신장이식

김찬덕 ( Chan Duck Kim ) 대한내과학회 2014 대한내과학회지 Vol.86 No.2

Kidney transplantation is the treatment of choice for end stage renal disease. Successful kidney transplantation improves the quality of life and reduces the mortality risk for most patients, when compared with maintenance dialysis. Recent advances, including immunosuppressants, desensitization treatment for highly sensitized kidney transplant candidates, and better medical care, have resulted in an increase number of transplants with improved outcomes. However, kidney transplant recipients require close follow-up after transplantation since they are on complex immunosuppressive regimens that render them susceptible to infection, malignancy, and cardiovascular disease. The additional obstacles of kidney transplantation include the lack of improvement in long term outcomes, shortage of organs, and multiple co-morbidities due to their underlying chronic kidney disease. To improve the long-term outcome of renal allograft, physicians must be aware in developing newer immunosuppressive regimens, with lower side effects, and reduction of death with functioning graft and chronic allograft dysfunction will be the greatest challenge of all physicians who care for kidney transplant recipients. This review highlights current status of kidney transplantation in Korea, brief transplant immunology, immunologic tests, donor/recipient evaluation, immunosuppressive medications, and complications of kidney transplantation involving rejection, post transplantation infections, malignancy, cardiovascular disease and recurrence of primary disease. (Korean J Med 2014;86:142-151)

이식 : 신이식 수혜자의 G-137C IL-18 유전자 다형성이 급성거부반응에 미치는 영향

김찬덕 ( Chan Duck Kim ),류혜명 ( Hye Myung Ryu ),최지영 ( Ji Young Choi ),최희정 ( Hee Jeong Choi ),최혁준 ( Hyuk Joon Choi ),조지형 ( Ji Hyung Cho ),박선희 ( Sun Hee Park ),김용림 ( Yong Lim Kim ) 대한신장학회 2008 춘계학술대회 초록집 Vol.28 No.1

컴퓨터화 된 요소 역동학 모델 ( Urea Kinetic Modeling ) 을 이용한 지속성 외래 복막투석 환자의 투석용량에 따른 투석적절도 연구

김용림(Yong Lim Kim),김준철(Jun Chul Kim),김찬덕(Chan Duck Kim),김준홍(Jun Hong Kim),조동규(Dong Kyu Cho) 대한내과학회 1999 대한내과학회지 Vol.57 No.3

N/A The DOQI guidelines recommend that the delivered PD dose should be a total weekly Kt/Vurea and Ccr values of at least 2.0 and 60 L/week/1.73 m2 for CAPD patients. To achieve these recommended guidelines, the standard regime of four 2-L daily exchanges may not be sufficient even for Oriental patients whose body size are relatively smaller than those of Westerners. However, the option of a two-and-a-half liter bag (2.5L) and a simple automated overnight exchange device for a fifth exchange are not available in some countries. In order to evaluate the percentage of CAPD patients who receive dialysis meeting DOQI guidelines in different dialysis prescriptions, 110 Korean patients, treated for over a 3 month on CAPD, with a mean age of 46.912.6 years and dialysis duration of 37.6±28.1 months (range 3-116), were studied. Methods : Baseline urea kinetic data from a 24-hour dialysate collection was obtained and analyzed using the computerized urea kinetic model of peritoneal urea transport (PACK-PD, vers 1.01, Fresenius). The potential Kt/Vurea and Ccr values using four 2L and 2.5L daily exchanges were calculated with the PC program. Results : The mean weekly Kt/Vurea and Ccr values were 2.01±0.67 and 66.4±29.6 L/week/1.73 m2 respectively, with a median body surface area (BSA) of 1.61 m2 (75th percentile 1.73 m2). The mean 24 hour dialysate-to-plasma creatinine ratio was 0.75±0.16. Fourty-five of the 110 patients (41%) had no residual renal function. Upon logistic regression analysis, Kt/Vurea was independent factor affecting serum albumin and NPCR. 1) In forty-eight (44%) of the 110 patients, both Kt/Vurea and Ccr values with four 2-L daily exchanges were adequate. In twenty-two (20%), one of Kt/Vurea and Ccr values with four 2-L daily exchanges was inadequate. In fourty (36%), both Kt/Vurea and Ccr values with four 2-L daily exchanges were inadequate. 2) In eighty-four (77%) of the 110 patients, both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were adequate. In nineteen (17%), one of Kt/Vurea and Ccr values with four 2.5-L daily exchanges was inadequate. In seven (6%), both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were inadequate. 3) In three (7%) of the fourty-five anuric patients, both Kt/Vurea and Ccr values with four 2-L daily exchanges were adequate. In eleven (24%), one of Kt/Vurea and Ccr values with four 2-L daily exchanges was inadequate. In thirty-one (69%), both Kt/Vurea and Ccr values with four 2-L daily exchanges were inadequate. 4) In twenty-seven (60%) of the fourty-five anuric patients, both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were adequate. In thirteen (29%), one of Kt/Vurea and Ccr values with four 2.5-L daily exchanges was inadequate. In five (11%), both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were inadequate. Conclusion : The anuric Korean patients may need four 2.5L daily exchanges for acceptable adequacy target. Special attention must be given to those patients with no residual renal function. (Korean J Med 57:313-322, 1999)

지속성 복막투석의 동물 모델에서 복막휴식이 용질 수송과 복막 섬유화에 미치는 영향

김석재(Seog Jae Kim),김용림(Yong Lim Kim),조동규(Dong Kyu Cho),김용진(Yong Jin Kim),김준홍(Jun Hong Kim),김성호(Sung Ho Kim),김찬덕(Chan Duck Kim),남직화(Jick Hwa Nam) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.3

N/A Ultrafiltration failure has been known as a major cause of dropout from long-term peritoneal dialysis and is often related to peritoneal hyperpermeability. This can be explained in part by progressive peritoneal fibrosis. The present experiment has been under- taken to evaluate the effects of peritoneal rest on peritoneal transport and morphology in rat model of peritoneal dialysis. Twenty-four male rats(Sprague-Dawley, 250-300g) were used and divided into three groups : group 1 (control, n=6) without dialysis, group 2(n=9) sacrificed immediately after 3 weeks of dialysis, and group 3 (n=9) sacrificed after 4 weeks of peritoneal rest after 3 weeks of dialysis. Peritoneal dialysis was performed twice a day with 25mL of 3.86% dextrose solution for 3 weeks. Peritonitis was induced by supplementing lipopolysaccharide(5μg/mL) in the dialysis fluid on days 8, 10 and 12 of peritoneal dialysis. Peritoneal equilibration tests were performed before dialysis and repeated on the 4th and 8th week of dialysis. Mor-phometric analysis of the peritoneal membrane and immunohistochemistry for collagen type I and type III were done in tissue specimens obtained at the time of sacrifice. The D/Do ratio for glucose at two hours in groups 2 and 3 at the beginning of week 4 were signifi-cantly lower than baseline value, indicating increase in the peritoneal penneability to glucose after 3 weeks of dialysis. D/Do in group 3 at the beginning of week 8, after 4 weeks of peritoneal rest, was significantly higher than at week 4. The drained dialysate volumes in groups 2 and 3 at week 4 were significantly lower than at baseline; however, The drained dialysate volume in group 3 at week 8 was significantly greater than at week 4. The thickness of the parietal peritoneal membraoe in group 2 and 3 were significantly greater than in group 1. Severity of the thickness of the parietal peritoneal membrane in group 3 was not much than that of group 2(group 1, 11.4±7.6; group 2, 37.5±18.4; group 3, 21.4±12.1 pm). Histologically, the thickened peritoneum in group 2 showed a monolayer of mesothelial cells and under-lying multilayer of curled collagen bundles. Mononu-ciear cells and fibroblasts were embedded in these collagen layers and capillary proliferation was present. Immunohistochemistry for collagen type I and Z demonstrated that the distribution of collagen type llI was richer than that of collagen l in group 2 at fibrotic area of submesothelial region. These findings were decreased in group 3. Ultrastructural examination of the peritoneum showed thicker fibrotic zone and the activated fibro-blasts in group 2 compared to group 1 and 3. Meso-thelial cells were plump and the number of meso-thelial microvilli was decreased in group 2. Nucleus was enlarged and irregular. Intracytoplasmic orga-nelles were also richer than those of group I or 3. In conclusion, peritoneal rest improves ultrafil- tration in rats by decreasing the hyperpermeability of glucose and also reduces the degree of peritoneal fibrosis. These data suggest that dialysis-induced changes in peritoneal transport and morphology are reversible under the condition of peritoneal rest in this experimental model.

복막투석 환자에서 TGF-β1 유전자 다형성과 동맥경화성 혈관질환 유병율과의 관계

조성 ( Seong Cho ),김찬덕 ( Chan Duck Kim ),류혜명 ( Hye Myung Ryu ),박선희 ( Sun Hee Park ),김용림 ( Yong Lim Kim ) 대한신장학회 2007 Kidney Research and Clinical Practice Vol.26 No.6

Purpose : Atherosclerotic vascular disease (AVD) is a leading cause of morbidity and mortality in patients with end-stage renal disease (ESRD) on peritoneal dialysis (PD). Transforming growth factorbeta1 (TGF-β1) is a multifunctional cytokine that inhibits the atheromatous process. The author studied polymorphisms of the TGF-β1 gene (-509C>T and 869T>C) as genetic susceptibility factors for AVD in PD patients. Methods : Genotyping was carried out using the LightCycler 480 with melting curve analysis function. Prevalent vascular disease was defined by the presence of ischemic heart disease (IHD), peripheral vascular disease (PVD), cerebrovascular disease (CVD), or congestive heart failure (CHF). The presence of AVD was derived by the presence of any vascular disease (i.e., any degree of IHD/PVD/CVD). Results : In total, 109 PD patients were recruited (38.7% male, and 28.7% diabetic). The mean age was 49.1±14.1 years, and mean dialysis duration was 61.3±34.1 months. The most frequent genotype at -509C>T was CT (49.5%) and at 869T>C was TC (47.7%). No significant differences were observed in the genotype distributions of the investigated TGF-β1 (CC:CT:TT, 18.5%:55.6%:25.9%vs 26.8%:47.6%:25.6%, χ2=0.246, p=0.884; TT:TC:CC, 18.5%:55.6%:25.9% vs 28.0%:45.1%:26.8%, χ2=1.188, p=0.552) between AVD group and no AVD group. Conclusion : TGF-β1 gene polymorphisms at both -509C>T and +869T>C were not associated with an increased risk for prevalent vascular diseases. Further studies are required to evaluate the role of TGF-β1 as a candidate gene.

증례 : 신장 ; 비스테로이드 소염제 복용 후 발생한 신경색

윤세희 ( Se Hee Yoon ),김용림 ( Yong Lim Kim ),박선희 ( Sun Hee Park ),김찬덕 ( Chan Duck Kim ),최지영 ( Ji Young Choi ),윤성로 ( Sung Ro Yun ) 대한내과학회 2012 대한내과학회지 Vol.82 No.5

Nonsteroidal anti-inflammatory drugs (NSAIDs) are popular in general practice. Their adverse renal effects have been well documented. Common NSAID-related renal side effects range from dysfunctional renal hemodynamic responses, nephrotic syndrome, electrolyte disturbances, acute interstitial nephritis, chronic interstitial nephritis with papillary necrosis, and acute flank pain syndrome to acute renal failure. Decreased prostaglandin synthesis can lead to renal ischemia and hemodynamically related acute renal failure. Cases of acute renal failure syndrome accompanied by severe loin pain after anaerobic exercise (ALPE) or binge drinking have previously been reported in individuals taking NSAIDs. However, severe flank pain after high-dose NSAID treatment in the absence of other conditions (exercise or volume contraction) is rare. We report a case of a 51-year-old man who suffered from severe pain in both flanks after NSAID treatment. Computed tomography revealed hypodense lesions in both kidneys. (Korean J Med 2012;82:618-622)

증례 : 신장 ; 복막투석의 합병증으로 발생한 복막-후복막 누출 1예

최혁준 ( Hyuk Joon Choi ),김종열 ( Jong Yeol Kim ),최지영 ( Ji Young Choi ),조지형 ( Ji Hyung Cho ),김찬덕 ( Chan Duck Kim ),박선희 ( Sun Hee Park ),김용림 ( Yong Lim Kim ) 대한내과학회 2011 대한내과학회지 Vol.80 No.1

복막투석액의 누출은 복막투석 환자의 10% 미만에서 발생하는 합병증으로, 투석액은 도관출구, 흉강, 복부 탈장, 복벽으로 누출될 수 있으며, 개방성 초상돌기를 통한 외부생식 기로도 누출될 수 있다. 저자들은 흔히 발생하는 누출경로가 아닌 후복막으로 투석액이 누출되는 드문 예를 경험하였다. 배액감소로 내원한 환자에서 CT peritoneography를 시행함으로써, 투석액이 후복막으로 누출된 후 누출된 투석액이 우측 고환까지 이동함을 확인하였기에 이를 보고하는 바이다. We report a case of retroperitoneal and scrotal dialysate leakage resulting from peritoneal-retroperitoneal communication in a patient on peritoneal dialysis (PD). The ultrafiltration volume was reduced and the scrotum became enlarged in a patient who had been undergoing PD for 4 years. Retroperitoneal and scrotal leakage of dialysate was confirmed by computed tomography (CT) performed 1 hour after the intraperitoneal infusion of contrast-containing dialysate. The PD was halted and the patient was transferred to hemodialysis (HD). One month after the transfer to HD, the PD was resumed and there were no signs of extraperitoneal leakage. (Korean J Med 2011;80:108-112)

지속외래복막투석 환자에서 잔여신기능의 감소에 영향을 미치는 인자

박선희 ( Sun Hee Park ),김건현 ( Gun Hyun Kim ),현승혜 ( Seung Hyea Hyun ),서혜진 ( Hye Jin Seo ),최지영 ( Ji Young Choi ),조지형 ( Ji Hyung Cho ),김찬덕 ( Chan Duck Kim ),김용림 ( Yong Lim Kim ) 대한신장학회 2010 Kidney Research and Clinical Practice Vol.29 No.6

Purpose: Preservation of residual renal function (RRF) after initiation of peritoneal dialysis (PD) is beneficial for patient survival. It is unclear that same risk factors of pre-dialysis chronic kidney disease (CKD) patients affect RRF in PD patients. This study was aimed to evaluate factors affecting RRF after commencement of PD. Methods:Data from 80 patients commencing CAPD at Kyungpook National University Hospital between January 2001 and December 2008 were retrospectively collected. After PD commencement, biochemical and clinical data at baseline (1 month), 6, and 12 month were obtained. RRF was calculated as the average of creatinine clearance and urea nitrogen clearance from 24-hour urine collection and normalized with body surface area and mean RRF decline rate was calculated by dividing RRF difference between baseline to 12 month by period. Results:Mean RRF decline rate (mL/min/1.73m2/month) was negatively correlated with left ventricular posterior wall thickness (LVPWT) (R2=0.097, p=0.023) and proteinuria (R2=0.126, p=0.003), whereas positively correlated with hematocrit (R2=0.076, p=0.013) at baseline. Comparison between the two groups divided by median RRF decline rate (-0.082 mL/min/1.73m2/ month) showed that baseline proteinuria (p<0.001), the number of antihypertensive agents (p=0.030) and LVPWT (p=0.039) were higher in the decline group. In addition, the number of antihypertensive agents was higher in the decline group at 1 year, although there was no difference of blood pressure between the two groups. Using multiple binary logistic regression, it was shown that more rapid RRF decline (<-0.082 mL/min/ 1.73m2/month) was likely to have higher proteinuria [adjusted odd ratio (AOR) 3.310, 95% confidence interval (CI) 1.363-8.041], and thicker LVPWT [AOR 1.682, 95% CI 1.043-2.711] at baseline. Conclusion:Decline of RRF during a year after commencement of PD was associated with baseline proteinuria and LVPWT.

소아 신장이식 환자에서 연령 및 성별에 따른 타크롤리 무스의 약동학적 차이에 관한 단일기관 연구

최재영,장경미,황영주,최봉석,박종광,윤영란,김찬덕,조민현,Choe, Jae Young,Jang, Kyung Mi,Hwang, Young Ju,Choi, Bong Seok,Park, Jong Kwang,Yoon, Young Ran,Kim, Chan Duck,Cho, Min Hyun 대한소아신장학회 2014 Childhood kidney diseases Vol.18 No.1

목적: 소아 신장 이식 환자에서 흔히 사용되는 면역 억제제 타크롤리무스는 성별, 연령별, 인종별로 다양한 약동학적 특성이 있음이 알려져 있다. 본 연구는 우리나라 소아신장 이식 환자가 가지는 타크롤리무스의 약동학적 특징을 파악하고 관련되는 인자를 알아보기 위해 시행되었다. 방법: 경북대병원 소아청소년과에서 신장 이식을 시행받고 초기 면역 억제치료로 타크롤리무스가 사용된 환자 9명을 대상으로, 사용된 약 용량과 혈중 최저 농도 등을 후향적으로 조사하였고 이들의 약동학적 특성을 성인 대조군과 비교하였다. 결과: 남아의 평균 약 용량은 여아에 비해 유의하게 높았으나 혈중 최저 농도는 두 군 간에 유의한 차이가 없었고 청소율 또한 남아에서 유의하게 높았다. 12세 이상의 평균 약 용량은 12세 미만에 비해 낮았고 혈중 최저 농도는 높은 경향을 보였으나 유의한 차이는 없었다. 성인은 12세 이상, 미만 모두의 경우 보다 유의하게 약 용량이 적었으나 혈중 최저 농도에서는 유의한 차이가 없었다. 또한, 청소율와 반감기에서도 모두 유의한 차이를 보였다. 결론: 소아 신장 이식에서 사용되는 타크롤리무스는 나이가 어릴수록, 남아의 경우에 좀 더 많은 용량을 투여해야 할 가능성이 있음을 확인할 수 있었다. 우리나라 소아 신장 이식 환자에서 타크롤리무스의 적절한 치료용량을 확인하기 위해서는 이상의 관련인자에 대한 추가적인 전향적인 연구가 필요하다고 사료 된다. Purpose: The pharmacokinetics of tacrolimus, one of the most widely used immunosuppressive drugs, are known to vary by sex, age, and ethnicity during pediatric transplantation. This study assessed the pharmacokinetic characteristics and associated factors of tacrolimus in Korean children receiving a kidney transplant. Methods: We retrospectively reviewed the pharmacokinetic data (therapeutic dose, trough level, clearance, and half-life) of 9 children who were given tacrolimus as one of their initial immunosuppressive drugs after kidney transplantation. In addition, we compared the findings to data from 10 adult kidney transplant recipients. Results: The mean age of our pediatric patients was 13.9 years, and the maleto- female ratio was 4:5. The mean dose of tacrolimus was $0.19{\pm}0.14$ mg/kg/day. The mean dose of tacrolimus for males was $0.23{\pm}0.12$ mg/kg/day, which was significantly higher than the dose for females ($0.16{\pm}0.14$ mg/kg/day). The trough level was not significantly different between both groups. The clearance rate of tacrolimus for males was also significantly higher than females. Although the dosage of tacrolimus for patients over the age of 12 years was lower ($0.18{\pm}0.13$ vs. $0.21{\pm}0.16$ mg/kg/day) and the trough level was higher ($8.2{\pm}4.5$ vs. $7.2{\pm}4.2$ mg/mL) than that for patients under the age of 12 years, there was no significant difference between them. However, there were significant differences between children and adults in dose, clearance, and half-life of tacrolimus. Conclusion: Out study suggests that the pharmacokinetics of tacrolimus tends to vary with sex and age. Therefore, large-scale prospective studies are required to verify the proper therapeutic dosage of tacrolimus in Korean children.

신이식 공여자 술전 평가에서 자기공명 혈관조영술의 효용성

박자용 ( Ja Yong Park ),김준철 ( Jun Chul Kim ),이현철 ( Hyun Chul Lee ),최지영 ( Ji Young Choi ),현승혜 ( Seung Hye Hyun ),박성원 ( Sung Won Park ),배호상 ( Ho Sang Bae ),김찬덕 ( Chan Duck Kim ),박선희 ( Sun Hee Park ),김용림 ( 대한신장학회 2006 Kidney Research and Clinical Practice Vol.25 No.2