control group, 33 hypertensive patients (55.2+/-11.4 years-old, M:F=17:16) with normal renal function were selected and FMD was also measured. RESULTS:FMD was significantly reduced in the ESRD group compared to the control group (3.8+/-1.9 vs. 4.9+/-2.4%, p<0.05). When the ESRD group was divided into either DM or non-DM group according to DM status, there was a significant difference in FMD between the two groups (DM, 3.1+/-1.9%; non-DM, 4.4+/-1.9%, p<0.05). In the ESRD group, FMD was inversely related to systolic blood pressure, mean arterial pressure, pulse pressure, and DM duration (p< 0.05). CONCLUSION:ED was already present in patients at the time of starting dialysis treatment and was more severe in the DM compared the non-DM patients.

Usefulness of Peritoneal Dialysis (PD) in Patients with Refractory Heart Failure (RHF) / 대한신장학회잡지

BACKGROUND:Though PD has served as a treatment method for metabolic derangement in acute or chronic renal failure, it has also been used as a palliative therapy or as a bridge to definite surgery or transplantation in patients with RHF. Some studies have demonstrated that PD reduced hospitalization rates and improved functional capacity in these patients, but changes in echocardiographic findings after PD have not been thoroughly explored. In this study, the effects of PD on hospitalization rates and days, functional status, and echocardiographic parameters were evaluated. METHODS:Thirteen patients, in whom PD was performed to treat heart failure, were enrolled. Patients with serum creatinine levels more than 3.0 mg/dL and with acute cardiac event within 1 month before the start of PD were excluded. The clinical, laboratory, and echocardiographic findings before and after the start of PD were compared by carrying out a paired t-test or Wilcoxon signed rank test. RESULTS:Among 13 patients, 11 patients experienced improvement in functional status after the initiation of PD, and the mean NYHA class improved from 3.5+/-0.5 to 2.3+/-0.9 after PD treatment (p<0.005). Significant reductions in hospitalization rates (from 1.7+/-0.4 to 0.2+/-0.4 episodes/patient-year, p<0.001) and in hospitalization days (from 62.1+/-26.5 to 3.8+/-8.9 days/patient-year, p<0.001) were also observed since the start of PD. Echocardiographic findings revealed that right ventricular pressure was significantly reduced in both right-sided and left-sided heart failure patients (p<0.05), whereas there were no significant changes in left ventricular end-diastolic diameter and left ventricular ejection fraction after PD therapy. CONCLUSION:PD treatment improved quality of life, shortened hospitalization period, and reduced right ventricular pressure in patients with RHF. These findings suggest that PD should be considered as an alternative therapeutic modality for RHF.