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

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

Effect of Peritoneal Dialysis Duration on the Outcome of Peritonitis in CAPD Patients / 대한신장학회잡지

BACKGROUND: The clinical manifestations of peritonitis in long-term PD patients may be more severe due to structural and functional alterations of the peritoneum caused by repeated exposure to the bioincompatible dialysate. However, the study in which outcome of peritonitis was compared to the duration of PD has been reported rarely. This study was performed to evaluate the effect of PD duration on the outcome of peritonitis. METHODS: Medical records of patients cared for in Kyungpook University Hospital between June 1998 and May 2001 were reviewed retrospectively. Patients were divided into three groups by PD duration: group 1, or =37 months. RESULTS: There were 303 episodes (156 patients) of peritonitis during the study periods: 77 episodes in group 1, 115 episodes in group 2 and 111 episodes in group 3. There was no difference in gram- positive, gram-negative or fungal rate of peritonitis among three groups. In group 3, 16.2% of the patients transferred to hemodialysis, while 3.9% and 7.0% of patients in group 1 and 2 transferred to hemodialysis (p<0.05). CONCLUSION: Patients maintained on PD for over three years are associated with higher rate of technique failure than patients maintained on PD for less than three years. PD duration may be considered as a factor for predicting prognosis of peritonitis. Peritonitis in patients on long-term PD needs special attention.

The Relationship between the Histological Findings and beta ig-h3 in IgA Nephropathy / 대한신장학회잡지

BACKGROUND: TGF-beta is involved in the pathogenesis of various kidney diseases characterized by glomerulosclerosis and tubulointerstitial fibrosis. It is reported that urinary TGF-beta reflects the grade of interstitial fibrosis in glomerular disease. Here, we evaluated the relationship between the histological findings and beta ig-h3 in IgA nephropathy. METHODS: In patients with IgA nephropathy, we measured blood pressure (BP), serum creatinine, 24-hour urinary protein excretion (UTp), creatinine clearance (Ccr), serum and urine beta ig-h3 levels, and urine TGF-beta levels at the time of renal biopsy. Histologic findings were semiquantitively scored according to the extent of glomerulosclerosis (GG), tubulointerstitial fibrosis (TIG) and hyaline arteriolosclerosis (HA) by the criteria suggested by To. Semiquantitive scoring of immunohistochemistry for beta ig-h3 was done. RESULTS: Mean BP 95.4+/-14.5 mmHg, serum creatinine 1.06+/-0.35 mg/dL, 24-hour UTp 1, 423+/-1, 439 mg/day, and Ccr was 97.84+/-59.73 mL/min. The number of patients that showed GG 3 were 5, GG 2 was 1, GG 1 were 12. And, the number of patients that showed TIG 3 were 2, TIG 2 were 5, TIG 1 were 11. HA was shown in 4 patients. beta ig-h3 immunostaining was observed in glomerular Bowman's capsules and basement membrane of proximal tubules. The degree of beta ig-h3 immunostaining was positively correlated with the degree of glomerulosclerosis (r=0.72, p<0.001), interstitial fibrosis (r=0.91, p<0.001), serum creatinine (r=0.592, p<0.05) and Ccr (r=-0.626, p<0.05), but not with 24-hour UTp. Serum and urine beta ig-h3 levels did not correlate with any of these parameters. CONCLUSION: Renal beta ig-h3 expression in patients with IgA nephropathy may be related to glomerulosclerosis and interstitial fibrosis. However, urinary beta ig-h3 levels did not represent the pathologic changes of IgA nephropathy. Long-term study to measure renal beta ig-h3 expression and urinary beta ig-h3 is required to elucidate the roles of beta ig-h3 in IgA nephropathy.

Long Term Effects of Dialysis Adequacy, Residual Renal Function, Nutritional Indices on CAPD Patient Outcome / 대한신장학회잡지

PURPOSE: Several factors including dialysis adequacy are now known to be related to clinical outcomes of CAPD patients. In our study, the long term effects of dialysis adequacy, residual renal function, nutritional indices, and peritoneal membrane transport characteristics on the outcomes of CAPD patients were evaluated. METHODS: Prevalent or incident 127 patients were enrolled from February 1998 to January 1999. Follow-up was terminated in January 2003. In 41 patients, parameters of adequacy were reevaluated, and the effects of parameter change over time on patient outcomes were analyzed. RESULTS: Seventy-two were male. Twenty-nine (23%) were diabetic. Mean age was 47+/-2.9 years, and the mean follow up period was 45+/-.8 months. The baseline serum albumin was 3.7+/-.5 g/dL. nPCR was 0.8+/-.2 g/kg/d, and %lean body mass was 68.4+/-4.3. Kt/V was 2.0+/-.7, and Ccr was 64.5+/-8.8 L/wk/1.73 m2. The estimated GFR was 1.1+/-.3 mL/min. The multivariated analysis demonstrated that diabetes, serum albumin, and the patent residual renal function were independent factors of the patient and technique survival. Membrane transport characteristic was a predictor of technique survival. Among patients for whom the parameters of adequacy were reevaluated, a more rapid decrease of serum albumin and a more rapid increase of membrane transport characteristics were associated with increased risk of either death or technique failure. CONCIUSION: Nutritional indices and presence of residual renal function have a significant impact on the clinical outcome. The decrease of serum albumin and the increase of membrane transport characteristic have negative impacts on patient and technique survival.

Long Term Effects of Dialysis Adequacy, Residual Renal Function, Nutritional Indices on CAPD Patient Outcome / 대한신장학회잡지

PURPOSE: Several factors including dialysis adequacy are now known to be related to clinical outcomes of CAPD patients. In our study, the long term effects of dialysis adequacy, residual renal function, nutritional indices, and peritoneal membrane transport characteristics on the outcomes of CAPD patients were evaluated. METHODS: Prevalent or incident 127 patients were enrolled from February 1998 to January 1999. Follow-up was terminated in January 2003. In 41 patients, parameters of adequacy were reevaluated, and the effects of parameter change over time on patient outcomes were analyzed. RESULTS: Seventy-two were male. Twenty-nine (23%) were diabetic. Mean age was 47+/-2.9 years, and the mean follow up period was 45+/-.8 months. The baseline serum albumin was 3.7+/-.5 g/dL. nPCR was 0.8+/-.2 g/kg/d, and %lean body mass was 68.4+/-4.3. Kt/V was 2.0+/-.7, and Ccr was 64.5+/-8.8 L/wk/1.73 m2. The estimated GFR was 1.1+/-.3 mL/min. The multivariated analysis demonstrated that diabetes, serum albumin, and the patent residual renal function were independent factors of the patient and technique survival. Membrane transport characteristic was a predictor of technique survival. Among patients for whom the parameters of adequacy were reevaluated, a more rapid decrease of serum albumin and a more rapid increase of membrane transport characteristics were associated with increased risk of either death or technique failure. CONCIUSION: Nutritional indices and presence of residual renal function have a significant impact on the clinical outcome. The decrease of serum albumin and the increase of membrane transport characteristic have negative impacts on patient and technique survival.

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

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

ReVersible MRI Changes in a Patient with Uremic Encephalopathy / 대한신장학회잡지

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

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

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

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

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

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

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

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

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

Malignancy Following Renal Transplantation / 대한이식학회지

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