혈연간 동종 조혈모세포 이식 후 이식편대숙주질환과 함께 발생한 급성 호산구성 폐렴

박환성 ( Hwan Sung Park ),옥태진 ( Tae Jin Ok ),김유재 ( You Jae Kim ),김광운 ( Guang Un Kim ),박소은 ( So Eun Park ),안지현 ( Ji Hyun An ),김윤구 ( Yun Ku Kim ),정재호 ( Jae Ho Jeong ),김수정 ( Su Jeong Kim ),이유미 ( Yu Mi Lee ) 대한결핵 및 호흡기학회 2011 Tuberculosis and Respiratory Diseases Vol.71 No.6

Pulmonary complications occur in 40~60% of patients who receive hematopoietic stem cell transplantation (HSCT) and are a source of substantial morbidity and mortality. Acute eosinophilic pneumonia (AEP) is an uncommon, non-infectious pulmonary complication occurring in HSCT recipients. We now report the case of a 52-year-old man with AEP who was treated with allogenic HSCT due to acute myeloid leukemia. He complained of fever, cough and dyspnea 390 days after allogenic HSCT. He also had skin and hepatic graft versus host disease (GVHD). Hypoxemia, diffuse pulmonary infiltrates on a chest x-ray and eosinophilia in bronchoalveolar lavage fluid were also noted in several tests. His symptoms, pulmonary infiltrates, hepatic dysfunction and skin lesions rapidly improved after treatment with corticosteroid therapy. Our case supports the idea that AEP is a late phase non-infectious pulmonary complication and one of the manifestations of chronic GVHD.

당뇨병성 신부전의 관리와 최신 치료 ; 우리나라에서 당뇨병성 신증의 실태

이유지 ( Yu Ji Lee ),김윤구 ( Yoon Goo Kim ) 대한내과학회 2009 대한내과학회지 Vol.77 No.6

The number of patients beginning renal replacement therapy (RRT) in Korea has grown exponentially over the past two decades. Patients with end-stage renal disease attributed to diabetes accounted for most of this increase (45% of new patients requiring RRT). The estimated prevalence of diabetic nephropathy in diabetics in Korea is 30% or more. The early detection and effective treatment of nephropathy in diabetics would prevent or delay the progression of chronic kidney disease. Therefore, comprehensive health intervention to control the increasing prevalence of diabetes and promote early awareness and aggressive management of diabetic nephropathy are needed. (Korean J Med 77:667-669, 2009)

Anti-myeloperoxidase antineutrophil cytoplasmic antibodies 양성의 급속진행성 사구체신염이 동반된 후복막 섬유증식증

이유지 ( Yu Ji Lee ),정혜원 ( Hae Won Jung ),이정은 ( Jung Eun Lee ),허우성 ( Woo Seong Huh ),김대중 ( Dae Joong Kim ),오하영 ( Ha Young Oh ),김윤구 ( Yoon Goo Kim ) 대한신장학회 2009 Kidney Research and Clinical Practice Vol.28 No.3

Idiopathic retroperitoneal fibrosis is a rare disease characterized by the presence of retroperitoneal fibroinflammatory tissue, which often surrounds the abdominal aorta, the ureters, or other abdominal organs. There have been sporadic reports of an association with autoimmune diseases, although the pathogenesis of idiopathic retroperitoneal fibrosis is unclear. However, there are very few reports ofidiopathic retroperitoneal fibrosis associated with rapidly progressive glomerulonephritis. We report a case with idiopathic retroperitoneal fibrosis associated with rapidly progressive glomerulonephritis, and anti-myeloperoxidase antineutrophil cytoplasmic antibodies (anti MPO-ANCA), that was improved by the combination therapy of steroids and cyclophosphamide.

Tacrolimus를 근간으로 한 면역억제제를 복용하는 장이식 환자에서 이식 후 새로 발생한 당뇨병의 위험인자

허우성 ( Woo Seong Huh ),최유경 ( Yu Kyong Choi ),김예지 ( Ye Jee Kim ),최남경 ( Nam Kyong Choi ),김민영 ( Min Young Kim ),백나나 ( Na Na Baek ),염지연 ( Ji Youn Youm ),이정은 ( Jung Eun Lee ),김대중 ( Dae Joong Kim ),김윤구 ( Yoo 대한신장학회 2010 Kidney Research and Clinical Practice Vol.29 No.6

Purpose: This study was conducted to identify risk factors for new onset diabetes after transplantation (NODAT) among renal transplant recipients treated with tacrolimus-based immunosuppressant. Methods: We selected renal transplant recipients who underwent surgery at Samsung Seoul Hospital between May 2001 and July 2009. Exclusion criteria were as follows: recipients <18 years old, history of diabetes mellitus (DM) or impaired glucose tolerance. Analysis of possible risk factors for NODAT included age, gender, body mass index, co-morbid diseases, family history of DM, infection of hepatitis B or polyomavirus, type of donors (cadaver or living) and acute rejection. Overall incidence and median value of NODAT onset day were analyzed with Kaplan-Meier curve. We calculated crude incidence rate and relative risk (RR) and 95% confidence interval (CI) for independent risk factors of NODAT using Cox proportional hazard analysis. Results: A total of 278 patients were included and the incidence of NODAT was 13.3% (5.6/100 person-year) and the median duration of NODAT onset was 28 days. In Cox analysis, risk factors for NODAT were age (45-59 years: RR=1.41, 95% CI 1.09-1.83, 60> years: RR=4.36, 95% CI 2.00-9.49), family history of DM (RR=1.62, 95% CI 1.12-2.34) and polyomavirus infection (RR=1.40, 95% CI 1.08-1.81). Conclusion: The risk factors for NODAT among renal transplant recipients treated with tacrolimus- based regimen were age (>45 years old), family history of DM and polyomavirus infection.

증례 : 스테로이드 사용 중 슬부 무혈성골괴사와 만성 활동성 골수염이 병발된 1예

강나리 ( Na Ree Kang ),이유지 ( Yu Ji Lee ),신준암 ( Jun Am Shin ),정혜원 ( Hae Yon Jung ),안긍환 ( Ahn Geung Hwan ),정혜원 ( Hae Won Chung ),김윤구 ( Yoon Goo Kim ) 대한내과학회 2006 대한내과학회지 Vol.71 No.1S

증례 : 신장 ; 특발성 후복막 섬유증 환자에 동반된 종격동 섬유증 1예

최희정 ( Hee Jung Choi ),김수민 ( Soo Min Kim ),최이령 ( E Ryoung Choi ),송재욱 ( Jae Uk Song ),이유지 ( Yu Ji Lee ),김윤구 ( Yoon Goo Kim ) 대한내과학회 2009 대한내과학회지 Vol.77 No.5S

특발성 후복막 섬유증은 후복막강 내 결체 조직의 섬유성 증식 질환으로 초기에 효과적으로 치료가 되더라도 이후 다른 장기의 섬유화를 동반할 수 있으며 대동맥 및 다른 혈관을 침범하여 다양한 증상을 유발할 수 있으므로 장기간의 추적관찰이 필요하다. 저자들은 특발성 후복막 섬유증으로 진단되어 치료받던 환자에서 종격동 및 경부 혈관 섬유증이 동반된 증례를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Idiopathic retroperitoneal fibrosis is a rare disease characterized by proliferation of fibrous tissue with inflammation in the retroperitoneal cavity, which is often associated with fibrosis of other organ systems. Multifocal fibrosclerosis is a term used to describe a combination of multiple organ system fibrosis, such as mediastinal fibrosis, retroperitoneal fibrosis, orbital pseudotumor, sclerosing cholangitis, and Reidel`s thyroiditis. Although there are several reports of retroperitoneal fibrosis associated with a combination of fibrosis in variable organ systems, reports of combined retroperitoneal fibrosis and mediastinal fibrosis are rare. We report a case of mediastinal fibrosis in a patient with idiopathic retroperitoneal fibrosis. (Korean J Med 77:S1258-S1262, 2009)

증례 : 심한 증식성 루푸스 신염과 혈전성 혈소판 감소성 자반증이 병발한 남성 환자에서 cyclophosphamide 치료 경험 1예

정혜원 ( Hae Won Jung ),신준암 ( Jun Am Shin ),이유지 ( Yu Ji Lee ),강나리 ( Na Ree Kang ),권기영 ( Ghee Young Kwon ),한봉준 ( Bong Jun Han ),김윤구 ( Yoon Goo Kim ) 대한내과학회 2006 대한내과학회지 Vol.71 No.2

TTP가 병발한 SLE에서 조기에 신선 냉동 혈장 투여와 혈장 교환술을 적극적으로 시행해야 한다. 이러한 적극적인 초기 치료에도 불구하고 병이 진행하거나, 루푸스 신염이 동반된 경우에 cyclophosphamide의 병합 요법이 치료에 도움이 됨을 저자들은 경험하여 보고하는 바이다. Thrombotic thrombocytopenic purpura is a rare but fatal complication of systemic lupus erythematosus. The diagnosis of thrombotic thrombocytopenic purpura as a syndrome distinct from systemic lupus erythematosus may be challenging particularly when thrombotic thrombocytopenic purpura is presented concomitantly with systemic lupus erythematosus. Early diagnosis and aggressive treatment including plasmapheresis would be required. However, recent reports have suggested that the use of cyclophosphamide may have a role. We describe a patient with systemic lupus erythematosus who was first presented with severe thrombotic thrombocytopenic purpura. Diagnosis was based on typical clinical features of thrombotic thrombocytopenic purpura and laboratory findings of active lupus nephritis. Renal biopsy also confirmed the coexistence of thrombotic thrombocytopenic purpura and diffuse proliferative lupus nephritis. Although prompt extensive plasmapheresis and high dose steroid therapy were performed, oliguric renal failure and thrombocytopenia persisted. After addition of cyclophosphamide to the treatment with plasmapheresis and steroid, clinical manifestations of thrombotic thrombocytopenic purpura and lupus nephritis were markedly improved. (Korean J Med 71:214-218, 2006)

투석용 동정맥루의 개통율과 이에 영향을 주는 인자의 분석: 자가혈관 동정맥루와 인조혈관 동정맥루의 비교, 단일기관 연구

정혜원 ( Hae Won Jung ),임영환 ( Young Hwan Lim ),이유지 ( Yu Ji Lee ),강나리 ( Na Ree Kang ),이정은 ( Jung Eun Lee ),허우성 ( Woo Seong Huh ),오하영 ( Ha Young Oh ),김윤구 ( Yoon Goo Kim ),김대중 ( Dae Joong Kim ) 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.1

목적: 당뇨병과 고령의 환자들이 증가함에 따라 인조혈관을 이용한 동정맥루 수술이 점차 증가하고 있다. 그러나 자가혈관 동정맥루와 인조혈관 동정맥루의 개통율의 비교에 대한 국내 자료는 미미한 실정이다. 저자들은 자가혈관 동정맥루와 인조혈관 동정맥루의 개통율을 비교하고, 동정맥루의 개통율에 영향을 미치는 인자에는 어떤 것들이 있는지 알아보고자 하였다 방법: 2003년 1월 1일부터 2003년 12월 31일까지 대학병원에서 자가 또는 인조혈관 동정맥루 수술을 받은 환자들을 대상으로 후향적 연구를 진행하였다. 동정맥루의 일차, 이차 개통율을 분석하였고, 개통율에 관련된 인자를 성별, 연령 및 기저 질환을 보정하여 분석하였다. 또한 일차 혈로 부전 발생율도 조사하였다. 결과: 2003년에 총 196건의 동정맥루 수술이 시행되었다. 이중 추적 되지 않은 14건을 제외한 182건을 대상으로 연구를 진행하였다. 자가혈관 동정맥루 수술은 142건 (78%)이었고, 인조혈관 동정맥루 수술은 40건 (22%)이었다. 수술 후 일차 혈관 부전 발생율은 자가혈관 동정맥루와 인조혈관 동정맥루 사이에 통계적으로 차이가 없었다. 일차 개통율 (1, 2, 3년 째 78%, 72%. 68% vs. 62%, 41%, 22%; p<0.001)과 이차 개통율 (1, 2, 3년 째 93%, 88%, 85% vs. 84%, 74%, 73%; p=0.087)은 자가혈관 동정맥루가 인조혈관 동정맥루보다 우수하였다. 동정맥루의 종류와 계획된 수술로 만들었는지 여부가 동정맥루의 개통율에 영향을 미치는 인자였다. 결론: 자가혈관 동정맥루가 인조혈관 동정맥루보다 개통율이 우수하였다. 또한 계획적으로 만들어진 혈관 통로일수록 개통율이 우수하였다. Purpose: As the proportion of patients with diabetes and old age increases, the use of arteriovenous graft (AVG) is increasing. However, there are few data about the comparison of the patency rate of native arteriovenous fistula (AVF) to that of AVG in Korea. We compared the outcome of native AVF to that of AVG with analysis of the factors affecting the patency of the permanent vascular access in use. Methods: A retrospective database of all vascular access related procedures performed from January 1, 2003 to December 31, 2003 was established. We evaluated the primary unassisted and cumulative access patency rate with analysis of patency-related factors. We also evaluated the primary failure rate of AVF and AVG. Results: 196 new vascular access surgeries were performed during the period. 14 cases were excluded due to loss of follow-up. 142 native arteriovenous fistulas (78%) and 40 grafts (22%) were constructed. The primary failure rate was similar between AVF and AVG group. The primary unassisted (78%, 72%, 68% vs. 62%, 41%, 22% at 1, 2, 3 year; p<0.001) and cumulative patency rate (93%, 88%, 85% vs. 84%, 74%, 73% at 1, 2, 3 year; p=0.087) were better in AVF group than in AVG group. The factors affecting the patency of vascular access were the type of vascular access and planned construction of permanent vascular access. Conclusion: Patency of native AVF as the permanent vascular access was better than that of AVG. Planned construction of permanent vascular access improved the patency of the access.

만성 신질환 환자에서 관상동맥 조영술 후 투석이 필요한 급성 신부전증의 임상상

임영환 ( Young Hwan Lim ),정혜원 ( Hae Won Jung ),이유지 ( Yu Ji Lee ),강나리 ( Na Ree Kang ),이정은 ( Jung Eun Lee ),허우성 ( Woo Seong Huh ),오하영 ( Ha Young Oh ),김윤구 ( Yoon Goo Kim ),김대중 ( Dae Joong Kim ) 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.3

목적: 만성 신질환 (chronic kidney disease, CKD) 환자에서 관상동맥 조영술 또는 관상동맥 중재술을 시행하는 경우 조영제 콩팥병증은 흔히 발생할 수 있으며 시술과 연관된 심각한 합병증으로 이환율과 사망률을 증가시킨다. 조영제 콩팥병증 중 투석이 필요한 급성 신부전증 (acute renal failure requiring dialysis, ARFD)의 발생은 드물지만 임상경과는 불량한 것으로 알려져 있으나 국내에는 ARFD의 임상상에 대한 문헌 보고가 없어서 본 연구를 시행하였다. 방법: 2004년 4월부터 2007년 6월까지 관상동맥 조영술 또는 관상동맥 중재술을 시행한 환자 중 혈중 크레아티닌이 1.3 mg/dL 이상인 성인 환자 178명을 대상으로 기저 사구체 여과율 중증도에 따른 유병율과 위험인자, 임상경과를 조사하였다. ARFD의 정의는 시술 후 7일 이내에 응급 혈액투석을 시행한 경우로 하였다. 사구체 여과율은 MDRD 공식을 이용하여 계산하였다. 결과: 대상 환자군의 평균 연령은 68.8±9.5세 (남자 143명 68.6±9.9세, 여자 35명 69.8±7.9세)이었다. 조사기간 중 20명에서 ARFD가 발생하였으나 10명은 시술 전 심인성 쇼크로 인해 대동맥 내 풍선펌프를 사용하여 조사대상에서 제외하였다. ARFD는 178명 중 10명 (5.6%)에서 발생하였으며, 만성 신질환 단계에 따른 ARFD의 발생빈도는 각각 기저 eGFR이 30-59 mL/min/1.73m2인 (CKD stage 3) 136명 중 0명, 15-29 (CKD stage 4)인 32명 중 3명, 15 이하 (CKD stage 5)인 10명 중 7명으로 유의하게 차이가 있었다 (0% vs 9.4% vs 70% p<0.0001). ARFD 발생의 위험인자로 연령, 성별, 당뇨병, 기저 eGRF, 좌심실 박출율, 급성 심근경색증을 분석하였고 이중 기저 eGRF만이 유의하였다. 기저 eGFR이 10 mL/min/1.73m2씩 감소함에 따라 ARFD의 발생 위험도는 26.5배 증가하였다 (p=0.005; odds ratio 26.46; 95% confidence interval, 2.73 to 256.66). ARFD가 발생한 10명 중 2명은 각각 응급 혈액투석 3일 및 1개윌 뒤 신기능이 기저치로 회복되어 투석을 중단하였으며 나머지 8명은 유지투석을 하게 되었다. 유지투석을 하게 된 8명중 1명은 응급 혈액투석 4개월째 뇌출혈로 사망하였고 7명은 5개월에서 40개월째 생존하여 추적관찰 중이다. 결론: 관상동맥 조영술 또는 관상동맥 중재술을 시행하게 되는 만성 신질환 환자에서 투석이 필요한 급성 신부전증의 발생은 기저 사구체 여과율의 중증도에 비례하여 증가하였고 응급혈액투석 후 대부분 유지투석을 하게 되었다. Purpose: Acute renal failure requiring dialysis (ARFD) after coronary intervention is a rare but serious complication, and it is associated with poor prognosis. This study investigated the clinical characteristics and risk factors of ARFD after coronary intervention in patients with chronic kidney disease (CKD). Methods: This study included 178 adult patients with CKD (baseline serum creatinine of >1.3 mg/dL) undergoing coronary intervention at Samsung Medical Center from April 2003 through June 2007. We retrospectively evaluated the incidence, clinical outcome, and risk factor of ARFD via medical records. ARFD was defined as a decrease in renal function necessitating hemodialysis in the first 7 days after percutaneous coronary intervention. The estimated glomerular filtration rate (eGFR) was obtained using the Levey Modification of Diet in Renal Disease (MDRD) formula. Results: Ten of the 178 patients (5.6%) developed ARFD with a subsequent in-hospital mortality rate of 10% (n=1). According to CKD stage, incidence of ARFD was 0/136 patients (baseline eGFR 30 to 90 ml/min/1.73m2 4/32 (15 to 29,) and 7/10 (<15) respectively (0% vs 9.4% vs 70%, p<0.0001). Multivariate analysis found eGFR (OR=0.5, 95% CI 0.3 to 0.9, p=0.02) to be only independent predictor of ARFD. Of those who developed ARFD (n=10), 2 patients stopped dialysis, 8 had required permanent dialysis. Conclusion: Incidence of ARFD increased according to the severity of renal dysfunction. The majority of ARFD patients had required permanent dialysis.

투석이 필요했던 중증 급성 신손상 환자에서 신장기능의 예후

최경아 ( Kyung A Choi ),권정아 ( Jeong Ah Kwon ),김영훈 ( Young Hoon Kim ),이유지 ( Yu Ji Lee ),오하영 ( Ha Young Oh ),김대중 ( Dae Joong Kim ),김윤구 ( Yoon Goo Kim ),허우성 ( Woo Seong Huh ),이정은 ( Jung Eun Lee ) 대한신장학회 2009 Kidney Research and Clinical Practice Vol.28 No.4

Purpose: Acute tubular necrosis (ATN) is a serious complication in critically ill patients. This study investigated the renal outcome of severe ATN requiring RRT and prognostic factors for renal recovery. Methods: Between January 2000 and May 2008, surviving patients with presumed ATN requiring dialysis were analyzed retrospectively. Patients with pre-existing chronic kidney disease and other causes of ARF rather than ATN were excluded. Primary outcomes were complete renal recovery (CR) and dialysis withdrawal. CR was defined as a return to basal serum creatinine level or creatinine <1.5 mg/dL (male) or <1.3 mg/dL (female) without dialysis. Results: Of one hundred twenty two patients, 79 (65%) patients were male. The mean age was 54±16 years and 87 patients (71%) received continuous renal replacement therapy. 55% had ischemic ATN, 29% had septic ATN, and 16% had nephrotoxic ATN. Mean duration of dialysis was 12 (6-29) days. Dialysis withdrawal rate at 30 days and at 60 days after initiation of dialysis were 51% and 77%, respectively. CR at 60 days after initiation was 50%. Multivariate analysis revealed that older age (per year, Hazard ratio (HR)=0.981, 95% Confidence interval (CI) 0.963 to 0.999), ischemic ATN (vs. toxic ATN, HR=0.481, 95% CI 0.238 to 0.974),and longer duration of oliguria (per day, HR=0.979, 95 % CI 0.962 to 0.996) were independent prognostic factors of renal recovery. Conclusion: Young age and short duration of oliguria were favorable factors for renal recovery from ATN requiring dialysis. The cause of ATN might be also an independent prognostic factor.