A Case of Klebsiella pneumoniae Peritonitis in CAPD Patient with Liver Abscess / 대한신장학회지

A 42-year-old male was hospitalized with abdominal pain, dyspnea, and turbid peritoneal fluid. He was diagnosed with hypertension, diabetes and started continuous ambulatory peritoneal dialysis (CAPD) 11 months ago. He was treated with intraperitoneal cefazolin and ceftazidime, and then white blood cell counts of dialysate decreased. Incidentally, liver abscess was found in chest CT performed for the evaluation of dyspnea, and patient was febrile persistently. So percutaneous abscess drainage was done by pigtail catheter. We changed the antibiotics to ceftriaxone and metronidazole, and hemodialysis was started. Klebsiella pneumoniae was cultured from peritoneal fluid and blood simultaneously. We concluded that liver abscess is a primary cause of CAPD peritonitis.

Analysis of the acid-base disorders of critically ill patients in the medical intensive care unit / 대한내과학회지

BACKGROUND: Acid-base imbalances are common in critically ill patients; however, the incidence of acid-base imbalances in the medical intensive care units has not been fully determined. In this study, we investigated the incidence and the type of acid-base imbalances in critically ill patients and we assessed which variables were associated with the patients' outcome. METHODS: One hundred eighty-seven patients (122 men, age: 61.2+/-12.8 years) were enrolled. All the patients were admitted to the medical intensive care unit between January 2005 and December 2005. All the data sets included simultaneous measurements of an arterial blood gas with base excess, the serum electrolytes, the anion gap and the APACHE II scores. RESULTS: The mortality rate was 56.7%. The incidence of acid-base imbalances was as follows: 25.1% were single disorders that existed with only a single primary acid-base imbalance, 48.7% were double disorders, 13.4% were triple disorders and 12.8% were normal (no disorders). The incidence of metabolic acidosis was 57.8% and the mortality rate was not different according to the type of acid-base imbalances. There were significant differences between the nonsurvivors and survivors according to the pH (7.34 vs. 7.41, respectively), HCO(-)3 (20.68 mmol/L vs. 25.90 mmol/L, respectively), ECF base excess (-5.19 vs. 1.19, respectively), the anion gap (18.57 mmol/L vs. 13.77 mmol/L, respectively), the corrected anion gap (23.63 mmol/L vs. 17.96 mmol/L, respectively), the serum albumin (2.37 g/dL vs. 2.74 g/dL, respectively), and the APACHE II scores (20.7 vs 17.2, respectively). However, on the Cox proportional hazard regression analysis, only the APAHCE II scores affected the patients' outcome. CONCLUSIONS: There were diverse acid-base imbalances in the critically ill patients and the incidence of metabolic acidosis was highest among the acid-base imbalances. The best predictor of the patients' outcome was the APACHE II scores.

A Case of Crescentic IgA Nephropathy with Positive ANCA Serology / 대한신장학회지

Immunoglobulin A (IgA) nephropathy in patients with the clinical findings of rapidly progressive glomerulonephritis usually demonstrate crescentic glomerulonephritis (CrGN). It is characterized by mesangial immune complex deposits containing IgA and is rarely associated with ANCA. The following case report illustrates a CrGN with mesangial & capillary wall IgA deposits by immunofluorescence (IF) and mesangial & endocapillary electron dense deposits by electron microscopy (EM) in patient with positive ANCA serology. A 54-year-old male visited due to the discomfort of right flank. Blood pressure was 150/90 mmHg. BUN and serum Creatinine was 40 mg/dL, 4.4 mg/dL respectively. Urinalysis revealed protein 2+, >30 RBC's/ HPF (dysmorphic), 24hr urine protein 1,612 mg/day and creatinine clearance 19 mL/min/1.73m2. Serological P-ANCA was positive by indirect immunofluorescence & ELISA. The histologic findings showed global scleorsis and fibrocelluar crescent without hypercellularity on LM, mesangial IgA deposition on IF, mesangial and subendothelial electrone dense material depositions on EM. After treatment (Methylprednisolon 500 mg/day for 3 days and then prednisolone 60 mg/day), Serum creatinin level, proteinuria and ANCA titer were decreased.

Catheter Colonization in Hemodialysis Patients : Comparison with Cuffed & Tunnelled Dialysis Catheter (Permcath(R)) and Noncuffed Dialysis Catheter (Gamcath(R)) / 대한신장학회지

PURPOSE: The aim of this study is to investigate incidence and related affecting factors on bacterial colonization and bacteremia of cuffed & tunnelled dialysis catheter and noncuffed dialysis catheter. METHODS: This study was performed retrospectively through review of medical records from May 2005 to May 2006. 102 central venous catheters for hemodialysis were analyzed: cuffed & tunnelled dialysis catheter (n=32, group P); noncuffed dialysis catheter (n=70, group G). RESULTS: There was no difference between group P (15.6%) and group G (15.7%) in cumulative incidence of catheter colonization. However, in terms of risk for colonization with time, incidence density of group P was lower than group G (group P, 1.17/1,000 catheter days; group G, 12.97/1,000 catheter days). In the subgroup analysis of group G, incidence density of internal jugular vein group was lower than femoral vein group (internal jugular vein catheter, 7.54/1,000 catheter days; femoral vein catheter, 32.43/1,000 catheter days). CONCLUSION: The risk of catheter colonization turned out higher in noncuffed dialysis catheter than in cuffed & tunnelled dialysis catheter. Therefore, more delicate antiseptic cares for dialysis catheter were needed in case of emergency. Additionally, permanent vascular access should be placed earlier to avoid insertion of temporary dialysis catheter in end-stage renal disease.

Nutcracker syndrome: treatment with an intravascular stent / 대한내과학회지

The nutcracker syndrome refers to compression of the left renal vein between the aorta and the superior mesenteric artery, which results in renal vein and left gonadal vein varices. This is an unusual, but well accepted cause of hematuria. We report a case of the nutcracker syndrome which is diagnosed by CT angiography before venography and pressure measurement of the left renal vein and managed by intravascular stent placement. A 47-year-old female patient was presented with gross hematuria. Urinalysis revealed hematuria with only 1% of dysmorphism. Abdominal spiral CT and 3D CT angiography revealed compression of the left renal vein between the aorta and superior mesenteric artery because of an acute branching angle of superior mesenteric artery from the aorta. Renal venography showed compression of the left renal vein and collateral circulations to the left ovarian vein and lumbar vein. The pressure gradient between the left renal vein and inferior vena cava was 4 mmHg. Intravascular stent was placed in this patient. We conclude that in patients with the nutcracker syndrome, CT angiography could be considered before venography and venous pressure measurements. When this syndrome leads to clinical symptoms, Intravascular stent placement should be considered. Well designed stent offers minimal invasiveness and physiologic relief as in the present case.

The correlation of microalbuminuria and glomerular filtration rate in normotensive patients with type 2 diabetes mellitus / 대한내과학회지

BACKGROUND: Diabetic nephropathy is one of the major causes of end-stage renal disease. Microalbuminuria predicts not only progressive renal disease, but also increased cardiovascular morbidity and mortality. But, the relationship between urinary albumin excretion rate (UAER) and glomerular filtration rate (GFR) remains an unresolved issue. In order to investigate the early renal function abnormalities, UAER and GFR were assessed and their relationship was examined in normotensive patients with type 2 diabetes mellitus (DM). METHODS: Between January 1997 and June 2001, in a cross sectional study of 112 normotensive patients with type 2 DM not showing overt proteinuria and thirty healthy subjects served as control group. According to UAER, type 2 DM patients were divided into normoalbuminuria group and microalbuminuria group. The GFR was measured using 99mTc-DTPA renal scan. Clinical values in type 2 DM patients and control subjects were compared using one-way analysis of variance (ANOVA) with Scheffe's F test. In type 2 DM patients, Univariate Chi-square analysis was used to evaluate the prevalence of diabetic retinopathy and the differences in anti-diabetic treatment. Pearson correlation coefficients were used to demonstrate a strength of an association between UAER and other variables including GFR. RESULTS: Three groups were well matched with regard to gender, age and body mass index. There were no significant differences in disease duration and anti-diabetic treatment in type 2 DM patients. The GFR in microalbuminuric patients was significantly higher than in normoalbuminuric patients (124.0 17.6 vs 102.9+/-15.5 mL/min/1.73 m2, p<0.05). The prevalence of diabetic retinopathy in microalbuminuric patients was significantly higher than in normoalbuminuric patients (53.8% vs 24.7%, p<0.05). Only there was significant positive correlation between log UAER and GFR (r=0.303, p<0.05). CONCLUSION: As in type 1 DM patients, there was a significant relationship between UAER and GFR in normotensive type 2 DM patients without overt proteinuria.

Asymptomatic Bacteriuria in Patients with Chronic Renal Failure / 대한신장학회잡지

BACKGROUND: In patients with chronic renal failure, infection is caused by altered host defense mechanism, and contributes significantly to their morbidities and mortalities. Especially, urinary tract infection often occurs in patients with chronic renal failure and is due to azotemia, infrequent voiding, low urinary flow rate and urinary concentration defects. This study was designed to compare the incidence of asymptomatic bacteriuria with chronic renal failure with that of normal control group. We also investigated whether risk factors for urinary tract infections in patients with chronic renal failure are similar to those in normal control groups. METHODS: 34 patients (M : F=13 : 21) with chronic renal failure and 30 normal control groups (M : F= 11 : 19) were evaluated in the Pusan National University Hospital from January 2001 through December 2001. Etiology of chronic renal failure included diabetes mellitus (n=16, 47.1%), hypertension (n=14, 41.2%) and glomerular diseases (n=4, 11.7%). 25 patients were treated with hemodialysis and 5 patients were treated with peritoneal dialysis. Others (n=4) were not treated with dialysis. Clean-catch, first voided urine was collected in the morning and examined by routine urinalysis and urine culture. RESULTS: 7 of 34 (20.6%) patients with chronic renal failure were positive in urine cultures and only one of 30 (3.3%) from the normal control group were positive. E. coli (n=2), Acinetobacter baumanii (n=2), Enterococcus spp. (n=2), S. aureus (n=1), P. aeruginosa (n=1), S. epidermidis (n=1) and Str. viridans (n=1) are cultured from urine specimens. There was a significant difference between the incidence of asymptomatic bacteriuria in patients with chronic renal failure and that of normal control group. But there was no significant difference in the presence of bacteriuria according to sex, age, etiology of renal failure, dialysis modality and pyuria. CONCLUSION: Patients with chronic renal failure have higher frequency of asymptomatic bacteriuria and pyuria than healthy subjects and tend to lead to symptomatic urinary tract infections.

The Correlation between Relative Renal Uptake of (99m)Tc-DMSA Renal Scan and Glomerular Filtration Rate in Patients with Reduced Renal Function / 대한신장학회잡지

BACKGROUND: Glomerular filtration rate(GFR) is an important parameter for the evaluation and monitoring of renal function. The aim of this study was to investigate the correlation between the relative 1 hour uptake of (99m)Tc-DMSA renal scan(DMSA- %uptake, TRUR) and GFR which was estimated by (99m)Tc-DTPA, serum creatinine and 24 hour-urinary creatinine excretion. METHODS: Between January 1998 and March 2001, 65 patients had undergone (99m)Tc-DMSA renal scan, (99m)Tc-DTPA renal scan, serum creatinine and 24 hour-urinary creatinine excretion. Of them, 42 patients had moderately or severely reduced renal function(DTPA-GFR 0.05). In group B, TRUR (mean+/-S.D. 16.3+/-7.4%) was significantly correlated with DTPA-GFR(r=0.731, p < 0.01). In both group, serum creatinine, Ccr and C and G Ccr were significantly correlated with TRUR. CONCLUSION: Although the relative 1 hour uptake of the (99m)Tc-DMSA renal scan, as a method of renal cortical image could not estimate the true GFR, it showed a good correlation with GFR in patients with moderately reduced renal function. (99m)Tc-DMSA renal scan seems to be helpful to evaluate the renal function in patients with moderately reduced renal function.

A study of central venous hemodialysis catheter colonization and peripheral bacteremia in patients undergoing hemodialysis / 대한내과학회지

BACKGROUND: Central venous hemodialysis is often used and is respectively safe in hemodialysis patients. But, many complications have been reported. Peripheral bacteremia after insertion of central venous hemodialysis catheter is a major cause of morbidity. We undertook a prospective study to investigate the colonization of central venous hemodialysis catheter and subsequent related episodes of peripheral bacteremia. METHODS: Twenty-nine patients were enrolled ; who had been in hemodialysis program from July, 1999 to June, 2000 in Pusan National University Hospital. Blood cultures were taken from the catheter weekly after insertion. When the result of blood cultures through the central venous catheter became positive, indicating the colonization in the central venous catheter, peripheral venous blood cultures were taken before starting dialysis to detect the peripheral bacteremia. The data were analyzed by Mann-Whitney test. RESULTS: The mean age of patients was 53 years old and a prospective study of 29 central venous hemodialysis catheter was performed. Seven catheters (24%) became colonized on their instrumental surface. The mean time to colonization was 21 days after insertion. The colonizing organisms were Staphylococcus epidermidis, Staphylococcus aureus, Pseudomonas aeruginosa, Enterococcus. Four catheters (13%) developed peripheral bacteremia with the same organism of colonization in the central venous catheter. The mean time to bacteremia was 19 days after insertion. The organisms of peripheral bacteremia were Staphylococcus epidermidis (n=2), Staphylococcus aureus (1), Enterococcus (1). Bacteremia only occured when blood drawn through the catheter cultured more than 1000 colony forming units per mL. The risk of subsequent bacteremia is not related to time left in. CONCLUSION: Bacterial colonization in the central venous catheter often led to bacteremia in hemodialysis patients. The risk of subsequent bacteremia is not related to time left in situ but to degree of colonization. In future, prospective study is needed in more patients.

The changes in cardiac dimensions and function in patients with end stage renal disease undergoing hemodialysis / 대한내과학회지

BACKGROUND: It is absolutely necessary to evaluate cardiac function at starting and during hemodialysis in patients with end stage renal disease. In this study, we tried to determinate the changes of cardiac function associated with hemodialysis. METHODS: Twenty patients with end stage renal disease were enrolled , who had been in hemodialysis program from February, 1997 to August, 1999 in Pusan National University Hospital. They were examined with echocardiography and gated blood pool scintigraphy at starting hemodialysis and after follow-up. The data were analyzed by paired T-test. RESULTS: The patients were 46.2+/-16.8 years old and male to female ratio was 8 : 12. The underlying diseases were diabetes mellitus(n=10), hypertension(7), glomerulonephritis (2) and others(1). The duration of symptoms associated with end stage renal dis- ease and underlying diseases was 3.4+/-2.6 years, and the duration of hemodialysis was 13.8+/-7.0 months. The LVEDID, LVESID and RVC decreased significantly (-6.10, -7.80 and -20.00%, respectively, p0.05). In ten cases associated with diabetes, LVEDID decreased (-7.90%, p<0.05). In twelve cases associated with cardiac diseases, LVEDID and LVESID decreased (-8.60 and -10.50%, respectively, p<0.05). In four cases associated with diabetes without cardiac diseases, LAD decreased (-5.10%, p<0.05). And in four cases associated with cardiac diseases without diabetes, there were no significant changes in cardiac dimensions and EF. In seven cases associated with diabetes and cardiac diseases, LVEDID decreased (-10.50%, p<0.05). The EF on gated blood pool scintigraphy decreased (-0.9%, p<0.05) as a whole, while increased (5.90%, p<0.05) in the cases associated with diabetes and cardiac diseases. CONCLUSION: During the early hemodialysis stage of end stage renal disease, we found a change of concentric left ventricular hypertrophy and relatively preserved left ventricular function. Furthermore we can expect that adequate hemodialysis -with dry-weight as low as possible - may prevent progression to eccentric left ventricular hypertrophy and dilated cadiomyopathy.