A Case of Peritonitis caused by Chryseobacterium meningosepticum in a Patient Treated with Peritoneal Dialysis / 대한신장학회지

Chryseobacterium meningosepticum is rarely encountered as a pathogen causing peritonitis in peritoneal dialysis (PD) patients. We report a case of peritonitis due to Chryseobacterium meningosepticum, which was treated successfully with intraperitoneal (IP) vancomycin and ciprofloxacin, and without PD catheter removal. Peritonitis was developed in a 53-year-old PD patient on the third hospital day. Although empirical IP treatment with cefazolin and tobramycin was initiated and maintained for 3 days, the fever and signs of peritonitis persisted. Antibiotics were changed to cefoperazone/sulbactam, amikacin, and vancomycin due to clinical deterioration. After 3 days of vancomycin use, leukocyte count in PD fluid was less than 100/mm3 and the patient became asymptomatic. On seventh day after the onset of peritonitis, Chryseobacterium meningosepticum was isolated from initial dialysate sample, and this strain was susceptible to ciprofloxacin, piperacillin, and piperacillin/tazobactam. Accordingly, we changed the antibiotics to ciprofloxacin and vancomycin, which were given for the total of 14 days. Even though Chryseobacterium meningosepticum is an uncommon causative organism of peritonitis in PD patients, this report suggests that vancomycin and ciprofloxacin are effective as empiric therapy, and early suspicion and appropriate antimicrobial therapy are crucial to the successful treatment of peritonitis due to Chryseobacterium meningosepticum without catheter removal.

Spontaneous Remission of Nephrotic Syndrome in IgA Nephropathy / 대한신장학회지

Although a moderate degree of proteinuria is common in patients with IgA nephropathy (IgAN), nephrotic syndrome combined with IgAN is rare. It has been reported that approximately 5% of all patients with IgAN are complicated by minimal change disease and these patients respond well to corticosteroid therapy. However, spontaneous remission is uncommon in heavy proteinuric patients with IgAN. Recently, we experienced two cases of spontaneous remission of nephrotic syndrome combined with IgAN without use of corticosteroid. In these patients, heavy proteinuria disappeared in 1 month after the onset and no recurrence occurred during follow-up. With such limited number of cases, factors associated with spontaneous remission in these patients could not be explored. Further study with a larger number of patients is required and careful attention should be paid to these complicated cases.

A Case of IgA Nephropathy associated with Acute Hepatitis A / 대한신장학회지

IgA nephropathy is the most common type of glomerulonephritis worldwide. Although primary IgA nephropathy receives the most attention, many other diseases are also associated with IgA nephropathy. Among these, chronic liver diseases such as alcoholic liver disease or hepatitis B or C have been reported as secondary causes of glomerular IgA deposits. Recently, as the prevalence of hepatitis A virus (HAV) infection is increasing in Korea, HAV-associated renal diseases occur frequently. Acute kidney injury (AKI) is one of the most common complications of HAV infection, mainly due to acute tubular necrosis or interstitial nephritis. However, unlike hepatitis B and C, glomerular involvement is extremely rare in acute HAV infection. Here, we report a case of biopsy-proven IgA nephropathy with serologically documented HAV infection. The patient presented moderate degree of proteinuria without evidence of AKI. Renal biopsy revealed mesangial IgA deposits but tubular or interstitial inflammation was not observed. This report suggests that HAV infection may be a secondary cause of IgA nephropathy. However, further studies are required to elucidate a causal link between hepatitis A and mesangial IgA deposits.

Scalp Edema and Insufficient Maturation of Arteriovenous Fistula Due to Cephalic Vein Variation in Patient with End Stage Renal Disease / 대한신장학회잡지

Vascular access is the prerequisite and mainstay of extra-corporeal renal replacement therapy and its management is central to maintain the health and quality of life of end-stage renal disease (ESRD) patients. Success of maturation of AVF depends on the quality and size of the vessels and anatomic structure. There have been several reports on non-maturation by vascular stenosis or small vascular size after AVF procedure, but reports demonstrating that AVF non-maturation is due to by latent vessel variation are uncommon. We report a rare case of scalp edema and insufficient maturation of AVF due to cephalic vein variation in a 27 year-old female patient with ESRD on hemodialysis. Conclusively, meticulous observation on not only vessels used for AVF but also its proximal connection to other vessels should be considered.

Effects of Walking Exercise Program for Health Status in Patients on Continuous Ambulatory Peritoneal Dialysis / 대한신장학회잡지

BACKGROUND: It is necessary to exercise in Continuous Ambulatory Peritoneal Dialysis (CAPD) patients but it's difficult because of their physical condition and little motivation. The purpose of this study was to evaluate the effects of the walking exercise program on health status in CAPD patients. METHODS: A nonequivalent control group with pre- and post-test was designed to examine the effects of the program. Data collection was done from December, 2002 to June, 2003. The study participants were selected according to the criteria among the patients who were receiving CAPD at the department of Kidney Center, NIHC Ilsan hospital. The walking exercise program was consisted of an exercise education protocol, an exercise prescription, and a counselling protocol based on a framework of self-efficacy promotion. The exerciser group which was composed of 19 participants was educated based on an exercise education protocol and carried out walking exercise for two to four times a week upon taking verbal persuasion biweekly through telephone or face-to-face interview for 12 weeks, while 17 participants in control group were received no intervention. RESULTS: There was significant differences between two groups; the exerciser group showed better physical function (p=0.03), higher VO2 max (p=0.01) and higher serum albumin level (p=0.02) than the results of control group. However, there were no differences in lipid metabolism. CONCLUSION: The walking exercise program was found to have an effect to increase health status of CAPD patients. The results provided evidences for the importance of continuous physical activity in CAPD patients.

The Effects of On-line Hemodiafiltration on Oxidative Stress and beta2-Microglobulin in Comparison with High-Flux Hemodialysis / 대한신장학회잡지

OBJECTIVE: On-line hemodiafiltration (OL-HDF) is a method that combines diffusive and convective solute transport component. OL-HDF provides improved solute clearance for both low-and large molecular-weight uremic toxins by enhancing convective clearance through highly permeable membranes. The aim of this study is to evaluate the effect of OL-HDF on oxidative stress and beta2-microglobulin (beta2-MG) in comparison with high-flux hemodialysis (HF-HD). METHODS: Twenty-one patients on thrice-weekly low-flux hemodialysis (LF-HD) for at least 6 months were studied. Every patient underwent OL-HDF and HF-HD for four weeks, respectively. There were 2 weeks of wash-out period in which patients were treated with LF-HD, between different treatment periods. Predialysis and postdialysis solute (creatinine, BUN, phosphate, beta2-MG) concentrations were measured in the serum. In addition, predialysis solute (MDA, TAC, hsCRP) concentrations were measured. RESULTS: The urea reduction ratio (64.2+/-14.5 vs. 60.1+/-11.2%), Kt/V (1.4+/-0.2 vs. 1.3+/-0.3), beta2-MG reduction ratio (53.8+/-9.7 vs. 44.3+/-8.7%) and beta2- MG clearance (120.7+/-33.4 vs. 92.7+/-17.6 mL/min) were significantly higher in patients treated with on- line HDF compared with those treated with HF-HD. After 4 weeks of treatment, predialysis serum MDA levels were significantly lower in patients treated with OL-HDF compared with those treated with HF-HD (1.04+/-0.26 vs. 1.19+/-0.25 umol/L). After 4 weeks of treatment with 2 different dialysis modes, predialysis serum beta2-MG (3.7+/-1.0 vs. 2.2+/-0.4 mg/ dL), MDA (1.19+/-0.21 vs. 1.04+/-0.26 umol/L), TAC (265.9+/-21.1 vs. 290.2+/-23.9 umol/L) and log hsCRP (0.07+/-0.51 vs. -0.23+/-0.62) levels were significantly improved compared to the baseline in OL-HDF patients. However, for HF-HD patients, only predialysis serum beta2-MG level at 4 weeks was significantly lower than baseline (3.8+/-1.0 vs. 2.5+/-0.4 mg/dL). CONCLUSION: This study shows that OL-HDF has been significant increase in oxidative stress and inflammatory marker removal compared to HF-HD.

Causative organisms and patterns of antibiotics sensitivity of CAPD peritonitis in different dialysis centers / 대한내과학회지

BACKGROUND: The International Society for Peritoneal Dialysis (ISPD) changed their recommendations for empiric therapy of peritonitis to a first generation cephalosporin to substitute vancomycin and a ceftazidime or an aminoglycoside to cover Gram negative organisms. These guidelines have been recently challenged based on microbiologic evidence and practical considerations. We believe that the management of CAPD peritonitis should be adapted to the specific circumstances affecting the patient, geographic location, local epidemiology of causative bacteria and availability of specific antibiotics. METHODS: To evaluate causative microorganisms and patterns of antibiotics sensitivity of CAPD peritonitis in different dialysis centers, we performed retrospective analysis in three dialysis centers located at different geographic area : Kyungpook University Hospital (Center A), Samsung Seoul Hospital (Center B), Ilsan Hospital (Center C). Among a total of 642 patients on CAPD from January 2001 to December 2001, 113 patients who experienced peritonitis (157 episodes of peritonitis) were included. For microbiologic culture, dialysate effluent was plated in blood agar, thioglycollate broth and McConkey medium. The pattern of antibiotic sensitivity was assessed using broth dilution and disc diffusion method. RESULTS: The sex ratio and proportion of diabetic patients were not different among each center, but the age of center C was higher than that in center A (A: 56.2 13.6, C: 64.6 14.1, p<0.05). Distribution of the causative microorganisms was not different among each center but the pattern of antibiotic sensitivity was different. The incidence of methicillin-resistant staphylococcus species and aztreonam-resistant Gram negative organisms was significantly different among each center. Regimen of 2000 ISPD empiric treatment protocol was ineffective in about 23% of all peritonitis episodes. A treatment with cefazolin instead of vancomycin was associated with resistance in 32.1% of Gram positive organisms and with mobactam instead of ceftazidime was associated with resistance in 23.1% of Gram negative organisms. CONCLUSION: Individual centers should continue to monitor the epidemiology of CAPD peritonitis and the epidemiology of the causative organisms and their sensitivity patterns in order to adapt general guidelines into a center-tailored empirical treatment protocols.

Symptomatic Eosinophilic Peritonitis in CAPD Treated with Low Dose of Oral Prednisolone / 대한신장학회잡지

Eosinophilic peritonitis is not uncommonly observed in patients on peritoneal dialysis. It typically occurs within the first 3 months after the initiation of peritoneal dialysis. Eosinophilic peritonitis is usually a benign and self-limiting process with the exception of fungal eosinophilic peritonitis. The use of oral or intraperitoneal steroids has been suggested only for patients with abdominal pain or with markedly turbid peritoneal effluent. We report a case of eosinophilic peritonitis with severe abdominal pain, which successfully resolved on treatment with single dose of oral prednisolone.

Clinical Outcome and Prognostic Factors of Biopsy-proven Diffuse Proliferative Lupus Nephritis / 대한신장학회잡지

Lupus nephritis is a major cause of morbidity and mortality arising from systemic lupus erythematous. It is generally acknowledged that the presence of diffuse proliferative lupus nephritis(DPLN) is highly predictive of a poor prognosis in terms of renal and patient out- come on survival. The objective of this study was to evaluate the clinicopathologic characteristics, renal out- come according to therapeutic regimen, and prognostic factors of biopsy-proven diffuse proliferative lupus nephritis. Among the biopsy-proven lupus nephritis patients who were admitted to Yonsei University Medical Center from January 1986 to June 1997, 36 patents who were diagnosed DPLN by renal biopsy and treated for at least 6 months and regularly followed-up for at least 12 months were included. We retrospec-tively reviewed the medical recorders. Patients were treated with steroid regimen with or without cyclo-phosphamide. According to the therapeutic response, patients were divided into two groups : a therapeutic response group(n=24), and a therapeutic non-response group

Evaluation of Residual Renal Function of Chronic Renal Failure at the Initiation of Dialysis / 대한신장학회잡지

The decision to initiate dialysis in a patient with progressive renal disease often depends on the physician's assessment of the patient's subjective symptoms of uremia. Decreased residual renal function and malnutrition at the initiation of dialysis is a strong predictor of subsequent increased relative risk of death on dialysis. In this context, to investigate the residual renal function and nutritional parameters of chronic renal failure patients at the initiation of dialysis, 103 patients with chronic renal failure patients were studied. The residual renal function(estimated GFR) was ascertained by measuring simultaneously the 24-h creatinine and urea clearances and averaging the two values and Krt/V. Nutritional parameters were ascertained by measuring the nPNA, %LBM and serum albumin. The mean estimated GFR was 5.97+/-2.88ml/min, the mean weekly Krt/V was 1.24+/-0.80, the mean %LBM was 61.66+/-22.41 and the mean nPNA was 0.89+/-0.30 g/day/kg. We knew that the time of initiation of dialysis, which was based on the manifestation of symptoms of certain patients in conjunction with selected laboratories indices, was delayed than that of NKF- DOQI recommendation. This study suggests that the timely initiation of dialysis is determined by not clinical symptoms and signs but estimated GFR, krt/V and nPNA.

A Case of Drug-Induced Chylous Ascites in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis / 대한신장학회잡지

A chylous ascites, especially drug-induced, is very rare complication in CAPD. The diagnostic criteria for the drug-induced chylous peritoneal dialysate include 1) turbid dialysate developed within Chrs after the administration of causative drug, 2) no clinical symptoms being suggestive of peritoneal inflammation, 3) the fluid containing normal leukocyte counts and being negative for bacterial and fungal culture, and 4) it disappeared spontaneously after the withdrawal of the assumed causative agent and never recurred thereafter. We report a case of chylous ascites emerging after use of manidipine, dihydropyridine calcium channel blocker, in a patient undergoing CAPD. The chylous ascites in that patient was improved after discontinuation of manidipine.

Effect of High Glucose on Nitric Oxide Production in Culteured Rat Mesangial Cells / 대한신장학회잡지

Diabetic nephopathy is one of the leading causes of end-stage renal disease and characterized pathologically by the glomerular mesangial expansion and increased extracellular matrix(ECM) formation. Glomerular hyper-filtration and increased vascular permeability observed in the early stage of diabetic nephropathy have been proposed to play a significant pathophysiologic role in the eventual development of glomerulosclerosis of dia-betic nephropathy. Some studies have suggested that this glomerular hyperfiltration is mediated by increased nitric oxide(NO) production via the constitutive nitric oxide synthase(cNOS) pathway present in endothelial cells under the high glucose environment. However, the exact role of the inducible NOS(iNOS) pathway present in mesangial cells in the pathogenesis of diabetic neph-ropathy is not clearly established. The present study was carried out to examine whether NO production via the iNOS pathway is mo-dulated in cultured rat mesangial cells exposed to the high glucose environment and underlying mechanism of this modulation. For this purpose, the production of the stable metabolite of NO(nitrite), intracellular cyclic gu-anosine monophosphate(cGMP), iNOS mRNA expression and iNOS protein synthesis were examined under different glucose concentrations. Rat mesangial cells cultured in high glucose concen- tration(30mM D-glucose) increased significantly nitrit#e/ nitrate production and intracellular cGMP levels upon stimulation with lipopolysaccharide(LPS) plus interfer-on-r (IFN-r ) compared with control glucose concen- tration(5.6mM D-glucose). Mesangial iNOS mRNA expression and protein synthesis also increased signifi- cantly in response to high glucose. This enhanced iNOS mRNA expression induced by high glucose concentration was significantly suppressed by protein kinase C(PKC) inhibitor, calphostin C, and the aldose reductase inhibitor, 6-bromo-l, 3-dioxo-1H- benz[d, elisoquinoline-2(3H)-acetic acid. These results indicate that high glucose in combination with stimulation by LPS plus IFN- r enhances NO production from mesangial cells by the iNOS pathway, and that the activation of PKC and the polyol pathway may play a role in this enhancement.

Patients' Referral Pattern and Dialysis Initiation Practice: Single Center Experience / 대한신장학회잡지

Despite improvements in dialysis care, the mortality of patients with end-stage renal disease(ESRD) remains high. One factor that has so far received little attention, but which might contribute to morbidity and mortality, is the timing of referral to the nephrologist. We performed a retrospective analysis in 358 patients(male 275, female 151) who were initiated renal replacement therapy first at this hospital from Jan 1995 to Dec 1996. Patients were defined by the time of first nephrology as early referral(E, n=163) encountered after more than 8 weeks; late early referral(LE, n=19) encountered between 8 weeks and 4 weeks; late referral(L, n=55) encountered from 1 week to 4 weeks; urgent referral(U, n= 121) encountered less than 1 week. There were no differences in age, gender, primary renal disease, cause of dialysis, and renal replacement therapy modalities. However, there were significant differences in rnean arterial pressure and serum phosphate levels between these 4 groups. The mean arterial pressures (mmHg) were 109.15 +/- 17.16, 105.37+/-18.76, 117.24 +/- 27.24 and 116.98+/-24.26 for E, LE, L and U, respectively(p0.05). In the E group, there was more controlled blood pressure and serum phosphate levels compared to the U group at initiation of renal replacement therapy, but other parameters were not significantly different among the 4 groups. Delays in initiation of renal replacement therapy may result in patients entering dialysis in a compromised state, therefore adequate long-term predialysis care by a nephrologist is important. Socioeconomic - and medical factors respon-sible for late referral and late initiation of dialysis need to be evaluated and corrected to further improve the outcome of these patients.

A Prospective Comparative Study Between Manual and Automated Renal Biopsy by Randomized Sampling / 대한신장학회잡지

OBJECTIVES: Percutaneous renal biopsy may be carried out in several ways. Recently, the use of a spring-loaded biopsy gun has become popularized. There have been much controversies on the tissue adequacy and the incidence of complications when compared to the manual biopsy. The present study was performed to compare tissue adequacy and the incidence of complications between manual biopsy and automated biopsy. METHODS: We have studied 108 patients in whom the method of renal biopsy was assigned to one of the two methods[14G Tru-cut needle manual bx (group I) and 18G automated gun biopsy(group II)] according to their national resident's identification number in a randomized and prospective manner. RESULTS: There were 50 patients in group I and 58 patients in group II. There was no difference in gender, age, hemoglobin, prothrombin time, partial thromboplastin time, diastolic and systolic blood pressure pre-biopsy in group I and II. Indications for biopsies were proteinuria accompained by hematuria (37%), proteinuria(34.3%), acute renal failure (9.3%), SLE (8.3%), chronic renal failure (5.6%), hematuria only (5.6%). In Group I the number of passes was 2.4+/-0.8, the glomeruli obtained were 25.3+/-13.2 and the number of glomeruli per pass were 11.6+/-6.5, and in Group II 3.4+/-1.1, 19.4+/-10.8, and 6.8+/-4.0, respectively. These showed a significant difference (p<0.05). In all cases pathological diagnosis were possible. The histology showed IgA nephropathy in 27.8%, MCNS in 14.8%, lupus nephritis in 11.1, MGN in 11.1%, MPGN in 7.4%, and others. The incidence and area of perinephric hematoma demonstrated on ultrasound 24 hours post-biopsy was increased in group I (24%, 937.7+/-640.0mm2 compared to 10.3%, 372.4+/-327.4mm2 in group II) although no statistically significant difference existed. There was no significant difference in gender, age, prothrombin time, partial thromboplastin time, systolic and diastolic blood pressure between the group with and without hematomas. Hematocrit levels before and after biopsy showed a significant difference (34.5+/-8.2, 33.5+/-8.1, p<0.05) in group I, but no significant difference was observed in group II (34.7+/-6.4, 34.8+/-6.4). CONCLUSION: Both techniques rendered adequate tissue sampling, but the extent of bleeding seems to be more severe with manual 14G Tru-cut needle biopsy.

A Case of Multiple Myeloma of Kappa Light Chain Type Associated with Gastric Amyloidosis and Acute Renal Failure and Pathologic Fracture Due to Femur Plasmacytoma / 대한신장학회잡지

Primary amyloidosis has been reported to develop in 6 to 15% of patients with multiple myeloma and especially in 20 to 24% of patients with light chain myeloma. Although deposition of amyloid in the gastric mucosa is common in primary systemic amyloidosis(AL), gastric amyloidosis in AL type is rarely symptomatic. Also, pathologic fracture of the femur secondary to plasmacytoma is quite rare for the first manifestation of multiple myeloma. A case of gastric amyloidosis associated with gastric outlet obstruction and femur plasmacytoma in multiple myeloma is reported with review of literatures.

Coronary Flow Doppler Profile in No-Reflex Phenomenon after Direct PTCA in Acute Myocardial Infarction

Profound reduction of anterograde coronary flow with concomitant ischemia is seen occasionally during percutaneous coronary intervention despite technically successful procedure. We found interesting coronary flow pattern in a patient with acute myocardial infarction, showing angiographic no reflow phenomenon after direct PTCA. The coronary blood flow pattern of the angiographic no-reflow phenomenon in this case was characterized by minimal systolic flow and sharp deceleration of diastolic flow. Coronary flow reserve calculated by the ratio of adenosine induced maximal hyperemic velocity and basal velocity was reduced. The Dopplertipped guide wire was useful for observation of phasic coronary flow pattern of angiographic no-reflow phenomenon.