Coronary-artery Calcium Scores Using Electron Beam CT in Patients with Chronic Renal Failure

We evaluated the risk of coronary-artery disease in patients with chronic renal failure (CRF) by measuring the coronary-artery calcium scores with electron beam CT (EBCT). A total of 81 CRF patients were divided into three groups; pre-dialysis (group I, n=35), hemodialysis (group II, n=31) and peritoneal dialysis (group III, n=15). The several serum biochemical markers and calcium score levels by EBCT were determined. The Ca x P products were significantly higher in groups II (p 400 was significantly higher than the 66 patients with a score < or =400 (p<0.01). The calcium score was significantly higher in the 15 patients with cardiovascular complications than in the 66 patients without cardiovascular complications (628.9+/-904.8 vs. 150.4+/-350.9, p<0.01). EBCT seemed to be a good diagnostic tool for evaluating the risk of coronary-artery disease ''noninvasively'' in CRF patients who are at increased risk of cardiovascular morbidity and mortality.

Analysis of renal biopsies performed in 208 patients with asymptomatic urinary abnormalities / 대한내과학회지

BACKGROUND: Asymptomatic urinary abnormalities are one of the most frequent abnormalities in clinical nephrology. However, there are few large-scaled studies about the clinical manifestations and the pathologic findings of the disease. The aim of present study was to evaluate the clinicopathologic nature of the patients with asymptomatic urinary abnormality proven by renal biopsy. METHODS: Between January 1998 and July 2002, two hundred and eight patients with asymptomatic urinary abnormality at three hospitals in Daegu were studied for age, sex, initial urinary findings, serum creatinine, daily urine protein and pathologic findings by renal biopsy. RESULTS: Mean age was 28.0 years (range 14-60 years) at diagnosis of 208 patients and sex ratio of male to female was 141:67. One hundred and two patients (49.0%) had hematuria and proteinuria, 94 (45.2%) had pure microscopic hematuria and the remaining 12 (5.8%) had isolated proteinuria. Pure microscopic hematuria was the dominant urinary abnormality in younger patients. In pathologic findings, 120 patients (57.7%) were IgA nephropathy, 35 (16.8%) thin glomerular basement membrane disease, 8 (3.8%) minimal change disease, 6 (2.9%) membranous glomerulonephropathy and 22 (10.6%) showed no histologic abnormality. The most common pathologic diagnosis in all three groups was IgA nephropathy. In pure microscopic hematuria group, 38 patients (40.4%) were IgA nephropathy and 27 patients (28.7%) were thin glomerular basement membrane disease. There were no significant difference in pathologic findings depending on the severity of proteinuria (p>0.05). CONCLUSION: In our study, the most common cause of asymptomatic urinary abnormalities was IgA nephropathy. In patients with pure microscopic hematuria, IgA nephropathy and thin glomerular basement membrane disease were two leading causes.

ReVersible MRI Changes in a Patient with Uremic Encephalopathy / 대한신장학회잡지

Uremic encephalopathy is a well-known complication in uremia and may result from changes of cerebral metabolism due to uremic toxins. Specific morphological changes have not been observed and pathogenesis is still unclear. We experienced a case with uremic encephalopathy in whom reVersible abnormalities were observed on brain magnetic resonance image (MRI). A 61-year-old man with chronic renal faliure due to diabetic nephropathy started automated peritoneal dialysis (APD) one year ago (therapy time: 10 hours, number of cycles: 5, fill volume per cycle: 2 L). He developed gait disturbance and dysarthria after he dwelled icodextrin contained 2 L dialysate over night instead of APD. In that time, his weekly Kt/V and creatinine clearance were 1.5 and 87.5 L/week/1.73 m2, respectively. On brain MRI, low signal in T1 image and high signal in T2 image were seen in putamen and globus pallidus bilaterally. Insufficient peritoneal dialysis adequacy was documented, and the patient was switched from APD to continuous ambulatory peritoneal dialysis (CAPD). After than, his symptom gradually improved. On follow-up MRI 2 months later, previous lesion has disappeared.

Causative organisms and patterns of antibiotics sensitivity of CAPD peritonitis in different dialysis centers / 대한내과학회지

BACKGROUND: The International Society for Peritoneal Dialysis (ISPD) changed their recommendations for empiric therapy of peritonitis to a first generation cephalosporin to substitute vancomycin and a ceftazidime or an aminoglycoside to cover Gram negative organisms. These guidelines have been recently challenged based on microbiologic evidence and practical considerations. We believe that the management of CAPD peritonitis should be adapted to the specific circumstances affecting the patient, geographic location, local epidemiology of causative bacteria and availability of specific antibiotics. METHODS: To evaluate causative microorganisms and patterns of antibiotics sensitivity of CAPD peritonitis in different dialysis centers, we performed retrospective analysis in three dialysis centers located at different geographic area : Kyungpook University Hospital (Center A), Samsung Seoul Hospital (Center B), Ilsan Hospital (Center C). Among a total of 642 patients on CAPD from January 2001 to December 2001, 113 patients who experienced peritonitis (157 episodes of peritonitis) were included. For microbiologic culture, dialysate effluent was plated in blood agar, thioglycollate broth and McConkey medium. The pattern of antibiotic sensitivity was assessed using broth dilution and disc diffusion method. RESULTS: The sex ratio and proportion of diabetic patients were not different among each center, but the age of center C was higher than that in center A (A: 56.2 13.6, C: 64.6 14.1, p<0.05). Distribution of the causative microorganisms was not different among each center but the pattern of antibiotic sensitivity was different. The incidence of methicillin-resistant staphylococcus species and aztreonam-resistant Gram negative organisms was significantly different among each center. Regimen of 2000 ISPD empiric treatment protocol was ineffective in about 23% of all peritonitis episodes. A treatment with cefazolin instead of vancomycin was associated with resistance in 32.1% of Gram positive organisms and with mobactam instead of ceftazidime was associated with resistance in 23.1% of Gram negative organisms. CONCLUSION: Individual centers should continue to monitor the epidemiology of CAPD peritonitis and the epidemiology of the causative organisms and their sensitivity patterns in order to adapt general guidelines into a center-tailored empirical treatment protocols.

The Effect of Tumor Necrosis Factor-Alpha to Glomerular Epithelial Cells in Glomerular Permeability / 대한해부학회지

Minimal Change Disease (MCD) is the most common primary nephrotic syndrome in children. Some suggested that tumor necrosis factor-alpha (TNF-alpha) are involved in the pathogenesis of MCD. This study was done to see changes of plasma and urinary TNF-alpha, and its effect on determination of permeability of glomerular basement membrane (BM) contributed by heparan sulfate proteoglycan (HSPG). Study patients consisted of 19 biopsy-proven MCD children aged 2-15 years old. Both plasma and urinary TNF-alpha were measured. Employing the Millicell system, TNF-alpha was screened for the permeability factors. We examined whether TNF-alpha regulated BM HSPG gene expression and HS synthesis in the glomerular epithelial cells (GECs). Urinary TNF-alpha during relapse was also significantly increased (364.4+/-51.2 vs 155.3+/-20.8, 36.0+/-4.5 ng/mg.cr) (p<0.05). However, the negative results were obtained in the permeability assay using the Millicell system. No difference was seen in BM HSPG gene expression and HS synthesis in the GECs. Therefore, it seems that TNF-alpha may not play a disease-specific role in the pathogenesis of MCD.

A Case of Spontaneous Renal Artery Dissection with Renal Infarction in a Healthy Man Without Hypertension / 대한신장학회잡지

It is usually known that arterial dissection is associated with malignant hypertension, severe atherosclerosis or trauma. Marfan syndrome or Ehlers- Danlos syndrome may also be rare causes. However, as in this case, spontaneous arterial dissection without aortic dissection in normotensive men is rarely reported. A 39-year-old man presented with acute onset right flank pain with microscopic hematuria. Physical examination was unremarkable and his blood pressure was normal. Clinical impression was urolithiasis because he experienced two episodes of urolithiasis previously. IVP was not completed due to adverse reaction during study. Right renal infarction was diagnosed by contrast-enhanced computed tomography. To search for possible cardiac embolic disease, the patient underwent surface echocardiography, which was normal and a detailed evaluation for a thrombotic tendency was unremarkable. A renal arteriogram showed dissection of the main right renal artery with extension to renal artery branches and a wedge-shape perfusion defect in the distal part of the occluded artery. He received aorto-renal bypass surgery using his great saphenous vein. The patient developed hypertension 3 months later. To summary, we report a case of spontaneous renal artery dissection with renal infarction in a healthy man without hypertension.

Significance of overnight D/P sodium test in continuous ambulatory peritoneal dialysis / 대한내과학회지

BACKGROUND: Standard PET (peritoneal equilibration test) is time consuming and it cannot reflect the water removal accurately because it measures solute transport by diffusion only. Thus, it is important to find parameters that can be used to predict both the diffusive permeability of peritoneal membrane and the peritoneal fluid removal. Sodium removal in CAPD is strongly related to the ultrafiltration and the recent study has suggested that dialysate sodium concentration at 240 minutes could reflect both peritoneal fluid removal and peritoneal transport characteristics. In this study, we investigated whether a single dialysate sodium test after overnight dwell could provide the same information as the standard PET and could reflect ultrafiltration failure. METHODS: A 9-hour overnight dwell study with 2L of 3.86% glucose dialysis solution was carried out in 48 clinically stable CAPD patients. All patients underwent a PET test with 2L of 2.27% glucose solution in the morning after an overnight dwell study. According to ultrafiltration (UF) failure (net UF<100 mL/4 hour on 2.27% glucose solution), patients were divided into two groups (group I, UF failure group; group II, non UF failure group). D/P(Na540) and D(Na540) at the end of the 9-hour dwell were compared between two groups RESULTS: D/P(Na540) was significantly correlated with D/Pcreatinine (r=0.551, p<0.001) and drained volume (r=-0.536, p<0.001) at 240 minutes on PET. There was also a significant correlation between D/P(Na540) and drained volume (r=-0.555, p<0.001) at 540 minutes after overnight dwell. D(Na540) was significantly correlated with D/Pcreatinine (r=0.448, p<0.01) at 240 minutes on PET and also weakly correlated with drain volume at 240 minutes (r=-0.37, p<0.01). There was a significant difference in D/P(Na540) between the group I and group II (p<0.05), but not in D(Na540). CONCLUSION: Overnight 9-hour dwell study with 3.86% glucose solution is a simple procedure and easy to perform on outpatient basis. D/P(Na540) is comparable with PET results and may discriminate the different transport groups. D/P(Na540) may also be used as an indicator of ultrafiltration failure.

Clinical Usefulness of Low Calcium Dialysate in CAPD Patients with High Risk of Low-turnover Bone Disease / 대한신장학회잡지

Hypercalcemia is a common complication in CAPD patients treated with calcium-containing phosphate binders and using the standard dialysate(Ca++ : 3.5 mEq/L). Furthermore, the high calcium concentration in standard dialysate may have a suppressive effect on parathyroid hormone(iPTH) level, contributing to the high prevalence of low-urnover bone disease. We studied the effect of low calcium dialysate(Ca++ : 2.5 mEq/L) for those patients with high risk of low- turnover bone disease. Among 386 patients(1996. 1.- 1999. 12.) who had been stable on CAPD for at least 3 months, 46 patients were included in this study. The patients were divided into 3 groups on the basis of the iPTH levels(10 mg/dL) before the conversion to low calcium dialysate. Group 1(n=29), iPTH 10 mg/dL; Group 2 (n=14), iPTH 150 pg/mL and Ca++ >10 mg/ dL. During a 2-month run-in period, those patients were treated with standard dialysate. After that, a 12-month therapy with low calcium dialysate was followed. Biochemical data including calcium, phosphorus, iPTH and alkaline phosphatase were measured regularly and daily phosphate binder and calcitriol intake(pill counting) were assessed during the run-in and therapy period. We obtained the following result: the prevalence of hypercalcemia(Ca++>10.5 mg/dL) was 5.7%(22/ 386 patients). Serum calcium levels decreased during the therapy period(12 months)(10.5+/-1.4 vs 9.4+/-1.3 mg/dL, p<0.05). Serum phosphorus levels remained unchanged. Mean serum alkaline phosphatase level increased(203.0+/-92.9 vs 257.2+/-103.4 U/L, p<0.05). Serum iPTH levels increased (92.7+/-128.8 vs 225.3+/-237.3 pg/mL,p<0.05). The mean intake of oral phosphate binders was not significantly different between run-in period and therapy period. But calcitriol doses increased 0.038+/-0.087 at run-in period to 0.158+/-0.288 tablets/person/day at therapy period(p<0.05). In the six patients, low calcium dialysate was converted to standard dialysate due to high iPTH level (n=3), symptomatic hypo calcemia(n=2), and uncontrolled edema(n=1). In conclusion, in the study of 46 patients over 12 month period, the usage of 2.5 mEq/L calcium dialysate resulted in a significant decrement in calcium levels and increased iPTH levels. Therefore, we propose that dialysis with a low calcium dialysate is an acceptable form of therapy for the patients with high risk of low-turnover bone disease showing hypercalcemia and low iPTH level. However, further study will be needed for evaluating the effect of low calcium dialysate in low-turnover bone disease.

Cadmium Intoxication and Its Effects on Kidney Function / 대한신장학회잡지

Cadmium-containing compounds are widely used in the manufacturing of pigments, plastics, glass, metal alloys, and electrical equipment. Chronic low exposure of cadmium causes renal tubular dysfunction, emphysema, bronchial cancer, osteomalasia, multiple fracture or urethral stone. Occupations exposed to cadmium are increasing in industsralized country such as Korea, but there is a few systemic study on cadmium intoxication until nowadays. We studied the effects of cadmium on renal function, pulmonary function and bone mineral density in 5 workers exposed to cadmium. Cadmium in urine were increased [38.51+/-42.68 (7.27-101.07)mug/g creatinine(1 st exam), 0.70+/-7.16 (3.88-21.05)mug/g creatinine(2 nd exam)], respectively. Urine N-acetyl-beta-D-glucosaminidase(NAG) excretion rates[9.19+/-2.21(7.25-12.79) U/g creatinine] were increased, but urinary beta2-microglobulin(beta2- MG), urinary methalothionein(MT) excretion, 24 hour urinary protein, calcium excretions were not increased. Cadmium in urine was correlated with urine NAG(r=0.912, p=0.031) but no relationship with others. Glomerular filtration rate were all within normal limits. Complete blood counts, liver function, renal function, electrolytes were all within normal limits. In urinalysis and sediment examination, 4 cases showed no abnormalities, but 1 case showed proteinuria(30 mg/dL) and hematuria with dysmorphic RBC dominance(This case was diagnosed accompanying IgA nephropathy). In pathologic examination, all biopsy specimens showed mild interstitial fibrosis without inflammatory cell infiltration. Osteoporosis and obstructive lung defect were diagnosed in one case. We found urinary NAG excretion were increased and mild interstitial fibrosis at biopsy specimen were seen in all cases. It is necessary to follow-up for detection of proteinuria and decrement of GFR in each patients.

New Curriculum at Kyungpook National University School of Medicine / 한국의학교육

The curriculum reform was undertaken at Kyungpook National University School of Medicine (KNUSM) to meet new educational objectives in order to cope with a rapid societal changes anticipated occurring in 21st century. The KNUSM Curriculum Development Committee was charged to formulate a new curriculum, which consisted of enhancement of patient-centered care based clerkship, integrated courses based on organ systems, problem-based learning, and additional teaching on social medicine, medical informatics and biomedical engineering. The philosophy of this curricular reform has been to modify methods of teaching medical students toward self-directed learning and student-centered. This whole concept was a drastic departure from the traditional lecturing. In the new curriculum, total of 180 credit courses, 4395 hours to graduate medical school were reduced to 170 credit courses, 4250 hours. As a part of the social medicine course, a 2 credit-hour course on patient-doctor relationship was taught and two credit-hour PBL tutorials were added to freshman, sophomore and junior years. In order to carry out this education reform, three new departments were inaugurated such as Biomedical Engineering, Medical Informatics and Medical Education. The school facility has also been improved during this preparatory period. The new curriculum has been implemented in 1999 academic year after approximately 4 years of preparatory period and annual faculty workshops have been held to monitor the progress of the reform and improve courses by evaluating impact of the change on both faculty members and students as well. The interim evaluation revealed several issues remained to be resolved. In conclusion, the acceptance of this reform was excellent from both faculty members and students although there have been continuous problem solving and adjustments necessary. The real assessment of the outcome of the reform requires many years to come and there has to be continuous monitoring of the progress and adjustment of curriculum are the pivotal of a success of the sort of education reform.

Comparison of the Survival Rates of Spousal Kidney Transplantation and Parental Donor Kidney Transplantation / 대한이식학회지

PURPOSE: The continuing shortage of donors has escalated the waiting times for kidney transplantation in most nations. In instances where first-degree relatives of the patient are not appropriate, living unrelated transplantations are considered as the next possible choice. In this category, genetically unrelated but emotionally related spouses are always preferred for organ donation rather than both genetically and emotionally unrelated donors. The aim of this study was to compare the results of parental donor kidney transplantation with spousal kidney transplantation. METHODS: Patient and graft survival were assessed with the Kaplan- Meier curve and statistical significance was determined by log-rank comparisons. RESULTS: In the spousal group, 1-, 3-, and 5-year graft survival rate were 84.6%, 72.3%, and 66.3%, in the parental donor group, 89.2%, 75.4% and 62.3% respectively. 1-, 3-, and 5-year patient survival rate were 84.6%, 80.4%, and 71.5% in the spousal group and 97.3%, 94.3% and 90.6% respectively in the parental donor group. Survival rate of grafts from spouses was comparable to that of parental-donor grafts, despite the average of 4.1 HLA mismatches in the spousal group, as compared with one haplotype sharing in the latter group (P<0.001) and higher donor age in the parental donor group (P<0.001). The survival rates were similar in the wife-to-husband and the husband-to-wife groups. CONCLUSION: While providing the couple with a better quality of life, spousal kidney transplantation also enables the couple to share the joy of giving and receiving the "gift of life" from one another. We believe that transplantation from a healthy volunteer spouse is a good alternative resource to years of dialysis while waiting for another donor that may never appear, to increase the donor pool and reduce the increasing length of waiting lists.

Effects of Peritoneal Rest on Peritoneal Fibrosis in CAPD Rats / 대한신장학회잡지

Ultrafiltration failure has been known as a major cause of dropout from long-term peritoneal dialysis and is often related to peritoneal hyperpermeability. This can be explained in part by progressive peritoneal fibrosis. The present experiment has been undertaken to evaluate the effects of peritoneal rest on peritoneal transport and morphology in rat model of peritoneal dialysis. Twenty-four male rats(Sprague-Dawley, 250-300g) were used and divided into three groups : group 1 (control, n=6) without dialysis, group 2(n=9) sacrificed immediately after 3 weeks of dialysis, and group 3 (n=9) sacrificed after 4 weeks of peritoneal rest after 3 weeks of dialysis. Peritoneal dialysis was performed twice a day with 25mL of 3.86% dextrose solution for 3 weeks. Peritonitis was induced by supplementing lipopolysaccharide(5 microgram/mL) in the dialysis fluid on days 8, 10 and 12 of peritoneal dialysis. Peritoneal equilibration tests were performed before dialysis and repeated on the 4th and 8th week of dialysis. Morphometric analysis of the peritoneal membrane and immunohistochemistry for collagen type I and type III were done in tissue specimens obtained at the time of sacrifice. The D/Do ratio for glucose at two hours in groups 2 and 3 at the beginning of week 4 were significantly lower than baseline value, indicating increase in the peritoneal penneability to glucose after 3 weeks of dialysis. D/Do in group 3 at the beginning of week 8, after 4 weeks of peritoneal rest, was significantly higher than at week 4. The drained dialysate volumes in groups 2 and 3 at week 4 were significantly lower than at baseline; however, The drained dialysate volume in group 3 at week 8 was significantly greater than at week 4. The thickness of the parietal peritoneal membraoe in group 2 and 3 were significantly greater than in group 1. Severity of the thickness of the parietal peritoneal membrane in group 3 was not much than that of group 2(group 1, 11.4+/-7.6; group 2, 37.5+/-18.4; group 3, 21.4+/-12.1 micromiter). Histologically, the thickened peritoneum in group 2 showed a monolayer of mesothelial cells and under-lying multilayer of curled collagen bundles. Mononuciear cells and fibroblasts were embedded in these collagen layers and capillary proliferation was present. Immunohistochemistry for collagen type I and Z demonstrated that the distribution of collagen type llI was richer than that of collagen l in group 2 at fibrotic area of submesothelial region. These findings were decreased in group 3. Ultrastructural examination of the peritoneum showed thicker fibrotic zone and the activated fibroblasts in group 2 compared to group 1 and 3. Meso-thelial cells were plump and the number of mesothelial microvilli was decreased in group 2. Nucleus was enlarged and irregular. Intracytoplasmic orga-nelles were also richer than those of group I or 3. In conclusion, peritoneal rest improves ultrafiltration in rats by decreasing the hyperpermeability of glucose and also reduces the degree of peritoneal fibrosis. These data suggest that dialysis-induced changes in peritoneal transport and morphology are reversible under the condition of peritoneal rest in this experimental model.

Nutrition and Dialysis Adequacy of Korean Patients on Long-term CAPD / 대한신장학회잡지

CAPD may have many negative impacts on nutritional status. Protein and caloric malnutrition are highly prevalent in chronic CAPD patients. In order to evaluate the relationship between nutritional and dialysis adequacy of long-term CAPD patients, twenty patients treated for aver 5 years on CAPD, with a mean age of 50.5+/-12.2 years and dialysis duration of 82.6+/-19.5 months(range 60-116) were studied. Fourteen of the twenty patients(70%) had no residual renal function(RRF). In these twenty patients the mean weekly Kt/Vurea and Ccr were 1.85+/-0.24 and 58.110.8L/week/1.73m2 with the median body surface area(BSA) of 1.61m2. Female(n=7) patients had lower BSA(1A7 vs 1.69m2), TBW(27.7 vs 35.6L), and higher serum albumin (4.01 vs 3.41g/dL), weekly Kt/Vurea(2.02 vs 1.76) than male(n=13) patients. Six patients had nPCR0.9 and nPCR was negatively correlated with age(r=-0.53, p or =3.5g/dL) and 6 had hypoalbuminemia(2.0 and Kt/Vurea was negatively correlated with BSA(r=-0.61, p<0.001). In conclusion, for Korean patients on long-term CAPD, small body size is the key for adequate dialysis and nutrition. Low serum albumin levels may be related with high peritoneal transport.

The Efficacy and Safety of Cyclosporin A(Cipol-N(R) soft capsule) in Adult Nephrotic Syndyrome: 16 Weeks, Open Label, Multicenter Study(Phase III Clinical Trial / 대한신장학회잡지

A multicenter prospective study was done in four-university hospital to evaluate the efficacy and safety of cyclosporin A(CyA, Cipol-N(R)) in 64 patients with adult nephrotic syndrome mean age 34.8 years, male:female 2.4:1, duration of disease 38.0+/-40.9months, 31 patients with MCD, 33 patients with Non-MCD (8 FSGS, 14 MGN, 7 MPGN, 2 lupus nephritis, 1 HBsAg associated GN)]. The prior steroid responses of these patients were 17 steroid dependent, 9 frequent relapser, 4 steroid resistant and 1 other in MCD patients, and 5 steroid dependent, 5 frequent relapser, 22 steroid resistant and 1 other in Non-MCD patients. After a 2-week steroid (predni-solon 10mg/day or deflazacort 12mg/day) run-in period, CyA 5mg/kg/day and prednisolone 10mg/day (or deflazacort 12mg/day) were administered for up to 16 weeks. Of the 64 patients enrolled, ll patients were dropped out prematurely due to adverse events or protocol violation. Of the 53 patients who completed the study, 27 had MCD and 26 had Non- MCD. High response (CR and PR) rate of 68% (36/53) were obtained with CyA treatment in all patients. Although the response rate in MCD was significantly higher than that in Non-MCD (89 vs. 46%, p<0.05) and response rates were significantly different according to the previous steroid responses by univariate analysis, only previous steroid responses affected the response to CyA significantly by Logistic multiple regression analysis (p=0.03, RR 7.08); responses were 84% (27/32) in steroid dependent and frequent relapser patients, and 37% (7/19) in steroid resistant patients. 24-hr proteinuria significantly decreased after 2 weeks and serum albumin and cholesteroi increased significantly after 4 weeks of treatment compared to baseline level. The serum creatinine level was not changed during the study. No serious and unexpected side event was observed. In conclusion, cyclosporine therapy is a safe and effective mode of treatment in patients with ne-phrotic syndrome, especially in those who need prolonged administration of steroids with resulting in unavoidable steroid complications such as frequent relapser and steroid dependent type. The patients with steroid resistant type and contraidications of steroid administration such as DM, aseptic bone neerosis etc. can also be candidates for this treatment.

The Type and Outcome of Exit-Site Infection in CAPD Patients / 대한신장학회잡지

Exit-site infection(ESI) is a troublesome catheter related complication of CAPD that may lead to peritonitis and require catheter removal, ESI is variably defined and classified. The rate of ESI and the outcome of treatment are also variably reported in literature. We conducted a retrospective study of 58 episodes of ESI(40 patients) between August 1997 and February 1999, and evaluated the episodes and types of ESI, organism isolated from ESI and their sensitivity, outcome of ESI, number and reason for catheter loss, and the current modality. The mean age was 48.9+/-11.5 years(31-70) and the male to female ratio was 22:18. The mean duration of CAPD before ESI was 34.1+/-29.6 months (1.5-114.2), and diabetic nephropathy was the cause of ESRD in 17.5% of cases. The types of catheter were two-cuff, coiled Tenckhoff in 17 patients, two-cuff, coiled swan-neck in 10 patients, two-cuff, straight swan-neck in 10 patients, and two-cuff, straight Tenckhoff in 3 patients. According to Twardowski's classification, acute infection in 33 patients and chronic infection in 25 patients were noted. Causative organisms of ESI were S. aureus, S. epidermidis, Pseudomonas, and E. cali in diminishing order of frequency. S. aureus was the most common organism in acute infection, and S. epidermidis was the most common organism in chronie infection. The mean duration of CAPD before ESI was 27.6+/-27.2 months in acute infection, and 42.8+/-30.8 in chronic infection (p<0.05). The duration of antibiotic treatment was 19.9+/-14.4 days in acute infection, and 42.7+/-27.2 days in chronic infection(p<0.05). In acute infection, peritonitis developed in 2 patients and 1 catheter was removed. In chronic infection, peritonitis developed in 1 patient and the catheter was removed. Three patients had the external cuff shaved due to persistent ESI which was unresponsive to antibiotics and local care. By the end of the study, 36 patients(90%) were still on CAPD, 2 patients(5%) had transferred to hemodialysis, and 2 patients(5%) had died. The cause of death was peritonitis in 1 patient, and cachexia in the other patient. In conclusion, exit-site infection responded relatively well to conservative treatment. However, exit-site infection is one of the major causes of catheter failure in CAPD. Therefore, careful exit-site care and examinations are needed.

Changes of Circulating Blood Volume and Plasma Nitric Oxide Level During Hemodialysis: Relationship to Intradialytic Hypotension / 대한신장학회잡지

No abstract available.

Malignancy Following Renal Transplantation / 대한이식학회지

PURPOSE: Survival rate after renal transplantation has increased after intense immunosuppressive agents and sophisticated operative techniques were introduced, but incidences of malignancy increase with time after transplantation. METHODS: We reviewed our experiences about post-transplant malignancy in patients who received renal allografts in our hospital from January 1981 to December 1999. The incidences and types of malignancy were analysed in 241 renal allograft recipients, who were followed-up for 1265 patient-years. RESULTS: Seven malignancies were found in 241 patients (2.9%). The mean age of these patients at diagnosis of malignancy was 45.5 years and the average interval between transplantation and diagnosis of malignancy was 34.9 (9.8-71.6) months. The types of malignancy were non-Hodgkin's lymphoma (n=2; CNS and nasal cavity), colon cancer with metastasis (n=2), in situ carcinoma of uterine cervix (n=1), follicular carcinoma of thyroid (n=1) and transitional cell carcinoma of bladder (n=1). Surgical resection was performed in 5 patients and 2 of them developed distant metastasis during follow-up periods. Radiotherapy was performed in 2 patients with non-Hodgkin's lymphoma and 1 patient with cord compression due to vertebral metastasis. Four patients are now alive and 3 of them have functioning renal allografts. CONCLUSION: We reviewed the incidences and types of post-transplant malignancy in our center and concluded that regular screening for malignancy and meticulous diagnostic approach for suspected symptoms or signs are important to immunosuppressed renal allograft recipients.

Percentage of Korean CAPD patients meeting DOQI guidelines - Analyzed using the computerized urea kinetic modeling - / 대한내과학회지

The DOQI guidelines recommend that the delivered PD dose should be a total weekly Kt/Vurea and Ccr values of at least 2.0 and 60 L/week/1.73 m2 for CAPD patients. To achieve these recommended guidelines, the standard regime of four 2-L daily exchanges may not be sufficient even for Oriental patients whose body size are relatively smaller than those of Westerners. However, the option of a two-and-a-half liter bag (2.5L) and a simple automated overnight exchange device for a fifth exchange are not available in some countries. In order to evaluate the percentage of CAPD patients who receive dialysis meeting DOQI guidelines in different dialysis prescriptions, 110 Korean patients, treated for over a 3 month on CAPD, with a mean age of 46.912.6 years and dialysis duration of 37.6+/-28.1 months (range 3-116), were studied. METHODS: Baseline urea kinetic data from a 24-hour dialysate collection was obtained and analyzed using the computerized urea kinetic model of peritoneal urea transport (PACK-PD, vers 1.01, Fresenius). The potential Kt/Vurea and Ccr values using four 2L and 2.5L daily exchanges were calculated with the PC program. RESULTS: The mean weekly Kt/Vurea and Ccr values were 2.01+/-0.67 and 66.4+/-29.6 L/week/1.73 m2 respectively, with a median body surface area (BSA) of 1.61 m2 (75th percentile 1.73 m2). The mean 24 hour dialysate-to-plasma creatinine ratio was 0.75+/-0.16. Fourty-five of the 110 patients (41%) had no residual renal function. Upon logistic regression analysis, Kt/Vurea was independent factor affecting serum albumin and NPCR. 1) In forty-eight (44%) of the 110 patients, both Kt/Vurea and Ccr values with four 2-L daily exchanges were adequate. In twenty-two (20%), one of Kt/Vurea and Ccr values with four 2-L daily exchanges was inadequate. In fourty (36%), both Kt/Vurea and Ccr values with four 2-L daily exchanges were inadequate. 2) In eighty-four (77%) of the 110 patients, both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were adequate. In nineteen (17%), one of Kt/Vurea and Ccr values with four 2.5-L daily exchanges was inadequate. In seven (6%), both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were inadequate. 3) In three (7%) of the fourty-five anuric patients, both Kt/Vurea and Ccr values with four 2-L daily exchanges were adequate. In eleven (24%), one of Kt/Vurea and Ccr values with four 2-L daily exchanges was inadequate. In thirty-one (69%), both Kt/Vurea and Ccr values with four 2-L daily exchanges were inadequate. 4) In twenty-seven (60%) of the fourty-five anuric patients, both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were adequate. In thirteen (29%), one of Kt/Vurea and Ccr values with four 2.5-L daily exchanges was inadequate. In five (11%), both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were inadequate. CONCLUSION: The anuric Korean patients may need four 2.5L daily exchanges for acceptable adequacy target. Special attention must be given to those patients with no residual renal function.

Continuous Ambulatory Peritoneal Dialysis(CAPD) in Patients with Diabetic Nephropathy / 대한신장학회잡지

OBJECTIVE: Diabetic nephropathy is one of leading causes of end stage renal disease(ESRD). The ability to control anemia and hypertension without sudden drastic body fluid changes was thought to favor CAPD over hemodialysis for the management of diabetic ESRD with severe cardiovascular disease. To assess survival and risk factors in diabetic end stage renal failure, clinical studies were carried out on the 68 cases on CAPD who had been treated from January 1988 to February 1997. Methods - The mean age was 55.5 years and the sex distribution was 43 males to 25 females. Mean CAPD duration was 16.4 months ranged from one to 68 months. Five patients had insulin-dependent dia- betes ; 63 had non-insulin-dependent diabetes. Mean duration of diabetes was 13.8 years. All patients used curl catheter. Blood glucose was controlled by oral hypoglycemics(n=17) or subcutaneous regular insulin(n=51). Results - The incidence of peritonitis was 1.1 episodes/patient-year and exit site infection was 0.3 episodes/patient-year. Other complications were lea- kage, catheter dislodgement, transient hypotension. Mean hospital stay was 48.6 days/patient-year. Patient survival rates at 1, 2, 3, and 4 years were 73, 51, 30, and 30%, respectively for diabetic CAPD patients and 92, 85, 72, and 68%, respectively for non-diabetic patients. Diabetic CAPD patients had significantly lower survival when compare to nondiabetics(p<0.01). Catheter survival rates were 85% at one year, and 42% at three years in diabetics. Catheter were removed in 19 cases and the causes were peritonitis(84.2%) and catheter obstruction and malfunction(15.8%). By the end of the study, 38.2% of the patients were still on CAPD, 44.19% had died, 17.6M had transferred to hemodialysis. Common cause of deaths were cachexia, CAPD peritonitis with sepsis, cerebrovascular accidents and cardiovascular complications. CONCLUSION: Although diabetic CAPD patients had significantly lower survival compared to non-diabetics, CAPD seems a good renal replacement modality for patients with diabetic renal failure as yet.

The Risk of Aspiration in Laryngeal Mask Airway: Laryngeal Mask Airway vs Endotracheal Tube

BACKGROUND: There were several studies for the incidence of gastroesophageal reflux associated with the laryngeal mask airway(LMA), but the results of those studies were much different much different from one another. The aim of this study was to compare the incidence of gastroesophageal reflux and regurgitation of gastric contents between the LMA and the endotracheal tube(ETT). METHOD: Ninety patients scheduled for elective orthopedic surgery with a standardized general anesthetic technique were randomly allocated to receive either a LMA(n-49) or a ETT(n=41) for airway management. The esophageal manometry was carried out for the exclusion of esophageal motility disorders and the 24-hour ambulatory pH metry was done from one day before the operation. A methylene blue(50mg) capsule was swallowed just before the induction and the simultaneous recordings of pH were maintained during anesthesia. At the end of anesthesia, the episodes of regurgitation of gastric contents above hypopharynx were analyzed by the pharyngeal blue staining and the pH metric data were analyzed for the detection of gastroesophageal relux episodes during anesthesia. RESULTS: There was no significant difference in the incidence of gastroesophageal relux(pH< or =4) between two groups; only two patients in LMA and three patients in ETT had reflux episodes during the removal or arousal phase. There was no episode of the pharyngeal blue staining in both group. All of the gastroesophageal reflux patients in both group developed a cough or straining during those phases. There was no clinical evidence of aspiration of gastric contents in both group. CONCLUSION: In comparison with ETT, use of LMA does not appear to increase the incidence of gastroesophageal reflux and regurgitation above hypophryngeal level in positive pressure ventilating patients during long surgical procedures. Therefore, the risk of aspiration in LMA will not be much more than ETT.