Serum calcium and phosphorus levels in patients undergoing maintenance hemodialysis: A multicentre study in Korea

BACKGROUND: In many countries, nephrologists follow clinical practice guidelines for mineral bone disorders to control secondary hyperparathyroidism (SHPT) associated with abnormal serum calcium (Ca) and phosphorus (P) levels in patients undergoing maintenance hemodialysis (MHD). The Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines have long been used in Korea, and this study was undertaken to investigate the current status of serum Ca and P control in MHD patients. METHODS: Data were collected from a total of 1,018 patients undergoing MHD without intercurrent illness, in 17 hemodialysis centers throughout the country. Serum levels of Ca, P, and intact parathyroid hormone (iPTH) were measured over 1 year, and the average values were retrospectively analyzed. RESULTS: Serum levels of Ca, P, and the CaxP product were 9.1+/-0.7mg/dL, 5.3+/-1.4mg/dL, and 48.0+/-13.6mg2/dL2, respectively. However, the percentages of patients with Ca, P, and Ca x P product levels within the KDOQI guideline ranges were 58.7%, 51.0%, and 70.7%, respectively. Of the 1,018 patients, 270 (26.5%) had iPTH >300pg/mL (uncontrolled SHPT), whereas 435 patients (42.7%) showed iPTH <150pg/mL. Patients with uncontrolled SHPT had significantly higher values of serum Ca, P, and CaxP product than those with iPTH < or =300pg/mL. CONCLUSION: Despite the current clinical practice guidelines, SHPT seems to be inadequately controlled in many MHD patients. Uncontrolled SHPT was associated with higher levels of serum Ca, P, and Ca x P product, suggestive of the importance of SHPT management.

Urinary Biomarkers for Early Detection of Recovery in Patients with Acute Kidney Injury

Urinary biomarkers of acute kidney injury (AKI) have been revealed recently to be useful for prior prediction of AKI. However, it is unclear whether these urinary biomarkers can also detect recovery from established AKI. Urinary biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C, were measured every 2 days for 8 days in 66 patients with AKI. At day 0, there were no significant differences in plasma creatinine, BUN, and urine cystatin C between AKI patients in the recovery (n = 33) and non-recovery (n = 33) groups. Plasma creatinine concentrations were significantly lower in the recovery group (3.0 +/- 2.0 mg/dL) than in the non-recovery group (5.4 +/- 1.9 mg/dL) on day 4 after AKI diagnosis (P < 0.001). In contrast, there were significant differences in urine NGAL between the two groups starting on day 0 (297.2 +/- 201.4 vs 407.6 +/- 190.4 ng/mL, P = 0.025) through the end of the study (123.7 +/- 119.0 vs 434.3 +/- 121.5 ng/mL, P < 0.001). The multiple logistic regression analysis showed that urine NGAL could independently predict recovery from AKI. Conclusively, this prospective observational study demonstrates that urine NGAL can be a highly versatile marker for early detection of the recovery phase in established AKI patients.

Iodinated Contrast Media Can Induce Long-Lasting Oxidative Stress in Hemodialysis Patients

PURPOSE: Due to their comorbidities, dialysis patients have many chances to undergo radiologic procedures using iodinated contrast media. We aimed to assess time-sequenced blood oxidative stress level after contrast exposure in hemodialysis (HD) patients compared to those in the non-dialysis population. MATERIALS AND METHODS: We included 21 anuric HD patients [HD-coronary angiography (CAG) group] and 23 persons with normal renal function (nonHD-CAG group) scheduled for CAG, and assessed 4 oxidative stress markers [advanced oxidation protein products (AOPP); catalase; 8-hydroxydeoxyguanosine; and malondialdehyde] before and after CAG, and subsequently up to 28 days. RESULTS: In the nonHD-CAG group, only AOPP increased immediately after CAG and returned to baseline within one day. However, in the HD-CAG group, all four oxidative stress markers were significantly increased starting one day after CAG, and remained elevated longer than those in the nonHD-CAG group. Especially, AOPP level remained elevated for a month after contrast exposure. CONCLUSION: Our study showed that iodinated contrast media induces severe and prolonged oxidative stress in HD patients.

Spontaneous Mediastinal Hemorrhage in a Patient with End Stage Renal Disease: An Unusual Case of Uremic Bleeding / 대한신장학회지

Hemorrhagic complications in patients with end stage renal disease (ESRD) are common. These abnormal bleeding tendencies are caused by several factors including anticoagulation during hemodialysis, anemia, and uremic platelet dysfunction. The most common clinical manifestation of uremic bleeding is hemorrhage of the gastrointestinal tract from gastric ulcer disease. Mediastinal bleeding, however, is rare in ESRD patients. Here, we report a case of spontaneous mediastinal bleeding in a patient with hemodialysis. A huge periesophageal hematoma was observed on the chest CT scan and the bleeding time representing platelet function was prolonged. This case underlies the diversity of uremic bleeding.

A Thrombotic Coronary Artery Aneurysm Associated with Atherosclerosis in a Patient with End Stage Renal Disease / 대한신장학회지

We present a case of thrombotic coronary aneurysm of the left anterior descending artery (LAD) presenting with recurrent severe orthopnea in an end stage renal disease patient. She was admitted to the hospital with progressive dyspnea, exertional chest pain, and profound orthopnea. The echocardiography revealed a well marginated mass lesion between the main pulmonary artery and the left atrium. Chest CT showed a space-occupying lesion surrounded by the main pulmonary artery, the left atrium and the appendage adjacent to the atherosclerotic calcified lesion. Coronary angiography confirmed a huge thrombotic aneurysm with total occlusion of the proximal LAD. The presentation and management of the coronary aneurysm was reviewed.

A Case of Replacement Lipomatosis of Allograft Kidney Presented with Deep Vein Thrombosis / 대한신장학회지

Replacement lipomatosis of the kidney is a rare disorder in which a massive fatty tissue proliferation occurs within the renal sinus, hilum and perirenal region. Clinical symptoms includes flank pain, hematuria, fever usually associated with urinary tract infection and renal stone. But deep vein thrombosis due to mass effect has not been reported to be associated with replacement lipomatosis of kidney. A 37-year-old male was referred for the initiation of hemodialysis due to chronic rejection of allograft kidney. Collateral superficial veins were observed on his anterior abdominal wall and firm mass was palpable in the right lower quadrant abdomen. Abdominal-pelvis computed tomography revealed huge fatty mass originated from allograft kidney and non-visualization of inferior vena cava with lower density thrombus at both the common femoral veins. We report a rare case of replacement lipomatosis of the kidney complicated by deep vein thrombosis after renal transplantation.

Clinical Risk Factors for Bacteremia in Patients with Acute Pyelonephritis / 대한신장학회지

PURPOSE: Acute pyelonephritis (APN) is among the most common infectious diseases. Most APN occurs in young women and easily treated. Bacteremia has been associated in approximately 20-30% of those with APN. But recent documents demonstrated that blood cultures provide no useful information toward the clinical management of acute pyelonephritis. Thus we compared demographic and clinical characteristics as related to the bacteremic status, and investigated the risk factors for bacteremia. METHODS: One hundred sixty five patients, who visited myongji hospital for APN from January, 2004 to December, 2006 were included. Retrospective data were analyzed by medical record review. RESULTS: Bacteremic patients (N=51, 30.9%) were significantly older than those in nonbacteremic group (p<0.0001), had elevated serum creatinine (p=0.008), decreased platelet counts (p=0.029), lower serum protein (p=0.010), and lower serum albumin (p=0.011) than those without bacteremia. Hematuria was more severe in bacteremic patients (p<0.0001). The bacteremic cases were observed more frequently in patients with complicated APN patients than uncomplicated patients (46.7% vs. 21.4%, p=0.001). No significant difference existed between the bacteremic and non-bacteremic patients in the prevalence of resistance to quinolone of E. coli. In multivariate logistic regression analysis, serum albumin (p= 0.023), hematuria (p=0.003), and age (p=0.003) at presentation were found to be independent risk factors for bacteremia in acute pyelonephritis. CONCLUSION: Our study reveals that patients with bacteremia have different clinical characteristics compared to those without bacteremia. It is recommended to concern about the presence of bacteremia in the treatment of APN.

A Case of Membranoproliferative Glomerulonephritis with False-Positive Reaction for Anti-GBM Antibody / 대한신장학회지

Anti-glomerular basement membrane (Anti-GBM) nephritis is an autoimmune disorder characterized by rapidly progressive crescentic glomerulonephritis (RPGN). The treatment of anti-GBM nephritis with plasmapheresis, steroids and immunosuppressant has improved outcomes. An early diagnosis is essential for the survival of patients and a recovery of renal function. The diagnosis of anti-GBM disease has been traditionally based on the demonstration of linear deposits of immunoglobulins along the glomerular basement membrane by immunofluorescence (IF) microscopy. However, a kidney biopsy cannot always be easily performed in such ill patients. Recent development of specific enzyme immunoassays for anti-GBM antibody in the serum has made possible a provisional diagnosis without a kidney biopsy. A 46-year-old male patient with hypertension and hepatitis B presented with generalized edema and general weakness. Laboratory findings were compatible with acute renal failure and nephrotic syndrome with positive serum anti-GBM antibodies. After plasmapheresis with steroid pulse therapy, renal biopsy was performed and diagnosed as membranoproliferative glomerulonephritis (MPGN) with granular deposit of Ig G and C3. Follow-up antibody titers were negative. This case demonstrates the possibility of false-positive anti-GBM antibody in the serum. Therefore, enzyme immunoassay for anti-GBM antibody should be used only as a screening or follow-up test in patients that have been confirmed positive by IF microscopy.

A Case of IgA Nephropathy with a Membranoproliferative Glomerulonephritis-like Pattern Presenting as Massive Ascites in a Patient with Alcoholic Liver Disease / 대한신장학회지

IgA nephropathy can occur commonly in alcoholic liver cirrhosis and is the most common form of secondary IgA nephropathy. Defective clearance of IgA-containing complexes by liver is thought to contribute to the development of IgA nephropathy in alcoholic cirrhosis. Although IgA deposition is found up to 64% in autopsy cases of alcoholic cirrhosis, most patients have mild clinical symptoms, and nephrotic range proteinuria occurs rarely in these patients. We report a case of IgA nephropathy with a membranoproliferative pattern that is detected with unusual massive ascites in a patient with alcoholic liver disease. A 60-year-old male patient was referred to our hospital for evaluation and management of abdominal distension. Abdominal ultrasonographic findings were compatible with diffuse liver cirrhosis with splenomegaly and large amount of ascites. He had nephrotic range proteinuria, azotemia, hyperlipidemia, and hematuria in dipstick. Renal biopsy performed under the impression of acute nephritis revealed mesangial and endocapillary proliferative glomerulonephritis with double contour of capillary loop. Immunofluorescence findings showed mesangial IgA and C3 deposit, compatible with IgA nephropathy. He was treated with high dose steroid, and steroid was tapered during 2 months. Steroid treatment induced complete remission state, and ascites was resolved.

Tc-99m MDP-induced Acute Hepatitis in a Hemodialysis Patient / 대한신장학회지

Bone scan is one of the most frequently performed studies in nuclear medicine with few adverse reactions for the examination of pathologic conditions of bone. Diffuse liver uptake of Technetium-99m methylene diphosphonate (Tc-99m MDP) is a rare occurrence with only a few reports in the literature. Furthermore, there is no report of Tc-99m MDP-induced liver injury. Here we report a case of acute hepatitis with diffusely increased uptake of Tc-99m MDP in a hemodialysis patient.

Early Detection of Hemodialysis Ateriovenous Fistula Dysfunction by Trend Analysis of Intra-access Pressure / 대한신장학회지

PURPOSE: To detect early arteriovenous fistula (AVF) dysfunction, we have developed a new method of intra-access total pressure (pT), and static pressure (pS) measurements. The purpose of this study is to assess the relationship between intra-access pressure and vascular stricture in order to establish the clinical validity of the method. METHODS: Total 46 of native AVFs were enrolled. They were measured intra-access pS and pT monthly. In initial angiography, 6 of 10 inflow stricture (As), 6 of 7 outflow stricture (Vs) and 2 having both lesions were taken PTA (percutaneous angioplasty) and compared pressure and ratio changes. If delta p (pT-pS) decreased more than 10% over 3 months or pT/MAP (mean arterial pressure) ratio dropped more than 10% over 3 months with below 0.8, then the patients were referred to angiography. Thirtyone patients were performed final angiography, and we compared the results with those of initial angiography. RESULTS: Although pT/MAP ratio and delta p were increased after PTA, there was no statistical significance in 6 As (+) patients (p>0.05). Six Vs (+) and 2 AS (+) and Vs (+) patients' delta p were increased significantly (p0.45). CONCLUSION: Intra-access stricture could be detected with pT/MAP ratio and delta p change. However, more careful MAP and pT measurement should be recommended for accurate diagnosis.

Recurrent Acute Uremic Encephalopathy Associated with Reversible Bilateral Basal Ganglia Lesion / 대한신장학회지

Uremic encephalopathy is a well-known complication in uremia and rarely occurs with involuntary movements which represent basal ganglia lesion. We experienced a cases of recurrent acute uremic encephalopathy associated with reversible bilateral basal ganglia lesion. A 49-year-old man with end stage renal disease due to diabetic nephropathy on continuous ambulatory peritoneal dialysis (CAPD) treatment for the last 2 months was admitted for mental change. His blood sugar was 60 mg/dl, and his mentality was recovered after glucose solution infusion. Five days after admission, he suddenly developed dysarthria and chorea. Brain magnetic resonance imaging (MRI) demonstrated low and high signals on bilateral basal ganglia in T1-weighted and T2-weighted images, respectively. After intensified CAPD treatment, his neurologic manifestations were resolved. One month after discharge, follow-up brain MRI showed decreased size of low attenuation on the basal ganglia. Two months later, he repeatedly developed dysarthria and involuntary movement of extremities. Newly developed bilateral symmetric T1 low and T2 high signal lesion on the basal ganglia was repeatedly observed on brain MRI. At that time, (his) Kt/V was 1.33. So we decided on him to switch from CAPD to hemodialysis, after then his symptoms disappeared.

A Case of Rhabdomyolysis and Acute Renal Failure Associated with Primary Hypothyroidism / 대한신장학회지

Hypothyroidism is a clinical state which results from decreased production of thyroid hormone, and its symptoms are various including lack of energy, dryness of skin and hair, dyspnea, bradycardia, hypotension, body weight gain, and constipation. Muscle disorders due to hypothyroidism may include myalgia, muscle weakness, stiffness, delayed tendon reflex, abnormality of electromyography, changes of muscle tissues and increased muscle enzymes. Hypothyroid myopathy manifests as a mild form of myopathy rather than an acute rhabdomyolysis, that is a very rare complication of hypothyroid myopathy and that can cause acute renal failure. We report a case of primary hypothyroidism presented with rhabdomyolysis and acute renal failure. A 50-year-old male referred to our hospital for evaluation and management of generalized edema, muscle weakness, fatigue and myalgia. He had acute rhabdomyolysis and progressed to acute renal failure due to newly developed primary hypothyroidism. After hormone replacement therapy with levothyroxine, the patients renal function and muscular symptom completely recovered.

Early Detection of Hemodialysis Arteriovenous Fistula Dysfunction with Intra-access Static and Total Pressure Measurement / 대한신장학회잡지

PURPOSE: To detect the dysfunction of arteriovenous fistula (AVF) early, we have developed a new method to calculate the intra-vascular conduit flow rate based on the Bernoulli's theory. However, this method has limitation on detection of inflow stenosis. For detection of both in- and out-flow stenosis, we tried to measure intra-access static (pS) and total pressure (pT), and compared with angiographic findings. METHODS: From a total of 46 cases of native AVFs, of at least 3 months of construction, intra-access pS and pT were measured, before starting hemodialysis. deltap (pT-pS) and pT/mean arterial pressure (MAP) ratio were calculated, and compared with angiographic findings. RESULTS: Among 37 patients without outflow stenosis (Vs) in fistulogram, 10 patients with inflow stenosis (As) had significantly lower pT/MAP ratio and deltap than those without As patients (p<0.005). Among 34 patients without As, deltap was significantly lower in 7 patients with Vs than those 27 patients without Vs (p=0.001). CONCLUSION: pT/MAP ratio was correlated with As, and deltap reflects Vs in angiography. The measurement of pS and pT might be useful to predict inflow and outflow stenosis of AVFs.

Serial Changes of QT Dispersion in Continuous Ambulatory Peritoneal Dialysis Patients / 대한신장학회잡지

PURPOSE:To evaluate the changes of QT dispersion (QTd) in CAPD patients serially from the period before the initiation of CAPD until several years after CAPD, and to find any associated factors. METHODS:We performed a retrospective cohort study with a total of 101 patients who initiated CAPD between 1990 and 1996. All data were recruited from the patients' medical records before CAPD initiation, within one year after CAPD, and between one and three years after CAPD. RESULTS:QTd and Corrected QTd (QTdc) values after CAPD did not show differences in the paired t-test of those before CAPD and within one year after CAPD. There was a definite correlation between the QTds before CAPD and that within one year after CAPD (r=0.530, p<0.001). In addition, the QTds from within one year after CAPD showed a correlation with those taken from one to three years after CAPD (r=0.487, p=0.019). Upon analysis of all-cause mortality, the change rate of QTd after CAPD initiation was revealed as a predicting factor along with the QTd, QTc max, and QTdc within one year after CAPD (RR=1.055, p=0.005). The change rate also remained a predictor of cardiovascular mortality (RR= 1.088, p=0.007). In a multivariate Cox regression, cardiomegaly and previous cardiovascular disease were revealed to be independent factors for the change rate of QTd. CONCLUSION:QTd in CAPD patients did not change after initiation of CAPD, and the change rate of QTd after CAPD initiation was revealed as a risk factor for both all-cause mortality and cardiovascular mortality.

Clinical and Hematological Analysis on the 110 Cases of Childhood Leukemia

No abstract available.