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간경변증이 동반된 말기신부전환자에서의 지속성 외래복막투석
김용림,권태한,조동규 경북대학교 의학연구소 1999 경북대학교병원의학연구소논문집 Vol.3 No.1
Obijectives : The spontaneous tendency to arterial hypotension in cirrhotic patients makes adequate hemodialysis therapy extremely difficult. Hemedialysis in these patients may produce intradialytic hypotension, limiting the amount of ultrafiltration. These patients are also at high risk for gastrointestinal bleeding, which can be exacerbated by anticoagu-lation. Recently peritoneal dialysis has been sug-gested for the management of this population. Methods : Seven patients with chronic renal failure and liver cirrhosis treated by CAPD are described. Six of the seven patients were complicated by ascites on starting CAPD. Hepatocellular carcinoma was identified in one patient. Three had been transferred from hemodialysis for henmodynamic intolerance, one far vascular access problem. All PD catheters were surgically placed. Results : The hemodynamic tolerance was excellent in all patients. Four patients developed bleeding immediately after catheter insertion. Two patients developed early leaks and one patient late leak. Four patients had a decline in serum albumin level of 0.5 gm/dL or more during the course of chronic PD. Peritonitis occurred on average at 8.7 month interval. Three episodes of catheter removal occurred in 148 patient-months of PD(0.24 per patient-year). Four patients died while maintained on PD; three deaths were due to hepatic encephalopathy on PD far dura-tion of 4 to 60 months and the fourth was due to Perironitis after 24 months of PD. One patient died due to malnutrition after 2 months on switching to hemodialysis because of peritonitis after 32 months of PD. Conclusion : Early mechanical complications after catheter insertion(bleeding, leak) were more common than usual. But CAPD was better tolerab1e than hemodialysis and may be a reasonable choice with an acceptable survival rate in end-stage renal disease patients with preexisting liver cirrhosis.
김용림,서인수 慶北大學校 醫科大學 1988 慶北醫大誌 Vol.29 No.3
최근 우리나라에서 몇례가 보고되고 있고, 저자도 임상적으로 경험한 잉어류의 담즙 생식후에 발생한 신부전증의 발병기전을 알아보기 위해 본 실험을 계획하였다. 이스라엘 잉어의 담즙을 채취하여 암컷 흰쥐에 1㎖ 및 2㎖를 경구 투여하고 임상적 관찰과 더불어 신조직의 형태적 변화를 광학 및 전자현미경으로 관찰하였던 바 그 성적을 요약하면 다음과 같다. 이스라엘 잉어의 담즙을 투여한 후 실험동물은 활동성이 뚜렷이 저하되었으며 수시간후에는 혈뇨를 보이고 2㎖를 투여한 군은 하루가 지나고부터 사망하는 동물도 볼 수 있었다. 형태적으로 담즙의 투여량이 많은 동물에서 더 심한 변화를 보였고 양자에서 본질적인 차이는 없었다. 광학현미경으로 근위 뇨세관 상피세포의 미만성 괴사, 원위 뇨세관의 원주 형성등이 담즙 투여 30분 후 부터 볼 수 있었으며 이 변화는 시간이 지날수록 심해져서 8시간에 최고도에 달하였다. 24시간후에는 뇨세관 상피세포의 재생을 볼 수 있었고 5일후에는 거의 모든 뇨세관에서 형태적인 원상 복구를 볼 수 있었다. 전자 현미경으로는 광학현미경에서 관찰된 소견에 해당하는 소견에 더하여 괴사까지는 달하지 않은 뇨세관 상피세포에서도 mitochondria의 종창과 파괴, 공포의 출현, lysosome의 증가등이 관찰되었고, 간질에 있는 소혈관의 내피세포의 손상이 관찰되었다. 상기한 본실험의 성적으로 미루어 보아서 잉어류의 담즙에 의한 신상해의 본질은 독성 급성 뇨세관 괴사증 (toxic acute tubular necrosis)이며, 따라서 신상해의 발병기전은 담즙에 함유된 유독물질에 의한 직접 작용에 의한 것으로 추론된다. 다만 간질에 있는 소혈관 내피세포의 상해는 혈류장애를 일으킬 수도 있을 것이며 이는 뇨세관 상피세포의 상해에 보조적 역할을 할 것으로 생각된다. Recently clinical cases of acute renal failure after ingestion of raw-bile of carp were reported, which were also experienced by author. This study was carried out to investigate the mechanism of renal failure induced by carp bile experimentally. Raw-bile of carp was fed to albino rats, 1 and 2 ㎖ per oral route, respectively. Sequential morphlogic changes were observed by light and electron microscopes. The results obtained were summarized as follow : Physical activities were markedly reduced after ingestion of bile. Hematuria was developed after 2 hours and few animals were died after one day particularly in 2 ㎖ adminstered group. Morphologic changes were more severe in the 2 ㎖ administered group, but there were no basic differences in both groups. Light microscopic changes consisted of diffuse necrosis of proximal tubular epithelial cells and cast formation on the distal tubules, which appeared 30 minutes after ingestion, and reached peak after 8 hours. Regenerative activities of the proximal epithelial cells were noted after 24 hours, and almost all tubules showed morphologic recovery after 5 days. Electron microscopical changes consisted of swelling and increased number of lysosomes in the non necrotized epithelial cells near the necrotic cells, in addition to widespread necrosis of epithelial cells observed by light microscope. Endothelial cells of small blood vessels on the interstitium showed also damaging effects. The results suggested that the nature of renal injury induced by raw-bile of carp was toxic acute tubular necrosis, which were thought to be exerted by direct effects of some toxic fraction contained in carp bile. The evidence of injuries on the endothelial cells would indicate possible role of derangement of blood flow on the pathogenesis of renal tubular injuries, and another alternative mechanism of tubular injuries.