Renovascular Hypertension and Nephrotic Range Proteinuria Developed after the Renal Artery Ligation: Successful Treatment by Combination of ACE Inhibitor and Angiotensin II Type 1 Receptor Blocker / 대한신장학회지

A 27-year-old woman presented with severe hypertension and nephrotic range proteinuria. She had a blunt renal trauma 4 weeks ago and was treated by the left main renal artery ligation. The plasma renin activity, angiotension II and aldosterone levels were very high and the abdominal angiography showed the occlusion of the left main renal artery with relatively preserved blood flow in upper pole of the left kidney. In captopril renal scan, relatively preserved perfusion in upper pole of left kidney was further compromised after captopril administration. The massive proteinuria and hypertension were improved after combination of ACE inhibitor and angiotensin II type 1 receptor blocker treatment.

A Case of Pneumocystis jirovecii Pneumonia Following CMV Duodenitis in a Kidney Transplant Patient / 대한신장학회지

Solid organ transplant recipients are at increased risk for various opportunistic infections because of their immunocompromised state. Pneumocystis jirovecii (carinii) infection has posed serious problems in these patients which can be life threatening. It has been reported that incidences of Pneumocystis infection have dramatically decreased with the use of prophylactic antibiotics. However, there have been reports that say the risks of Pneumocystis infection are increasing with the use of new immunosuppressive drugs and in presence of preceding immunomodulating infections such as CMV infection which is another common opportunistic infection in transplant patients. There were only a few case reports abroad on Pneumocystis infection following CMV infection in patients who underwent kidney transplantation. In Korea, however, there hasnt been any report of such cases. Herein we report a case of a kidney transplant patient who experienced a serious episode of Pneumocystis jirovecii pneumonia following CMV duodenitis. After adequate mechanical ventilation and use of antibiotics the patient completely recovered without any complications.

Intensive Hemodialysis in Patients with ESRD Improves Cardiac Function Through Inflammatory Regulation / 대한신장학회지

PURPOSE: CHF is a life threatening acute complication in ESRD populations. An intensive hemodialysis (HD) has been effective in reducing intravascular volume and in removing uremic toxin with improved systolic function. Although recent progress has identified an inflammation as an important contributor to the pathogenesis of CVD, the effect of intensive HD on inflammatory parameters and left ventricle (LV) systolic dysfunction is not clear. The purpose of this study is to examine the effect of intensive HD on LV systolic function and serum cytokines levels. METHODS: Among ESRD patients who underwent dialysis and developed acute pulmonary edema due to LV systolic dysfunction were enrolled. Intensive HD consisted of daily 4 hours HD for 7 consecutive days. Data were prospectively collected and 2-D echocardiography was done before and after intensive HD. Serum levels of TNF-alpha and IL-10 were compared and lipopolysaccharide (LSP)-stimulated of these cytokines were measured. RESULTS: After intensive HD, weight and mean arterial blood pressure decreased significantly and ejection fraction (EF) increased significantly. Serum IL-10 and TNF-alpha levels decreased significantly after intensive HD. In contrast, LPS stimulated production of these cytokines increased significantly after intensive HD. The difference of CRP between after HD and before HD was negatively correlated with the difference of EF. CONCLUSION: In ESRD patients with acute LV dysfunction, intensive HD significantly improved EF and restored the immune responsiveness. These results suggest that intensive HD has the advantage of improving EF through modulating inflammation and correcting immune dysfunction in ESRD patients with acute LV dysfunction.

Signaling pathway for 2,3,7,8-tetrachlorodibenzo- p-dioxin-induced TNF-alpha production in differentiated THP-1 human macrophages

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD), a prototypic halogenated aromatic hydrocarbon (HAH), is known as one of the most potent toxicants. At least a part of its toxic effects appears to be derived from its ability to induce TNF-alpha production. However, the signaling pathway of TCDD that leads to TNF-alpha expression has not been elucidated. In this study, we investigated the signaling mechanism of TCDD-induced TNF-alpha expression in PMA-differentiated THP-1 macrophages. TCDD induced both mRNA and protein expression of TNF-alpha in a dose- and time-dependent manner. Alpha-Naphthoflavone (NF), an aryl hydrocarbon receptor (AhR) inhibitor, prevented the TCDD-induced expression of TNF-alpha at both mRNA and protein levels. Genistein, a protein tyrosine kinase (PTK) inhibitor, and PD153035, an EGFR inhibitor, also blocked the increase of TNF-alpha expression by TCDD, indicating the role of EGFR in TCDD-induced TNF-alpha expression. On the other hand, PP2, a c-Src specific inhibitor, did not affect TCDD-induced TNF-alpha expression. EGFR phosphorylation was detected as early as 5 min after TCDD treatment. TCDD-induced EGFR activation was AhR-dependent since co-treatment with alpha-NF prevented it. ERK was found to be a downstream effector of EGFR activation in the signaling pathway leading to TNF-alpha production after TCDD stimulation. Activation of ERK was observed from 30 min after TCDD treatment. PD98059, an inhibitor of the MEK-ERK pathway, completely prevented the TNF-alpha mRNA and protein expression induced by TCDD, whereas inhibitors of JNK and p38 MAPK had no effect. PD153035, an EGFR inhibitor, as well as alpha-NF significantly reduced ERK phosphorylation, suggesting that ERK activation by TCDD was mediated by both EGFR and AhR. These results indicate that TNF-alpha production by TCDD in differentiated THP-1 macrophages is AhR-dependent and involves activation of EGFR and ERK, but not c-Src, JNK, nor p38 MAPK. A signaling pathway is proposed where TCDD induces sequential activation of AhR, EGFR and ERK, leading to the increased expression of TNF-alpha.

The First Case of Human Brucellosis in Korea

Brucellosis is usually transmitted to human by direct contact with infected animals or by ingestion of unpasteurized dairy products. Because of the wide spectrum of its clinical manifestations, brucellosis may appear as other infections and asymptomatic conditions and, therefore, the diagnosis of the disease is frequently missed or delayed. A 41-years-old livestock worker was attended at a local clinic with headache, undulating fever, fatigue, weight loss presentations but the symptoms were not improved in spite of symptomatic therapy of the disease for 6 weeks. Epidemiological background showed that the patient had often ingested unpasteurized cow milk. We confirmed Brucella abortus infection by STA, ELISA and PCR methods. Symptomatic therapy of the disease with appropriate antibiotics (streptomycin, doxicyclin), had favourable outcome. It's the first case report of human brucellosis caused by direct contact of brucella infected milk cow or ingestion of raw milk in Korea, since its original identification in 1939.

The First Case of Human Brucellosis in Korea

Brucellosis is usually transmitted to human by direct contact with infected animals or by ingestion of unpasteurized dairy products. Because of the wide spectrum of its clinical manifestations, brucellosis may appear as other infections and asymptomatic conditions and, therefore, the diagnosis of the disease is frequently missed or delayed. A 41-years-old livestock worker was attended at a local clinic with headache, undulating fever, fatigue, weight loss presentations but the symptoms were not improved in spite of symptomatic therapy of the disease for 6 weeks. Epidemiological background showed that the patient had often ingested unpasteurized cow milk. We confirmed Brucella abortus infection by STA, ELISA and PCR methods. Symptomatic therapy of the disease with appropriate antibiotics (streptomycin, doxicyclin), had favourable outcome. It's the first case report of human brucellosis caused by direct contact of brucella infected milk cow or ingestion of raw milk in Korea, since its original identification in 1939.

A case of polymyositis associated with scrub typhus / 대한내과학회지

We report the case of a 32-year-old female who developed polymyositis associated with scrub typhus. She exhibited the eschar with high titer of anti-Rickettsia(R)-tsutsugamushi antibody, severe muscle weakness, markedly elevated serum levels of muscle enzymes, EMG changes, and infiltration of macrophages in a muscle biopsy specimen. Initiation of appropriate antibiotic therapy resulted in complete healing of scrub typhus and disappearance of symptoms and signs of polymyositis within 1 month after high dose steroid therapy. We suggest that scrub typhus also be included within the causes of idiopathic inflammatory polymyositis.

Two Cases of Tuberous Sclerosis Patients with Renal Anomaly / 대한신장학회잡지

Tuberous sclerosis is a rare disease, which occurs sporadically or hereditarily and is recognized by its neurological and dermatological manifestations and may be accompanied with renal anomalies. The classical triad is composed of seizure, mental retardation and adenoma sebaceum on face. We experienced two cases of tuberous sclerosis in sporadic forms by mutation without any familial history which suggests the diseases were occurred by mutation rather than by autosomal dominant inheritance. In the first case, a 24-year-female patient with hypertension and abnormal renal function tests which were noted on the routine prenatal check at 32 weeks of gestation delivered normally at 37 weeks. The daughter of patient had seizure when she was 6 years old and was diagnosed as polycystic kidney disease by abdominal computed tomography. This case developed sporadic form of disease without familial history but, the daughter of patient might inherited by autosomal dominant form. The patient's clinical feature was characterized by history of epilepsy, painless abdominal mass due to polycystic kidney disease, abnormal renal function, skin abnormalites including angiofibroma and shagreen patch. Abdominal computed tomography demonstrated numerous variable sized cysts throughout both kidney. In second case, the patient was a 32-year-female patient complaining of 5kg weight gain, abdominal distension due to palpable masses. Her clinical feature was characterized by bilateral huge renal angiomyolipoma with normal renal function and skin abnormality such as erythematous papule on the face. Abd CT and MRI revealed huge angiomyolipoma of about 15cm X 18.5cm X 30cm and 14.5cm X 18cm X 30cm respectively. We presented the two cases with brief review of the literatures.

The Clinical Characteristics of Hepatitis-B Virus Associated Membranous Nephropathy and Membranoproliferative Glomerulonephritis / 대한신장학회잡지

Chronic hepatitis B viral infection causes membranous nephropathy and membranoproliferative glomerulonephritis. Patients with positive serum HBsAg with membranous nephropathy or membranoproliferative are considered as hepatitis B virus associated glomerulonephritis(HBV-GN) in epidemic areas of hepatitis B viral infection. To elucidate the clinical difference between hepatitis B virus-associated membranous nephropathy and membranoproliferative glomerulonephritis, and idiopathic membranous nephropathy and membranoproliferative glomerulonephritis, the authors conducted a clinical study including 71 cases of patients with renal biopsy proven diagnoses. Among the patients with hepatitis B virus antigenemia, the pathologic diagnoses were 7 membranous nephropathy(HBV-MN), 13 membranoproliferative glomerulonephritis(HBV-MPGN) but patients with mixed pattern of both membranous nephropathy and membranoproliferative glomerulonephritis were excluded. For the patients with idiopathic glomerulonephritis, 35 of membranous nephropahty(MN) and 16 cases of membranoproliferative glomerulonephritis (MPGN) were enrolled in this study. The patients of HBV-GN groups had more than 80% of HBe antigenemia. The nephrotic range proteinuria presented more frequently in HBV-MN(86%) than in MN group(54%). The cases of HBV-MPGN group(4 cases, 31%) showed nephrotic range proteinuria less frequently than those with MPGN(69%, p< 0.05) and significant discrepancy existed in HBV- MN vs HBV-MPGN and HBV-MPGN vs MPGN. The cases with decreased serum C3 level below normal were over 50% of HBV-GN and MPGN group except MN group. Serum levels of SGOT and SGPT were significantly elevated in HBV-MN and HBV- MPGN groups than those of MN and MPGN groups, respectively(p<0.05). The number of cases with increased SGOT, SGPT and gamma-GTP were 4(57%), 2 (29%) and 1(16%) in HBV-MN and 15(83%), 12(67%) and 9(75%) cases in HBV-MPGN group, in respectively. The cases developed progressive renal functional impairment during follow-up period of at least one year were 3 of 5(60%) in HBV-MN, 2 of 8 (25%) in MPGN and 3 of 9(33%) in HBV-MPGN groups which were significantly more than 2 of 22 cases(9%) in MN group(respectively p<0.05, not in HBV-MPGN vs MN). The renal functional impairment rate defined by the ratio of patients with their serum creatinine elevated above 2mg/dL over 3 months in each group was more rapidly increased in HBV-MPGN and HBV-MN than the idiopathic groups by Kaplan-Meier statistic analysis. We suggest that the patients with HBV-associated glomerulonephropathy seem to have worse prognosis in terms of renal functional impairment than those with idiopathic types of glomerulonephropathy with same pathology.

Acute Closure of Target and Remote Coronary Arteries Complicated by Balloon Rupture during Primary Stenting of Acute Myocardial Infarction

Primary coronary stenting is one of the established therapeutic options for acute myocardial infarction. The risk of balloon rupture during stenting may be increased after high pressure inflation technique was introduced. Balloon rupture during stenting may cause catastrophic complications such as extensive dissection, acute closure, coronary perforation. We report a case of balloon rupture during primary stenting in acute myocardial infarction, which caused acute thrombotic closure of target and remote coronary arteries simultaneously.

Prediction of Steroid Responsiveness in Adult Minimal Change Nephrotic Syndrome Using Urinary beta2-Microglobulin / 대한신장학회잡지

Urinary protein per se causes renal tubular injury and stimulates immunologic reaction. The extent of proximal tubular injury can be estimated by measuring the amount of 24 hours urinary beta2-microglobulin (U beta2-MG). The aim of this study was whether U beta2-MG level could predict the response to the initial steroid treatment for the patients with minimal change nephrotic syndrome (MCNS). We analyzed 58 adult patients (33 M, 25 F), aged 33+/-15 years (range 16-76), with biopsy-proven MCNS treated with 40 to 60mg of oral prednisolone daily up to 16 weeks. The responsiveness (44 cases) inculded complete and partial remission or steroid resistance (14 cases). No difference was found between the steroid responsive and resistant group with regard to age, BUN, serum creatinine, albumin, cholesterol, and urinary protein. The levels of U beta2- MG (microgram/g creatinine) were 250808+/-478917 and 1648+/-2386 in resistan ia Kwang-Yul Chang, et al.:Prediction of Steroid Responsiveness in Adult Minimal Change Nephrotic. Syndrome Using Urinary beta2-Microglobulint group and responsive group, respectively (P<0.05). The cut off value was 400microgram/ g creatinine with 78% of sensitivity and 48% of specificity. The likelihood ratio for the resistance was 2.5 to 2.8 with the U beta2-MG levels over 400 ug/g creatinine and was 0.2 to 0.3 below that value. Multivariate analysis confirmed that higher U beta2- MG level was associated with a lower likelihood of steroid responsiveness, independent of age, sex, creatinine, serum protein, and urinary protein. This study showed that the pretreatment U beta2- MG level may be used to identify subgroup of patients with MCNS who are more likely to be responsive to initial steroid treatment.