Clinical Manifestations and Prognostic Factors of IgA Nephropathy with Long-Term Follow-Up / 대한내과학회지

BACKGROUND/AIMS: Immunoglobulin A nephropathy (IgAN) is the most common type of primary glomerulonephritis worldwide. Although several studies have identified IgAN prognostic factors in Korea, the follow-up period was insufficient to evaluate the natural history of IgAN. METHODS: A total of 471 patients were diagnosed with IgAN after percutaneous renal biopsy between April 1985 and March 2003. Patients with secondary IgAN and patients with a follow-up 1.3 mg/dL, estimated glomerular filtration rate or = 1 g/day, and severe renal pathology by the Haas sub-classification were significantly associated with ESRD. When these factors were included in multivariate Cox regression analyses, only severe renal pathology by the Haas sub-classification was an independent prognostic factor for IgAN. CONCLUSIONS: Careful follow-up and treatment is recommended, particularly in patients with IgAN and severe renal pathology by the Haas sub-classification.

A Case of Complete Recovery from Late Insidious Type of Acute Phosphate Nephropathy / 대한내과학회지

The widespread use of colonoscopy for early detection of colorectal pathology has increased the use of osmotic laxatives for colonic cleansing. Among these, oral sodium phosphate preparations can cause renal insufficiency through the development of acute phosphate nephropathy. Acute phosphate nephropathy can be distinguished as early symptomatic and late insidious patterns. Patients whose presentation is insidious are easily overlooked and can progress to chronic kidney disease. We report a case of complete recovery from the late insidious type of acute phosphate nephropathy.

A Brain Tumor from a Posttransplant Lymphoproliferative Disorder in a Kidney Transplant Recipient / 대한이식학회지

Posttransplant lymphoproliferative disorder (PTLD) is a life-threatening complication from organ transplantation. PTLD usually manifests as a mass in the lymph node or an extranodal mass in solid organs, such as the liver, transplanted kidney, tonsil, bone marrow, or spleen. PTLD rarely involves the central nervous system (CNS); however, here we report a case of PTLD that manifested as a brain tumor after kidney transplantation. A 52-year-old man who started peritoneal dialysis due to autosomal dominant polycystic kidney disease, underwent kidney transplantation 4 years ago. After kidney transplantation, he took tacrolimus, mycophenolate mofetil, and steroids. He was admitted to our hospital, complaining of a severe headache. Brain magnetic resonance imaging showed a multifocal, irregular, and round enhancing mass in the left basal ganglia. He underwent a needle biopsy for the enhancing mass and the pathological diagnosis was diffuse large B cell lymphoma. After this mass was confirmed as PTLD by histologic diagnosis, the patient had a reduction in his immunosuppression regimen (including a change from tacrolimus to sirolimus) and was treated with chemotherapy for PTLD. After 20 days, the patient expired from sepsis. PTLD involving the CNS is a rare and serious complication associated with solid organ transplantation. PTLD should be included in the differential diagnosis of brain tumors in recipients of solid organ transplants.

Two Cases of Anti-Glomerular Basement Membrane Antibody Disease Associated with Perinuclear-Anti-Neutrophil Cytoplasmic Antibody / 대한내과학회지

Anti-glomerular basement membrane antibody (anti-GBM Ab) disease is characterized by circulating antibodies to the glomerular basement membrane and the deposition of IgG or, rarely, IgA along the glomerular basement membrane. This disease accounts for 10-20% of crescentic glomerulonephritis. We report two patients with anti-GBM Ab disease who were positive for perinuclear-anti-neutrophil cytoplasmic antibody (p-ANCA). Percutaneous renal biopsies showed many crescent formations and linear deposits of IgG along the glomerular basement membrane. Serologic tests for p-ANCA were positive. They were treated with steroid pulse and cyclophosphamide and one patient also underwent plasma exchange therapy. Despite immunosuppressive therapy, their renal functions did not improve and both required regular hemodialysis.

Successful Renal Transplantation in Patients with Polycystic Kidneys after Renal Contraction by Renal Artery Embolization: Report on 2 Cases / 대한이식학회지

Autosomal polycystic kidney disease is responsible for about 10% of the cases of end stage renal disease. The increase in kidney size is usually proportional to the degree of deterioration in renal function. At the time of transplantation, these nonfunctional kidneys can be massively enlarged and nephrectomy is required before renal transplantation. However, pretransplantation nephrectomy of polycystic kidneys has the potential risk of surgical complications, including ileus, hernias, infection, excessive bleeding and/or intestinal injury. We report here on two cases successful renal transplantation in patients with polycystic kidneys after renal contraction by renal artery embolization and without nephrectomy. The volume reduction was evaluated by CT before and 3 months after renal artery embolization and the reduction in volume was 48% and 44% in each case, respectively. The embolization was well tolerated in both cases without immediate or delayed complications except for fever and lumbar flank pain. Four months after renal artery embolization, both of the patients successfully received a transplant from living donors.

Hospitalization in Peritoneal Dialysis Patients / 대한신장학회지

PURPOSE: Hospitalization as a measure of morbidity in peritoneal dialysis (PD) patients is mainly related to peritonitis. And the hospitalization rate is expected to decrease as the peritonitis rate has decreased substantially with development of connectology. Yet there is no internal study on hospitalization. We evaluated hospitalization rates, causes and duration of admission of PD patients, and their prognosis. METHODS: We retrospectively reviewed the medical records of 414 patients who started and followed up at least three months at the Keimyung University Dongsan Hospital from January 2003 to December 2008. RESULTS: There were 1,036 admissions in 328 patients during a mean follow-up of 29.9 months. The admission rate was 1.0 per patients-year and hospital days were 17.1 per patients-year. The number of patients admitted once was 102 (31.1%), and more than 5 was 71 (21.7%). The most common cause of hospital admission was peritonitis (36.5%), followed by volume imbalance (13.8%), gastrointestinal disease (6.9%), other infection (6.2%), neurologic disease (5.5%), surgery (5.4%) and cardiac disease (4.3%). Catheter-related problems, including catheter related infection (1.8%) and catheter dysfunction (1.4%) were uncommon. Duration of admission was longest in neurologic disease (18.0+/-19.0) and shortest in catheter-related problems (9.3+/-3). Duration of admission of peritonitis (16.1+/-8.0) was similar to mean duration. Hospitalization was significantly greater in patients with prior history of peritonitis (p<0.000), and longer duration on PD (p<0.000). There were no significant differences in one and five year patient and catheter survival between hospitalized and non-hospitalized PD patients. CONCLUSION: Peritonitis remains a major cause of hospitalization in PD patients. To decrease admissions of PD patients, patient education and attention needs to be focused on preventing peritonitis. Also we should pay more attention to prevent multiple admissions due to recurrent peritonitis.

Crude Incidence Rate of Malignancy after Kidney Transplantation / 대한이식학회지

BACKGROUND: The incidence pattern of malignancy after kidney transplantation is different from that of the general population. Because increased exposure to immunosuppressants results in an increased incidence of malignancy, institutional reports that do not consider duration of immunosuppression have limited value for providing future kidney recipients with the actual risk for malignancy or for developing a kidney allograft recipient surveillance program. Thus, we retrospectively analyzed our institutional data with regard to the duration of exposure to immunosuppressants. METHODS: A total of 757 patients who had kidney transplantation and were followed-up for at least 6 months at our hospital were reviewed retrospectively. The crude incidence rate (CI) was calculated by counting the days of exposure to immunosuppressants. RESULTS: Most malignancies after kidney transplantation were solid tumors (85.3%). The CI of malignancies was 641.1 in allograft recipients and 329.6 in the general population per 100,000 persons per year. Solid tumor cancers of the stomach, liver, lung, breast, cervix, and pancreas showed an increased CI in the allograft recipient group than the general population but cancers of the thyroid and colon did not. Based on the type of immunosuppressive agent, the CI was highest in the cyclosporine group (866/12 months/100,000 persons) than the other groups. CONCLUSIONS: We have provided the CIs of cancers after kidney transplantation at our institute. The pattern of post-transplant malignancy is different from that of western countries. Nationwide registration is needed to provide a more rational approach to post-transplant cancer surveillance in Korea.

The Risk Factors and Outcome of Acute Kidney Injury in the Intensive Care Units

BACKGROUND/AIMS: Acute kidney injury (AKI) is a common and serious complication in critically ill patients, especially in the intensive care unit (ICU). The present study was performed to evaluate the occurrence rate of AKI using the RIFLE (increasing severity classes risk, injury, and failure, and the two outcome classes loss and end-stage kidney disease) classification, to define factors associated with AKI and hospital mortality. METHODS: We performed a retrospective study of all ICU patients over a 6-month period at Keimyung University Dongsan Hospital, Daegu, Korea. AKI was evaluated according to the RIFLE classification. RESULTS: AKI occurred in 156 of the 378 patients (41.3%) during their ICU stay, with maximum RIFLE-R, I, and F in 13.8%, 12.4%, and 15.1%, respectively. In univariate analysis, the proportion of medical admission and maximum Sequential Organ Failure Assessment (SOFA) score (SOFAmax) were significantly higher in patients with AKI than in those without. However, these factors did not remain significant in a multivariate analysis. The overall mortality rate of ICU patients was 25.7%. In multivariate analysis, mean age, occurrence of AKI, SOFAmax score, pulmonary disease, and malignancy were independent risk factors for hospital mortality. CONCLUSIONS: In these ICU patients, AKI is associated with increased hospital mortality. The RIFLE classification is a simple and useful clinical tool to detect and stratify the severity of AKI, and may aid in the prediction of outcome.

Intracardiac Migration of a Renal Stent from the Left Renal Vein to the Right Ventricle during the Treatment of Nutcracker Syndrome: A case report / 대한흉부외과학회지

We report her on a rare case of a renal stent that migrated into the right ventricle in a patient with nutcracker syndrome. A 29-year-old woman was admitted to the hospital and she was suffering from flank pain. The computed tomography of the abdomen demonstrated that the left renal vein was compressed between the abdominal aorta and the superior mesenteric artery (nutcracker syndrome). A self expandable stent was placed across the left renal vein for treating her nutcracker syndrome. The next day after the procedure, the follow up chest radiograph showed that the displaced stent had migrated into the right ventricle. After percutanous endovascular stent removal had failed, the stent was ultimately removed by performing cardiac surgery. At the 6th postoperative month, there have been no abdominal or cardiac symptoms.

Treatment of Lupus Nephritis: A 21 Year, Single Center Experience / 대한신장학회지

PURPOSE:Renal disease is the major cause of mortality and morbidity in systemic lupus erythematosus. The aim of this study was to examine the therapeutic outcome of patients with lupus nephritis (LN) for 21 years. METHODS:We conducted a retrospective study of 100 patients with biopsy proven LN who were admitted at Keimyung University Dongsan Hospital between 1985 and 2006, and were followed with a mean of 73 months. We diagnosed renal pathology according to WHO 1995 classification, and analyzed the therapeutic and long-term outcome of patients with LN treated with steroid alone or steroid with intravenous cyclophosphamide (CYC). RESULTS:The mean age at the time of renal biopsy was 28. 3 years and male to female ratio was 1:9.9. The initial therapy consisted of steroid alone in 69 patients and steroid with intravenous CYC in 31 patients. The proportion of diffuse proliferative LN and titer of anti ds-DNA were significantly higher in patients treated with steroid and CYC than in patients with steroid alone. The percentage of patients with clinical response was significantly higher in patients with steroid and CYC than in patients with steroid alone (p=0.018). The patients who experienced clinical response had an excellent long term outcome compared with those who had no clinical response. CONCLUSION:The clinical response was significantly higher in CYC combination regimen than steroid alone. The response to therapy in LN was an important factor for long-term prognosis. The early diagnosis and aggressive treatment with immunosupppressive agents are valuable for better outcome in patient with LN.

Continuous Renal Replacement Therapy (CRRT) in Intensive Care Unit (ICU) Patients with Acute Renal Failure / 대한신장학회지

PURPOSE: The mortality rate in critically ill patients with acute renal failure (ARF) remains unacceptably high, despite numerous advances in dialysis techniques and intensive care medicine. We evaluated clinical characteristics and prognostic factors in ICU patients with ARF requiring continuous renal replacement therapy (CRRT). METHODS: We retrospectively reviewed the medical records of all ICU patients who received CRRT at the Keimyung University Dongsan Hospital from September 2002 to October 2007. RESULTS: Total number of patients who required CRRT in ICU was 58. The mean age was 58.3+/-14.8 years. The treatment duration of CRRT was 63.5+/-40.7 hours. The mechanical ventilation rate was 82.8%, vasoactive drug 79.3%, sepsis 39.7%. APACHE II score was 25.2+/-7.9, SAPS II score 48.1+/-15.1, CCF score 9.3+/-3.6, the number of organ dysfunction 2.1+/-1.3. Overall mortality rate was 48%. When we compared sepsis group with non-sepsis group, the number of organ dysfunction and severity of illness were significantly higher in sepsis group than that of non-sepsis group. A mortality rate of sepsis group was significantly higher than non-sepsis group (82.6% vs 31.3%, p<0.001). In univariate analysis, significant risk factors for mortality were the number of organ dysfunction, severity of illness, MAP, platelet count, serum albumin level, and a type of hemofilter. Significances of all these factors were lost in multiple linear regression analysis. CONCLUSION: A large scaled, prospective randomized multi-center trials are needed to confirm the beneficial effect of CRRT in patient with ARF in ICU.

An Analysis of 3,000 Cases of Percutaneous Renal Biopsy: Single Center Study / 대한신장학회지

PURPOSE: The incidence of glomerular diseases varies according to population characteristics and time period. METHODS: A total of 3,000 renal biopsies were performed over the 29 years' period from 1978 to 2007. We reviewed the patient records of all patients who underwent renal biopsies at our institution. The patients were grouped for analysis in three time intervals: before 1990, 1991 to 2000, and after 2001. RESULTS: There were 2,377 cases of native kidney biopsies and 623 cases of allograft kidneys. The principal long-term changes were an increase in the mean age of patients with undergoing biopsy and an increase in the percentage of asymptomatic urinary abnormalities as an indication for biopsy. In the primary glomerulonephritis (GN), the most common pathologic diagnosis was IgA nephropathy (IgAN, 26.6%), followed by minimal change disease (MCD, 21.4%), membranous nephropathy (8.9%), focal segmental glomerulosclerosis (7.7%). The major changes noted in primary GN were a marked increase in the frequency of IgAN and decrease in the frequency of MCD. Major causes of secondary GN were lupus nephritis (37.9%), and hepatitis associated GN (28.9%). In allograft biopsies, acute rejection (42.3%) and chronic rejection (19.4%) were the two most common diagnoses. Documented complications of renal biopsies included perirenal hematoma (25.1%), but the rate of serious complications that required surgical intervention or embolization was very low (1.0%). There was no death or nephrectomy case in our study. CONCLUSION: IgAN was the most common primary GN in this study. The multi-center studies are needed to evaluate the distribution and changing trends of renal disease in Korea.

Factors Affecting the Result of Kidney Retransplantation / 대한이식학회지

BACKGROUND: As the result of renal transplantation improving, also increasing the number of graft failure which will be a candidate for second renal transplantation. The purpose of this study is to evaluate the factors that influence the survival of retransplanted kidney. METHODS: Among 775 renal transplantations that have been performed in Dongsan Medical Center until August 2007, 225 cases were failed their graft function and 59 of them were retransplanted during their follow up period. Graft survival of retransplanted kidney was compared with primary renal transplantation and factors that affecting the survival of kidney retransplantation were evaluated. RESULTS: Main causes of graft failure of first kidney transplantation were chronic rejection, followed by recurrence of original disease of recipient and acute vascular rejection. Mean survival time was 72.6 months (15 days~161 months). One and 5 years graft survivals were 94.6%, 90.7%, and patient survivals were 100.0%, 97.8%, respectively. Among the factors which showed significance in univariate analysis, short interval between failure of first transplantation and retransplantation, and graft failure due to chronic rejection were statistically significant unfavorable factors for survival of retransplanted kidney. CONCLUSIONS: Kidney retransplantation showed similar graft and patient survival compare to the first one. However, retransplantation should be performed after enough time after graft failure and should be cautious in a patient who lost their graft due to chronic rejection.

A Case of Emphysematous Pyelitis in a Renal Transplant Recipient / 대한이식학회지

Emphysematous pyelitis (EP) is a rare complication of urinary tract infection, which has been defined as isolated gas production inside the excretory system. Contrary to emphysematous pyelonephritis, which is more severe, necrotizing infection of the renal parenchyma, EP is a benign entity. To our knowledge, it has not been reported in the Korean literature, particularly in renal transplant recipients. Herein we report a case of EP in a living renal transplant recipient. A 32-year-old man received a living related renal transplant 4 years earlier for end-stage renal disease secondary to chronic glomerulonephritis. The patient presented with a sudden onset of chills, nausea, vomiting and pain on graft area. He was diagnosed as EP by computerized tomography. Immunosuppressive agents were modified and he was successfully treated with parenteral antibiotics with complete disappearance of air in the renal pelvis.

Change of Parathyroid Hormone and Markers of Bone Metabolism after Renal Transplantation / 대한신장학회지

PURPOSE: The aims of this retrospective study were to evaluate the sequential changes of parathyroid hormone (iPTH) and calcium metabolism after renal transplantation (RTP) and to identify risk factors for hypertension (HPT). METHODS: Biochemical bone parameters were reviewed in 264 patients at pre-transplant, 6, 12, 36 and 60 months after RTP. RESULTS: iPTH levels fell significantly during the first six months after RTP and remained substantially stable thereafter. The mean total serum calcium level showed significant increase during the first six months and progressive and significant decline after the first year. The mean serum phosphorus level returned to the normal range during the first six months and remained normal thereafter. The serum alkaline phosphatase (ALP) level increased during the first year and gradually decreased after then. The prevalence of persistent HPT was 17.8%. Patients with persistent HPT had significantly elevated serum levels of iPTH at the time of RTP and had spent a longer time on dialysis. Significant positive correlations were observed between the serum iPTH levels on the one hand and the pre-transplant iPTH, serum ALP, and creatinine levels on the other hand. CONCLUSION: The prevalence of persistent HPT after RTP is not uncommon. The patients with long duration of dialysis showing high serum level of iPTH at the time of transplantation are at risk for persistent HPT.

Clinicopathologic Study on Adults Idiopathic Nephrotic Syndrome in Korea / 대한신장학회잡지

PURPOSE: We examined the clinical characteristics and incidence of adults idiopathic nephrotic syndrome (NS) according to pathologic diagnosis, age, sex. METHODS: We retrospectively reviewed the clinical and pathological characteristics of primary glomerular lesions in adults idiopathic NS taken a renal biopsy from 1978 to 2005 at the Dongsan Medical Center. We compared the prevalence of adults idiopathic NS according to the pathologic diagnosis between two time intervals 1978 to 1990 and 1991 to 2005. RESULTS: The patients had mean age of 36.7+/-16.3 years and male to female ratio was 1.7:1 with male predominance. The frequency of histopathologic diagnoses were minimal change nephrotic syndrome (MCNS) 51.6%, membranous glomerulonephritis (MGN) 21.3%, focal segmental glomerulosclerosis (FSGS) 12.1%, IgA nephropathy 9.1%, membranoproliferative glomerulonephritis (MPGN) 4.2% in decreasing order of frequency. The mean age was youngest in MCNS (32.9+/-15.1) and oldest in MGN (46.2+/-16.6). Between 1978 to 1990 period and 1991 to 2005 period, the prevalence of MGN was significantly increased, whereas the prevalence of MPGN was decreased significantly. The prevalence of MCNS had a tendency to decrease and that of IgA nephropathy had a tendency to increase, however, both didn't reach statistical significance. The incidence of FSGS didn't show a significant change during the both study periods. CONCLUSION: MCNS was the most common disease among adults idiopathic NS. MGN was the most frequent etiology in patients older than 45 years. The incidence of MGN was increased over the 28-year period, and that of MPGN decreased significantly. There was no change in the frequency of FSGS.

Peritonitis by Chryseobacterium indologenes and Sphingomonas paucimobilis in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD) / 대한신장학회지

Bacterial peritonitis is a well-recognized complication of continuous ambulatory peritoneal dialysis (CAPD) in patients with end-stage renal failure. Chryseobacterium indologenes is a non-fermentative Gram-negative bacillus that is a rare pathogen in humans and Sphinomomas paucimobilis has rarely been reported as an opportunistic human pathogen. We present a case of peritonitis due to unusual pathogens, C. indologenes and S. paucimobilis, unresponsive to the standard antibiotics therapy. A 51-year-old diabetic man undergoing CAPD for 45 days developed the first peritonitis due to C. indolegenes. Although he had received intraperitoneal antibiotics with good in vitro activity against organism, the signs of peritonitis persisted. S. paucimobilis was isolated from dialysate sample. The Tenckhoff catheter was finally removed on 19th day of hospitalization and the fever and abdominal pain subsided.

A Case of Posttransplant Lymphoproliferative Disorder in the Duodenum after Kidney Transplantation / 대한신장학회지

Posttransplant lymphoproliferative disorder (PTLD) is an uncommon but life-threatening complication of immunosuppressive therapy following solid organ transplantation. It encompasses a heterogeneous group of lymphoproliferative disorders ranging from reactive, polyclonal hyperplasia to aggressive non- Hodgkin's lymphoma. The majority of PTLD is of B-cell origin and associated with Epstein-Barr virus (EBV) infection. Gastrointestinal involvement, especially small bowel and colon, is common in patients with PTLD, but the duodenum is rarely involved. We have experienced a case of PTLD involving the duodenum eight years after kidney transplantation in 50-year-old man. Two weeks before admission, he had complained of epigastric pain, and was diagnosed as pangastritis and duodenal ulcer by upper gastrointestinal endoscopy. He was admitted due to aggravated epigastric pain despite anti-ulcer medication. On the seventh hospital day, we found a new mass-like lesion in the pyloric area of antrum and diffuse ulceration in the duodenum by follow-up endoscopy. Histologic findings revealed diffuse large B-cell lymphoma. During reduction in immunosuppressive regimens, his conditions deteriorated rapidly. He died of sepsis associated with duodenal ulcer perforation, 18 days after diagnosis.

Successful Treatment of Severe Lactic Acidosis by Continuous Venovenous Hemodiafiltration / 대한신장학회잡지

Lactic acidosis is often associated with a strikingly high mortality. The effective therapy involves treatment of the underlying cause and correction of acidemia by infusion of sodium bicarbonate. When lactic acidosis is accompanied by oliguric renal failure, bicarbonate therapy becomes more complex with volume overload and hypernatremia. Hemodialysis against a bicarbonate-buffered dialysate will achieve this. However, it is generally tolerated poorly by hemodynamically unstable patients. We report here three hemodynamically unstable patients with severe lactic acidosis, which was treated successfully by the use of continuous venovenous hemodiafiltration with bicarbonate based dialysate and replacement solution. We would suggest that continuous renal replacement with bicarbonate buffer should be indicated in the treatment of severe lactic acidosis.

Paired Hemodiafiltration: Single Center Experience / 대한신장학회잡지

BACKGOUND: On-line hemodiafiltration (HDF) is a technique that relies on the re-injection of pyrogen-free substitution fluid obtained by cold filtration of dialysate. Therefore, safety of this therapy depends on the quality of dialysate and, mainly, on the integrity of the ultrafilters employed. Paired hemodiafiltration (PHF) is a new technique where re-infusion takes place inside the dialyzer by means of dialysate backfiltration. METHODS: To assess safety and feasibility, we carried out prospective cross-over trial comparing PHF with hemodialysis (HD) in five stable HD patients RESULTS: All PHF sessions were well tolerated. No pyrogenic reactions were observed during the study period. No significant difference was found in the incidence of intradialytic hypotension. PHF led to significantly higher small and middle molecule clearance than HD. The reduction rates of urea, creatinine and beta2-M were significantly higher in PHF than in HD, while no difference was found for phosphate. The serum beta2-M levels fell progressively from the HD value of 29 mg/L to 17 mg/L at the end of 3 months's PHF treatment. CONCLUSION: In conclusion, PHF is a feasible and safe convective therapy to increase beta2-M removal compared with HD. Long-term, prospective multicenter clinical studies are mandatory to assess the clinical outcome of this new on-line technique of HDF.