Spontaneous Clearance of Hepatitis B Surface Antigenemia in a Hemodialysis Patient / 대한내과학회지

The incidence of hepatitis B has been reported to be high in dialysis centers. Dialysis patients are at increased risk of acquiring hepatitis B due to their immunodeficient state, which impairs elimination of the hepatitis B virus; chronic dialysis patients rarely clear hepatitis B surface antigen (HBsAg) spontaneously. Hepatitis B virus infection is associated with a high risk of hepatic complications. We report the case of a 66-year-old HBsAg-positive female patient who had undergone hemodialysis for 58 months due to end-stage renal failure and became HBsAg-negative followed by the development of hepatitis B surface antibody.

Dioscorea Quinqueloba-Induced Tubulointerstitial Nephritis / 대한내과학회지

Drug-induced tubulointerstitial nephritis is one cause of acute kidney injury. Although traditional remedies have been widely used in South Korea, Dioscorea quinqueloba-induced tubulointerstitial nephritis has not been reported in the general population. A 72-year-old male patient was transferred to our hospital with pulmonary edema, oliguria, decreased mentality, severe generalized edema after taking D. quinqueloba 25 days ago. His initial lab findings showed a blood urea nitrogen level of 43.4 mg/dL, a creatinine level of 5.3 mg/dL. Urinalysis revealed SG (1.015), blood (many), protein (++) and WBC (0-3/HPF). Kidney biopsy demonstrated severe mononuclear cell infiltration into the renal interstitium with mild tubular atrophy. Aggressive renal replacement therapy and supportive care resulted in gradual restoration of his renal function. This case implies that D. quinqueloba may be one cause that induces tubulointerstitial nephritis in some patients.

A Rare Cause of Automated Peritoneal Dialysis-Related Peritonitis: Aeromonas caviae / 대한내과학회지

Peritonitis is a major cause of morbidity in peritoneal dialysis patients; however, Aeromonas caviae rarely causes peritonitis in these patients. We report peritonitis due to A. caviae in a 72-year-old male with end-stage renal failure who had been undergoing automated peritoneal dialysis for 1 year. The white blood cell (WBC) count in the peritoneal fluid was 2,722/mm3 with 85% neutrophils. Gram staining of the peritoneal fluid yielded Gram-negative rods. Empirical antibiotic therapy with ceftriaxone was initiated intraperitoneally. However, drug sensitivity testing revealed that the organism was resistant. On the third hospital day, A. caviae was cultured from the peritoneal effluent, and the antibiotic regimen was switched to ciprofloxacin. The patient recovered rapidly and the WBC count of the peritoneal effluent decreased. He was discharged and the intraperitoneal ciprofloxacin therapy was continued for 14 days. The peritoneal catheter was not removed.

Corni Fructus-Induced Acute Interstitial Nephritis / 대한내과학회지

Drug-induced interstitial nephritis is one cause of acute kidney injury. Although traditional remedies have been widely used in South Korea, Corni fructus-induced interstitial nephritis has not been reported in the general population. A 65-year-old female patient was admitted with sudden onset of gross hematuria after ingesting Corni fructus tea for 2 weeks. Her initial lab findings showed a blood urea nitrogen level of 35.1 mg/dL, creatinine level of 1.7 mg/dL, albumin level of 4.5 g/dL, and hemoglobin level of 10.3 g/dL. Urinalysis revealed SG (1.025), blood (many), protein (+), and WBC (0-3/HPF). Her 24-hour total protein level was 1,120 mg/day. No specific abnormalities were found on serum and urine protein electrophoresis. Kidney biopsy demonstrated severe mononuclear cell infiltration into the renal interstitium with mild tubular atrophy and pericapsular fibrosis. Immediate withdrawal of Corni fructus, appropriate education, and conservative management resulted in gradual restoration of her renal function. This case implies that Corni fructus may be a causative allergen that induces acute interstitial nephritis in some patients.

Corni Fructus-Induced Acute Interstitial Nephritis / 대한내과학회지

Drug-induced interstitial nephritis is one cause of acute kidney injury. Although traditional remedies have been widely used in South Korea, Corni fructus-induced interstitial nephritis has not been reported in the general population. A 65-year-old female patient was admitted with sudden onset of gross hematuria after ingesting Corni fructus tea for 2 weeks. Her initial lab findings showed a blood urea nitrogen level of 35.1 mg/dL, creatinine level of 1.7 mg/dL, albumin level of 4.5 g/dL, and hemoglobin level of 10.3 g/dL. Urinalysis revealed SG (1.025), blood (many), protein (+), and WBC (0-3/HPF). Her 24-hour total protein level was 1,120 mg/day. No specific abnormalities were found on serum and urine protein electrophoresis. Kidney biopsy demonstrated severe mononuclear cell infiltration into the renal interstitium with mild tubular atrophy and pericapsular fibrosis. Immediate withdrawal of Corni fructus, appropriate education, and conservative management resulted in gradual restoration of her renal function. This case implies that Corni fructus may be a causative allergen that induces acute interstitial nephritis in some patients.

Intraperitoneal Paricalcitol Treatment for Secondary Hyperparathyroidism in CAPD patient: A Case Report / 대한신장학회지

Secondary hyperparathyroidism is a major complication in ESRD patients undergoing dialysis. In hemodialysis patients with secondary hyperparathyroidism, intravenous administration of paricalcitol became widely utilized. In CAPD patients, however, the intravenous administration of paricalcitol which requires frequent visits to the clinic is not practical. The subject of this study was one CAPD patient with secondary hyperparathyroidism. He had already received oral calcitriol pulse therapy for 6 months and thereafter refused parathyroidectomy and intravenous paricalcitol which required frequent visits to the hospital. Furthermore, paricalcitol capsule is not yet introduced in Korea. Consequently, intraperitoneal paricalcitol therapy was tried whereby the patient was taught how to inject the paricalcitol (5 ug) directly into the dialysate for three times per week before bedtime. Blood samples for measurement of intact parathyroid hormone (iPTH), serum ionized calcium, serum phosphate, serum total alkaline phosphatase levels were obtained at baseline and after 1, 2, 3 and 4 months of treatment. After usage of intraperitoneal paricalcitol for 2 months, there was a significant decrease in iPTH level. In conclusion, intraperitoneal paricalcitol therapy might be effective for suppressing iPTH in CAPD patients with secondary hyperparathyroidism. A large-scale and long-term study must be conducted for safety and clinical effect.

Peritonitis by Achromobacter xylosoxidans in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis(CAPD): A Case Report / 대한신장학회지

Peritonitis is a major cause of morbidity in continuous ambulatory peritoneal dialysis (CAPD) patients. Achromobacter xylosoxidans is a rarely reported cause of peritonitis in CAPD patients. In this report, a peritonitis case due to Achromobacter xylosoxidans in a 60-year-old male patient with end-stage renal failure receiving CAPD for 7 years, has been reported. White blood cell (WBC) count in peritoneal fluid was 3,160/mm3 with 95% neutrophil. Gram staining of the peritoneal fluid yielded gram negative rod. Empirical antibiotic therapy with ceftriaxone was initiated intraperitoneally. But drug sensitivity test revealed these regimens were resistant. On fourth hospital day, Achromobacter xylosoxidans was cultured from peritoneal effluent, the antibiotic regimen was switched to piperacillin/tazobactam intraperitoneally. The patient rapidly recovered and the WBC count of the peritoneal effluent decreased. The therapy was continued for 14 days and then the patient was discharged. The peritoneal catheter was not removed.

Comparison of heart rate variability between ESRD patients on peritoneal dialysis and hypertensive patients / 대한내과학회지

BACKGROUND/AIMS: Heart rate variability (HRV) is regulated by the balance between the sympathetic and parasympathetic tones. HRV can be used to assess the effects of drugs and other interventions on cardiac autonomic tone, including exercise, respiration, metabolic change, and psychological or physical stress. As few studies have examined HRV in end-stage renal disease (ESRD) patients in Korea, we investigated autonomic nervous system activity reflected in HRV in patients on peritoneal dialysis for ESRD. METHODS: We compared the pattern of cardiac sympathetic and parasympathetic activity through time-and frequency-domain analysis of HRV in 20 ESRD patients and 65 hypertensive control subjects using 24-hour Holter monitoring. The patients had been undergoing peritoneal dialysis at the Bongseng Hospital between January 2006 and December 2008. RESULTS: The mean age of the patients and controls was 53.8+/-13.1 and 55.1+/-13.7 years, respectively. In the patient group, all of the time- and frequency-domain HRV measures were reduced compared with the control group, including the HRV index, normalized unit of low-frequency (LF norm), and ratio of low-frequency power to high-frequency power (LF/HF), whereas the normalized unit of high frequency (HF norm) was increased. CONCLUSIONS: Autonomic tone in ESRD patients on peritoneal dialysis is decreased compared with patients with hypertension. The parasympathetic tone in ESRD patients on peritoneal dialysis dominates over the sympathetic tone.

A Case of Asymptomatic Disseminated Cryptococcosis in a Renal Transplant Patient / 대한신장학회지

Cryptococcosis is recognized as one of the most important complications in an organ transplant recipient. Cryptococcosis occurs in 2.5-39% of renal transplant recipients. This infection generally presents as symptomatic disseminated disease with an accelerated clinical course, involves multiple sites including the central nervous system, lungs, and skin. And if diagnosis or treatment is delayed, the prognosis is generally poor. The asymptomatic infection is rare and there are no case reports of asymptomatic disseminated cryptococcosis after renal transplantation in Korea. We experienced a case of asymptomatic cryptococcal multi-organ infection detected incidentally in a 51-year-old male received a living related renal transplant 35 months earlier for end-stage renal disease due to diabetic nephropathy. We treated successfully with amphotericin B and fluconazole and hereby report this case with a review of the relevant literature.

Expression of MUC1 and MUC4 and Its Prognostic Significance in Non-Small Cell Lung Carcinoma

BACKGROUND: Mucin (MUC)1 and MUC4 (MUC1, 4) are high molecular weight glycoproteins expressed in normal and malignant epithelial cells, and these expressions are related to the prognosis of some carcinomas. In non-small cell lung carcinoma (NSCLC), the relationship between MUC1, 4 expressions and their prognostic significance is not well known. We evaluated these relationships in a series of NSCLC: 1) between MUC1, 4 expression levels and histologic subtypes, and 2) between high expression of MUC1, 4 and their prognostic significance. METHODS: We performed immunohistochemical staining for MUC1, 4 in paraffin-embedded tissues from 165 NSCLC cases arranged in a tissue microarray. RESULTS: We found a significant correlation between MUC1, 4 expressions and NSCLC histologic subtypes (p < 0.05). High MUC1 expression was characteristic of adenocarcinoma. Low MUC1, 4 expressions were characteristic of squamous cell carcinoma. In adenocarcinoma, we found significant association between diffuse MUC1 expression and short patient survival (p = 0.005). In squamous cell carcinoma, diffuse MUC4 expression showed long patient survival trend (p = 0.128). CONCLUSIONS: MUC1, 4 expression levels were significantly correlated with NSCLC histologic subtypes. Diffuse MUC1 expression was significantly associated with shortened survival in NSCLC patients, especially in adenocarcinoma.

Combination Treatment of Rituximab and Plasmapheresis in Acute Cellular Rejection with Focal Segmental Glomerular Sclerosis after Renal Transplantation / 대한이식학회지

Focal segmental glomerular sclerosis (FSGS) accounts for recurrence in 20% to 40% of the renal allografts after transplantation, and it causes graft loss in 13% to 20% of the cases. We report here on successfully treating acute cellular rejection (ACR) combined with FSGS after a kidney transplantation with a combination treatment of plasmapheresis, rituximab and steroid pulse therapy. A 53-year-old female patient whose primary kidney disease was unknown developed massive proteinuria after living donor kidney transplantation. A urine protein/creatinine ratio of 13.42 and an elevated serum creatinine level was detected on postoperative days (POD) 10 and a renal biopsy showed acute cellular rejection (Banff IIb) combined with FSGS. We started steroid pulse therapy on POD 11. She underwent 5 plasmapheresis sessions in the first 3 week after transplantation and she received one dose of rituximab (375 mg/m2) on POD 12. The proteinuria decreased below the nephrotic range at POD 20 and the serum creatinine level was normalized. Three months later, the proteinuria was at 35 mg/day with stable graft function. Rituximab and plasmapheresis is a possible option to treat FSGS combined with a relapse of proteinuria after renal transplantation.

Brunn Nests Masquerading as Bladder Tumor: A Case Report

Brunn nests are the most common proliferative lesions of the bladder uroepithelium, but exuberant proliferation can mimic bladder tumor on radiologic imaging and cystoscopy. We describe a case of pathologically proven Brunn nests in a 34-year-old man, misdiagnosed as bladder tumor on preoperative imaging studies.

A Case of Renal Transplantation in a Patient with Goodpasture's Syndrome / 대한이식학회지

Goodpasture's syndrome is a clinical complex of anti-GBM (glomerular basement membrane) nephritis and lung hemorrhage. Anti-GBM nephritis is an autoimmune disease in which autoantibodies directed against type IV collagen induce RPGN (rapid progressive glomerulonephropathy) and crescentic glomerulonephritis. 50 to 70% of patients have pulmonary hemorrhage. We have one case of a successful renal transplantation in a patient with Goodpasture's syndrome. A 51 year old male had arrived in the emergency room due to dyspnea. 20 days prior to admission he had suffered from fever and then progressively developed nausea and weakness. He underwent hemodialysis with the dual lumen catheter which was inserted in the right internal jugular vein. Goodpasture's syndrome was confirmed by the measurement of serum anti-GBM Ab titer, renal biopsy and clinical manifestations of pulmonary hemorrhage. Renal biopsy findings showed diffuse proliferative glomerulonephritis on light microscopy and linear ribbon-like deposition of IgG along the GBM. The patient was placed on CAPD on the 30th hospital day. After six months of CAPD, the patient received a renal transplant from a HLA-haploidendical brother. Which was done after negative seroconversion of circulating antibody of GBM. With a induction of IL-2 receptor blocker (Basiliximab), cyclosporine-A and prednisone were administered for their immunosuppressants. He had good health for 37 months with excellent graft function.

An Analysis of Histopathologic Evaluation of Lung Carcinomas in Last Ten Years

Lung cancer is one of the most common types of malignancy in western nations with serious health problem, and it has become the leading cause of cancer death of males, second only to stomach cancer, in Korea. A review of the histopathology of 1363 cases (1231 patients) of lung carcinoma, diagnosed at the Keimyung University Medical center from 1987 to 1996, was performed to reclassify the type of carcinomas and to investigate the change in the distribution of histologic types of lung carcinoma according to age, sex and year. Among the 1363 cases, 132 patients underwent a surgical operation after biopsy. The diagnosis of each case was proven by histopathologic analysis of surgical specimens (13.2%) and biopsy materials (86.8%). The histologic types in our study were basically based on modified WHO classification (1982) and on new WHO classification (1999). The classification of small cell carcinoma was based on International Association for the Small Cell Lung Cancer (IASLC, 1988). Of the 1231 patients with lung carcinoma, 1012 were male and 219 were female (male to female ratio was 3.6:1). According to the analysis of age distribution, the most prevalent age group was 60~69 years in both sex as (n=516, 42.0%). Changing trends in sex distribution of lung carcinoma patients showed that the proportion of men had decreased throughout the years, whereas the proportion of women had significantly increased. Histologically, squamous cell carcinoma was the most common (n=624, 50.7%), followed by small cell carcinoma (21.1%), adenocarcinoma (18.1%), large cell undifferentiated carcinoma (2.1%), adenosquamous carcinoma (0.4%), and large cell neuroendocrine carcinoma (0.4%), in order of frequency. In men, squamous cell carcinoma was the most frequent type (55.1%). In women, adenocarcinoma was the most frequent type (39.7%). In both sexes, adenocarcinoma was the most common type in patients under the age of 40 (n=12, 41.4%), while squamous cell carcinoma proved the most frequent type in patients over the age of 40 (n=617, 51.3%). Changing trends of histologic types of lung cancer showed that the incidences of squamous cell carcinoma had significantly decreased throughout the years, whereas those of adenocarcinoma and small cell carcinoma had increased. In conclusion, the results showing increases in the percentage of female patients and in the number of cases of adenocarcinoma were noteworthy, and well correlated with other related reports.

Morphologic Changes of Pulmonary Tissue Secondary to Sidestream Cigarette Smoke

Chronic bronchiolitis is a condition associated with cigarette smoking, and later associated with pulmonary parenchymal alteration and progressive deterioration of lung function. Early respiratory bronchiolitis was produced in Sprague-Dawley rats by indirect inhalation of cigarette smoke daily in a smoke exposure chamber designed by authors for 1 month. Experimental group A (n=5) was sacrificed after having smoked 30 cigarettes, group B (n=5) after 80 cigarette, and group C (n=7) after 140 cigarettes, respectively. Examination of morphologic changes in the lungs was done on light microscope, transmission and scanning electron microscopes. Light microscopically, increase in number of goblet cells in the bronchial mucosa, brown-pigmented macrophages in the alveoli, multifocal alveolar collapse adjacent to the bronchioles, dilatation of alveolar ducts and alveolar spaces were observed. Transmission electron microscopically, irregularly shaped Clara cells, alveolar wall collapse, and focally type I epithelial cell injury were seen. Scanning electron microscopically, scattered alveolar collapse, irregular dilatation of alveolar ducts, alveolar spaces and interalveolar pores (pores of Kohn) were seen. The terminal and respiratory bronchioles showed morphological alteration of Clara cells, but no evidence of cellular bronchiolitis or bronchiolar obstruction. We conclude that sidestream smoke induces an early respiratory bronchiolitis including aggregates of brown pigmented macrophages and varying degrees of structural alteration of adjacent pulmonary parenchyma.

Synaptic Reorganization of Dentate Mossy Fibers and Expression of Calcium Binding Proteins in Hippocampal Sclerosis of Temporal Lobe Epilepsy

This study was designed to identify expression of calcium-binding proteins and synaptic reorganizations of dentate mossy fibers in hippocampal sclerosis of human temporal lobe epilepsy. Hippocampal neuronal density was quantitively analyzed in temporal lobe epilepsy group (n=50) to investigate the degree of hippocampal sclerosis and it was compared with that of autopsy control (n=3). To verify the distribution of calcium-binding proteins in neurons of epileptic hippocampi, the parvalbumin (PV)-immunoreactive and calbindin-D28K (CB)-immunoreactive neurons were quantitively analyzed in each area of Ammon's horn by immunohistochemical stain. Also, to clarify synaptic reorganizations of the dentate mossy fibers, a part of each hippocampus was examined under light microscopy and transmission electron microscopy using Timm sulphide silver method. In epileptic hippocampi, severity of hippocampal sclerosis (HS) was graded four, which consisted of 3 cases with no HS, 6 mild HS, 12 moderate HS, and 29 severe HS. The hippocampal neuronal loss was most prominent in CA1, followed by CA4 and CA2. Expression of calcium-binding proteins was more prevalent in CA2 of all groups. The proportion of PV-immunoreactive neurons in CA1 and CA4 significantly increased in the moderate and severe HS group, whereas the proportion of CB-immunoreactive neurons did not correlated with the severity of HS. Timm granules were noted in inner molecular supragranular layer of dentate gyrus of epileptic hippocampi and they tended to increase in proportion along with the severity of hippocampal sclerosis. Transmission electron microscopy showed that supragranular Timm granules corresponded to synaptic terminals of mossy fibers. These results suggest that parvalbumin appears to have more protective effect against neuronal loss and that mossy fiber synaptic reorganization seems to play a major role in pathogenesis of hippocampal sclerosis of human temporal lobe epilepsy.