Clinical Analysis of Hemodialysis Vascular Access: Comparision of Autogenous Arterioveonus Fistula & Arteriovenous Prosthetic Graft

BACKGROUND: Mature autogenous arteriovenous fistulas have better long term patency and require fewer secondary interventions compared to arteriovenous prosthetic graft. Our Study evaluated vascular patency rates and incidence of interventions in autogenous arteriovenous fistulas and grafts. MATERIAL AND METHODS: A total of 166 vascular access operations were performed in 153 patients between December 2002 and November 2009. Thirty seven caeses were excluded due to primary access failure and loss of follow-up. One group of 92 autogenous arterioveous fistulas and the other group of 37 arteriovenous prosthetic grafts were evaluated retrospectively. Primary and secondary patency rates were estimated using the Kaplan-Meier method. RESULTS: The primary patency rate (84%, 67%, 51% vs. 51%, 22%, 9% at 1, 3, 5 year; p=0.0000) and secondary patency rate (96%, 88%, 68% vs. 88%, 65%, 16% at 1. 3, 5 year; p=0.0009) were better in autogenous fistula group than prosthetic graft group. Interventions to maintain secondary patency were required in 23% of the autogenous fistula group (average 0.06 procedures/patient/year) and 65% of prosthetic graft group (average 0.21 procedures/patient/year). So the autogenous fistula group had fewer intervention rate than prosthetic graft group (p=0.01) The risk factor of primary patency was diabetus combined with ischemic heart disease and the secondary patency's risk factor was age. CONCLUSION: Autogenous arteriovenous fistulas showed better performance compared to prosthetic grafts in terms of primary & secondary patency and incidence of interventions.

Erratum: Risk Factors Influencing Decline of Residual Renal Function in Patients on Continuous Ambulatory Peritoneal Dialysis / 대한신장학회지

No abstract available.

Peritoneal-Retroperitoneal-Scrotal Leakage as a Complication of Peritoneal Dialysis / 대한내과학회지

We report a case of retroperitoneal and scrotal dialysate leakage resulting from peritoneal-retroperitoneal communication in a patient on peritoneal dialysis (PD). The ultrafiltration volume was reduced and the scrotum became enlarged in a patient who had been undergoing PD for 4 years. Retroperitoneal and scrotal leakage of dialysate was confirmed by computed tomography (CT) performed 1 hour after the intraperitoneal infusion of contrast-containing dialysate. The PD was halted and the patient was transferred to hemodialysis (HD). One month after the transfer to HD, the PD was resumed and there were no signs of extraperitoneal leakage.

Risk Factors Influencing Decline of Residual Renal Function in Patients on Continuous Ambulatory Peritoneal Dialysis / 대한신장학회지

PURPOSE: Preservation of residual renal function (RRF) after initiation of peritoneal dialysis (PD) is beneficial for patient survival. It is unclear that same risk factors of pre-dialysis chronic kidney disease (CKD) patients affect RRF in PD patients. This study was aimed to evaluate factors affecting RRF after commencement of PD. METHODS: Data from 80 patients commencing CAPD at Kyungpook National University Hospital between January 2001 and December 2008 were retrospectively collected. After PD commencement, biochemical and clinical data at baseline (1 month), 6, and 12 month were obtained. RRF was calculated as the average of creatinine clearance and urea nitrogen clearance from 24-hour urine collection and normalized with body surface area and mean RRF decline rate was calculated by dividing RRF difference between baseline to 12 month by period. RESULTS: Mean RRF decline rate (mL/min/1.73m2/month) was negatively correlated with left ventricular posterior wall thickness (LVPWT) (R2=0.097, p=0.023) and proteinuria (R2=0.126, p=0.003), whereas positively correlated with hematocrit (R2=0.076, p=0.013) at baseline. CONCLUSION: Decline of RRF during a year after commencement of PD was associated with baseline proteinuria and LVPWT.

Technique survival in peritoneal dialysis: A single-center experience / 대한내과학회지

BACKGROUND/AIMS: Continuous ambulatory peritoneal dialysis (CAPD) is an established treatment in patients with end-stage renal disease (ESRD), and innovations in the connection system have improved the survival of peritoneal dialysis patients over the last two decades. We investigated the outcome of CAPD over a 15-year period at our institution. METHODS: Patients who underwent peritoneal dialysis since 1994 were recruited retrospectively. Patients younger than 15 years at the initiation of CAPD and those who had less than 1 month of follow-up or missing data were excluded. The technique survival rate and causes of technique failure were evaluated. RESULTS: In all, 608 CAPD patients (342 males, 56.3%) were analyzed using the Kaplan-Meier method and log-rank test. The mean age at the start of CAPD was 50.7+/-15.1 years and the mean duration of CAPD was 50.2+/-41.5 months. The most common primary renal disease was diabetes (39.6%), followed by chronic glomerulonephritis (37.2%) and hypertension (13.0%). The 1-, 3-, 5-, and 10-year death-censored technique survival rates were 97.3, 91.7, 82.8, and 67.5%, respectively. Sex or diabetic status did not affect the technique survival rate. Patients younger than 60 years at the start of CAPD had a better technique survival than older patients (p=0.005). The main cause of technique failure was peritonitis (71.6%), followed by mechanical malfunction (10.5%), ultrafiltration failure (7.4%), and inadequate dialysis (6.3%). CONCLUSIONS: Complicating peritonitis was the most common cause of CAPD technique failure at our center. To reduce the technique failure in high-risk groups, more intensive management is needed.

A Case of BK Virus Nephropathy with Strong C4d Deposition in a Renal Allograft Recipient / 대한신장학회지

C4d deposition in peritubular capillaries in renal allograft biopsies is a significant marker for diagnosis of antibody-mediated rejection. However, it is unclear whether C4d deposition could be derived from BK virus infection. We present a case of BK virus nephropathy with strong C4d deposition 10 months after kidney transplantation. The diagnosis of BK virus nephropathy was missed out, whereas strong C4d deposition was noted in the first biopsy and therefore anti-rejection therapy was started. The deterioration of renal function led to a evaluate the possibility of BK virus nephropathy with second graft biopsy and further studies of BK virus replication status. Second graft biopsy revealed BK virus nephropathy without rejection. Finally, discontinuation of immunosuppressants and addition of anti-viral therapy for BK virus resulted in recovery of renal function, despite development of pancytopenia and subsequent fungal infection after leflunomide therapy. As in this case, initial focal pathologic changes from BK virus nephropathy could be overlooked by light microscopy. In addition, even though C4d positivity in peritubular capillaries is a good marker for diagnosis of antibody-mediated rejection, the meticulous examinations of the localization of C4d is needed, considering BK virus activates complement pathways and therefore leads to deposition of C4d mainly in tubular basement membrane. Based on our case of BK virus nephropathy with strong C4d deposition, we suggest that C4d deposition could be derived from BK virus nephropathy and therefore, it should be differentiated from acute antibody- mediated rejection in a renal allograft recipient.

Postural epigastric pain as an indication of CMV gastritis / 대한내과학회지

Cytomegalovirus (CMV) infection is an important cause of morbidity and mortality in recipients of organ transplantation. CMV can affect any segment of the gastrointestinal tract. CMV gastritis has been reported in transplant patients. We present a case of CMV gastritis with postural epigastric pain, which increased upon standing or walking and decreased in the supine position. A persistent or unexplained symptom of epigastric pain warrants further investigations by upper and/or lower endoscopies and biopsies, particularly in the early post-transplantation period.

Postural epigastric pain as an indication of CMV gastritis / 대한내과학회지

Cytomegalovirus (CMV) infection is an important cause of morbidity and mortality in recipients of organ transplantation. CMV can affect any segment of the gastrointestinal tract. CMV gastritis has been reported in transplant patients. We present a case of CMV gastritis with postural epigastric pain, which increased upon standing or walking and decreased in the supine position. A persistent or unexplained symptom of epigastric pain warrants further investigations by upper and/or lower endoscopies and biopsies, particularly in the early post-transplantation period.

Catastrophic antiphospholipid syndrome presenting with disseminated intravascular coagulation, cerebral infarction, and acute respiratory distress syndrome / 대한내과학회지

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial or venous thrombosis and recurrent fetal loss accompanied by elevated titers of antiphospholipid antibodies. Catastrophic APS is a small subset of APS, characterized by widespread systemic thrombotic disease with multiorgan failure. The diagnosis of catastrophic APS may be difficult, predominantly due to its frequently atypical presentation. In the present work, we describe a case of a 68-year-old male who presented with cerebral infarction, disseminated intravascular coagulation (DIC), and acute respiratory distress syndrome. The patient was successfully treated with anticoagulants, antibiotics, and steroid therapy. Physicians should be aware of the possibility of this syndrome as a cause of DIC with thrombotic disease because prompt recognition is essential for effective treatment.

Catastrophic antiphospholipid syndrome presenting with disseminated intravascular coagulation, cerebral infarction, and acute respiratory distress syndrome / 대한내과학회지

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial or venous thrombosis and recurrent fetal loss accompanied by elevated titers of antiphospholipid antibodies. Catastrophic APS is a small subset of APS, characterized by widespread systemic thrombotic disease with multiorgan failure. The diagnosis of catastrophic APS may be difficult, predominantly due to its frequently atypical presentation. In the present work, we describe a case of a 68-year-old male who presented with cerebral infarction, disseminated intravascular coagulation (DIC), and acute respiratory distress syndrome. The patient was successfully treated with anticoagulants, antibiotics, and steroid therapy. Physicians should be aware of the possibility of this syndrome as a cause of DIC with thrombotic disease because prompt recognition is essential for effective treatment.

Life-threatening transplant renal artery rupture after cadaveric kidney transplantation in China / 대한내과학회지

Surgical complications are still an important cause of graft loss after kidney transplantation. The most serious of these complications is arterial anastomosis rupture, which may cause not only graft loss and lower limb ischemia but can also be fatal. This paper presents a case of life-threatening transplant renal artery rupture after cadaveric kidney transplantation in China. With regard to cadaveric kidney transplantation in China, the shortage of donor information and operative findings is an obstacle to the post-transplant evaluation and management of overseas transplant recipients. Moreover, a high incidence of surgical complications and infection are present in this population of patients;therefore, these patients should be monitored more closely.

Life-threatening transplant renal artery rupture after cadaveric kidney transplantation in China / 대한내과학회지

Surgical complications are still an important cause of graft loss after kidney transplantation. The most serious of these complications is arterial anastomosis rupture, which may cause not only graft loss and lower limb ischemia but can also be fatal. This paper presents a case of life-threatening transplant renal artery rupture after cadaveric kidney transplantation in China. With regard to cadaveric kidney transplantation in China, the shortage of donor information and operative findings is an obstacle to the post-transplant evaluation and management of overseas transplant recipients. Moreover, a high incidence of surgical complications and infection are present in this population of patients;therefore, these patients should be monitored more closely.

Change of Body Composition Analyzed by Bioelectrical Impedance Analysis (BIA) in Renal Transplant Recipients / 대한신장학회지

PURPOSE: To investigate the changes of body fluid status after kidney transplantation (KT) and to find out the associated factors. METHODS: Forty-five patients who had received KT were classified into hemodialysis (n=32), peritoneal dialysis (n=5), and preemptive (n=8) groups by dialysis modality. %TBW, %ECF, %ICF, and edema index which were examined by bioelectrical impedance analysis as well as clinical parameters were prospectively measured before KT and 1st month, 3rd month, 6th month after KT. RESULTS: Before KT, there were no significant differences in all of the parameters listed above among the three groups. Mean %TBW and %ICF were not different compared to those of before KT. In contrast, mean %ECF markedly decreased within 1st month (before KT 21.13+/-3.04 L/kg, 1st month 20.03+/-2.37 L/kg, 3rd month 19.61+/-2.18 L/kg, 6th month 18.32+/-5.02 L/kg: p=0.007, p<0.001, p=0.001, respectively). Edema index also decreased from 1st month (1st month 0.354+/-0.014, 3rd month 0.352+/-0.011, 6th month 0.348+/-0.014: p=0.016, p=0.012, respectively). Only edema index was higher at 1st and 3rd month in hemodialysis group. Serum creatinine and 24 hour urine total protein were positively correlated with %ECF at 1st and 3rd month, and with %TBW at 3rd month. CONCLUSION: The recovery of body water distribution after KT starts with reduction of ECF within the 1st month. Serum creatinine and proteinuria are related to the recovery. No significant difference according to dialysis modality was found. Further study with larger sample size is necessary to confirm these findings.

The Effect of Adenoviral-mediated Gene Transfer of Bone Morphogenic Protein-7 on Peritoneal Fibrosis in an Animal Model of Peritoneal Dialysis / 대한신장학회지

PURPOSE: TGF-beta-induced epithelial-mesenchymal transition (EMT) is associated with peritoneal fibrosis during PD. We conducted this study to evaluate the effect of BMP-7 adenoviral gene transfer on the functional and structural changes of peritoneum and whether it is associated with peritoneal EMT using an animal PD model. METHODS: Forty Sprague-Dawley rats were divided into five groups; Control (C, n=8), Dialysis (D, n= 8), Rest (R, n=8), BMP-7 (B, n=8) and LacZ (L, n=8) group. Peritoneal function was assessed on baseline, 3rd, 6th, 8th weeks after PD. Immunohistochemistry for TGF-beta, VEGF, laminin and aquaporin-1 was performed in addition to morphometric analysis of peritoneum. Immunofluorescence staining with western blotting for alpha-SMA and E-cadherin, as markers of EMT, was performed. RESULTS: The thickness of submesothelial matrix was highest in D and significantly decreased in B compared to D, R and L. D/D0 glucose at 8 weeks was significantly increased in B and L compared to that of at 6 weeks, but there were no significant differences among R, B and L at 8 weeks. TGF-beta1 and VEGF expression was observed in submesothelial matrix in D and decreased in R, B and L. Peritoneal fibrosis and functional deterioration of peritoneal membrane were associated with EMT, which was partially reversed in R, B and L. CONCLUSIONS: BMP-7 gene transfer to peritoneum was not associated with the additive therapeutic effect on peritoneal function compared to the peritoneal rest, although it improved morphologic changes of peritoneum.

Association of Transforming Growth Factor-beta1 and Vascular Endothelial Growth Factor Gene Polymorphisms with Chronic Allograft Nephropathy and Graft Survival in Korean Renal Transplant Recipients / 대한신장학회지

PURPOSE: Transforming growth factor-beta1 (TGF-beta1) has been associated with the promotion of renal allograft interstitial fibrosis and thereby chronic allograft nephropathy (CAN). Vascular endothelial growth factor (VEGF) has been shown to contribute to cytoprotection of the graft after kidney transplantation. We investigated the influence of single nucleotide polymorphisms (SNPs) of the TGF-beta1 (C-509T and T869C) and the VEGF gene (C-2578A and C405G) on graft survival and the development of CAN. METHODS: Genotyping was carried out using a real-time polymerase chain reaction which was performed on the LightCycler480 in 221 Korean renal transplant recipients and 148 healthy controls. According to the presence of CAN or chronic calcineurin inhibitor nephrotoxicity, the recipients were separated into the CAN (n=21) and the No CAN (n=200) groups. RESULTS: The genotype frequencies of the SNPs were in Hardy-Weinberg equilibrium. The distributions of genotypes and alleles did not differ between recipients and controls. No significant differences were observed in the genotype distributions and allele frequencies between the CAN and the No CAN groups. The frequencies of haplotypes were not significantly different between the two groups, either. There were no statistically significant effects of TGF-beta1 and VEGF gene polymorphisms on graft survival. CONCLUSION: This study did not show any statistically significant effects of four selected SNPs of the TGF-beta1 and the VEGF genes on the development of CAN and graft survival in Korean renal transplant recipients.

Comparison of Cardiovascular Risk Profiles and Graft Function between Cyclosporin A-based and Tacrolimus-based Immunosuppression in Renal Transplant Recipients / 대한신장학회지

PURPOSE: Tacrolimus (TAC) may be less unfavorable than cyclosporin A (CsA) on cardiovascular morbidity and mortality in renal transplant recipients, but well controlled studies are insufficient. METHODS: In this prospective randomized controlled study, fifty seven consecutive renal transplant recipients were treated with CsA-based (CsA, MMF and steroid, CsA group: n=27) or TAC-based (TAC, MMF and steroid, TAC group: n=30) immunosuppressive regimens by randomized ratio of 1:1. In the baseline (pre-operation), 1, 3, and 6 months after transplantation, several cardiovascular risk factors and graft function were evaluated. RESULTS: There were no significant differences in the renal function, glucose regulation, the incidence of acute rejection and post-transplant diabetes mellitus for the post-transplant 6 months between the two groups. The blood pressure of the CsA group was maintained higher than TAC group through 6 months after transplantation even though the number of antihypertensive drugs in the CsA group was significantly higher at 3 and 6 month after transplantation. The lipid profiles except oxidized LDL were similar, but oxidized LDL level was significantly higher for the post-transplant 6 months in the CsA group (p<0.05). There were no significant differences in levels of fibrinogen, PAI-I, t-PA, hs-CRP, homocysteine, spot urine TGF-beta a and beta ig-h3, but the uric acid level was significantly higher in the CsA group (p<0.05). CONCLUSION: This study demonstrates that TAC tends to have a beneficial effect on cardiovascular risk profiles, with regard to BP and atherogenic properties of serum lipids in early post-transplant period.

Coronary-artery Calcium Scores Using Electron Beam CT in Patients with Chronic Renal Failure

We evaluated the risk of coronary-artery disease in patients with chronic renal failure (CRF) by measuring the coronary-artery calcium scores with electron beam CT (EBCT). A total of 81 CRF patients were divided into three groups; pre-dialysis (group I, n=35), hemodialysis (group II, n=31) and peritoneal dialysis (group III, n=15). The several serum biochemical markers and calcium score levels by EBCT were determined. The Ca x P products were significantly higher in groups II (p 400 was significantly higher than the 66 patients with a score < or =400 (p<0.01). The calcium score was significantly higher in the 15 patients with cardiovascular complications than in the 66 patients without cardiovascular complications (628.9+/-904.8 vs. 150.4+/-350.9, p<0.01). EBCT seemed to be a good diagnostic tool for evaluating the risk of coronary-artery disease ''noninvasively'' in CRF patients who are at increased risk of cardiovascular morbidity and mortality.

Effect of Peritoneal Dialysis Duration on the Outcome of Peritonitis in CAPD Patients / 대한신장학회잡지

BACKGROUND: The clinical manifestations of peritonitis in long-term PD patients may be more severe due to structural and functional alterations of the peritoneum caused by repeated exposure to the bioincompatible dialysate. However, the study in which outcome of peritonitis was compared to the duration of PD has been reported rarely. This study was performed to evaluate the effect of PD duration on the outcome of peritonitis. METHODS: Medical records of patients cared for in Kyungpook University Hospital between June 1998 and May 2001 were reviewed retrospectively. Patients were divided into three groups by PD duration: group 1, or =37 months. RESULTS: There were 303 episodes (156 patients) of peritonitis during the study periods: 77 episodes in group 1, 115 episodes in group 2 and 111 episodes in group 3. There was no difference in gram- positive, gram-negative or fungal rate of peritonitis among three groups. In group 3, 16.2% of the patients transferred to hemodialysis, while 3.9% and 7.0% of patients in group 1 and 2 transferred to hemodialysis (p<0.05). CONCLUSION: Patients maintained on PD for over three years are associated with higher rate of technique failure than patients maintained on PD for less than three years. PD duration may be considered as a factor for predicting prognosis of peritonitis. Peritonitis in patients on long-term PD needs special attention.

Analysis of renal biopsies performed in 208 patients with asymptomatic urinary abnormalities / 대한내과학회지

BACKGROUND: Asymptomatic urinary abnormalities are one of the most frequent abnormalities in clinical nephrology. However, there are few large-scaled studies about the clinical manifestations and the pathologic findings of the disease. The aim of present study was to evaluate the clinicopathologic nature of the patients with asymptomatic urinary abnormality proven by renal biopsy. METHODS: Between January 1998 and July 2002, two hundred and eight patients with asymptomatic urinary abnormality at three hospitals in Daegu were studied for age, sex, initial urinary findings, serum creatinine, daily urine protein and pathologic findings by renal biopsy. RESULTS: Mean age was 28.0 years (range 14-60 years) at diagnosis of 208 patients and sex ratio of male to female was 141:67. One hundred and two patients (49.0%) had hematuria and proteinuria, 94 (45.2%) had pure microscopic hematuria and the remaining 12 (5.8%) had isolated proteinuria. Pure microscopic hematuria was the dominant urinary abnormality in younger patients. In pathologic findings, 120 patients (57.7%) were IgA nephropathy, 35 (16.8%) thin glomerular basement membrane disease, 8 (3.8%) minimal change disease, 6 (2.9%) membranous glomerulonephropathy and 22 (10.6%) showed no histologic abnormality. The most common pathologic diagnosis in all three groups was IgA nephropathy. In pure microscopic hematuria group, 38 patients (40.4%) were IgA nephropathy and 27 patients (28.7%) were thin glomerular basement membrane disease. There were no significant difference in pathologic findings depending on the severity of proteinuria (p>0.05). CONCLUSION: In our study, the most common cause of asymptomatic urinary abnormalities was IgA nephropathy. In patients with pure microscopic hematuria, IgA nephropathy and thin glomerular basement membrane disease were two leading causes.

ReVersible MRI Changes in a Patient with Uremic Encephalopathy / 대한신장학회잡지

Uremic encephalopathy is a well-known complication in uremia and may result from changes of cerebral metabolism due to uremic toxins. Specific morphological changes have not been observed and pathogenesis is still unclear. We experienced a case with uremic encephalopathy in whom reVersible abnormalities were observed on brain magnetic resonance image (MRI). A 61-year-old man with chronic renal faliure due to diabetic nephropathy started automated peritoneal dialysis (APD) one year ago (therapy time: 10 hours, number of cycles: 5, fill volume per cycle: 2 L). He developed gait disturbance and dysarthria after he dwelled icodextrin contained 2 L dialysate over night instead of APD. In that time, his weekly Kt/V and creatinine clearance were 1.5 and 87.5 L/week/1.73 m2, respectively. On brain MRI, low signal in T1 image and high signal in T2 image were seen in putamen and globus pallidus bilaterally. Insufficient peritoneal dialysis adequacy was documented, and the patient was switched from APD to continuous ambulatory peritoneal dialysis (CAPD). After than, his symptom gradually improved. On follow-up MRI 2 months later, previous lesion has disappeared.