Delivery of Dialysis Dose of Intermittent Hemodialysis in the Patients with Acute Renal Failure and its Contributing Factors / 대한신장학회잡지

BACKGROUND: Recent studies have suggested that the outcomes of the patients with acute renal failure (ARF) may related to delivered dose of dialysis. In such context, a number of investigators have reported about delivered dose of dialysis and its contribution to outcomes of ARF, using Kt/V. The purpose of the study was to evaluate actual delivered dose of dialysis in intermittent hemodialysis (HD) in critically ill ARF patients, clinical factors contributing delivery of dialysis dose, and relationship of delivered dialysis dose and survival. METHODS: Delivered and prescribed dose of dialysis, presented as Kt/V, were measured in ARF patients intermittent HD in intensive care unit of Inha University Hospital from January 1999, until December 1999, using single pool urea kinetic model. RESULTS: All subjects received intermittent HD of 6.4+/-4.8 times with mean of 225.6+/-40.4 min per session. Overall survival was 55.5%. Prescribed Kt/V in all subjects was 1.24+/-0.39, but actual delivered Kt/ V was 1.08+/-0.17. A mean delivered/prescribed Kt/V ratio was 87.1+/-43%. Duration of HD session (R= -0.547, p=0.019), Cleveland Clinic Foundation Severity Score (R=-0.486, p=0.041), and frequency of hypotensive episodes (R=-0.419, p=0.043) were significantly correlated with delivered/prescribed Kt/V ratio. Delivered dose was under 1.2 in 66.7% of the subjects. Survival rate of these patients was 50.0%, which was lower as compared to 66.6% of the patients with delivered dose over 1.2. Patients with low delivered dose (Kt/V<1.2) showed significantly low prescribed dose and short HD time (p<0.05). Delivered Kt/V was correlated with BUN at initiation of dialysis, HD duration, and prescribed Kt/V (p<0.05). Non-survivors showed significantly low initial serum creatinine, low CCF severity score, high frequency of hypotensive episodes, and less use of heparin (p< 0.05). Prescribed Kt/V was not different between survivors and non-survivor (1.22+/-0.30 vs 1.31+/-0.45), but delivered Kt/V (1.17+/-0.17 vs. 1.04+/-0.17; p<0.05) and delivered/prscribed Kt/V (95.9+/-22.6% vs. 73.9+/-15.6%; p<0.05) were significantly higher in survivors than in non-survivors. CONCLUSION: In ARF patients, the delivery of dialysis was significantly lower than as was expected. Delivered/prescribed Kt/V was about 87% and more than half of the patients received intermittent HD of Kt/V less than 1.2. Better survival was associated with higher delivered dose of dialysis. We need further prospective studies about the causal relationship between delivered dose of dialysis and outcomes in ARF patients.

The Usefulness of Endoscopic Retrograde Biliary Drainage Using Plastic Stents for Patients with Common Bile Duct Stone / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic sphincterotomy is considered the primary option for treatment of common bile duct (CBD) stones. In some cases, however, complete stone removal is difficult or even impossible. Endoscopic retrograde biliary drainage (ERBD) has been suggested to be an alternative treatment in such cases or in patients with high surgical risks. In this study, we evaluated the effectiveness of ERBD using a plastic stent for treatment of CBD stones. METHODS: From Mar. 1996 to Aug. 1999, ERBD was performed in 12 patients with CBD stones. Indications for ERBD were old age in 4, a large perivater diverticulum in 4, refusal of surgery in 2, bleeding risk and biliary stricture in 1 each. Nine had one of the significant associated medical conditions. RESULTS: Six of the 12 patients were symptom-free at the time of evaluation (mean 32.9 months). Of the remaining 6 patients, 3 had operation, 1 had a successful endoscopic stone removal, 1 had a stent exchange, and 1 was lost to follow-up at 26 months. Thus, overall success rate of ERBD for treatment of CBD stones was 75% (9/12). Median symptom-free duration was 41 months (range 18~59 months). CONCLUSIONS: In view of its relatively high success rate and long-term effect, ERBD is an alternative modality for treatment of CBD stones, especially in patients with high surgical risks.

Additive Antiproteinuric Effect of Combination Therapy with ACE Inhibitor and Angiotensin II Receptor Antagonist: Differential Short-term Response between IgA Nephropathy and Diabetic Nephropathy

In previous studies, the synergistic antiproteinuric effect of the combination therapy of ACE inhibitors and angiotensin II receptor antagonists (ATRAs) has been inconsistent in relation to underlying renal diseases. The influence from the blood pressure (BP) - reducing effect in some studies might also contribute to this inconclusiveness. To examine the possibility of the benefit being different according to underlying renal diseases, we undertook a crossover therapeutic trial of the combination therapy in two selected homogenous groups of patients with diabetic and non-diabetic renal diseases. The BP-reducing effect was excluded during the study. Nineteen biopsy-proven IgA nephropathy, as examples of non-diabetic renal diseases, and 24 type 2 diabetic nephropathy patients were selected as the study subjects. The subjects had to meet the follow criteria: a creatinine clearance (Ccr) between 25 - 90 ml/min/1.73 m2, 24-hr urinary protein excretion rate over 1.0 g/day and a BP maintained at less than 130/80 mmHg, with more than six-month therapy of ramipril, (5.7 +/- 0.4 mg/day, 13 +/- 2 month). The baseline data between the two groups showed no significantly differences. After a 12-week stabilization period (control period), 4 mg, once daily, dose of candesartan (combination period) followed by a placebo (placebo period), or vice versa, were administered in addition to the ramipril, for 12 weeks. The combination, with candesartan, did not change the Ccr, BP, serum and urinary electrolytes or the urea. The 24 hour urinary protein excretion rate was significantly reduced by the combination therapy in the patients with IgA nephropathy (3.1 +/- 0.3 g/day in combination, 4.2 +/- 0.3 in control, and 4.3 +/- 0.2 in placebo; p < 0.05). However, the patients with diabetic nephropathy showed no reduction in their proteinuria with the combination therapy (3.8 +/- 0.2 g/day in combination, 3.9 +/- 0.3 in control, and 4.1 +/- 0.3 in placebo; p=NS). The changes in proteinuria showed no relationship with the changes in the BP in IgA nephropathy. In conclusions, the benefit of combination therapy of its antiproteinuric effect was different between IgA and diabetic nephropathy over the 12-week trial. The difference in the pathophysiological role, and the importance of the renin- angiotensin system, between the two diseases might contribute to the discrepancy in the result. We suggest the discrimination of the underlying renal diseases in the study subjects is an important prerequisite for future studies on this issue.

Foreign body-induced Actinomycosis Mimicking Bronchogenic Carcinoma

Actinomycosis is a slowly progressive infectious disease caused by an anaerobic and microaerophilic bacteria that colonizes the face, neck, lung, pleura and the ileocecal region. There have been a few cases of this disease which have involved in the lung but one very rare case has been reported. We report a case of foreign body-induced endobronchial actinomycosis mimicking bronchogenic carcinoma in a 69-year-old man. On admission, the patient presented with weight loss, cough and hemoptysis. The fiberoptic bronchoscopy revealed a soft tissue mass, with a partial occlusion of the left upper bronchus, which resembled bronchogenic carcinoma. Contrary to the first impression, the biopsy of the bronchus revealed the mass lesion to be an actinomycotic infection involving the bronchus. After the confirmation of the lesion, treatment with penicillin was initiated. The follow-up bronchoscopy revealed an aspirated fish bone at the site of infection. The foreign body was safely removed.

Early dipyridamole stress myocardial SPECT to detect residual stenosis of infarct related artery: comparison with coronary angiography and fractional flow reserve

BACKGROUND: The detection of residual stenosis of infarct related artery (IRA) at early stage after acute myocardial infarction (AMI) is crucial in clinical decision making for interventional revascularization. The aim of this study was to evaluate the relevancy of early dipyridamole stress myocardial SPECT to detect functionally and luminologically significant residual stenosis of IRA after AMI. METHOD: Twenty five consecutive patients (M:F=19:6, age: 56+/-13yrs) with AMI underwent SPECT and coronary angiography within 5 days of the attack. Infarct related arteries with FFR 70% were regarded to have functionally and morphologically significant residual stenosis. Reversible perfusion defect was defined if there was improvement of the perfusion score more than one grade in infarct segments on rest images of SPECT compared with stress images. RESULTS: Mean FFR and DST were 0.76+/-0.14 and 74+/-15%. SPECT showed no significant correlation with both FFR and DST with Kendall's coefficiency of 0.28 (p=0.05) and 0.13 (p=0.35). The sensitivity and specificity of SPECT to detect functionally and morphologically significant residual stenosis were 92%, 31% and 83%, 29%. CONCLUSION: The early dipyridamole stress myocardial SPECT after AMI does not seem to be a useful non-invasive test for the detection of functionally and luminologically significant residual stenosis of IRA.

Isolated Splenic Infarction in a Patient with Systemic Lupus Erythematosus / 대한류마티스학회지

Systemic lupus erythematosus (SLE) is a multisystemic inflammatory autoimmune disease caused by various autoantibodies and immune complexes. Splenic involvement in SLE includes hypersplenism, splenic atrophy, and splenic infarction, which has rarely been reported. We report a case of SLE with isolated splenic infarction. A 20-year-old female patient was admitted complaining of general weakness, malar rash, and easy fatigue. She was diagnosed as having SLE with thrombocytopenia and received steroid treatment. On the 7th hospital day, she complained of severe left upper abdominal pain with sudden-onset. While abdominal ultrasonography showed only mild splenomegaly, abdominal CT and 99mTc-RBC splenic scintigraphy revealed segmental splenic infarction. She had no evidence of additional thrombotic event or hemorrhage. After administration of high dose steroid, abdominal pain subsided and splenic infarction was resolved.