Effects of preanesthetic single administration of dexmedetomidine on the remifentanil and propofol requirement during laparoscopic cholecystectomy

BACKGROUND: Dexmedetomidine, an α2-adrenergic agonist, can be used for sedation and as an adjuvant to anesthetics. This study aimed to evaluate the effects of preanesthetic administration of dexmedetomidine on the propofol and remifentanil requirement during general anesthesia and postoperative pain in patients undergoing laparoscopic cholecystectomy. METHODS: Sixty patients were randomly assigned to group D or S (n = 30 each). Dexmedetomidine (0.5 µg/kg) and a comparable volume of saline were administered in groups D and S, respectively, over a 10 minutes period before induction. General anesthesia was induced and maintained with propofol and remifentanil; the bispectral index was maintained at 40–60. The intraoperative remifentanil and propofol dosages were recorded, and postoperative pain was assessed using a visual analog scale (VAS). RESULTS: In groups S and D, propofol dosage was 8.52 ± 1.64 and 6.83 ± 1.55 mg/kg/h, respectively (P < 0.001), while remifentanil dosage was 7.18 ± 2.42 and 4.84 ± 1.44 µg/ kg/h, respectively (P < 0.001). VAS scores for postoperative pain were 6.50 (6–7) and 6.0 (6–7), respectively, at 30 minutes (P = 0.569), 5 (4–5) and 4 (3–5), respectively, at 12 hours (P = 0.039), and 2 (2–3) and 2 (1.25–2), respectively, at 24 hours (P = 0.044). The Friedman test revealed that VAS scores changed over time in both groups (P < 0.001). CONCLUSIONS: Preanesthetic single administration of a low dose of dexmedetomidine (0.5 µg/kg) can significantly decrease the remifentanil and propofol requirement during short surgeries and alleviate postoperative pain.

Posterior Nutcracker Syndrome with Microscopic Hematuria / 대한내과학회지

Nutcracker syndrome (NCS) refers to left renal vein compression with impaired blood outflow. The etiology of NCS has been attributed to various anatomic anomalies. Posterior NCS is caused by compression of the retroaortic left renal vein between the aorta and spine. The classic symptoms of NCS include left flank pain with gross or microscopic hematuria. The frequency and severity of the syndrome vary from asymptomatic microhematuria to severe pelvic congestion. For this reason, diagnosis of NCS is difficult and often delayed. Here, we report a case of posterior NCS that was incidentally discovered.

Posterior Nutcracker Syndrome with Microscopic Hematuria / 대한내과학회지

Nutcracker syndrome (NCS) refers to left renal vein compression with impaired blood outflow. The etiology of NCS has been attributed to various anatomic anomalies. Posterior NCS is caused by compression of the retroaortic left renal vein between the aorta and spine. The classic symptoms of NCS include left flank pain with gross or microscopic hematuria. The frequency and severity of the syndrome vary from asymptomatic microhematuria to severe pelvic congestion. For this reason, diagnosis of NCS is difficult and often delayed. Here, we report a case of posterior NCS that was incidentally discovered.

The effect of intrathecal baclofen single injection on neuropathic pain

BACKGROUND: Baclofen is a gamma-aminobutyric acid B-receptor agonist, which is usually used for patients with spasticity or patients with nerve injury inducing both spasticity and neuropathic pain. Both oral administration and intrathecal injection via a continuous infusion pump are common treatment methods. The aim of this study was to evaluate the effectiveness of a series of three individual injections of intrathecal baclofen for neuropathic pain without spasticity. METHODS: Thirty-one patients with neuropathic pain were treated with a series of three monthly individual injections of intrathecal baclofen without pump implantation A dose of 50 µg of baclofen was used. 10-cm visual analog scale (VAS) scores of spontaneous pain, allodynia, and hyperalgesia were recorded a week after each injection. Vital signs were monitored to detect any hemodynamic changes, and a myelogram was performed to detect any undesirable cerebrospinal fluid leakage. All patients were hospitalized for at least one day following each injection for close observation and to control any adverse effects. RESULTS: VAS scores of spontaneous pain, allodynia, and hyperalgesia decreased significantly (P < 0.001). The major complications were general weakness, sleepiness, and urinary retention; most of these resolved within one day without any further serious symptoms. CONCLUSIONS: A series of three individual intrathecal baclofen injections was effective for those patients who suffered from neuropathic pain without spasticity or dystonia; no serious complications were observed. However, the average satisfaction score recorded for spontaneous pain was lower than those for allodynia and hyperalgesia.

A Case of Sarcoidosis Associated with Renal Failure in a Kidney Transplant Patient / 대한내과학회지

Sarcoidosis, systemic inflammatory disease characterized by non-caseating granulomas, is rarely associated with renal failure in a kidney transplant. We report a 51-year-old woman with a kidney transplant who was diagnosed to have renal sarcoidosis. After 7 years of renal transplantation, the patient presented with relatively rapid deterioration of renal function and, subsequently, she underwent kidney transplant biopsy. Renal biopsy revealed interstitial nephritis with non-caseating granulomas compatible with granulomatous interstitial nephritis (GIN). She was also found to have granulomatous lymphadenitis and skin lesions. Diagnosis of sarcoidosis was made based on histopathologic findings, the high serum angiotensin converting enzyme level and exclusions of other causes of GIN including tuberculosis, ANCA associated glomerulonephritis and tubulointerstitial nephritis and uveitis syndrome. The patient was started on oral prednisolone, and subsequently her renal function improved.

A Case of Acute Renal Failure Complicated by the Poisoning of Amanita virgineoides / 대한신장학회지

Mushroom poisonings are potentially fatal. Most fatalities are due to the amatoxin that causes fulminant hepatic failure and acute renal failure. We report a patient who developed acute renal failure after ingesting Amanita virgineoides, which required renal replacement therapy, despite recovery of liver injury. A kidney biopsy showed acute tubular necrosis. The patient was recovered with the supportive care and temporary hemodialysis.

Fractional Creatinine Clearance of the Donated Kidney As a Predictor of Graft Function after Living Donor Transplantation / 대한이식학회지

PURPOSE: An insufficient functioning nephron mass might fail to meet the metabolic demands of the recipient and lead to hyperfiltration. This hyperfiltration damage also increase allograft failure rates. During the preoperative evaluation of a potential kidney donor, it is important to estimate the renal function of donated kidney compared with the metabolic needs of the recipient. METHODS: The functional ratio of each kidney was measured using technetium-99m diethylenetriaminepentaacetic acid. The serum creatinine (Scr, mg/dL) and estimated creatinine clearance (Ccr, mL/min/1.73m2) using the Cockcroft-Gault formula were measured and calculated in 82 donors. We excluded recipients who had an episode of rejection, and followed all recipients for more than 12 months posttransplantation. RESULTS: The average functional proportion of the donated kidney was 50.5%+/-4.7% of the total Ccr 83.4+/-18.3 of donors. The Scr of recipients at 1,3,6 and 9months posttransplantation were significantly (P<.05) correlated with the fractional Ccr of thedonated kidney; however Scr at 1 year was not correlated (P=.307). Furth-ermore the Ccr of the recipient at 1, 3, and 6months post transplantation were significantly (P<.05) correlated with fractional Ccr ofthe donated kidney; however the Ccr at 9months and 1 year were not correlated (P=.094 and.141, respectively). CONCLUSION: The Scr and Ccr of recipients within 6 months after transplantation may depend on the functional mass of the donated kidney, which should be estimated prior to kidney donation and compared with the metabolic demands of the potential recipient.

Impacts of Metabolic Demand and Renal Mass Supply on the Early Graft Function Following Living Donor Renal Transplantation / 대한이식학회지

PURPOSE: Chronic rejection accounts for the majority of late renal graft losses and there is good evidence that both immunologic and non-immunologic factors are important in late graft loss. The hyperfiltration hypothesis postulates that kidneys with reduced renal mass will progress toward failure due to hypertrophy of the remaining nephron to meet the excess metabolic demand, eventually leading to nephron exhaustion. The impact of metabolic demand and renal mass supply on the early graft function, especially hyperfiltration phenomenon, remains uncertain. METHODS: In this study, we analyzed age, gender, body weight, height, body surface area (BSA), lean body weight (LBW), and serum creatinine (SCr) of both donors and recipients. We weighed the donated kidney and measured the recipient's SCr and LBW for six months postoperatively. Modified Cockcroft-Gault Equation standardized for BSA was used to calculate renal glomerular filtration rate (CrCl, mL/min/1.73 m2). The variables and the CrCl of the 3rd day and 6th month were analyzed with accordance to donor/recipient LBW ratio(D/R LBW) and graft weight/recipient LBW (GW/RLBW) by independent sample t-test and paired t-test using SPSS, and P1), the 3rd day and 6th month CrCl were 80.82+/-28.74 and 71.66+/-12.12, respectively. In R group (D/R LBW3), the 3rd day CrCl was 86.08+/-25.13, which was significantly decreased to 73.48+/-11.64 at the 6th month (P=0.023). In L group (GW/RLBW< or =3), the 3rd day and 6th month CrCl were 66.95+/-19.94 and 73.34+/-10.60 (P=0.158), respectively. the 3rd day CrCl of H group was higher than that of L group significantly (P=0.047), but 6th month CrCl showed no difference between the two groups (P=0.975). CONCLUSIONS: The 3rd day CrCl represents early graft function well. GW/RLBW has a strong correlation with early graft function. In L group with low early graft function, CrCl was tended to be increased to meet the metabolic demand for following the 6 months. Conversely, in H group with high early graft function, CrCl was decreased to reduce the excess graft function. So the 6th month CrCl represents adapted graft function. In this study, therefore, we postulate that the hyperfiltration or hypofiltration develops according to metabolic demand and renal mass supply.

The Effectiveness of the Serum IgA Level in Diagnosing IgA Nephropathy / 대한신장학회잡지

BACKGROUND: Immunoglogulin A(IgA) nephropathy is the most common primary glomerular disease throughout the world. 30-50% of patients with IgA nephropathy(IgAN) have high serum IgA concentrations. However, we do not know if the degree of elevation in IgA level increases the likelihood of having IgAN. Neither do we know if the IgA level has any association with pathological findings of IgAN. METHODS: We analyzed the relationships between IgAN and the levels of serum IgA which has been a routine part of the study in all patients with glomerulonephritis in our institution for the last 4 years. We reviewed 270 patients in whom the pathological diagnosis and the results of their IgA levels were both available. RESULTS: Of 80 patients who were IgA nephropathy, 26 patients(32.5%) had higher than normal cut- off value of serum IgA(385 mg/dL). In contrast, 8.9 % of patients with other types of glomerulonephropathies showed the values above normal(p<0.0001). The risk ratio for an increase of one unit of the IgA level was 1.0025(logistic regression, p=0.0043), which was increased to 1.0079 when patients with low complement levels were excluded from the analysis. The data were also analyzed according to the immunofluorescence microscopic findings of IgAN, which were found to have no significant correlation with IgA concentrations. CONCLUSION: The IgA level is a risk factor for IgAN throughout the whole range. However, it does not correlate with the IgA deposition in the renal tissue. We believe that this study will help understanding the interpretation of IgA levels in patients with IgAN.

Acute Hyperphosphatemia and Hypocalcemia Following the Administration of Phosphate-containing Laxatives in Patients with End Stage Renal Disease / 대한신장학회잡지

Oral or rectal sodium phosphate(NaP) preparation is commonly used for the colonic cleansing. Since the sole route of excretion of absorbed phosphate is renal, diminished renal function will limit the ability to excrete a sudden phosphate load. To date, about 20 adult cases of hyerphosphatemia associated with oral or rectal sodium phosphate solution have been reported, but not a single case in Korea to our knowledge. We report two cases of hyperphosphatemia and hypocalcemia after the administration of NaP(Colclean(R)) to reemphasizes the potential hazard of sodium phosphate bowel preparation in patients with compromised renal function.

The Expression of Peforin, Fas-ligand, and Granzyme B in Peripheral Blood Lymphocytes of Renal Allograft Recipients / 대한신장학회잡지

BACKGROUND: Previous findings demonstrated that the expression of cytotoxic effector molecules is increased in acute rejection of renal allografts. In the present study, we serially examined the gene expression of perforin, granzyme B and Fas ligand(FasL) in peripheral blood lymphocytes(PBLs) of renal allograft recipients to assess the potential of their expression as a marker of acute rejection. METHODS: PBLs were isolated from blood samples taken on days 2, 4, 6, 8, 10 and 12 after transplantation. Competitive PCR was performed to evaluate the abundance of mRNA of perforin, granzyme B and FasL. The mean value of each molecule plus 2 SD for the control group was set as a discriminatory level. RESULTS: When all measured samples were compared, perforin expression was significantly higher in patients with acute rejection than in the control group(1.84+/-3.01 versus 0.71+/-0.48, p=0.01). The percentage of perforin expression exceeding the discriminatory level was also significantly higher in patients with acute rejection(p=0.0003). Five patients in the rejection group(5/7, 71.4%) showed perforin expression exceeding the discriminatory level, while only 1 patient in the control group did so(1/8, 12.5%)(p= 0.02). Perforin expression of days 0 and 1 of rejection crisis was the highest over the study period. No consistent pattern of granzyme B and FasL expression was identified in relation to rejection crisis. CONCLUSION: Gene expression of perforin by PBLs was upregulated in accordance with acute rejection, thus offering the possibility that it may be utilized as a marker of acute rejection.

Type A Aortic Dissection with Aortocaval Fistula: Report of 1 case / 대한흉부외과학회지

Acute or chronic aortic dissection may lead to the rupture, which is the major cause of death. A dissecting aneurysm of ascending aorta(Stanford type A dissection) can rupture into the superior vena cava producing a aortocaval fistula, which is rare, but has been reported mostly in the cases of abdominal aortic aneurysm. We report a case of 67-year-old man with type A chronic dissection and aortocaval fistula, presenting symptoms of superior vena syndrome. The preoperative diagnosis was composed of radiologic examinations, including computed tomography, magnetic resonance imaging angiography and aortography. The dissecting aneurysm was resected and replaced, and the aortocaval fistula was repaired under deep hypothermic circulatory arrest. The details are described here.

The Clinical Experience of Hemodialyzer Reuse / 대한신장학회잡지

The major clinical advantages of dialyzer reuse are improved biocompatibility and a decrease in the frequency of the first use syndrome. Dialyzer reuse has made it possible to use biocompatible high flux membranes of the high price. Although dialyzer reuse in chronic hemodialysis patients is commonly practiced in the United States, it is not widely accepted in Korea. At Ajou University Hospital, we have reprocessed dialyzers since March 2000, and here we report our clinical experience for the 1st 8 weeks. We used high flux dialyzers with reprocessing practice in 24 chronic hemodialysis patients. Dialyzer reprocessing was performed by an automated machine(Renatron) using Renalin. We limited reuse upto 20 times, and we were able to reuse dialyzers upto this number in 17 patients. During the study period, no significant complication was observed as a result of the reuse program. Kt/Vurea and urea reduction ratio(URR) were not different between high and low flux dialyzers(1.41+/-0.29 vs 1.61+/-0.41 for Kt/Vurea and 66.70+/- 6.40% vs 65.69+/-5.63% for URR). In contrast, beta2-microglobulin(beta2M) reduction ratio and clearance were greater in high flux dialyzers than low flux dialyzers(p<0.001, -9.52+/-20.28% vs 42.00+/-8.61% for beta2M reduction ratio and 9.54+/-11.71mL/min vs 48.54+/-14.33mL/min for beta2M clearance). Kt/Vurea, URR, beta2M reduction ratio and beta2M clearance did not deteriorate with the increasing number of reuse. The predialysis values of beta2M decreased by 51% after 19 uses(p<0.001, 37.04+/-13.39 to 18.98+/-3.41mg/L). In summary, during the short pilot study period of 8 weeks, no significant clinical complication was encountered as a result of dialyzer reuse, and our results confirmed the effects of high flux dialyzers on removal of beta2M.

The Clinical Experience of Hemodialyzer Reuse / 대한신장학회잡지

The major clinical advantages of dialyzer reuse are improved biocompatibility and a decrease in the frequency of the first use syndrome. Dialyzer reuse has made it possible to use biocompatible high flux membranes of the high price. Although dialyzer reuse in chronic hemodialysis patients is commonly practiced in the United States, it is not widely accepted in Korea. At Ajou University Hospital, we have reprocessed dialyzers since March 2000, and here we report our clinical experience for the 1st 8 weeks. We used high flux dialyzers with reprocessing practice in 24 chronic hemodialysis patients. Dialyzer reprocessing was performed by an automated machine(Renatron) using Renalin. We limited reuse upto 20 times, and we were able to reuse dialyzers upto this number in 17 patients. During the study period, no significant complication was observed as a result of the reuse program. Kt/Vurea and urea reduction ratio(URR) were not different between high and low flux dialyzers(1.41+/-0.29 vs 1.61+/-0.41 for Kt/Vurea and 66.70+/- 6.40% vs 65.69+/-5.63% for URR). In contrast, beta2-microglobulin(beta2M) reduction ratio and clearance were greater in high flux dialyzers than low flux dialyzers(p<0.001, -9.52+/-20.28% vs 42.00+/-8.61% for beta2M reduction ratio and 9.54+/-11.71mL/min vs 48.54+/-14.33mL/min for beta2M clearance). Kt/Vurea, URR, beta2M reduction ratio and beta2M clearance did not deteriorate with the increasing number of reuse. The predialysis values of beta2M decreased by 51% after 19 uses(p<0.001, 37.04+/-13.39 to 18.98+/-3.41mg/L). In summary, during the short pilot study period of 8 weeks, no significant clinical complication was encountered as a result of dialyzer reuse, and our results confirmed the effects of high flux dialyzers on removal of beta2M.

Cyclophosphamide: Induced lung toxicity in a patient with Wegener's granulomatosis / 대한내과학회지

Lung toxicity associated with cyclophosphamide use is a rare but serious side effect, that may result in a fatal course. However no such cases have been reported in Korea, so clinicians would not be alert to this adverse effect. We recently experienced a woman with Wegener's granulomatosis and idiopathic pulmonary fibrosis. This patient had been administered 12 grams of cyclophosphamide for 4 months. At that time of admission, She felt aggravating dyspnea on exertion for 2 weeks. Her chest x-ray and high resolution CT revealed aggravated reticular opacities and ground glass appearances. Dyspnea was improved and ground glass appearances on HRCT was disappeared after discontinuation of cyclophosphamide. We diagnosed this case as cyclophosphamide-induced pneumonitis and report it with a brief review of the literature.

A Case of Rheumatoid Arthritis Associated with Renal Amyloidosis and Crescentic Glomerulonephritis / 대한신장학회잡지

A case of renal amyloidosis with crescentic glomerulonephritis associated with rheumatoid arthritis is described. A 60-year-old female with 15 years' history of rheumatoid arthritis developed nephrotic syndrome followed by rapid deterioration of renal function. Glomerular amyloid deposition and sclerotic change was present in kidney biopsy specimen and crescentic change was found in 85% of the glomerulus. Electron microscopic finding of glomerulus showed randomly oriented, rigid-appearing, long nonbranching fibrils. The patient was treated with intravenous high-dose methylprednisolone pulses combined with intravenous cyclophosphamide followed by oral corticosteroids. Three months after the above treatment, renal function gradually improved, reaching serum creatinine level to 2.5 mg/dL. But the nephrotic range proteinuria persisted.

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 Effect of ACE Inhibitors on The Gene Expression of TGF-beta and TNF-alpha in Renal Tissues from Patients with IgA Nephropathy / 대한신장학회잡지

Progressive nephropathies are characterized by the enhanced accmulation of extracellular matrix in the kidney. Overproduction of transforming growth factor-beta(TGF-beta) was shown to result in pathological fibrosis of tissue via the accumulation of extracellular matrix proteins. It has been proposed that angiotensin II stimulates the production of TGF-beta. Despite accumulating volume of data supporting the effects of angiotensin converting enzyme(ACE) inhibitors in the attenuation of TGF-beta in vitro and in rats, studies in humans are absolutely lacking. There is evidence that TNF-alpha expression is increased in various glomerulonephritis. The present study sought to determine the effects of ACE inhibitors on TGF-beta1 and TNF-alpha in patients with IgA nephropathy. Using competitive polymerase chain reaction, TGF-beta1 and TNF-alpha mRNA abundance were measured. Patients taking ACE inhibitors showed significantly lower renal TGF-beta1 gene expression compared with patients not on these medications(ratios of TGF-beta1/beta-actin, 4.27+/-0.62 versus 14.81+/-3.87, p<0.05), whereas no difference was noted between patients on ACE inhibitors and normal controls(4.27+/-0.62 versus 2.78+/-0.71). ACE inhibitor therapy did not affect the TNF-alpha mRNA expres- sion in renal tissue. In conclusion, we observed a significant reduction of the TGF-beta1 expression in the kidney by ACE inhibitors, and this suggests that the effects of ACE inhibitors observed in animals can be extrapolated to patients with chronic renal disease.

Blood Volume Change and Side Effects during Various Sodium Ramping in Hemodialysis / 대한신장학회잡지

Chronic hemodialysis patients frequently experience hemodialysis(HD)-related side effects caused by excessive ultrafiltration and abrupt change of osmolality. Sodium ramping in HD is known to reduce ultrafiltration-related side effects, but it frequently induces symptoms related to sodium overload. We wanted to know the relationship between blood volume changes and the side effects related to ultrafiltration during hemodialysis and whether we can individualize various sodium ramping methods according to the effect of change in blood volume( BV) and side effects of sodium ramping. We studied 9 hypotension-prone patients during HD. The duration of the study lasted for 5 weeks, each week using different sodium ramping protocols: protocol 1; dialysate [Na+] of 140mEq/L, protocol 2; dialysate [Na+] same as the predialysis serum [Na+], protocol 3; dialysate [Na+] was 20mEq/L greater than that of the patient's serum for 1hr, 10mEq/L greater than patient's serum [Na+] for 2hr and then the same as patient's serum [Na+] for the last 1hr, protocol 4; at the beginning of dialysis, dialysate sodium was ramped to 20mEq/L above the patient's serum sodium and then on a straight linear fashion lowered to the predialysis serum [Na+] at the end of dialysis, protocol 5; sodium was constantly ramped to 10 mEq/L above serum [Na+]. We measured the BV with Crit-Line IIR(In-Line Diagnostics, Corp., Riverdale, USA), the blood pressure during each HD and interdialytic weight gain. We documented subjective symptoms which occurred during the 5 treatment protocols by patient's questionnaire after each HD. The results were as follows. 1) The mean age of the patients(M:F=3:6) was 54.1years and 6 patients were diabetics. 2) There was no significant difference in the BV among the 5 protocols in both whole study population and individual. Neither was there a statistically significant difference in the BV with respect to hypotension during HD. 3) There were no episodes of hypotension(P value <0.001) with protocols 3, 4, 5 compared to protocols 1 and 2. 4) Three patients during protocols 4 and 5 experienced more thirst after HD than during protocol 1 and one patient during protocol 4, 5 had more interdialytic weight gain than the protocol 1. As a whole, patients while on protocol 4 & 5 experienced more thirst than protocol 1 but patients during protocol 3 experienced the same degree of thirst as protocol 1. In summary, sodium ramping reduced HD-related side effects but this benefit could not be explained on the basis of blood volume change measured by the Crit-Line IIR. Protocol 3 may be more appropiate sodium ramping method in 4 of the 9 patients. These data suggest that protocol 3 may be used before protocol 4, 5 when we apply sodium ramping to the patients who frequently have hypotension during HD.

The Effect of ACE Inhibitors on the Gene Expression of Various Cytokines in Peripheral Blood Mononuclear Cells from Patients with Glomerular Diseases: TGF-beta, IL-6, IL-10 and TNF-alpha / 대한신장학회잡지

Angiotensin II(ANG II) has been known to induce systemic and glomerular hypertension, which leads to renal tissue injury and progressive fibrosis of kidney. Some effects of ANG II may be mediated by its effect on the cytokine synthesis. In the present study, we investigated the effect of ANG II inhibition on the expression of various cytokines implicated in the pathogenesis and progression of the kidney disease. Blood samples of 11 patients with glomerulonephritis were obtained before the ACE inhibitor therapy and then while they were taking ACE inhibitors. Using peripheral blood mononuclear cells(PBMC) harvested from the samples, RT-PCR was performed to evaluate the changes in mRNA expression of TGF-beta1, IL-6, TNF-alpha and IL-10. The ratios of target cytokines and beta-actin were calculated. TGF-beta1 mRNA expression was decreased in five pat ients after ANG II inhibition with ACE inhibitors, while it was increased in the remaining six patients. ACE inhibitors consistently decreased IL-6 mRNA expression in all 11 patients. IL-10 expression was decreased in 4 patients, and increased in 3 patients after ANG II inhibition. It was not expressed in 4 patients. TNF-alpha expression was increased in 8 patients, and decreased in only 1 patient. In two patients, it was not changed while on ACE inhibitors. Conclusion: ACE inhibitors attenuate IL-6 expression consistently in all 11 patients. This is the first-time demonstration of the in vivo inhibitory effect of ACE inhibitors on IL-6 mRNA expression in humans. The lack of significant suppression of TGF-beta1 in PBMC suggests that the in vivo attenuating effect of ACE inhibitors on TGF-beta1 may be derived from renal hemodynamic changes. The tendency of heightened expression of TNF-alpha confirms the previous investigations in which IL-6 was shown to down regulate TNF-alpha expression