Cervical spinal extradural arteriovenous fistula successfully treated using transarterial balloon-assisted coil embolization

We present the case of a patient who developed compressive radiculopathy that was found to be associated with a spinal extradural arteriovenous fistula. The fistula was successfully obliterated with transarteiral balloon-assisted coiling, after which the patient was symptom-free. Although spinal extradural arteriovenous fistula is rare, this pathology should be considered in the differential diagnosis of spinal radiculopathy or myelopathy. Endovascular treatment appears to have been successful in resolving the symptoms associated with this pathology.

Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency

Objective@#The aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms. @*Methods@#A retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. @*Results@#Total 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy. @*Conclusions@#We suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.

Effects of Low-carbohydrate and High-fat Diet Supplemented with Ketogenic Drink on Cognitive Function and Physical Performance in the Elderly at High Risk for Dementia / 대한지역사회영양학회지

OBJECTIVES: Reduced glucose utilization in the main parts of the brain involved in memory is a major cause of Alzheimer's disease, in which ketone bodies are used as the only and effective alternative energy source of glucose. This study examined the effects of a low-carbohydrate and high-fat (LCHF) diet supplemented with a ketogenic nutrition drink on cognitive function and physical activity in the elderly at high risk for dementia.METHODS: The participants of this study were 28 healthy elderly aged 60-91 years showing a high risk factor of dementia or whose Korean Mini-Mental State Examination (K-MMSE) score was less than 24 points. Over 3 weeks, the case group was given an LCHF diet with nutrition drinks consisting of a ketone/non-ketone ratio of 1.73:1, whereas the control group consumed well-balanced nutrition drinks while maintaining a normal diet. After 3 weeks, K-MMSE, body composition, urine ketone bodies, and physical ability were all evaluated.RESULTS: Urine ketone bodies of all case group subjects were positive, and K-MMSE score was significantly elevated in the case group only (p=0.021). Weight and BMI were elevated in the control group only (p<0.05). Grip strength was elevated in all subjects (p<0.01), and measurements of gait speed and one leg balance were improved only in the case group (p<0.05).CONCLUSIONS: We suggest that adherence to the LCHF diet supplemented with a ketogenic drink could possibly influence cognitive and physical function in the elderly with a high risk factor for dementia. Further, we confirmed the applicability of this dietary intervention in the elderly based on its lack of any side effects or changes in nutritional status.

ABO Incompatible Living Donor Kidney Transplantation with Rituximab and Plasmapheresis: A Single Center Experience / 대한신장학회지

PURPOSE: ABO incompatibility had long been an obstacle in kidney transplantation. However, recent reports showed excellent outcomes. In this study, we evaluated the outcomes of ABO incompatible kidney transplantation with preconditioning protocol using rituximab and plasmapheresis. METHODS: The recipients who had an ABO-incompatible donor and underwent living donor kidney transplantation were enrolled. Preconditioning protocol was pretransplant single dose rituximab with plasmapheresis at pretransplantation 7-10 days. Immune suppression regimen consisted of tacrolimus, mycophenolate mofetil and steroid. Anti-A or anti-B antibody titer was monitored during preconditioning and post transplantation period. RESULTS: 37 patients underwent living donor ABO incompatible kidney transplantation. Median pre-treatment antibody titer was 1:64 and pre transplant antibody titer after 1-6 times of plasmapheresis was 1:2. Median follow-up duration was 332 days (range 156-681). One episode of acute T cell mediated rejection was observed. Mean serum creatinine at 2 weeks was 1.00+/-0.27 mg/dL and at 24 weeks was 1.21+/-0.37 mg/dL. CONCLUSION: ABO incompatible kidney transplantation with rituximab and plasmapheresis can be safely performed. It is therefore a valuable option for expanding donor pool and should be actively performed in Korea.

Fetal and Maternal Outcomes of Pregnancy in Women with IgA Nephropathy / 대한신장학회지

PURPOSE: To determine the effects of: 1) IgA nephropathy (IgAN) on fetal outcome; 2) gestation on maternal outcome; and 3) pregnancy on the long-term prognosis of IgAN. METHODS: Ninety pregnancies in 75 women with biopsy-proven IgAN between 1989 and 2004 were evaluated retrospectively. The long-term prognosis of IgAN was determined by estimating glomerular filtration rate (GFR) 5 years after delivery and comparing the results from 75 matched non-pregnant patients with IgAN. RESULTS: Multivariate analysis showed that baseline renal function was the only predictor of fetal outcome. Hypertension and impaired renal function before pregnancy were associated with poor maternal outcome during pregnancy, whereas histologic grade was related to the long-term prognosis of IgAN. Five years after delivery, GFR did not differ between pregnant (63.6+/-33.4 mL/min) and non-pregnant (63.2+/-32.5 mL/min) women with IgAN. CONCLUSION: Impaired renal function appears an important prognostic factor for fetal outcome. Short- term maternal prognosis was dependent on pre-pregnancy clinical parameters associated with IgAN, whereas long-term prognosis was dependent on histopathologic parameters of IgAN itself. Pregnancy per se had no adverse effects on the natural history of IgAN.

A case report of isoniazid-associated psychosis / 대한내과학회지

A 42-year-old woman without a prior psychiatric history presented with psychotic symptoms that were suspected as related to treatment of tuberculosis with isoniazid. The psychotic symptoms resolved after isoniazid was discontinued. Clinicians should be aware of the possibility of psychotic symptoms with use of this agent.

A Case of Familial Atypical Hemolytic Uremic Syndrome Associated with Complement Factor H Mutation in Adults / 대한신장학회지

The hemolytic uremic syndrome is a clinical syndrome defined by the presence of thrombocytopenia, microangiopathic hemolytic anemia and acute renal failure. Atypical hemolytic uremic syndrome (aHUS) which is not usually associated with prodromal symptoms, especially diarrhea, has a higher mortality rate and a stronger tendency to progress to chronic renal failure. In approximately 30-50% of patients with aHUS, mutations have been detected in complement factor H, membrane cofactor protein or factor I. Mutations in the complement regulator factor H are the most frequent and have a very poor prognosis, with most patients developing ESRD. We have experienced a 33-year-old man with a family history of renal failure diagnosed as aHUS resulted from factor H mutation, for whom we carried out hemodialysis, plasmapheresis and other conservative management.

Comparison of Erythropoietic Effect between Epoetin-alpha and Darbepoetin-alpha in Hemodialysis Patients: A Randomized Crossover Study / 대한신장학회지

PURPOSE: We aim to compare the erythropoietic effects of epoetin-alpha (EA, 4000 IU SC thrice a week) with those of darbepoetin-alpha (DA, 60ug IV weekly, conversion rate to EA=200:1). METHODS: Forty one stable hemodialysis patients were enrolled in this randomized crossover study. After a washout period of erythropoietin stimulating agents (ESA), the patients with hemoglobin (Hb) level of 11.0 g/dL, we stopped ESA. When Hb level decreased to 30% change in EA efficiency relative to DA efficiency. CONCLUSION: There was no significant difference in erythropoietic parameters for both EA and DA.

Spontaneous Subcapsular Hematoma on a Transplanted Kidney / 대한신장학회지

A 41-year-old female was admitted for a subcapsular hematoma of her graft kidney six weeks after she underwent a kidney transplant. No report on subcapsular hematomas of graft kidneys has been published in Korea. Subcapsular hematoma of graft kidneys is one of a few very rare causes of bleeding. The clinical manifestations of subcapsular hematoma are the abrupt onset of flank pain or upper abdominal pain, nausea, anorexia, dizziness, and decrease in hemoglobin. If it is diagnosed late, it can result in renal insufficiency, hypovolemic shock, and even death. During the authors' management of a subcapsular hematoma of a renal graft, pure red cell aplasia induced by the parvovirus B19 was found to coexist. Bone marrow suppression, immunosuppressants and other drugs, bleeding, iron deficiency, and renal graft function insufficiency can result in anemia after a kidney transplant. Even though pure red cell aplasia is a rare cause of anemia, it should not be forgotten that pure red cell aplasia induced by parvovirus B19 infection can cause anemia after a kidney transplant.

Intravenous Immunoglobulin Treatment in a Kidney Transplant Patient with Chronic Antibody-Mediated Rejection / 대한신장학회지

A 66-year-old male was admitted for increasing azotemia. He was diagnosed with chronic antibody- mediated rejection and had received a livingdonor renal transplant from his 32-year-old son prior to his admission. The peritubular capillaries of his kidney were diffusely positive on C4d immunostaining. It is known that there is an agreement between C4d staining and serological and histopathological data during rejection that is thought to have a humoral component. The role of alloantibodies in chronic renal allograft deterioration and the corresponding morphologic changes have been increasingly recognized during the recent years. However the treatment guidelines for chronic antibody-mediated rejection have not yet been established. Intravenous immunoglobulin (IVIG) has been shown to decrease the titers of anti-HLA antibodies in highly sensitized patients awaiting transplant. There are also numerous proposed mechanisms regarding how IVIG exerts its immunomodulatory action. As we have experienced chronic antibody-mediated rejection and how IVIG treatment improves renal function, we recognize that IVIG has the potential to be used for treating certain subgroups of chronic allograft nephropathy patients with positive C4d staining and anti-HLA antibodies.

De Novo Renal Artery Aneurysm Presenting 12 Years after Transplantation: Ex Vivo Repair and Allograft Autotransplantation / 대한신장학회지

Although renal artery aneurysms (RAAs) rarely occur, rupture of RAAs may be life-threateningand result in nephrectomy. To date, there has been only one case report providing histologic evidence of a true aneurysm in a transplanted renal artery. We report here a 51-year-old male with a de novo trueaneurysm in a donor renal artery that was detected 12 years postoperatively. This RAA was corrected by ex vivo repair and allograft autotransplantation.

A Case of Light Chain Deposition Disease Involving Kidney and Bone Marrow with Microangiopathic Hemolytic Anemia / 대한진단검사의학회지

We report a case of light chain deposition disease in a 59-yr-old female showing deposition of monoclonal light chain in the kidney and bone marrow accompanied with a schistocytosis, the morphologic finding of microangiopathic hemolytic anemia. The immunofluorescence examination of the kidney revealed strongly stained kappa-light chain deposits on the glomerular mesangium and capillary wall, tubules, and vessel wall. The electron microscopy demonstrated electron-dense deposits on the glomerular basement membrane and mesangium. Anemia was observed with schistocytosis and Howell-Jolly body in the peripheral blood smears. The immunohistochemical examination of the bone marrow showed the presence of kappa-light chain deposits in scattered plasma cells and thickened vessel wall in the absence of a prominent plasma cell proliferation. Although an immunofixation electrophoresis failed to detect a monoclonal gammopathy, the presence of monoclonal protein could be identified by an abnormal kappa/lambda ratio on the serum free light chain analysis.

Extended Unroofing Procedure for Creation of a New Ostium for an Anomalous Right Coronary Artery Originating from the Left Coronary Sinus: A case report / 대한흉부외과학회지

An anomalous origin of the coronary artery with subsequent coursing between the great vessels is a rare congenital heart defect that may cause myocardial ischemia and sudden death. Several surgical techniques have been described to address this defect. An extended unroofing procedure to create an alternative ostium for the right coronary artery was successfully carried out in a patient having an anomalous origin of the right coronary artery. The newly constructed orifice was widely patent 3 months later, without any episodes of myocardial ischemia or aortic regurgitation.

SIADH and Guillain-Barre Syndrome Associated with Pulmonary Tuberculosis / 대한신장학회지

Hyponatremia is one of the most common electrolyte disturbances in nephrologic clinical setting. SIADH is one of the causes of hyponatremia and can be accompanied with various conditions such as malignancies, infections and nervous system diseases. Guillain-Barre syndrome is an acute inflammatory polyneuropathy. It is reported that SIADH can be accompanied with Guillain-Barre syndrome although the mechanism is unclear. Symptoms of Guillain- Barre syndrome such as general weakness, decreased consciousness, and seizure are similar to those of hyponatremia. Thus the diagnosis of Guillain-Barre syndrome can be delayed if they coexist. Because Guillain-Barre syndrome leads to severe respiratory failure in its disease course and mechanical ventilatory assistance is mandatory for such cases, early diagnosis and treatment is critical. Korea is still endemic area for tuberculosis and clinicians often experience pulmonary tuberculosis in practice. But pulmonary tuberculosis-associated SIADH and Guillain-Barre syndrome were not reported in Korea. So far, 2 cases of gastrointestinal infection-associated SIADH and Guillain-Barre syndrome were reported. Hence, authors report here the case of SIADH associated Guillain-Barre syndrome associated with pulmonary tuberculosis.

A Case of Interstitial Pneumonitis Associated with Sirolimus Treatment in Renal Transplantation Recipient / 대한신장학회지

Sirolimus is a promising immunosuppressive drug for renal transplantation to avoid nephrotoxicity of calcineurin inhibitor. However, it has been associated with uncommon but, important pulmonary toxicity. We present a case of sirolimus related dyspnea with abnormal chest radiographic finding in a 63 year old male renal transplantation recipient. There was no evidence of bacterial, fungal, or viral infection. Dose reduction of sirolimus resulted in a significant improvement of the symptoms and chest radiographic finding.

A Case of Acute Renal Failure with Wernicke's Encephalopathy and Beriberi due to Severe Hyperemesis Gravidarum / 대한신장학회지

Severe hyperemesis gravidarum (HG) is a rare but potentially devastating complication of pregnancy. It can cause dehydration, electrolyte imbalance, malnutrition (especially, thiamine deficiency), and compromised renal function. We report a case of acute renal failure (ARF) with Wernicke's encephalopathy and beriberi due to severe HG. A 35-year-old woman at 16 weeks of gestation presented with confused mentality, quadriparesis, nystagmus, peripheral neuropathy, and tachycardia after prolonged nausea and vomiting. Her initial serum creatinine and blood urea were 2.6 mg/dL and 100 mg/dL, respectively. FLAIR image of the initial MR examination demonstrated bilateral symmetric high signal intensities in the medial and dorsal thalami. Echocardiography showed left ventricular dilatation and dysfunction. We thought that ARF, Wernicke's encephalopathy and beriberi were resulted from dehydration and thiamine deficiency due to HG. She was managed with intravenous fluid and 100-200 mg of parenteral thiamine. ARF was improved within one week and echocardiographic findings were normalized within 1 month. MR examination at the 21st week of pregnancy showed a decreased size of the lesion. After 4 months, her neuroloic status was recovered.

Treatment of Primary Spontaneous Pneumothorax Using a Commercialized 8-French Catheter (Pleuracan(R)) / 대한흉부외과학회지

Background: This retrospective study was undertaken to assess the effectiveness of the 8-French (Fr) catheter (Pleuracan(R)) for the initial treatment of primary spontaneous pneumothorax. MATERIAL AND METHOD: Between July 2004 and July 2006, 59 patients (72 cases) underwent a closed thoracostomy for primary spontaneous pneumothorax. We divided these patients into two groups: group T (large bore (>20 Fr) chest tube group) and group P (Pleuracan(R) group). RESULT: Initially, the Pleuracan(R) catheters were inserted in 41 cases. There were four catheter malfunctions (9.8%); three cases had a subsequent closed thoracostomy with a large bore chest tube. Ultimately, there were 34 cases in group T and 38 cases in group P. There were no significant differences in indwelling catheter time (T: 2.1+/-1.5 days, P: 2.1+/-1.3 days), hospital stay (T: 6.4+/-5.4 days, P: 5.2+/-2.9 days) and complications (T: 3%, P: 0%) between the two groups. The percentage of cases that needed intravenous analgesics in group P was 60% (23/38); this was significantly lower than the number for group T (90%, 31/34) (p=0.003). In a subgroup of patients that did not undergo bullectomy (T: 17 cases, P: 19 cases), there were no significant differences in the duration of air leakage (T: 0.5+/-0.7 days, P: 0.5+/-1.2 days) and in the percentage of patients with complete lung re-expansion (T: 94%, P: 84%) between the two groups. CONCLUSION: Application of the Pleuracan(R) catheter for the initial treatment of primary spontaneous pneumothorax was as effective as the large bore chest tube.

Calcium-Sensing Receptor Gene Polymorphism is Associated with the Parathyroid Response to Low Calcium Dialysate in Hemodialysis Patients with Low Parathyroid Hormone Secretion / 대한신장학회지

PURPOSE: Low level of parathyroid hormone (PTH) is a risk factor that might cause hip fracture in dialysis patients. Low calcium dialysate (LCD) has been suggested as an approach to increase PTH level. The calcium-sensing receptor (CaSR) polymorphism is known to be associated with the sensitivity to extracellular calcium. METHODS: We prospectively investigated the role of genetic polymorphism of CaSR codon 990 as one cause of the different parathyroid responses to LCD in maintenance hemodialysis (HD) patients. 48 patients, using 3.5 mEq/L calcium dialysate, with intact PTH below 100 pg/ml for the last one year underwent HD sessions on 2.5 mEq/L calcium dialysate for 12 weeks. Serum intact PTH, total calcium, phosphorus, alkaline phosphatase (ALP) and bone-specific ALP (BAP) were measured monthly. The CaSR gene from peripheral lymphocytes was amplified to confirm the genotype by polymerase chain reaction. RESULTS: According to the CaSR genetic polymorphism, subjects were divided into 3 groups, A/A (14.6 %), A/G (45.8%) and G/G (39.6%). Twelve weeks later, intact PTH (48.5+/-25.4 to 89.0+/-49.4 pg/mL, p<0.01), and ALP (78.7+/-25.7 to 87.4+/-27.2 IU/L, p<0.01) increased significantly in G/G group, but not in non-G/G groups. However, BAP significantly increased in both G/G group (24.3+/-11.9 to 29.5+/-10.6 U/L, p<0.01) and in non-G/G groups (21.4+/-4.5 to 26.1+/-9.1 U/L, p<0.01). During the study period, levels of corrected total calcium and phosphorus were not significantly changed. CONCLUSION: The CaSR polymorphism, G/G genotype, strongly influenced the responsiveness of parathyroid gland to LCD, compared with non-G/G genotypes. However, bone formation may occur actively on LCD, irrespective of CaSR genetic polymorphism.

Isolation of neural precursor cells from skeletal muscle tissues and their differentiation into neuron-like cells

Skeletal muscle contains several precursor cells that generate muscle, bone, cartilage and blood cells. Although there are reports that skeletal muscle-derived cells can trans-differentiate into neural-lineage cells, methods for isolating precursor cells, and procedures for successful neural induction have not been fully established. Here, we show that the preplate cell isolation method, which separates cells based on their adhesion characteristics, permits separation of cells possessing neural precursor characteristics from other cells of skeletal muscle tissues. We term these isolated cells skeletal muscle-derived neural precursor cells (SMNPs). The isolated SMNPs constitutively expressed neural stem cell markers. In addition, we describe effective neural induction materials permitting the neuron-like cell differentiation of SMNPs. Treatment with retinoic acid or forskolin facilitated morphological changes in SMNPs; they differentiated into neuron-like cells that possessed specific neuronal markers. These results suggest that the preplate isolation method, and treatment with retinoic acid or forskolin, may provide vital assistance in the use of SMNPs in cell-based therapy of neuronal disease.

The Attack of Ventricular Arrhythmia Caused by Low Potassium Level in Hemodialysis Patients / 대한신장학회잡지

ESRD patients have higher cardiovascular mortality risk than the general population. Increased QT dispersion has been shown to be a risk factor for cardiac arrhythmia in chronic hemodialysis patients with diabetes or arterial disease. It is known that QT dispersion is significantly prolonged in postdialysis than in predialysis. It is associated with a decrease in serum potassium. During hemodialysis, serum potassium is decreased and QT dispersion increases. Therefore ventricular arrhythmia frequently occurs in the latter half of dialysis. We report 2 cases of ventricular arrhythmia caused by potassium removal during dialysis in chronic hemodialysis patients.