Pericoronary fat attenuation index in computed tomography angiography is associated with mortality in end-stage renal disease

An increased pericoronary fat attenuation index (FAI) on computed tomography angiography (CTA) is associated with increased all-cause and cardiac mortality in the general population. However, the ability of pericoronary FAI to predict long-term outcomes in chronic kidney disease (CKD) patients is unknown. Methods: In this single-center retrospective longitudinal cohort study, we assessed the utility of CTA-based pericoronary FAI measurement to predict mortality of CKD patients, including those with end-stage renal disease (ESRD). Mapping and analysis of pericoronary FAI involved three major proximal coronary arteries. The prognostic value of pericoronary FAI for long-term mortality was assessed with multivariable Cox regression models. Results: Among 268 CKD participants who underwent coronary CTA, 209 participants with left anterior descending artery (LAD) FAI measurements were included. The pericoronary FAI measured at the LAD was not significantly associated with adjusted risk of allcause mortality (hazard ratio [HR], 2.08; 95% confidence interval [CI], 0.94–3.51) in any CKD group. However, ESRD patients with elevated pericoronary FAI values had a greater adjusted risk of all-cause mortality compared with the low-FAI group (HR, 2.26; 95% CI, 1.11–4.61). Conclusion: The pericoronary FAI measured at the LAD predicted long-term mortality in patients with ESRD, which could provide an opportunity for early primary intervention in ESRD patients.

Association between blood pressure and the risk of chronic kidney disease in treatment-naïve hypertensive patients

Although hypertension is a well-known risk factor for chronic kidney disease (CKD), the blood pressure (BP) at which antihypertensive interventions should be initiated remains to be determined. Therefore, we investigated the association between BP and CKD in treatment-naïve individuals. Methods: This prospective cohort study considered 7,343 individuals in the Korean Genome and Epidemiology Study who were not taking antihypertensive medications. Subjects were categorized into six groups according to their systolic BP (SBP) and five groups according to their diastolic BP (DBP). The primary outcome was incident CKD, which was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m2 or the development of proteinuria. The secondary outcome was incident cardiovascular disease (CVD). Results: In the time-varying Cox models, the hazard ratios (95% confidence interval [CI]) for CKD were 1.39 (1.10–1.77) with SBP 130–139 mmHg, 1.79 (1.40–2.28) with SBP 140–159 mmHg, and 3.22 (2.35–4.40) with SBP ≥ 160 mmHg, compared with SBP 100–119 mmHg. In addition, the hazard ratios (95% CI) for CKD were 1.88 (1.48–2.37) with DBP 90–99 mmHg and 4.30 (3.20– 5.76) with DBP ≥ 100 mmHg, compared with DBP 70–79 mmHg. A significantly increased CVD risk was also observed in subjects with SBP ≥ 130 mmHg or DBP ≥ 90 mmHg. Conclusion: Our findings indicate that SBP ≥ 130 mmHg and DBP ≥ 90 mmHg are associated with an increased risk of CKD. Therefore, BP-lowering strategies should be considered starting at those thresholds to prevent CKD development.

Metformin use and cardiovascular outcomes in patients with diabetes and chronic kidney disease: a nationwide cohort study

Background@#Metformin has recently been shown not to increase the risk of lactic acidosis in patients with chronic kidney disease (CKD). Thus, the criteria for metformin use in this population has expanded. However, the relationship between metformin use and clinical outcomes in CKD remains controversial. @*Methods@#This study considered data from 97,713 diabetes patients with an estimated glomerular filtration rate of <60 mL/min/1.73 m2. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), and the secondary outcomes were all-cause mortality and incident end-stage renal disease (ESRD). @*Results@#Metformin users had a significantly higher risk of MACCE than non-users (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.14–1.26; p < 0.001). However, metformin users had a lower risk of all-cause mortality (HR, 0.78; 95% CI, 0.74–0.81; p < 0.001) and ESRD (HR, 0.44; 95% CI, 0.42–0.47; p < 0.001) during follow-up than non-users did. The relationships between metformin use and clinical outcomes remained consistent in propensity score matching analyses and subgroup analyses of patients with adequate adherence to anti-diabetes medication. @*Conclusion@#Treatment with metformin was associated with an increased risk of MACCE in patients with diabetes and CKD. However, metformin users had a lower risk of all-cause mortality and ESRD during follow-up than non-users did. Therefore, metformin needs to be carefully used in patients with CKD.

Cytohesin-2 Is Upregulated in Malignant Melanoma and Contributes to Tumor Growth

No abstract available.

Cardiac arrest caused by nafamostat mesilate

A 65-year-old man was transferred from the Department of Vascular Surgery to Nephrology because of cardiac arrest during hemodialysis. He underwent incision and drainage for treatment of a buttock abscess. Nafamostat mesilate was used as an anticoagulant for hemodialysis to address bleeding from the incision and drainage site. Sudden cardiac arrest occurred after 15 minutes of dialysis. The patient was treated in the intensive care unit for 5 days. Continuous veno-venous hemodiafiltration was started without any anticoagulant in the intensive care unit. Conventional hemodialysis was reinitiated, and nafamostat mesilate was used again because of a small amount of continued bleeding. Ten minutes after hemodialysis, the patient complained of anaphylactic signs and symptoms such as dyspnea, hypotension, and facial swelling. Epinephrine, dexamethasone, and pheniramin were injected under the suspicion of anaphylactic shock, and the patient recovered. Total immunoglobulin E titer was high, and skin prick test revealed weak positivity for nafamostat mesilate. We first report a case of anaphylactic shock caused by nafamostat mesilate in Korea.

Clinical value of pathologic examination of non-neoplastic kidney in patients with upper urinary tract malignancies

BACKGROUND/AIMS: While surgical resection remains the standard of care in the treatment of upper urinary tract malignancies, nephrectomy is a risk factor for the development of chronic kidney disease (CKD). The aim of this study was to determine whether histologic evaluation of non-neoplastic kidney could enable early identification of unrecognized kidney disease and could be of prognostic value in predicting postoperative renal outcomes. METHODS: We retrospectively analyzed 51 patients with upper urinary tract malignancies who received uninephrectomy or uninephroureterectomy. A thorough pathologic evaluation of non-neoplastic kidney including special stains, immunofluorescence, and electron microscopic studies was performed. The degree of parenchymal changes was graded from 0 to 15. RESULTS: Of 51 patients, only 13 showed normal kidney pathology. Fifteen patients showed glomerular abnormalities, 14 showed diabetic nephropathy, and 11 showed vascular nephropathy. There was one case each of reflux nephropathy and chronic pyelonephritis. The median histologic score was 5 points. Only 25.4% of patients had ≤ 3 points. Score more than 5 was observed in 47.1% of patients. Postoperative estimated glomerular filtration rate (eGFR) at 3 to 36 months were obtained from 90.2% of patients, and of those, 34.8% had de novo CKD. Since no one had CKD in partial nephrectomized patients, we determined risk factors for CKD in radical nephrectomized patients. Cox regression analysis revealed that postoperative AKI, preoperative eGFR, and histologic score of non-neoplastic kidney were the independent predictors for CKD. CONCLUSIONS: We conclude that routine pathologic evaluation of non-neoplastic kidney provides valuable diagnostic and prognostic information.

Delayed Graft Function Is Associated with Microvascular Thrombosis in a Donor with Disseminated Intravascular Coagulation / 대한이식학회지

Microvascular thrombosis is an uncommon pathological finding in deceased donor kidneys. It is associated with disseminated intravascular coagulation (DIC) after brain injury in the donor. Although DIC in deceased kidney donors is known to have no association with graft outcome, microvascular thrombosis with DIC in a donor can cause renal graft impairment. For this reason, some transplantation centers do not accept these kidneys. A 39-year-old female donor had a subarachnoid hemorrhage. After a short period of cardiopulmonary resuscitation, we applied extracorporeal membrane oxygenation to maintain hemodynamic stability. The laboratory data were consistent with DIC. The recipient was a 38-year-old male patient who had been undergoing hemodialysis for 7 years because of end-stage renal disease of unknown cause. Zero-time graft biopsy revealed multiple intraluminal fibrin thrombi without peritubular capillaritis. Delayed graft function occurred after transplantation, and hemodialysis was started. Graft renal biopsy was performed on the third day after transplantation. The percentage of intraglomerular fibrin thrombi had decreased, and no significant peritubular capillaritis or C4d staining was observed. The function of the transplanted kidney started to recover, and hemodialysis was discontinued on the 10th day after surgery without specific treatment. Follow-up biopsy performed 20 days after the transplantation revealed normal kidney with completely resolved fibrin thrombi. We report herein a case of microvascular thrombosis in renal allograft from a DIC donor.

Relationship between duration of hospital-acquired acute kidney injury and mortality: a prospective observational study

BACKGROUND/AIMS: New definitions of acute kidney injury (AKI) have recently emerged. Some studies have suggested that duration of AKI is an additional predictive parameter for mortality. Here, we evaluated whether AKI duration was predictive of long-term mortality in patients with hospital-acquired acute kidney injury (HAAKI). METHODS: We prospectively enrolled patients who developed HAAKI at an urban university hospital, from September 2007 to August 2008 and followed them until December 2011. Patients were divided into two groups by duration of the AKI (1 to 5 days vs. > or = 6 days), and long-term mortality was compared. RESULTS: HAAKI developed in 1.2% of patients during the enrollment period. The median follow-up period was 240 days (interquartile range, 53 to 1,428). In 42.3% of patients (n = 52), the AKI lasted 1 to 5 days, while it lasted > or = 6 days in 57.7% (n = 71). Survival analysis showed that a longer duration of AKI increased the risk of death. Long-term survival was significantly different in the two groups. CONCLUSIONS: The duration of AKI influenced mortality rates in hospitalized patients. Thus, AKI duration is a parameter affecting mortality in HAAKI.

Treatment of Presumptive BK Nephropathy with Ciprofloxain in Kidney Transplant Recipients: Three Case Reports / 대한이식학회지

BK virus nephropathy has emerged as an important cause of renal allograft dysfunction. Reduction in immunosuppression is the mainstay of BK virus nephropathy treatment. However, decreasing immunosuppressive medications is not sufficient for treatment of BK virus nephropathy. Therefore, there is a need for other treatment strategies such as cidofovir, leflunomide, and intravenous immunoglobulin in combination with immunosuppression reduction. Ciprofloxacin has recently been reported to have antiviral activity and decrease BK viral load in kidney transplant recipients. These findings suggest that the use of ciprofloxacin represents a valuable treatment strategy in patients with BK virus nephropathy. Here, we report on our experience with three patients who developed presumptive BK virus nephropathy after kidney transplantation, who, after 2 months of ciprofloxacin treatment, showed disappearance of BK viremia and improvement in the estimated glomerular filtration rate. Ciprofloxacin may be considered an effective treatment option for BK viremia in kidney transplant recipients.

Treatment of Refractory Antibody-mediated Rejection with Bortezomib in a Kidney Transplant Recipient: A Case Report / 대한이식학회지

Antibody-mediated rejection (ABMR) is associated with poor renal allograft survival. It shows poor response to conventional treatment with plasmapheresis, rituximab, and intravenous immunoglobulin. Bortezomib, a proteasome inhibitor used for treatment of multiple myeloma, has recently been reported as a treatment alternative for recipient desensitization and ABMR. A 58-year-old man was diagnosed with mixed-type ABMR with donor specific antibodies and acute T cell-mediated rejection early after kidney transplantation. Conventional therapy was administered, including antithymocyte globulin, plasmapheresis, and rituximab; however, his condition was found to be refractory to these antihumoral therapies. Following administration of bortezomib, his serum creatinine level returned to baseline with stable graft function. His serum creatinine level remains stable at 1.3 mg/dL at 10 months posttransplantation. Bortezomib is effective for treatment of refractory ABMR following kidney transplantation.

Category Migration of Renal Cystic Masses with Use of Gadolinium-Enhanced Magnetic Resonance Imaging

The Bosniak renal cyst classification has been accepted by urologists and radiologists as a way of diagnosing cystic renal masses and determining the management approach. We report two cases of a renal cystic mass that showed a category change from category II on the basis of enhanced computed tomography to category IV after further gadolinium-enhanced magnetic resonance imaging. In both cases, the cysts were later confirmed as kidney cancer by pathology.

Validation of the Oxford Classification of IgA Nephropathy: A Single-Center Study in Korean Adults

BACKGROUND/AIMS: The recently published Oxford classification of IgA nephropathy (IgAN) proposed a split system for histological grading, based on prognostic pathological features. This new classification system must be validated in a variety of cohorts. We investigated whether these pathological features were applicable to an adult Korean population. METHODS: In total, 69 adult Korean patients with IgAN were analyzed using the Oxford classification system at Soonchunhyang University Hospital, Seoul, Korea. All cases were categorized according to Lee's classification. Renal biopsies from all patients were scored by a pathologist who was blinded to the clinical data for pathological variables. Inclusion criteria were age greater than 18 years and at least 36 months of follow-up. We excluded cases with secondary IgAN, diabetic nephropathy combined other glomerulopathies, less than 36 months of follow-up, and those that progressed rapidly. RESULTS: The median age of the patients was 34 years (range, 27 to 45). Mean arterial blood pressure was 97 +/- 10 mmHg at the time of biopsy. The median follow-up period was 85 months (range, 60 to 114). Kaplan-Meier analysis showed significant prognostic predictions for M, E, and T lesions. A Cox proportional hazard regression analysis also revealed prognostic predictions for E and T lesions. CONCLUSIONS: Using the Oxford classification in IgAN, E, and T lesions predicted renal outcome in Korean adults after taking clinical variables into account.

Significance of Peritoneal Protein Clearance in Peritoneal Dialysis Patients / 대한신장학회지

PURPOSE: It has been reported recently that peritoneal protein clearance (Pcl) is a marker of endothelial dysfunction and cardiovascular disease in peritoneal dialysis patients. We evaluated whether baseline or longitudinal follow-up Pcl is a factor to consider in predicting the outcome in peritoneal dialysis patients for the follow-up period. METHODS: Patients who initiated continuous ambulatory peritoneal dialysis at our center from September 1994 to January 2006 and had a baseline peritoneal equilibration test, measurement of dialysis adequacy, and 24-h dialysate Pcl (24hr dialysate protein loss/ [serum albumin/0.4783]) were included. Demography, comorbidities, and biochemical data were retrospectively collected. Follow-up was until death or the end of the period studied (November 2009). RESULTS: A total of 203 patients (56% men, mean age 55.0+/-12.5; 55.2% with diabetes; 22.2% with cardiovascular disease) were included. The mean follow up period was 38 months (3-170 months). Baseline Pcl was 128.2 ml/day. Follow up data of Pcl were not changed from baseline period. Cox's analysis revealed the predictors of mortality (and technical failure) were age and diabetes mellitus but not dialysate/plasma creatinine ratio (D/Pcr) and Pcl. On multivariate analysis, Pcl was negatively correlated with serum albumin and triglyceride and positively correlated with D/Pcr and peritoneal creatinine clearance. CONCLUSION: Our study showed that the changes in Pcl over time were not significant from baseline up to 53 months. Neither baseline nor mean Pcl during the follow-up period were independent predictors for technical or patient survival.

Two Cases of Respiratory Distress Syndrome Caused by Hospital-Acquired Pandemic Influenza (H1N1 2009) in Kidney Transplant Recipients / 감염과화학요법

Since pandemic influenza was declared by WHO at June 2009, severe pandemic influenza cases were reported among pregnant, obese, immunocompromised patients including transplant candidates and recipients were reported. Here we report two cases of pandemic influenza (H1N1 2009) with respiratory distress syndrome in adult patients with kidney transplantation. They were successfully treated with combination of antiviral therapy including high dose oseltamivir. Although clinical symptoms and signs were improved immediately when anti-viral therapy was started, radiologic finding resolved after several weeks.

Attitudes of Dialysis Unit Physicians with Regard to Withholding and Withdrawing Dialysis / 대한신장학회지

PURPOSE:In many countries, patients and dialysis unit physicians attempt to address issues regarding withholding and withdrawing dialysis through advance directives and clinical guidelines for dialysis utilization. However, there are only a few reports of withholding and withdrawing dialysis in Korea. This study was developed to investigate the attitudes of dialysis unit physicians regarding withholding and withdrawing dialysis in Korea. METHODS:A questionnaire survey was conducted among 45 dialysis unit physicians from January, 2006 to January, 2008. Physicians were asked about their decision making process to withhold and withdraw dialysis, and their opinions regarding the necessities of advance directives and guidelines for withholding and withdrawing dialysis. RESULTS:Analysis of surveys revealed that physicians agreed more about whether to withhold and withdraw dialysis in vegetative patients compared to patients with dementia ( p<0.001, p<0.001). There were more agreements about whether to withhold dialysis than whether to withdraw dialysis in patients with unimpaired cognition ( p<0.037). However, there were no differences in agreements between withholding and withdrawing dialysis in patients with severe neurological impairments. There appeared to be a general consensus regarding the need for guidelines addressing withholding and withdrawing dialysis (84.4%). However, opinions supporting the necessity for advance directives were not strongly favored (33.3%). CONCLUSION:Conflicting opinions are present among dialysis unit physicians regarding whether to withhold and withdraw dialysis according to a patient's neurological impairments. However, most dialysis unit physicians were of one accord regarding the need of guidelines for withholding and withdrawing dialysis.

Attitudes of Dialysis Unit Physicians with Regard to Withholding and Withdrawing Dialysis / 대한신장학회지

PURPOSE:In many countries, patients and dialysis unit physicians attempt to address issues regarding withholding and withdrawing dialysis through advance directives and clinical guidelines for dialysis utilization. However, there are only a few reports of withholding and withdrawing dialysis in Korea. This study was developed to investigate the attitudes of dialysis unit physicians regarding withholding and withdrawing dialysis in Korea. METHODS:A questionnaire survey was conducted among 45 dialysis unit physicians from January, 2006 to January, 2008. Physicians were asked about their decision making process to withhold and withdraw dialysis, and their opinions regarding the necessities of advance directives and guidelines for withholding and withdrawing dialysis. RESULTS:Analysis of surveys revealed that physicians agreed more about whether to withhold and withdraw dialysis in vegetative patients compared to patients with dementia ( p<0.001, p<0.001). There were more agreements about whether to withhold dialysis than whether to withdraw dialysis in patients with unimpaired cognition ( p<0.037). However, there were no differences in agreements between withholding and withdrawing dialysis in patients with severe neurological impairments. There appeared to be a general consensus regarding the need for guidelines addressing withholding and withdrawing dialysis (84.4%). However, opinions supporting the necessity for advance directives were not strongly favored (33.3%). CONCLUSION:Conflicting opinions are present among dialysis unit physicians regarding whether to withhold and withdraw dialysis according to a patient's neurological impairments. However, most dialysis unit physicians were of one accord regarding the need of guidelines for withholding and withdrawing dialysis.

Infective Endocarditis due to Ochrobactrum anthropi in a Hemodialysis Patient: A Case Report / 대한신장학회지

Ochrobactrum anthropi is an aerobic, gram-negative, motile, non-lactose-fermenting, oxidase-producing, and urease-positive bacillus. We reported a case of aortic valve endocarditis due to O. anthropi in a hemodialysis patient. To our knowledge, this is the first case of O. anthropi endocarditis in a hemodialysis patient in Korea. The organism was resistant to beta-lactam antibiotics and susceptible to ciprofloxacin, amikacin, trimethoprim-sulfamethoxazole, gentamicin and carbapenem. We treated O. anthropi endocarditis with meropenem for 6 weeks and the patient recovered completely.

A Case of Zosteriform Kaposi's Sarcoma after Prednisolon Treatment / 대한피부과학회지

Kaposi's sarcoma is a rare lympho-angioproliferative neoplasm with four types of variants: classic, iatrogenic immunosuppressive drug-associated, AIDS-related and Africa-endemic Kaposi's sarcoma. Most immunosuppressive drug- associated Kaposi's sarcomas usually occur after a kidney transplant or after receiving immunosuppressive therapy. A 64-year-old female patient showed numerous purpuric nodules and smaller erythematous plaques on the right lower leg for three months. Previously, the patient was treated with an immunosuppressive drug for rapidly progressive glomerulonephritis for a five-week period. A skin biopsy was performed under the clinical diagnosis of Kaposi's sarcoma. We performed immunohistochemical staining and polymerase chain reaction to detect human herpes virus 8 (HHV-8). We report a case of iatrogenic immunosuppressive drug-associated zosteriform Kaposi's sarcoma that rapidly occurred five weeks after prednisolon therapy in a rapidly progressive glomerulonephritis patient.

A Case of Lactic Acidosis Associated with Prolonged Linezolid Therapy / 대한신장학회지

Lactic acidosis is the most common cause of metabolic acidosis in hospitalized patients. Although impaired tissue oxygenation is usually responsible for the rise in lactate production, lactic acidosis could be caused by drugs including metformin and the nucleoside reverse-transcriptase inhibitors. Linezolid, an oxazolidinone antibiotic, is currently indicated to treat serious infections caused by vancomycin-resistant enterococcus and other gram-positive organisms. A 74-year old woman was found to have pyogenic vertebral osteomyelitis and treated with linezolid. Thirty-one days after linezolid therapy, she developed severe lactic acidosis. We report a case of lactic acidosis associated with prolonged linezolid therapy.

Normal Kidney Volume and Length in Korean Adults as Measured by Multidetector-row Computerized Tomography Imaging / 대한신장학회지

PURPOSE: Kidney length and volume are important parameters in the diagnosis of kidney disease. There has been no study for kidney volume in Korea. Therefore, we investigated the normal kidney volume and length using multidetector-row computerized tomography (MDCT). METHODS: One hundred and twenty-three Koreans were scanned for various medical reasons by MDCT. We measured kidney volume with three dimensional reconstruction programs. In the coronal section, we measured the craniocaudal length of both kidneys. Cross sectional kidney size was defined the sum of both sides of the rectangle enclosing the kidney at the level of the renal (hilum) vessel. Patients were excluded when they have the estimated GFR, calculated by modification of diet in renal disease, less than 90 ml/min/1.73m2, diabetes, any urinary abnormalities, renal anatomical abnormality, renal artery disease, more than three cysts and larger than 3 cm of cyst. RESULTS: Kidney volumes were 177+/-34 mL for men and 146+/-28 mL for women. There were no volume differences among age groups. Kidney lengths were 10.5+/-0.9 cm for left and 10.0+/-0.8 cm for right. The cross sectional kidney size was 10.8+/-1.1 cm for left and 10.7+/-1.0 cm for right. There was a high correlation between the kidney volumes and the cross sectional sizes (r=0.80). CONCLUSION: We suggest the reference values for kidney volume and length using MDCT. Measurement of kidney volumes may be more helpful to determine diagnosis and treatment of chronic kidney disease as compared with that of simple measuring kidney length.