Establishment of a Maximum Surgical Blood Order Schedule and Red Blood Cell Mean Transfusion Units Per Patient According to Adjacent Diagnosis Related Groups Patient Classification System

Background@#For effective management of blood components, periodic updates of the maximum surgical blood order schedule (MSBOS) using recent data are crucial. This study aimed to establish an updated MSBOS and red blood cell (RBC) mean transfusion units per patient according to the adjacent diagnosis related groups (ADRG) classification system. @*Methods@#This retrospective study was based on an audit of the medical records of inpatients at a tertiary hospital between January and December 2017. We investigated transfusion-related data to establish the MSBOS and determine the RBC mean transfusion units per patient according to the ADRG and compared these updated values with previous data. @*Results@#During the investigated period, a total of 5,607 RBC units were transfused in 17,382 patients. The revised MSBOS was similar to the previous MSBOS in most surgeries. Among the 130 ADRG codes analyzed, 34 codes showed an increase, while 96 codes showed a decrease in RBC mean transfusion units per patient, compared to data from 2007. Overall, the RBC mean transfusion units per patient in 2017 was 0.89 units less compared to that in 2007 after adjusting for age (95% CI: 0.853–0.912). @*Conclusions@#The revised MSBOS was similar to that of the previous versions. However, there were differences in the number of RBC transfusion units used in some surgeries and disease treatments compared to those in the past. Considering the changes within the medical environment, this study highlights the importance of periodic evaluation of MSBOS and RBC transfusion usage.

Time-course analysis of DNA damage response-related genes after in vitro radiation in H460 and H1229 lung cancer cell lines

Radiation is the most useful treatment modality for cancer patients. It initiates a series of signal cascades such as DNA damage response (DDR) signaling for repairing damaged DNA, arresting the cell cycle, and inducing cell death. Until now, few genes have been found to be regulated by radiation, which explains the molecular mechanisms of cellular responses to radiation. Although the transcriptional changes caused by radiation have been widely investigated, little is known about the direct evidence for the transcriptional control of DDR-related genes. Here, we examined the radiosensitivity of two non-small cell lung cancer cell lines (H460 and H1299), which have different p53 status. We monitored the time-dependent changes of 24 DDR-related gene expressions via microarray analysis. Based on the basal expression levels and temporal patterns, we further classified 24 DDR-related genes into four subgroups. Then, we also addressed the protein levels of several DDR-related genes such as TopBP1, Chk1 and Chk2, confirming the results of microarray analysis. Together, these results indicate that the expression patterns of DDR-related genes are associated with radiosensitivity and with the p53 statuses of H460 and H1299, which adds to the understanding of the complex biological responses to radiation.

The Prevalence and Clinical Characteristics of Reflux Esophagitis in Koreans and Its Possible Relation to Metabolic Syndrome

The prevalence of reflux esophagitis is increasing in Korea. To estimate the prevalence and clinical characteristics of reflux esophagitis in healthy subjects, we retrospectively examined the medical records of healthy subjects undergoing a routine check-up from October 2004 to September 2005. A total of 6,082 (3,590 men, mean age 44+/-10 yr) subjects were enrolled in this study. The prevalence of reflux esophagitis in healthy subjects was 10.5%. According to the univariate analysis, male sex (odds ratio [OR] 3.49, 95% confidence interval [CI] 2.84-4.30), smoking history (OR 1.91, 95% CI 1.60-2.28), body mass index (BMI) >30 kg/m2 (OR 2.13, 95% CI 1.37-3.33), total cholesterol >250 mg/dL (OR 1.50, 95% CI 1.05-2.14), low-density lipoprotein (LDL) cholesterol > or =160 mg/dL (OR 1.52, 95% CI 1.08-2.14), triglyceride > or =150 mg/dL (OR 1.92, 95% CI 1.61-2.30), high blood pressure (BP) (OR 1.46, 95% CI 1.20-1.76), and fasting glucose > or =110 mg/dL (OR 1.45, 95% CI 1.13-1.86) were significantly associated with reflux esophagitis (all p<0.05). However, age, alcohol drinking and Helicobacter pylori infection were not associated with reflux esophagitis. In conclusiosn, significant relationships of reflux esophagitis with obesity, low high-density lipoprotein (HDL) cholesterol, high triglyceride, high BP, and elevated fasting glucose suggested that reflux esophagitis might represent the disease spectrum of the metabolic syndrome.

A case of cytomegalovirus colitis in a patient with liver cirrhosis / 대한내과학회지

Most cases of cytomegalovirus (CMV) colitis are associated with an immunocompromised status, especially with human immunodeficiency virus (HIV) infections and transplantation. It rarely occurs in immunocompetent adults. We report a rare case of CMV colitis in a patient with HBV related liver cirrhosis. A 49 year-old patient presented with lower abdominal pain and bloody diarrhea. Sigmoidoscopic examination showed multiple shallow ulcerations and severe mucosal edema. Conservative treatment for the patient including antibiotics was not effective. Repeated sigmoidoscopic examination with re-biopsy showed intranuclear inclusion bodies suggestive of CMV infection. After administration of Ganciclovir, abdominal pain and bloody diarrhea improved.

Application of Advance Directives for Patients with End Stage Renal Disease / 대한신장학회지

PURPOSE: In other countries, government guidelines related to chronic illness are being used to enhance supportive care of renal patients. In Korea, the number of old ages and hemodialysis patients with many complications has been increased. But we don't have any guidelines for palliative care of end stage renal disease. This paper reports a study exploring decisions about end-of-life treatment (e.g. cardiopulmonary resuscitation, renal replacement therapy) via routine use of advance directives in people with end stage renal disease undergoing hemodialysis. METHODS: 1) We revised advance directives in Seoul Medical Center. 2) We recommended the routine use of advance directives to patients who were treated in hemodialysis room of Seoul Medical Center from Jan, 2007 to Jun, 2007. So 35 patients were enrolled. 3) They had been interviewed about end- of-life treatment plans and filled up advance directives. RESULTS: 23 males and 12 females in total were enrolled. The advance directives include 18 questions about patient preferences for treatment of end-of-life. The majority of hemodialysis patients replied "I will follow doctor's decisions including cardiopulmonary resuscitation and renal replacement therapy" 8 females (67%), 15 diabetes (53%) and 11 geriatric patients above 60yrs old (52%), however, were against cardiopulmonary resuscitation. CONCLUSION: Routine use of advance directives will provide basic sources for end-of-life decisions in the care of end stage renal patients. And they would like to keep the high quality of life with the help of prepared therapeutic plan of care and well-dying presented advance directives.

A Cases of Paraganglioma in Bladder of Patient who Visited with Acute Renal Failure / 대한신장학회지

Pheochromocytoma is a catecholamines secreting tumor that usually appears in the adrenal medulla, sympathetic ganglia and extra-adrenal chromaffin tissue. About 10% of this disease is detected in the extra-adrenal chromaffin tissue which is called paraganglioma. The three major clinical symptoms of pheochromocytoma are headache, syncope and hypertension. Approximately 0.1% of hypertensive patients have pheochromocytoma. The extra-adrenal paraganglioma is found in abdominal sympathetic nerve ganglion or Zukerkandle's organ with great frequency, but it also appears, albeit rare, in the cervical ganglion, thoracic cavity, bladder, and pelvic cavity. Some cases of paraganglioma in bladder are being reported internationally, but domestic reports are rare. We report a case of paraganglioma originating in the urinary bladder of patient who visited with acute renal failure associated with malignant hypertension. We treated him with phenoxybenzamine and later with partial cystectomy. High blood pressure was well controlled and acute renal failure was resolved.

Changes of pulse wave velocity findings and the effects of folic acid treatment on homocysteine levels in End Stage Renal Disease / 대한내과학회지

BACKGROUDN: In end-stage renal disease (ESRD) patients, cardiovascular disease (CVD) is a major cause of morbidity and mortality. These patients frequently have hyperhomocysteinemia, a putative risk factor for cardiovascular disease. Several studies suggest that lowering plasma homocysteine may improve endothelial dysfunction, a marker of atherothrombotic risk. Pulse wave velocity (PWV) is a useful diagnostic tool to access endothelial dysfunction, and is widely used screening test for atherosclerosis. METHODS: We measured fasting total plasma homocysteine (tHcy) in 84 hemodialysis patients and 21 peritoneal dialysis patients. Subjects were assigned to two groups. Group I (tHcy or =20 umol/L) consisted of 26 ESRD patients who have taken high dose folate (5 mg/day). For 15 Group I patients and 5 Group II patients, pulse wave doppler velocity (PWV) measurements were taken before and after 3 months of folate treatment. RESULTS: The mean tHcy concentration was higher in the ESRD patients (82 HD: 16.9+/-6.4 mol/L, 20 PD: 18.0+/-16.7 mol/L). The pulse wave velocity (PWV) was faster in ESRD patients-19 HD: Aorta (Ao)-PWV 8.98+/-1.4, lower extremities (LE)-PWV 10.15+/-1.3, upper extremities (UE)-PWV 8.80+/-0.8 (m/s); 8 PD: Ao-PWV 9.32+/-1.8, LE-PWV 10.64+/-1.4, UE-PWV 9.24+/-0.7 (m/s). The PWV increased in ESRD patients with coronary heart disease and who had a history of angioplasty because of thrombosis or stenosis of vascular access. There was a significant reduction in hyperhomocysteinemia after 3 months in the high dose folate supplement group as compared to the usual dose folate supplement group with a significant statistical difference between the two groups. (15 Group I patients: 13.9+/-4.9 mol/L->13.5+/-6.1 for 5 Group II patients: 34.3+/-27.5 mol/L->23.0+/-5.9 mol/L (p0.05, paired t-test). CONCLUSIONS: We assume that PWV and homocysteine concentration have some correlation and both studies are available as part of screening tests for atherosclerosis in ESRD. Although no significant interval change was detected for the PWV, this finding suggests that high-dose folate supplementation was helpful to minimize the risk of cardiovascular disease associated with hyperhomocysteinemia in ESRD patients.

Pyridostigmine for Treatment of Acute Colonic Pseudo-obstruction(Ogilvie's syndrome) in a Older Patient on CAPD

In acute colonic pseudo-obstruction(Ogilvie's syndrome, 1948), there is no distal obstruction but colonic obstruction symptom and distended colon is shown radiologicaly and clinically. The etiology of this syndrome are complex of any medical and surgical problem. Elderly patients who are undergoing CAPD have multiple medical problems. But among them only one case which was diagnosed with this syndrome was reported in Korea. Neostigmine is unstable medicine due to muscarinic effects if neostigmine(anticholinesterase inhibitor) has side effects to the CAPD patients with multiple medical problems, it can be fatal. We use pyridostigmine, which has less muscarinic effect, and has similiar potency compared to neostigmine to acute colonic pseudo-obstruction, and thus achieved radiological improvement.

Clinical significance of the serum levels of matrix metalloproteinases and the tissue inhibitors of metalloproteinases for gastric and colorectal cancer patients / 대한내과학회지

BACKGROUND: Matrix metalloproteinases (MMPs) and their inhibitors, the tissue inhibitors of metalloproteinase (TIMPs), are important factors related to invasion and metastasis in various human cancers. Different results have been reported about the correlation of the serum levels of MMPs and TIMPs and the cancer stages and prognoses in gastric and colorectal cancer patients. This study was designed to determine whether the serum levels of MMP-2, MMP-9, TIMP-1 and TIMP-2 are correlated with the pathologic findings and cancer stages. METHODS: This retrospective study included 46 gastric cancer patients, 30 colonic adenoma patients and 46 colorectal cancer patients. The serum levels of MMP-2, MMP-9, TIMP-1 and TIMP-2 were analyzed using an ELISA technique. The pathologic findings of the endoscopic biopsies and the operative specimens, and the clinicopathologic staging were analyzed. RESULTS: There were no significant differences in the serum levels of MMP-2, MMP-9, TIMP-1 and TIMP-2 according to the pathologic findings and the stages of the gastric and colorectal cancers. However the serum TIMP-1 levels were significantly higher in the advanced gastric cancer patients than in the control group and the early gastric cancer patients. The serum TIMP-2 levels were higher in the control group than in the tubular adenoma patients, the tubulovillous adenoma patients and the colorectal cancer patients. CONCLUSIONS: These results suggest that serum levels of TIMP-1 may be a good marker of invasive gastric cancer. The multistep process of colonic tumorigenesis may be modulated by TIMP-2.

A Case of Gastric Tuberculosis Mimicking Advanced Gastric Cancer

Tuberculosis of the stomach is quite rare, both as a primary or secondary infection. It can present as a facet of a multiorgan disease process or may result from immunodeficiency. Here, we report a rare, interesting case of gastric tuberculosis which morphologically mimicked advanced gastric cancer in a young, immunocompetent patient presenting with hematemesis and melena. The disease was diagnosed by biopsy, and responded well to antituberculosis medication without surgery. Clinicians must bear in mind that, even in the absence of immunodeficiency, as in this case, tuberculosis can involve any site in the gastrointestinal tract and may present with a variety of characteristics. Gastric tuberculosis should always be part of the differential diagnosis of chronic infiltrative lesions in the stomach.

A case of Burkholderia cepacia peritonitis in a patient on CAPD / 대한내과학회지

Burkholderia cepacia is an important opportunistic pathogen in immunocompromised and nosocomial patients, but this bacterial infection is rare in Korea. We report a case of Burkholderia cepacia peritonitis in a patient on CAPD. A 69-year-old male on CAPD for 5 years was presented with turbid peritoneal dialysate, diffuse abdominal pain and diarrhea. He was treated initially with intraperitoneal cefazolin and ceftazidime, and then intraperitoneal meropenem and oral TMP/SMX. His symptoms had improved with antibiotic treatment, but white blood cell counts of dialysate increased, instead. Burkholderia cepacia was isoloated from peritoneal fluid culture. The patient refused catheter removal in spite of our recommendation. He died of suddenly developed acute myocardial infarction and upper gastrointestinal bleeding. Catether tip culture also revealed Burkholderia cepacia.

A case of secondary amyloidosis presenting acute renal failure in rheumatoid arthritis patient / 대한내과학회지

Amyloidosis is a heterogenous group of often fatal disorders characterized by extracellular deposition of a proteinaceous material with a unique fibrillar form in various tissues and organs. Deposition of amyloid may cause widespread dysfunction of the involved organs. A secondary amyloidosis is AA amyloidosis and rheumatoid arthritis is one of the main underlying disease. We report a case of secondary amyloidosis in a 52 year old woman with rheumatoid arthritis. She had suffered from rheumatoid arthritis for 17 years and her hands and feet were deformed. She was presented with oliguric acute renal failure. She was confirmed by showing apple green birefringence under the polarized microscope with Congo-red stain through renal and rectal biopsy. We couldn't find any previous report of the secondary amyloidosis among the patients presenting oliguric acute renal failure without proteinuria in the Korean literatures.

A case of hydrothorax in peritoneal dialysis / 대한내과학회지

Continuous ambulatory peritoneal dialysis (CAPD) is an effective renal replacement therapy for the end stage renal disease. The hydrothorax secondary to leakage of dialysate via pleuroperitoneal communication is a rare complication of CAPD. A variety of symptoms are complained. The regular chest X-ray and pleural fluid examination are needed to find out this complication with vague symptoms. Although our understanding of its mechanisms is incomplete, it is apparent that the key to successful therapy is obliteration of a transdiaphragmatic route of dialysate leakage (pleuroperitoneal communication). Several treatments of CAPD-induced hydrothorax have included pleurodesis with tetracycline, talc, fibrin, or autologous blood and surgical treatment. We have recently managed with a patient CAPD-induced massive hydrothorax with decreased amount of effluent dialysate volumes using talc pleurodesis. This patient was successfully returned to CAPD.

Clinical Features of Chronic Myeloproliferative Disease / 대한혈액학회지

BACKGROUND: Philadephia chromosome negative chronic myeloproliferative disease (CMPD) is a clonal disorder which includes polycythemia vera (PV), essential thrombocythemia (ET) and idiopathic myelofibrosis (IMF). CMPD has chronic course and different clinical features with low rate of conversion to leukemia. We evaluated the clinical features of CMPD. METHODS: Since 1990, 57 cases of CMPD (18 PV, 35 ET and 4 IMF) were analysed and their clinical characteristics, survival and manner of evolution were evaluated retrospectively. RESULTS: Median age of 57 CMPD patients was 61 (range, 14~90) years and male to female ratio was 1:0.8. Most common clinical manifestations were dizziness/weakness (38.6%), headache (21.2%), cardiovascular events (19.3%) and other symptoms. Treatment with hydroxyurea was most frequent during clinical course of CMPD. Anagrelide was introduced in 12 patients recently. Complication of disease itself and treatment was not frequent except bleeding (3 cases) and thrombotic event (10 cases). Conversion to acute lekemia was none. Ten year overall survival was 83.3% in PV, 60.1% in ET and 4 cases of IMF were all alive at the 6 year follow up. CONCLUSION: CMPD is a chronic disease and long term control is much improved but definitive treatment without complication should be further investigated.

A Case of Henoch-Schonlein Purpura with Duodenal Involvement / 대한소화기내시경학회지

Henoch-Schonlein purpura is a form of systemic small-vessel vasculitis characterized by vascular purpura, predominantly occured on the lower limbs and articules with gastrointestinal and renal symptoms. The symptoms occur consecutively and purpura is the most common initial manifestation but if another symptoms prevails, the diagnosis often can be delayed. Any portion of the gastrointestinal tract distal to the esophagus may be involved, but most frequently affected sites are jejunum and ileum. Mucosal lesions found predominantly in the second portion of the duodenum seem to be characteristic of Henoch-Schonlein purpura and may assist the diagnosis in patients with atypical nonspecific symptoms. We report a case of Henoch-Schonlein purpura with the characteristic endoscopic finding in the second portion of duodenum, which helps to make the correct diagnosis and proper management of the patient.

Comparison of Midazolam versus Midazolam/Meperidine during Colonoscopy in a Prospective, Randomized, Double-Blind Study / 대한소화기학회지

BACKGROUND/AIMS: Colonoscopy is a painful procedure. Therefore conscious sedation is often used. However, the value of adding analgesics to sedatives has not been well evaluated. METHODS: The double blind, randomized controlled trial was carried out to compare patients' and endoscopist' assessments in both groups of patients: MP (Midazolam/Placebo) group (n=49) received midazolam plus placebo and MM (Midazolam/Meperidine) group (n=51) received midazolam plus meperidine. RESULTS: There was no significant difference of baseline characteristics except previous operation history. There were no significant difference of grade of tolerance, pain and willingness to another colonoscopy between the two groups. In endoscopist' satisfaction, the degree of difficulty was higher in MP group than in MM group (39.0 vs. 31.7,p<0.05). After the colonoscopy, systolic blood pressure, oxygen saturation, and pulse rate were significantly decreased (p<0.05) in both groups. However, there was no difference in the degree of decrease between the two groups. The incidence of adverse effect was not different in the two groups. However, one case of orthostatic hypotension with presyncope was noted in MM group. CONCLUSIONS: Adding meperidine to the midazolam before the colonoscopy does not seem to bring more beneficial effect to patients, whereas endoscopist favored the use of both medications.

Changes of the Thyroid Function in Continuous Ambulatory Peritoneal Dialysis Patients / 대한신장학회잡지

BACKGROUND: In peritoneal dialysis patients, altered thyroid function was reported but the frequncy and pathophysiology were not well understood. The object of this study is to evaluate the effect of continuous ambulatory peritoneal dialysis (CAPD) on thyroid function by observing the frequency of primary thyroid dysfunction and the sequential change of thyroid function after CAPD. METHODS: In a cross-sectional study, thyroid function test (TFT) was done for 192 CAPD patients between Jan. 2001 and Jan. 2002. For another 38 CAPD patients, we observed the sequential change of thyroid function by performing TFT before and 6, 12, 24 months after CAPD. Thyroid hormones were quantitated after 200 mL sample of 24-hour dialysate effluent was lyophilized. TFTs were interpreted as subclinical hypothyroidism (sbhypo) when TSH is over 5 uIu/mL, mild hypothyroidism (mhypo) when TSH is between 5 and 10 uIu/mL with decreased fT4, and overt hypothyroidism (ohypo) when TSH level is over 10 uIu/mL with decreased fT4. RESULTS: Frequencies of normal thyroid function, sbhypo, mhypo and ohypo were 81.2%, 11%, 5.2%, and 2.6% respectively. Serum levels of TSH before and 6, 12, 24 months after CAPD were 2.6 +/- 0.1, 3.8 +/- 0.3, 4.2 +/- 0.5, 4.1 +/- 0.5 uIu/mL respectively and the frequencies of thyroid dysfunction including subclinical hypothyroidism were 6.4, 23.6, 26.3, 28.8% respectively, which showed the increasing tendency. Peritoneal loss of TSH was 11, 067 +/- 1, 776 uIu/day, and that of TT4 was 11.68 +/- 2.7 microgram/day. These were approximately 7%, and 10% of daily production rate. CONCLUSION: TSH increased after start of CAPD and thyroid dysfunction including subclinical hypothyoidism was observed in significant proportion of CAPD patients. Thyroid hormones were eliminated by peritoneal dialysis. It can be suggested that CAPD affects thyroid function. Clinical significance of the above observation needs further well-controlled study.

Hemodialysis Using Heparin Bound Hemophan Hemodialysis in ESRD Patients at High Risk for Bleeding: A Seven-Year Experience / 대한신장학회잡지

OBJECTIVE: Positively charged N, N-diethyl-aminoehtyl groups on Hemophan enable negative charged heparin to be bound with the dialyzer membrane and hemodialysis using heparin bound Hemophan (HBH- HD) could be a hemodialysis modality in patients at risk of bleeding. We designed simplified heparin binding technique and evaluated the bleeding risk and efficiency of HBH-HD in chronic renal failure patients at risk of bleeding. METHODS: During the period from April 1995 through April 2002, 159 patients at high bleeding risk received 1057 HBH-HD (dialyzer: GFS plus 11, Gambro). The duration of each HBH-HD was standardized to 4 hours at blood-flow rate of 200-250 mL/min. To evaluate safety of HBH-HD, we measured serum heparin concentration (HC) and activated partial thromboplastin time (aPTT) at baseline, 15, 60, 120 minutes and endpoint (240 minutes) (n= 40). To evaluate the dialysis efficiency, HBH-HD and routine hemodialysis with systemic heparinization (R-HD) were compared for total blood compartment volume (TBCV) loss, dialyzer urea clearance (K) and Kt/V in same study group patients (n=20). RESULTS: Clotting of dialyzer necessitating termination of dialysis occurred in 11 (1.0%) out of 1, 057 dialyses at 150 minutes, and clotting requiring change of blood line occurred in 64 dialyses (6.1%) between 150 and 230 minutes. There was a slight increase in the aPTT (mean+/-SD, 49.8+/-10.5 sec) and HC (0.14+/-0.06 U/mL) at 15 min, compared to predialysis levels of 44.3+/-12.9 sec and 0.11+/-0.06 U/ mL, respectively (p>0.05). But no increase in aPTT, HC was observed in measurements at 60 min, 120 min, and at the endpoint. TBCV loss was significantly higher in HBH-HD (mean+/-SD, 17.2+/-9.6%), compared to R-HD (2.8+/-1.2%) (p0.05). CONCLUSION: HBH-HD could be a safe and efficient HD technique in patients at high risk of bleeding. Extracorporeal clotting, however, should be observed carefully during HBH-HD.

Patient with Renal Hypouricemia and Exercise Induced Acute Renal Failure / 대한신장학회잡지

We have described a male patient with a episode of acute renal failure after strenuous exercise. He was found to have low serum uric acid(0.6 mg/dL, after recovery) and normal 24 hour urinary excretion in the steady state. The possibility of other diseases that cause hypouricemia could be excluded, acute renal failure associated with idiopathic renal hypouricemia was diagnosed in this case. A renal computed tomography showed the delayed wedge shaped contrast enhancement, these findings suggested that the cause of acute renal failure could be renal vasoconstriction rather than obstruction by uric acid crystals. Hypouricemia appear to play a crucial role in this reperfusion oxygen free radical induced acute renal failure. We have suggested that the renal hypouricemia should be suspected in the case of acute renal failure associated with exercise when the patient's uric acid level was within or slight alone normal range at the time of acute renal failure.

Peritoneopleural Leakage in Continuous Ambulatory Peritoneal Dialysis : Successful Treatment with Video-Assisted Thoracoscopic Talc Pleurodesis / 대한신장학회잡지

Continuous ambulatory peritoneal dialysis (CAPD) is an effective renal replacement therapy for end- stage renal disease. Hydrothorax secondary to leakage of dialysate via pleuroperitoneal communication is a rare complication of CAPD. Earlier treatments of CAPD-induced hydrothorax have included pleurodesis with tetracycline, talc, fibrin, or autologous blood and surgical treatment. These procedure have made many patients switch to hemodialysis, because of the high relapse rate of the former and the invasiveness and morbidity of the latter. The talc pleurodesis with video-assisted thoracic surgery (VATS) allows not only direct visualization of potential diaphragmatic defect but also direct application of the talc to the visceral or parietal pleura. This procedure is less invasive than thoracotomy and can perform more accurate poudrage of talc than conventional methods. We have recently managed a patient CAPD-induced massive hydrothorax using thoracoscopic talc pleurodesis. This patient was successfully returned to CAPD.