Omega-3 fatty acids upregulate Nrf2 expression and attenuate apoptosis, inflammation, and fibrosis in a rat model of cyclosporine-induced nephropathy / 고신대학교의과대학학술지

Background@#Cyclosporine A (CsA)-induced kidney injury is characterized by renal impairment with inflammatory cell infiltrations, apoptosis, fibrosis, and hypoxic injury. It is not clear whether omega-3 fatty acids (O-3 FAs), which have anti-inflammatory and antioxidant roles, affect nuclear factor erythroid 2-related factor 2 (Nrf2) expression. The aim of this study was to investigate whether O-3 FAs affect Nrf2 expression and exert anti-inflammatory, anti-apoptotic, and anti-fibrotic effects in CsA-induced nephropathy. @*Methods@#Male Sprague-Dawley rats were divided into control, CsA-treated, and CsA-treated with O-3 FA groups. Nrf2 expression was measured by Western blots and immunohistochemical staining. @*Results@#Kidney function was impaired in the CsA-treated rats compared to the controls. Caspase-3 and caspase-7 were activated in the CsA-treated group, and the Bax/Bcl2 ratio was higher. O-3 FAs attenuated these apoptosis-related changes. ED-1 and inhibition of kappa B (IĸB) protein expression were significantly upregulated in the CsA-treated group. Compared to the control group, O-3 FA supplementation attenuated the increased expression of ED-1 and IĸB related to inflammation. Smad2/3, Smad4, and transforming growth factor-β1 were activated in the CsA group, and O-3 FA treatment prevented these changes related to renal fibrosis. The expression of Nrf2 was reduced in CsA-treated rats, but Nrf-2 was increased by O-3 FA treatment. @*Conclusions@#We suggest that Nrf2 is a potential mediator induced by O-3 FA supplementation and that it attenuates pro-inflammatory pathways, fibrotic processes, and apoptosis. Further studies are needed to elucidate the crosstalk between Nrf2 expression and signals related to O-3 FA treatment.

Effect of pravastatin on erythrocyte membrane fatty acid contents in patients with chronic kidney disease

Background@#Statin treatment has decreased the risk of cardiovascular events in patients with chronic kidney disease (CKD). Erythrocyte membrane oleic acid level is higher in patients with acute coronary syndrome. This study aimed to evaluate the effect of pravastatin on the erythrocyte membrane fatty acid (FA) contents in patients with CKD. @*Methods@#Sixty-two patients were enrolled from January 2017 to March 2019 (NCT02992548). Pravastatin was initially administered at a dose of 20 mg for 24 weeks. The pravastatin dose was increased to 40 mg after 12 weeks if it was necessary to control dyslipidemia. The primary outcome was change in erythrocyte membrane FA, including oleic acid, after pravastatin treatment for 24 weeks. @*Results@#Forty-five patients finished this study, and there was no adverse effect related to pravastatin. Compared with baseline, total cholesterol and low-density lipoprotein cholesterol levels were significantly decreased after pravastatin treatment. Compared with baseline, saturated FA, oleic acid, and arachidonic acid levels were significantly increased and polyunsaturated FA and linoleic acid (LA) levels were significantly decreased after pravastatin treatment. There was also a decrease in eicosapentaenoic acid after pravastatin treatment in CKD patients with estimated glomerular filtration rate <60 mL/min/1.73 m2. @*Conclusion@#Administration of pravastatin in patients with CKD leads to a decrease in FA known to be protective against the risk of CVD. Omega-3 FA or LA supplementation might be necessary to recover changes in erythrocyte membrane FA contents when pravastatin is used for treating dyslipidemia in patients with CKD.

Serum myostatin levels are associated with abdominal aortic calcification in dialysis patients

BACKGROUND: Serum myostatin levels are increased according to renal function decline and myostatin may be a main mediator of chronic kidney disease–related sarcopenia. A previous study reported that serum myostatin level was negatively associated with abdominal aortic calcification (AAC) in older males. The aim of this study was to assess the association between serum myostatin level and AAC among dialysis patients of both sexes. In addition, we analyzed the relationship between serum myostatin level, muscle mass, and bone mineral density (BMD).METHODS: In this cross-sectional study, we evaluated AAC in the lateral lumbar spine using plain radiography and BMD in 71 patients undergoing dialysis. We classified patients into two groups according to the median value of myostatin as follows: those with high myostatin levels (≥ 5.0 ng/mL) and those with low myostatin levels (< 5.0 ng/mL).RESULTS: The proportion of patients with an AAC score of five points or more was higher among those with low myostatin levels. Myostatin level was negatively associated with AAC scores on plain radiography and had a positive association with skeletal muscle mass and T-scores for BMD measured at the total hip and femur neck. Lower myostatin levels were independently associated with higher AAC scores following adjustment for age, sex, diabetes mellitus, dialysis vintage, dialysis modality, and osteoprotegerin level.CONCLUSION: Lower serum myostatin levels were associated with higher AAC scores, lower muscle mass, and lower BMD in dialysis patients. Further, prospective studies and those with larger cohorts are necessary to validate these findings.

Acute Hemolytic Transfusion Reaction due to ABO-Incompatible Blood Transfusion: A Fatal Case Report and Review of the Literature / 대한수혈학회지

A 77-year-old female patient who was suspected to have had an acute hemolytic transfusion reaction was admitted to the emergency room. She received one unit of type A red blood cells in a type B patient during a total knee arthroplasty operation at another medical institution. ABO-incompatible transfusion was carried out due to an identification error between the patient and blood product. At the time of admission, acute hemolytic reaction, lactic acidosis, and disseminated intravascular coagulation were observed. She was admitted to the intensive care unit and received continuous renal replacement therapy. She maintained renal function and was moved to the general ward on the 7th day. Complications such as pulmonary edema, gastrointestinal bleeding, and ischemic colitis persisted, and the patient died on the 111th after admission. This case is the first report of death due to an ABO-incompatible transfusion in Korea. Efforts to establish a safe transfusion environment are necessary not only at individual medical institutions but also at the national level.

Resistive index as a predictor of renal progression in patients with moderate renal dysfunction regardless of angiotensin converting enzyme inhibitor or angiotensin receptor antagonist medication

BACKGROUND: Previous studies have shown that a higher resistive index (RI) on renal duplex ultrasonography was related with renal progression and acute kidney injury, especially in patients with chronic kidney disease (CKD) using an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor antagonist (ARB). We evaluated whether a RI value is a predictive factor for renal progression regardless of ACEI or ARB medication in patients with moderate renal dysfunction. METHODS: We retrospectively analyzed 119 patients with moderate renal dysfunction that had been evaluated with renal duplex ultrasonography from February 2011 to April 2015. Moderate renal dysfunction was defined as a stage 3 to 4 CKD. Renal progression was defined as a doubling of the baseline serum creatinine (sCr), a decrease of baseline glomerular filtration rate by > 50%, or initiation of renal replacement therapy. RESULTS: The mean age was 64.7 ± 11.0 years and sCr level was 2.1 ± 1.2 mg/dL. The RI ≥ 0.79 group showed a higher incidence of renal progression (P = 0.004, log-rank test) compared with the RI < 0.79 group, irrespective of ACEI or ARB usage. In the Cox proportional hazard model, RI ≥ 0.79 was an independent prognostic factor after adjusting for age, sex, diabetes mellitus, sCr, proteinuria, and use of ACEI or ARB (hazard ratio, 4.88; 95% confidence interval, 1.06–22.53; P = 0.043). CONCLUSION: RI ≥ 0.79 on the renal duplex ultrasonography can be a helpful predictor for renal progression in patients with moderate renal dysfunction, regardless of their ACEI or ARB usage.

A Case of Steroid Resistant Minimal Change Disease Associated with Portal Vein Thrombosis Treated by Combined Immunosuppressive Agents / 고신대학교의과대학학술지

Minimal change disease (MCD) is a common cause of nephrotic syndrome and relatively well responds with steroid treatment. However, nearly half of patients with MCD experience recurrence of nephrotic syndrome. Thromboembolic events including renal vein thrombosis may occur in patients with MCD, but portal vein thrombosis rarely occurs. We experienced a case of frequent relapse/steroid dependent MCD with nephrotic syndrome progressed to steroid resistance associated with portal vein thrombosis. This patient showed complete remission of MCD and resolution of portal vein thrombosis after treatment with corticosteroid, cyclosporine, mycophenolate mofetil, and anticoagulant.

A Case of Lactate Containing Peritoneal Dialysis Solution Induced Lactic Acidosis Corrected by Changing to Hemodialysis / 고신대학교의과대학학술지

Elevated lactate levels are associated with acute illnesses, and the mortality is high. Here, we report a case of lactate-containing peritoneal dialysis (PD) solution inducing lactic acidosis corrected by changing to hemodialysis (HD). This 70-year-old female patient was treated with PD 8 months previously for end-stage renal disease caused by diabetes mellitus. She was admitted complaining of general weakness. Initial lactate level was 22.1 mg/dL and increased to 62.4 mg/dL showing high anion gap metabolic acidosis and compensatory hyperventilation. There are no definite causes of lactic acidosis besides the use of PD solutions containing a lactate component. The patient's lactate level was decreased after temporarily changing the dialysis modality to HD. Her lactate level was increased again after restarting PD, and decreased to normal after restarting HD. We report this case because physicians should consider lactate-containing PD solution as a possible cause of lactic acidosis.

Revisiting the Pre-transfusion Test: A Case of Acute Hemolytic Transfusion Reaction due to Multiple Alloantibodies of Anti-E, Anti-c, Anti-Jk(b) / 대한수혈학회지

We report a case of acute hemolytic transfusion reaction due to multiple alloantibodies. A 41-year-old male with multiple histories of transfusion was admitted for jaundice and oliguria after receiving two units of red blood cells in a local clinic. He showed acute renal failure and disseminated intravascular coagulation. Direct Coombs test was negative and antibody screening test showed strong positive results. Anti-E, anti-c, and anti-Jk(b) antibodies were identified in two panels of unexpected antibody assays. Acute hemolytic transfusion was diagnosed, and he was discharged after 1 month of supportive treatment. Unexpected antibody detection tests, including the antiglobulin phase, should be performed to prevent adverse transfusion reactions by unexpected antibodies. Better precision and quality control are necessary when performing pre-transfusion tests.

DRESS syndrome with acute interstitial nephritis caused by quinolone and non-steroidal anti-inflammatory drugs / 영남의대학술지

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and severe drug-induced hypersensitivity syndrome characterized by hematological abnormalities and multiorgan involvement. Liver involvement is the most common visceral manifestation. However, renal failure has been rarely described. The common culprit drugs are anticonvulsants and allopurinol. We experienced a patient with DRESS syndrome with acute interstitial nephritis caused by concomitant administration of quinolone and non-steroidal anti-inflammatory drugs (NSAIDs). A 41-year-old man presented with a diffuse erythematous rash and fever which developed after administration of quinolone and NSAIDs for a month due to prostatitis. He was diagnosed with DRESS syndrome. Skin rash, fever, eosinophilia, and elevations of liver enzymes improved with conservative treatment and discontinuation of the causative drugs. However, deterioration of his renal function occurred on day 8 of admission. The levels of blood urea nitrogen and serum creatinine increased and oliguria, proteinuria and urinary eosinophils were observed. Ultrasonography showed diffuse renal enlargement. The clinical features were compatible with acute interstitial nephritis. Despite intravenous rehydration and diuretics, renal function did not improve. After hemodialysis, his renal function recovered completely within 2 weeks without administration of systemic corticosteroid.

Comparison of exit site infection and peritonitis incidences between povidone-iodine and normal saline use for chronic exit site care in peritoneal dialysis patients

BACKGROUND: Catheter-related exit site infection is a major risk factor for the development of peritonitis and can contribute to failure of treatment maintenance in peritoneal dialysis (PD) patients. Although povidone-iodine can be used for exit site care, the irritation induced by the local application of povidone-iodine could lead to secondary infection. Therefore, we evaluated the clinical effectiveness of normal saline compared with povidone-iodine as a method of exit site care in chronic PD patients. METHODS: In all, 126 patients undergoing PD treatment for>46 months between January 2006 and December 2009 were enrolled. Data were retrospectively analyzed for the incidence of exit site infection and peritonitis for 2 years prior to and after December 2007. In addition, we identified the incidences of catheter- related infections during follow-ups from January 2010 to December 2013. RESULTS: The participants' mean age was 58.87+/-12.9 years. The incidences of exit site infection and peritonitis were one episode per 64.6 patients-months and one episode per 40.4 patients-months in the povidone-iodine group, respectively, whereas these were one episode per 57.5 patients-months and one episode per 45.6 patients-months in the normal saline group, respectively. Whereas Gram-positive bacteria most frequently caused catheter-related infections in both groups, culture-negative infections were dominant in the normal saline group. CONCLUSION: Exit site care using normal saline did not increase the incidence of exit site infection and peritonitis. Therefore, normal saline may be an alternative treatment for exit site care in patients receiving PD.

Resistive index as a predictor of acute kidney injury caused by an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker in chronic kidney disease patients

BACKGROUND: Angiotensin converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) may induce acutekidney injury (AKI).The aim of this study was to evaluate the role of the resistive index (RI), which reflects renal artery resistance on renal duplex ultrasonography, as a predictor of AKI in chronic kidney disease (CKD) patients who are prescribed an ACE inhibitor or ARB. METHODS: We screened 105 CKD patients evaluated with renal duplex ultrasonography from 2008 to 2012. We excluded patients not treated with ACE inhibitor or ARB and diagnosed with renal artery stenosis. Finally, we retrospectively analyzed the medical records of 54 patients. AKI was defined as increased serum creatinine by >30% compared with baseline after starting ACE inhibitor or ARB treatment. RESULTS: The mean age of the patients was 60.5+/-13.0 years, serum creatinine level was 1.85+/-0.85 mg/dL and 22.2% of the patients had AKI after the use of an ACE inhibitor or ARB. The RI (P=0.006) and the percentages of patients with diabetes (P=0.008)and using diuretics (P=0.046) were higher in the AKI group.The area under the receiver operating characteristics curve for the prediction of AKI was 0.736 (95% confidence interval=0.587-0.885, P=0.013),and RI> or =0.80 predicted AKI with 83.3% sensitivity and 61.9% specificity. In the multivariate analysis, RI> or =0.80 was an independent prognostic factor [Exp (B)=8.03, 95% confidence interval=1.14-56.74, P=0.037] for AKI. CONCLUSION: RI> or =0.80 on the renal duplex ultrasonography may be a helpful predictor for AKI in CKD patients who are prescribed an ACE inhibitor or ARB.

Effects of low-dose niacin on dyslipidemia and serum phosphorus in patients with chronic kidney disease

BACKGROUND: Niacin supplementation improves dyslipidemia and lowers serum phosphorus levels in patients with chronic kidney disease (CKD). We evaluated whether low-dose niacin supplementation can improve dyslipidemia, lower serum phosphorus levels, and be administered with a low frequency of adverse effects in patients with CKD. METHODS: We retrospectively analyzed the clinical records of patients with CKD who had taken niacin from January 2009 to June 2011. We excluded patients with CKD stage 1 and 5. We then enrolled 31 patients with CKD who had taken niacin at a fixed dose of 500mg/day for 6 months. We also randomly selected 30 patients with CKD who had been taking statin for 9 months as a control group. RESULTS: Among the 34 patients with CKD who were prescribed niacin, five (14%) complained of adverse effects, and three (8%) discontinued niacin. The proportion of patients in the niacin group who had been taking a statin or omega-3 fatty acids was 67.7% and 48.8%, respectively. In the niacin group, high-density lipoprotein cholesterol level was significantly increased and triglyceride level was significantly decreased at 12 and 24 weeks compared with baseline levels (P < 0.05). In the niacin group, phosphorous level (P < 0.05) was significantly decreased, and glomerular filtration rate (GFR) was significantly increased (P < 0.05) at 24 weeks compared with baseline values. CONCLUSION: Low-dose niacin had a low frequency of adverse effects and also improved dyslipidemia, lowered serum phosphorus level, and increased GFR in patients with CKD. Further studies are needed to evaluate the long-term effects of low-dose niacin for renal progression of CKD.

Effects of low-dose niacin on dyslipidemia and serum phosphorus in patients with chronic kidney disease

BACKGROUND: Niacin supplementation improves dyslipidemia and lowers serum phosphorus levels in patients with chronic kidney disease (CKD). We evaluated whether low-dose niacin supplementation can improve dyslipidemia, lower serum phosphorus levels, and be administered with a low frequency of adverse effects in patients with CKD. METHODS: We retrospectively analyzed the clinical records of patients with CKD who had taken niacin from January 2009 to June 2011. We excluded patients with CKD stage 1 and 5. We then enrolled 31 patients with CKD who had taken niacin at a fixed dose of 500mg/day for 6 months. We also randomly selected 30 patients with CKD who had been taking statin for 9 months as a control group. RESULTS: Among the 34 patients with CKD who were prescribed niacin, five (14%) complained of adverse effects, and three (8%) discontinued niacin. The proportion of patients in the niacin group who had been taking a statin or omega-3 fatty acids was 67.7% and 48.8%, respectively. In the niacin group, high-density lipoprotein cholesterol level was significantly increased and triglyceride level was significantly decreased at 12 and 24 weeks compared with baseline levels (P < 0.05). In the niacin group, phosphorous level (P < 0.05) was significantly decreased, and glomerular filtration rate (GFR) was significantly increased (P < 0.05) at 24 weeks compared with baseline values. CONCLUSION: Low-dose niacin had a low frequency of adverse effects and also improved dyslipidemia, lowered serum phosphorus level, and increased GFR in patients with CKD. Further studies are needed to evaluate the long-term effects of low-dose niacin for renal progression of CKD.

Reliability of Hemodialysis Adequacy Measured by Ionic Dialysance / 대한신장학회지

PURPOSE: Quantification of the dialysis dose is an essential element in the management of hemodialysis. The author investigates the reliability of hemodialysis adequacy measured by ionic dialysance (Online clearance monitoring(R), OCM). Because OCM is a non-invasive and instantly accessible method, it could be replaced Kt/V derived from single-pool variable volume urea kinetic model (UKM). METHODS: Kt/V using UKM and OCM were measured simultaneously in 51 patients who have received hemodialysis therapy via arteriovenous fistula. The analysis of the data collected from 186 hemodialysis sessions were performed. RESULTS: Kt/V of conventional hemodialysis, high efficiency hemodialysis and hemodiafiltration measured by UKM were 1.39+/-0.24, 1.41+/-0.23 and 1.53+/-0.17, and by OCM were 1.24+/-0.17, 1.26+/-0.19 and 1.39+/-0.19, respectively. The data of UKM were significantly higher than those of OCM (p=0.00). Also, there were strong positive correlations between UKM and OCM in hemodialysis (r=0.80, p=0.00), high efficiency hemodialysis (r=0.65, p=0.00) and hemodiafiltration (r=0.67, p=0.00). CONCLUSION: The Kt/V using OCM measured by ionic dialysance provided slightly lower data than that of UKM derived from single-pool variable volume urea kinetic model, but it may be a reliable test to evaluate dialysis adequacy in conventional hemodialysis, high efficiency hemodialysis and hemodiafiltration.

Comparison of Vascular Calcification Scores on Plain Radiographs to Predict Coronary Artery Disease According to Dialysis Modality / 대한신장학회지

PURPOSE: Vascular calcification (VC) scores on simple plain radiographic films are known to be associated with coronary artery disease (CAD) in hemodialysis (HD) patients. However, there is no report comparing VC scores on plain radiographic films according to dialysis modality. We hypothesized that there are some differences of VC scores on plain radiographs for the assessment of CAD according to dialysis modality. METHODS: We recruited 78 peritoneal dialysis (PD) patients and compared to 61 HD patients. We defined significant VC as any one finding among the abdominal aortic calcification (AAC) score > or =5, VC score of the hands and pelvis > or =3, or medial artery calcification of the feet on plain radiographs. RESULTS: The prevalence of CAD and significant VC were not different according to dialysis modality. Every VC score on the plain radiographs was highly correlated with each other, but VC evaluation on plain radiographs by single method overlooked nearly 30% of other significant VC sites in PD and HD patients. AAC score was most useful method for the prediction of CAD as a single VC scoring method. There was no association between VC of the feet and CAD in PD patients. Lower high density lipoprotein cholesterol was associated with significant VC on plain radiograph in PD patients. CONCLUSION: Significant VC formation on plain radiographs was not different according to dialysis modality. It is helpful to check several plain radiographs for the decision of CAD evaluation and not overlooking significant VC in both HD and PD patients.

Adult Onset Still's Disease Developed in a Patient with Membranous Nephropathy Treated with Immunosuppressive Agent / 대한신장학회지

Adult onset Still's disease (AOSD) is a rare systemic inflammatory disease characterized by high spiking fever, leukocytosis, high serum ferritin, salmon-colored rash, arthritis, lymphadenopathy, and hepatosplenomegaly. The etiology of AOSD is obscure. AOSD is diagnosed after exclusion of infection, malignancy and other connective tissue diseases. A 53-year-old female patient with membranous nephropathy was admitted with high fever and leukocytosis. She was taking immunosuppressive agents with low dose steroid and cyclosporine to control of proteinuria caused by membranous nephropathy. She was initially treated with antibiotics, antiviral agent and antifungal agent to control of hidden infection. High spiking fever was sustained for 2 weeks and controlled after hydrocortisone treatment. AOSD was diagnosed according to the criteria of Yamaguchi. It should be considered that AOSD is a cause of high fever in patients treated with immunosuppressive agents.

Prevalence of Primary Glomerulonephritis: A Single Center Analysis / 대한신장학회지

PURPOSE: To evaluate the exact prevalence of primary glomerular diseases in Korea. METHODS: We analyzed a retrospective cohort of biopsy proven 1,100 patients with primary glomerular disease in OO Hospital from April 1990 to March 2010. RESULTS: Pathologic diagnosises of 1,100 cases were as follows: IgA nephropathy (IgAN), 557 cases (50.6%), was the most common followed by 200 cases (18.1%) of minor glomerular abnormalities (MGA), 168 cases (15.2%) of focal segmental glomerulosclerosis (FSGS), 93 cases (8.0%) of membranous nephropathy (MN), 31 cases (2.8%) of membranoproliferative glomerulonephritis type I (MPGN), 17 cases (1.5%) of focal glomerulonephritis and 7 cases (0.6%) of diffuse mesangial proliferative glomerulonephritis (DMGN) in order. In idiopathic nephrotic syndrome, the most common pathologic diagnosis was minimal change nephrotic syndrome (MCNS) (40.2%), followed by FSGS (27.5%), MN (24.2%), MPGN (8.1%) and DMGN (0.5%). When the incidence rates between 1990-1992 and 2008-2010 were compared, IgAN and FSGS increased from 34.7, 12.5 to 47.8%, 30.4%, but MCNS (from 33.3 to 6.5 %) decreased significantly. CONCLUSION: IgAN was the most common primary glomerulonephritis. During the past 20 years, the prevalence of IgAN and FSGS were increased, while MCNS and MN were decreased.

Comparison of heart rate variability between ESRD patients on peritoneal dialysis and hypertensive patients / 대한내과학회지

BACKGROUND/AIMS: Heart rate variability (HRV) is regulated by the balance between the sympathetic and parasympathetic tones. HRV can be used to assess the effects of drugs and other interventions on cardiac autonomic tone, including exercise, respiration, metabolic change, and psychological or physical stress. As few studies have examined HRV in end-stage renal disease (ESRD) patients in Korea, we investigated autonomic nervous system activity reflected in HRV in patients on peritoneal dialysis for ESRD. METHODS: We compared the pattern of cardiac sympathetic and parasympathetic activity through time-and frequency-domain analysis of HRV in 20 ESRD patients and 65 hypertensive control subjects using 24-hour Holter monitoring. The patients had been undergoing peritoneal dialysis at the Bongseng Hospital between January 2006 and December 2008. RESULTS: The mean age of the patients and controls was 53.8+/-13.1 and 55.1+/-13.7 years, respectively. In the patient group, all of the time- and frequency-domain HRV measures were reduced compared with the control group, including the HRV index, normalized unit of low-frequency (LF norm), and ratio of low-frequency power to high-frequency power (LF/HF), whereas the normalized unit of high frequency (HF norm) was increased. CONCLUSIONS: Autonomic tone in ESRD patients on peritoneal dialysis is decreased compared with patients with hypertension. The parasympathetic tone in ESRD patients on peritoneal dialysis dominates over the sympathetic tone.

A Case of Nephrotic Syndrome with Acute Renal Failure Induced by Tramadol HCl/Acetaminophen / 대한신장학회지

Analgesics are used commonly because of their beneficial effects on various disease processes and pain control, and so the population of patients who are at risk for adverse effects of these drugs is rapidly expanding. A number of renal problems have been associated with the use of these drugs, including electrolyte imbalance, acute renal failure, nephrotic syndrome, and interstitial nephritis. We experienced a 65-year-old female patient who developed general edema and oliguria for 4 days and diagnosed as focal segmental glomerulosclerosis with interstitial nephritis. She had taken tramadol HCl/acetaminophen (Ultracet(R)) for 15 days before admission. Renal biopsy revealed that focal tubular atropy, focal interstitial fibrosis and evidence of diffuse inflammatory cell infiltrations. Tramadol HCl/acetaminophen (Ultracet(R)) was discontinued on admission because of the likelihood the renal disease was drug-related and the patient improved after discontinuation of this drug without remained renal damage. This case suggests that Ultracet(R) must be an agent that causes nephrotic syndrome with acute renal failure. Therefore clinicians should use it with caution in high risk patients.

Prognosis of IgA Nephropathy with No Proteinuria on Routine Urinalysis / 대한신장학회지

PURPOSE: In patients with IgA nephropathy, more than 1 g/day of proteinuria is a risk factor to develop end-stage renal failure. Uncommonly, patients with IgA nephropathy exhibit negative proteinuria on routine dipstick test during follow-up examination, spontaneously or after use of ACEI or ARB. We evaluated whether no proteinuric patients have good prognosis or not. METHODS: 41 patients who had no proteinuria on routine urinalysis for more than 6 months, were classified into spontaneous remission group (25 cases, SR) without any treatment and drug-induced remission group (16 cases, DR) with treatment of ACEI/ARB or both, were analyzed for clinical findings and renal function, retrospectively. We examined spot urine protein/creatinine ratio (Up/c) to evaluate exact amount of proteinuria and GFR was estimated by MDRD equation. RESULTS: Twenty eight percent of cases in SR and 50 percent in DR showed spot Up/c 0.3-1 g/g. After follow-up of 58+/-41 (9-192) months in SR and 79+/-56 (35-192) months in DR, the stages of CKD shifted to advanced levels as follows; in SR group, 11, 10, 4 patients in stage 1 (GFR> or =90 ml/min/ 1.73m2), 2 (GFR 60-89 ml/min/1.73m2), 3 (GFR 30-59 ml/min/1.73m2) to 7, 13, 5 patients, respectively; in DR, 7, 8, 1 patients in stage 1, 2, 3 to 3, 8, 5 patients, respectively. There was a tendency of slow decreasing GFR in both groups but no case progressed to CKD stage 4 and 5. CONCLUSION: Of IgA nephropathy patients with no proteinuria on routine urinalysis, 30-50% of patients have proteinuria 0.3-1.0 g/g on spot Up/c and there was also a risk of progression.