Effects of Lowering Dialysate Calcium Concentrations on Arterial Stiffness in Patients Undergoing Hemodialysis

BACKGROUND/AIMS: We assessed changes in hemodynamic and arterial stiffness parameters following reductions of dialysate calcium concentrations in patients undergoing hemodialysis. METHODS: In this prospective study, 20 patients on maintenance hemodialysis (10 females, 10 males) with dialysate calcium concentrations of 1.75 mmol/L were enrolled. At the start of the study, the dialysate calcium level was lowered to 1.50 mmol/L. Serial changes in biochemical, hemodynamic, and arterial stiffness parameters, including pulse wave velocity (PWV) and augmentation index (AIx), were assessed every 2 months for 6 months. We also examined changes in the calcification-inhibitory protein, serum fetuin-A. RESULTS: During the 6-month study period, serum total calcium and ionized calcium decreased consistently (9.5 +/- 1.0 to 9.0 +/- 0.7, p = 0.002 vs. 1.3 +/- 0.1 to 1.1 +/- 0.1, p = 0.035). Although no apparent changes in blood pressure were observed, heart-femoral PWW (hf-PWV) and AIx showed significant improvement (p = 0.012, 0.043, respectively). Repeated-measures ANOVA indicated a significant effect of lowering dialysate calcium on hf-PWV (F = 4.58, p = 0.004) and AIx (F = 2.55, p = 0.049). Accompanying the change in serum calcium, serum fetuin-A levels significantly increased (95.8 +/- 45.8 pmol/mL at baseline to 124.9 +/- 82.2 pmol/mL at 6 months, p = 0.043). CONCLUSIONS: Lowering dialysate calcium concentration significantly improved arterial stiffness parameters, which may have been associated with upregulation of serum fetuin-A.

A Case of Severe Metabolic Acidosis Associated with Sodium Hypochlorite (Bleach) Poisoning Treated by Hemodialysis / 대한내과학회지

Sodium hypochlorite (NaOCl) is commonly used as a disinfectant or bleaching agent. The ingestion of household bleach is often benign, with minimal irritating effect on the mucosa. Occasionally, however, it can be life-threatening. Here, we report an unusual case of acute poisoning involving household bleach with a near-fatal outcome that was treated with intense hemodialysis. A 42-year-old woman presented to the emergency room after ingesting 1 liter of 5% household bleach. Ten hours later, her metabolic acidosis, hypernatremia, hyperchloremia, and renal failure deteriorated gradually, despite aggressive medical treatment. Rapid, effective correction of the metabolic acidosis and electrolytes imbalance was needed and hemodialysis was performed immediately. After 3 days of dialysis, the laboratory imbalance was completely corrected.

Effects of Oral Adsorbent AST-120 (Kremezin(R)) on the Progression of Chronic Kidney Disease / 대한신장학회지

PURPOSE: AST-120 is known to delay progression of chronic kidney disease (CKD) when combined with other proven therapy. AST-120 is an oral adsorbent for uremic toxin, such as indoxyl sulfate from the gastrointestinal tract. There have been a lot of studies to show its effect in other countries, but there are few studies done in Korea yet. METHODS: 195 patients were included in the study (mean age, 64+/-14 years; diabetes mellitus (DM), 104 patients; male, 130 patients). The patients with CKD who started AST-120 and maintained the medication for at least 6 months were enrolled. The patients' laboratory results for 6 months before and after administrating AST-120 was surveyed. Then the rate of patients' renal functional deterioration was compared before and after AST-120. In addition, adverse effects during the medication were surveyed. RESULTS: There were no statistically significant differences in laboratory data between before and after AST-120 administration. But, after administrating AST-120, the renal deterioration slope has blunted significantly from -0.0123+/-0.0318 to -0.0013+/-0.0184 dL/mg/month (p<0.01) in 1/sCr and from -1.1423+/-2.3906 to 0.0639+/-1.3825 ml/min/1.73m2/month (p<0.01) in estimated glomerular filtration rate (eGFR). There were no differences between DM and non-DM patients in the effect of AST-120, as well as ages over 70 and below 70. There were no serious adverse effects during medication. CONCLUSION: This study showed that AST-120 had additive effect on retarding the CKD progression when combined with established therapy regardless of DM and ages without serious adverse effects.

A Case of Distal Renal Tubular Acidosis and Sjogren's Syndrome in a Patient with Autoimmune Thyroiditis / 대한신장학회지

A 52-year old woman, who had hypothyroidism associated with autoimmune thyroiditis for 5 years, was hospitalized for tingling sensation and muscle weakness of both lower extremities. Her initial laboratory findings showed severe hypokalemia, metabolic acidosis, and high titer of thyroid autoimmune antibodies. She was diagnosed of distal renal tubular acidosis by bicarbonate loading test (FEHCO(3)(-) <3.0 %) and renal calcifications on pre-enhanced CT scan. Since she had other symptoms of xerostomia and xerophthalmia, primary Sjogren's syndrome was diagnosed by Schirmer test, salivary scan, and serologic findings. She was treated with potassium citrate, potassium chloride, and hydroxychlorquine. Four months later, she has remained well with those treatments. There were only a few case reports about distal renal tubular acidosis associated with Sjogren's syndrome and autoimmune thyroiditis. In Korea, there has not been any report of such cases. Therefore, we report a case of distal renal tubular acidosis and Sjogren's syndrome in a patient with autoimmune thyroiditis.

A case of angiomyolipoma of the liver / 대한내과학회지

Angiomyolipoma occurs most commonly in the kidneys; the liver is the second most frequent site of involvement. Hepatic angiomyolipoma is a rare, benign, mesenchymal neoplasm, composed mainly of blood vessels, smooth muscle cells, fat, and myelocomponents. Radiologic findings are non-specific because the various elements of these neoplasms vary in their proportion and distribution within the tumor. Thus, data obtained by imaging technologies such as computed tomography, ultrasonography, or magnetic resonance imaging tend to be merely suggestive; definitive diagnosis usually requires histologic confirmation. We report here a case of angiomyolipoma in an incidental tumor of the liver of a 53-year-old female. Tissue was removed from the tumor by ultrasonography-guided gun biopsy and subjected to immunohistochemical analysis. Data showed that tumor cells were positive for HMB-45 and SMA, but negative for cytokeratin, anti-hepatocyte antigen, and alpha-fetoprotein. The patient did not receive any treatment and is being followed up.

Evaluation of the Effect of Initial dose of Vancomycin using Serum Cystatin C as a Marker in Elderly Patients / 감염과화학요법

BACKGROUND: It has been suggested that the glomerular filtration rate can be predicted on the basis of serum cystatin C concentration. The aim of this study was to investigate the clinical utility of serum cystatin C as a marker of renal function and to evaluate the effect of an initial dose of vancomycin using serum cystatin C concentration in elderly patients. MATERIALS AND METHODS: Data was collected from July 2006 to September 2008. The subjects were elderly patients (> or =60-years-of-age; n=number of patients) who had been treated with vancomycin. Serum concentrations of parameters including vancomycin, creatinine, and cystatin C were measured. Correlations between measured vancomycin concentrations and predicted vancomycin concentrations based on serum cystatin C or serum creatinine were compared, and the initial dose setting of vancomycin on the basis of serum cystatin C concentration was evaluated. RESULTS: Serum cystatin C was a good marker of renal function in comparison with serum creatinine for various doses of vancomycin in the elderly subject. In subpopulation (n=88) with normal serum cystatin C level (< or =1.2 mg/L) who were treated with routine adult vancomycin dose (1g q 12 hours), vancomycin concentration was within the therapeutic range (5-15 mg/L) in 68 patients (77.3%), and was <20 mg/L in 77 of the 88 patients (88.5 %). CONCLUSIONS: Predictive prowess of serum vancomycin concentrations on the basis of the serum cystatin C concentration could be better than that based on the serum creatinine concentration in elderly patients.

Evaluation of the Effect of Initial dose of Vancomycin using Serum Cystatin C as a Marker in Elderly Patients / 감염과화학요법

BACKGROUND: It has been suggested that the glomerular filtration rate can be predicted on the basis of serum cystatin C concentration. The aim of this study was to investigate the clinical utility of serum cystatin C as a marker of renal function and to evaluate the effect of an initial dose of vancomycin using serum cystatin C concentration in elderly patients. MATERIALS AND METHODS: Data was collected from July 2006 to September 2008. The subjects were elderly patients (> or =60-years-of-age; n=number of patients) who had been treated with vancomycin. Serum concentrations of parameters including vancomycin, creatinine, and cystatin C were measured. Correlations between measured vancomycin concentrations and predicted vancomycin concentrations based on serum cystatin C or serum creatinine were compared, and the initial dose setting of vancomycin on the basis of serum cystatin C concentration was evaluated. RESULTS: Serum cystatin C was a good marker of renal function in comparison with serum creatinine for various doses of vancomycin in the elderly subject. In subpopulation (n=88) with normal serum cystatin C level (< or =1.2 mg/L) who were treated with routine adult vancomycin dose (1g q 12 hours), vancomycin concentration was within the therapeutic range (5-15 mg/L) in 68 patients (77.3%), and was <20 mg/L in 77 of the 88 patients (88.5 %). CONCLUSIONS: Predictive prowess of serum vancomycin concentrations on the basis of the serum cystatin C concentration could be better than that based on the serum creatinine concentration in elderly patients.