Effect of pelvic drain displacement on anastomotic leakage-related morbidity after rectal cancer surgery

Purpose@#Drain insertion after proctectomy is common in clinical practice, although the effectiveness of drains has been questioned. However, drains are commonly displaced after surgery. We hypothesized that drain displacement is associated with clinical outcomes and aimed to assess differences in clinical outcomes, such as overall morbidity, including anastomotic leakage (AL), reintervention rates, length of hospital stay, and mortality rates, between patients who experienced displaced drains and those who did not. @*Methods@#Rectal cancer patients who underwent proctectomy at a single institution between January 2015 and December 2020 were retrospectively reviewed. Clinical characteristics were compared between patients who experienced displaced drains and those who did not. The primary endpoint was the occurrence of reintervention in patients with AL. The secondary endpoints were overall morbidity rates, AL rates, length of hospital stay, and mortality within 30 days. @*Results@#Among 248 patients who underwent proctectomy, 93 (37.5%) experienced displaced drains. A higher proportion of patients who experienced displaced drains required reintervention due to AL than those who did not experience displaced drains (odds ratio, 3.61; 95% confidential interval, 1.20–10.93; p = 0.016). However, no significant difference was found in the overall morbidity rate, mortality, and length of hospital stay between the groups. @*Conclusion@#Drain displacement does not worsen outcomes such as overall morbidity rate, mortality, and length of hospital stay after proctectomy but is associated with an increase in the need for reintervention in patients with AL.

Effect of pelvic drain displacement on anastomotic leakage-related morbidity after rectal cancer surgery

Purpose@#Drain insertion after proctectomy is common in clinical practice, although the effectiveness of drains has been questioned. However, drains are commonly displaced after surgery. We hypothesized that drain displacement is associated with clinical outcomes and aimed to assess differences in clinical outcomes, such as overall morbidity, including anastomotic leakage (AL), reintervention rates, length of hospital stay, and mortality rates, between patients who experienced displaced drains and those who did not. @*Methods@#Rectal cancer patients who underwent proctectomy at a single institution between January 2015 and December 2020 were retrospectively reviewed. Clinical characteristics were compared between patients who experienced displaced drains and those who did not. The primary endpoint was the occurrence of reintervention in patients with AL. The secondary endpoints were overall morbidity rates, AL rates, length of hospital stay, and mortality within 30 days. @*Results@#Among 248 patients who underwent proctectomy, 93 (37.5%) experienced displaced drains. A higher proportion of patients who experienced displaced drains required reintervention due to AL than those who did not experience displaced drains (odds ratio, 3.61; 95% confidential interval, 1.20–10.93; p = 0.016). However, no significant difference was found in the overall morbidity rate, mortality, and length of hospital stay between the groups. @*Conclusion@#Drain displacement does not worsen outcomes such as overall morbidity rate, mortality, and length of hospital stay after proctectomy but is associated with an increase in the need for reintervention in patients with AL.

High Peritoneal Transport Status is Not an Independent Risk Factor for High Mortality in Patients Treated with Automated Peritoneal Dialysis

We undertook this study to elucidate whether baseline peritoneal membrane transport characteristics are associated with high mortality in incident automated peritoneal dialysis (APD) patients. This retrospective study includes 117 patients who started APD at Yonsei University Health System from 1996 to 2008 and had a PET within 3 months of APD initiation. High transporters were significantly older and had a higher incidence of cardiovascular disease. Patient survival for years 1, 3, and 5 were 85%, 64%, and 35% for high transporter and 94%, 81%, and 68% for non-high transporter group (P<0.01). Multivariate analysis revealed that age, diabetes, cardiovascular disease, serum albumin level, and residual renal function were independently associated with high mortality in APD patients. In contrast, high transport status was not a significant predictor for mortality in this population when the other covariates were included. Even though high transport was significantly associated with mortality in the univariate analysis, its role seemed to be influenced by other comorbid conditions. These findings suggest that the proper management of these comorbid conditions, as well as appropriate ultrafiltration by use of APD and/or icodextrin, must be considered as protective strategies to improve survival in peritoneal dialysis patients with high transport.

Correlates of the Severity of Coronary Atherosclerosis in Long-term Kidney Transplant Patients

Coronary artery disease remains the leading cause of early death and graft loss in renal transplant patients. The aim of this study was to identify clinical and echocardiographic parameters independently associated with the angiographically-determined severity of coronary atherosclerosis in long-term kidney transplant patients. Fifty-two kidney transplant recipients who underwent elective coronary angiography were reviewed retrospectively. Angiographic severity was evaluated using the modified Gensini index (MGI). The mean age at coronary angiography was 52.5+/-7.9 yr with a mean prior transplant duration of 118.1+/-58.8 months. Pearson correlation analysis demonstrated a positive correlation of MGI with transplant duration before coronary angiography and chronic allograft nephropathy, whereas an inverse correlation was demonstrated with ejection fraction and statin use. On subsequent multivariate linear regression analysis, transplant duration before coronary angiography, statin use, and ejection fraction were independently associated with the severity of coronary atherosclerosis in long-term kidney transplant patients. In summary, our study demonstrates that statin use, ejection fraction, and transplant duration before coronary angiography are independent parameters associated with the severity of coronary atherosclerosis in long-term kidney transplant patients. Further investigation is required to reduce the atherosclerotic burden in kidney transplant patients.

Cancer in Patients on Chronic Dialysis in Korea

The study of cancer in patients treated with dialysis in Korea has not been reported. The aim of this study was to investigate the incidence and mortality of cancer among patients on dialysis in Korea. The study subjects were 106 cancer patients (2.3%) out of 4,562 end-stage renal disease (ESRD) patients maintained on hemodialysis (HD) or peritoneal dialysis (PD) at Yonsei University Health System from 1996 to 2005. We excluded patients in whom the diagnosis of cancer preceded dialysis or those who received renal allograft or started dialysis after renal allograft. Seventy- three (69%) of our subjects were male and 33 (31%) were female. The mean age at the time of cancer diagnosis was 57.9+/-11.7 yr. The mean time from the start of dialysis to the diagnosis of cancer was 75.2+/-63.9 months. The most common cancer site was gastrointestinal tract (GIT) (51%) followed by urinary tract (20%), lung (8%), and thyroid (7%). Sixty nine percent of the total mortality was due to cancer. The mean time from diagnosis to death was 2.9+/-2.5 yr. In ESRD patients with cancer, there were no significant differences in mortality rates by dialysis modality. In ESRD patients, the most common cancer was GIT cancer followed by urinary tract cancer. Therefore, careful surveillance of these cancers in ESRD patients is highly recommended.

Icodextrin Improves the Serum Potassium Profile with the Enhancement of Nutritional Status in Continuous Ambulatory Peritoneal Dialysis Patients

The impact of glucose-free icodextrin (ID) for overnight dwell as compared to conventional glucose-containing dialysate (GD) on potassium (K+) metabolism in continuous ambulatory peritoneal dialysis (CAPD) patients has not yet been investigated. Serum K+ in a total of 255 stable patients (116 on GD and 139 on ID) on CAPD for more than 6 months and in 139 patients on ID before and after ID use (Pre-ID and Post-ID) were observed along with nutritional markers in a 2-year study period (Jan. 2006 to Dec. 2007). The prevalence of hypokalemia was similar between patients on GD and ID (16.7% vs 17.3%), but was lower on Post-ID than Pre-ID (17.3% vs 20.5%) without statistic significance. The mean serum K+ level was higher on ID than on GD (P<0.05) as well as Post-ID than Pre-ID (P<0.001). In the multivariate analysis, serum K+ levels were positively correlated with serum albumin, and creatinine in all patients (P<0.05), and ID-use in younger patients (age< or =56, P<0.001). Serum albumin, creatinine, total CO2, and body mass index were significantly higher on Post-ID than Pre-ID. Icodextrin dialysate for chronic overnight dwell could increase serum K+ levels and lower the prevalence of hypokalemia compared to conventional glucose-containing dialysate. The improved chronic K+ balance in CAPD patients on icodextrin could be related to enhanced nutritional status rather than its impact on acute intracellular K+ redistribution.

An Anesthetic Experience in a Patient with Niemann-Pick Disease: A case report / 대한마취과학회지

Niemann-Pick disease (NPD) is an autosomal recessive, lipid storage disorder caused by the deficiency of the lysosomal enzyme sphingomyelinase or defective cholesterol transport from lysosome to cytosol. The clinical symptoms and signs include dysphagia, loss of motor function, hepatosplenomegaly, recurred respiratory infections, seizure, mental retardation, spasticity, myoclonic jerks and ataxia, but vary depending on the type of this disease. We report a successful anesthetic experience, including endotracheal intubation with Glidescope under propofol and remifentanil infusion without neuromuscular blockade, in a 21-year old woman with Niemann-Pick disease for wound revision of gastrostomy site.

A comparison study between mycophenolate mofetil and cyclophosphamide for treatment of proliferative lupus nephritis / 대한내과학회지

BACKGROUND/AIMS: Our study aimed to evaluate the efficacy of MMF as compared with intravenous cyclophosphamide as induction therapy for proliferative lupus nephritis in Koreans. METHODS: Forty-three patients who were diagnosed with proliferative lupus nephritis (WHO Class III and IV) between Jan 2000 and Dec 2006 were included in this study. Nineteen patients were treated with oral MMF (initial dose: 1.0 g/day and then it was increased to 2.0 g/day) and 24 patients were treated with 0.75-1.0 g/m2 of monthly intravenous cyclophosphamide (CP) followed by subsequent treatment with oral corticosteroid (initial dose 1 mg/kg/day and then it was slowly tapered down) for 6 months. The demographic and laboratory findings, the response rate and the adverse events were reviewed retrospectively and these were compared between the two groups. RESULTS: A complete response occurred in 7 out of the 19 patients (36.8%) treated with MMF and in 8 out of the 24 patients (33.3%) treated with CP, and the difference was not significantly different between the two groups (p=0.66). A partial response was achieved in 52.6% and 45.8%, respectively. There were no significant differences of the laboratory findings such as serum albumin, C3, C4, the urine protein/creatinine ratio and serum creatinine after treatment for 6 months. In addition, both groups had similar rates of adverse events. CONCLUSIONS: Our study showed that for the treatment of lupus nephritis, MMF was as effective as IV cyclophosphamide with similar adverse events. This finding suggests that MMF could be an alternative treatment for active lupus nephritis as induction therapy.

Idiopathic Retroperitoneal Fibrosis Associated with Hashimoto's Thyroiditis in an Old-aged Man

Idiopathic retroperitoneal fibrosis (IRPF) is a rare disease characterized by a retroperitoneal inflammatory proliferative fibrosing process. Hashimoto's thyroiditis is the most common inflammatory condition of the thyroid gland; and is a frequently-occurring autoimmune disorder manifesting predominantly in middle-aged women. We report a rare association of IRPF with Hashimoto's thyroiditis in a 67-year-old man demonstrating good response to steroid therapy.

A Case of Rapidly Progressive Glomerulonephritis in a Hepatitis B Virus Carrier Successfully Treated with High dose Immunosuppressive Therapy and Prophylactic Lamivudine / 대한신장학회지

A 35-year-old man, previously hepatitis B surface antigen (HBsAg) carrier, presented with gross hematuria and heavy proteinuria that he had been suffering from for 1 month. Serum creatinine was 4.4 mg/dL. Renal biopsy showed pauci-immune crescentic glomerulonephritis. He received plasmapheresis and was treated with high-dose steroids and cyclophosphamide. Lamivudine was started for the prevention of hepatitis B virus (HBV) activation. Serum creatinine and proteinuria were ameliorated one week after the treatment. There was no sign of HBV activation after six months of treatment. We report a case of rapidly progressive glomerulonephritis in a HBV carrier successfully treated with high dose immunosuppressive therapy and prophylactic lamivudine.

Renal Outcome Following Stenting for Renal Artery Stenosis / 대한신장학회지

PURPOSE: Renal artery stenosis (RAS) causes or deteriorates hypertension and/or renal insufficiency, and is known as a progressive disease. The aim of this study is to reveal the change of renal function after stenting for RAS. METHODS: We retrospectively analyzed 66 patients between 1999 and 2005 who had stenting for RAS. Renal function was assessed by modified MDRD equation. According to baseline glomerular filtration rate (GFR), patients were divided into subgroups with group A (n=37, GFR > or =60 mL/min/ 1.73m2) or group B (n=29, GFR <60 mL/min/1.73m2). Clinical parameters were compared between two groups. RESULTS: A total of 66 patients (male:female=37:29) were studied. The mean age was 61+/-12 years old and the mean follow-up duration was 54+/-27 months. Sixty-one (92.4%) patients had hypertension, 20 (30.3%) had diabetes, and 48 (73%) had unilateral RAS. Group B was older than group A (65+/-9 vs. 58+/-14 years old). The mean body mass index of group B was higher than that of group A. In group A, there was a decrease in the MDRD GFR (from 75+/-11 to 70+/-15 mL/min/1.73m2; p=0.038). In contrast, in group B there was no significant change in the MDRD GFR (from 48+/-9 to 48+/-15 mL/min/1.73m2). In group A and group B, renal function has been improved in 3% and 24%, and stabilized in 70% and 52%, respectively. CONCLUSION: Stenting for RAS has renal function preserving effect in patients with renal insufficiency. Therefore, stenting should be considered as a treatment modality in RAS patients even with deteriorated renal function.

The Effect of Uric Acid on GFR in Early Period after Kidney Transplantation / 대한신장학회지

PURPOSE: Hyperuricemia is a common complication occurring shortly after kidney transplantation. Although increased uric acid level is a risk factor for cardiovascular disease and mortality, the relationship between uric acid level and graft function after transplantation has been a controversial issue. Therefore, we investigated the effects of uric acid on glomerular filtration rate (GFR) and graft survival in the early periods of kidney transplantation. METHODS: Data were collected from 245 patients who underwent kidney transplantation between 2002 and 2004 at Yonsei University Medical Center. Uric acid level and estimated GFR were measured monthly during the first 6 months and then yearly for 3 years. RESULTS: The mean age of the study population was 40.2+/-11.7 years. The proportion of patients with hyperuricemia (uric acid < or =6.8 mg/dL) showed increment during the 3 year follow up. Increased serum uric acid level showed a negative correlation with estimated GFR during the initial 6 months after transplantation (r=-0.026, p<0.05). In Kaplan-Meier analysis, patients with a mean uric acid level higher than 6.8 mg/dL during the first 6 months showed a lower cumulative graft survival during the consecutive 3 years compared to patients with a uric acid level lower than 6.8 mg/dL (HR 1.7, p=0.003). CONCLUSION: Uric acid levels were associated with the changes of GFR in the initial 6 months of kidney transplantation, and the hyperuricemia during the early stages of transplantation might influence the long term graft survival.

Blood Eosinophilia in Patients Undergoing Continous Ambulatory Peritoneal Dialysis / 대한신장학회잡지

PURPOSE: The prevalence of blood eosinophilia in patients who are maintained on regular hemodialysis has been well established. Blood eosinophilia in patients initiating peritoneal dialysis has been mentioned, but its prevalence and etiologic factors have not been well delineated. Therefore, we performed this retrospective study to find out prevalence and possible etiologic factors of blood eosinophilia in patients undergoing continuous ambulatory peritoneal dialysis. METHODS: Between May 2001 to May 2004, the patients who began continuous ambulatory peritoneal dialysis at one renal center were included in this study. Patients with allergic history or allergic reaction during observed period were excluded. The routine peripheral WBC counts of 47 patients were reviewed and possible predisposing factors of eosinophilia were investigated. RESULTS: Blood eosinophilia was observed in 17 of 47 patients (35% of all patients). In most patients with blood eosinophilia, the time in which the eosinophil count began to be rise was within 40 days, and duration of eosinophilia was variable (mean+/-SD;74+/-67 days). The mean of the peak eosinophil count was 750+/-257/mm3 (mean+/-SD). Possible predisposing factors included recent parenteral iron therapy, but not statistically significant (p=0.09). CONCLUSION: Our retrospective study showed that the eosinophil counts in patients with end stage renal disease on continuous ambulatory peritoneal dialysis were frequently elevated. Predisposing factors for this eosinophilia were not clear, suggesting that immunologic disturbance by uremia or dialysis itself might have influence on eosinophil homeostasis.

The Prognostic Factors for Long-term Maintenance of CAPD: Importance of Early %lean Body Mass and Peritonitis / 대한신장학회지

PURPOSE: Lower technical survival rate of CAPD compared to hemodialysis is still concerned. We aimed to evaluate the characteristics of long-term CAPD survivors in pre-dialysis and early phase of CAPD for estimating predictive markers for long-term maintenance of CAPD. METHODS: We retrospectively reviewed records of long-term CAPD patients (LT group, >100 months, n=51) and short-term patients (ST group, <50 months, n=102) who were age-sex matched with the LT group in a 2:1 ratio. Clinical characteristics, serial biochemical parameters, Kt/V, and peritoneal equilibrium test (PET) within 1 month and at 1 year of CAPD were analyzed. RESULTS: LT group had lower prevalence of diabetes, higher pre-dialysis serum albumin, creatinine, % LBM at 1 month of CAPD and lower peritonitis rate compared to ST group. However, dialysis adequacy, residual renal function and transport status showed no differences between two groups at 1 month and 1 year of CAPD. In multivariate analysis, diabetes, peritonitis rate and %LBM were independent risk factors for failure of long-term maintenance of CAPD. Moreover, patients with high %LBM were more likely to be in LT group, had longer CAPD maintenance duration, and lower peritonitis rate. In multiple linear regression analysis for risk factors associated with peritonitis, %LBM at 1 month and pre-dialysis serum albumin were independently associated with peritonitis rate. CONCLUSION: The present study revealed that non-diabetic history, higher %LBM and lower peritonitis rate are important predictors of long-term CAPD survival. Also, poor nutritional status assessed by %LBM and serum albumin level was independently associated with high frequency of peritonitis.

A Case of Unilateral Renal Artery Stenosis with Contra-Lateral Focal Segmental Glomerulosclerosis in a Chronic Kidney Disease Patient / 대한신장학회지

We report a case of focal segmental glomerulosclerosis (FSGS) with chronic renal failure in a patient with unilateral renal artery stenosis. A 38-year-old woman presented with malignant hypertension, massive proteinuria and renal insufficiency. MR angiography showed proximal stenosis of the right renal artery and biopsy of the left kidney revealed focal segmental glomerulosclerosis. The patient responded favorably to the angiotensin II receptor antagonist, as the blood pressure and urinary protein decreased. This case showed that FSGS is a pathophysiologic mechanism of renal injury in uncontrolled renovascular hypertension.

A Case of Acute Renal Failure, Acute Pancreatitis and Delayed Recovery of Bone Marrow Suppression, Accompanied with Ethylene Glycol Intoxication / 대한신장학회잡지

Ethylene glycol is commonly found in automobile antifreeze and a variety of other commercial products. Ingestion of ethylene glycol, either accidentally or in a making an attempt at suicide, is characterized by severe metabolic acidosis, calcium oxalate crystal formation and deposition, and various end organ damages that may be fatal with about 80% mortality rate. We present here a case of a patient who ingested about 300cc of ethylene glycol to siucide, and developed acute renal failure, acute pancreatitis and bone marrow suppression, but successfully be treated with minimal sequelae.

A Case of Toluene-induced Renal Tubular Acidosis Presented with Hypokalemic Paralysis

Toluene is known to cause a moderate degree of hypokalemia, myalgia, and even muscular weakness. We encountered the patient with acute hypokalemic paralysis in a chronic glue sniffer. A 32-year-old Korean male was taken to the emergency room with muscle weakness and somnolence. His serum chemistries showed severe hypokalemia and hyperchloremic metabolic acidosis. The urine toxicology screening showed excess levels of hippuric acid. His serum potassium level and metabolic acidosis were corrected after interruption of the offending agents and KCl & bicarbonate replacement. We report a case of severe hypokalemic muscular paralysis with renal tubular acidosis resulting from toluene inhalation.

The Effect of Pioglitazone on the Expression of Transforming Growth Factor (TGF)-beta and Fibronectin in Diabetic Nephropathy / 대한신장학회잡지

BACKGROUND: Peroxisome proliferator-activated receptor (PPAR)-gamma is a member of the nuclear receptor superfamily. PPAR-gamma plays an important role in numerous cellular processes including adipogenesis, insulin sensitivity, cell cycle progression, cell differentiation, inflammation, and extracellular matrix production. This study investigated the effect of a PPAR-gamma agonist on the progression of diabetic nephropathy in OLETF rats. METHODS: 30 week-old male OLETF rats were treated for 10 weeks as follows:diabetic control (DM), no treatment:pioglitazone therapy (DM+Pio). LETO rats were used as non-diabetic control (control). Body weight, blood pressure, blood sugar, creatinine, total cholesterol, triglyceride, and urinary protein excretion were measured. Histological analysis was taken with light microscope. Glomerular protein and mRNA expression of transforming growth factor (TGF)-beta1 and fibronectin were estimated by Western blot and RT-PCR. Kidney sections were stained for fibronectin by immunohistochemistry. RESULTS: Serum glucose, triglyceride and urinary protein excretion were decreased in DM+Pio rats compared to DM rats (p<0.05). PAS staining showed glomerular hypertrophy, mesangial expansion, nodular sclerosis, and glomerular basement membrane thickening in glomeruli of DM rats, but these changes were attenuated in glomeruli of pioglitazone-treated rats. Treatment with pioglitazone resulted in a significant decrease in TGF-beta1 protein and mRNA expression in diabetic glomeruli (80.6% and 78.4%, respectively). Glomerular expression of fibronectin protein and mRNA were also decreased in pioglitazone treatment group compared with DM group (93.1% and 98.6%, respectively). Immunohistochemical staining for fibronectin showed similar results. CONCLUSION: Increased TGF-beta1 and fibronectin mRNA and protein expressions in diabetic rat glomeruli were significantly ameliorated by pioglitazone treatment. These data suggest that activation of PPAR-gamma may play an important role in prevention and treatment of diabetic nephropathy.

Clinical Implications of Pulse Pressure in Chronic Kidney Disease / 대한신장학회잡지

BACKGROUND: Arterial hypertension is one of the major factors for progression to end stage renal disease (ESRD) in chronic kidney disease (CKD). Pulse pressure, which stands for arterial stiffness, is a well known risk factor for cardiovascular disease, especially in old patients. A few reports showed that increased arterial stiffness is associated with decreased glomerular filtration rate (GFR). The aim of this study is to investigate the effects of pulse pressure on renal outcome in CKD patients. METHODS: Total 153 patients were included who visited our institution for the first time between January 2000 and December 2000. Patients' medical records were reviewed retrospectively. CKD was defined as GFR by MDRD equation less than 60 mL/ min/1.73 m2. Patients with CKD 5 were excluded. The primary end point of this study for progression of renal disease was doubling serum creatinine. RESULTS: On multivariate analysis based on baseline clinical and laboratory data, pulse pressure was an independent risk factor for progression of CKD. Antihypertensive treatment for 1 year (since the first visit) decreased both systolic and diastolic blood pressure (BP) significantly, and pulse pressure as well. At the end of follow up of 3.7 years (mean), while systolic BP tended to increase slightly, diastolic BP was persistently decreased. Consequently, pulse pressure was further widened compared to that of 1 year. Pulse pressure was positively correlated with age, fasting glucose, and calcium phosphorus product (CPP) whereas it was negatively correlated with hemoglobin and GFR. CONCLUSION: This study shows that pulse pressure is a good predictor for renal outcome in CKD. Besides age and hypertension, anemia, fasting glucose, CPP and uremia can adversely affect pulse pressure in CKD. Therefore, BP control and correction of those factors are recommended to attenuate the progression of CKD.

Scalp Edema and Insufficient Maturation of Arteriovenous Fistula Due to Cephalic Vein Variation in Patient with End Stage Renal Disease / 대한신장학회잡지

Vascular access is the prerequisite and mainstay of extra-corporeal renal replacement therapy and its management is central to maintain the health and quality of life of end-stage renal disease (ESRD) patients. Success of maturation of AVF depends on the quality and size of the vessels and anatomic structure. There have been several reports on non-maturation by vascular stenosis or small vascular size after AVF procedure, but reports demonstrating that AVF non-maturation is due to by latent vessel variation are uncommon. We report a rare case of scalp edema and insufficient maturation of AVF due to cephalic vein variation in a 27 year-old female patient with ESRD on hemodialysis. Conclusively, meticulous observation on not only vessels used for AVF but also its proximal connection to other vessels should be considered.