지속성 외래 복막투석 환자에서 혈청 알부민 농도에 영향을 미치는 인자

마경애(Kyoung Ai Ma),강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),조은영(Eun Young Cho),이종호(Jong Ho Lee),이승우(Seoung Woo Lee) 대한내과학회 1998 대한내과학회지 Vol.54 No.2

N/A Objectives: Protein-calorie malnutrition is a common problem in patients undergoing continuous ambulatory peritoneal dialysis (CAPD), Serum albumin(SA) concentration has been used as a marker for assessing nutritional status. Hypoalbuminemia has been linked to an increased risk of morbidity and mortality and more numerous, prolonged hospitalization for peritoneal dialysis patients. The aim of this study was to determine factors affecting SA value in CAPD patients. Methods: We performed a cross-sectional study which included patients` demographics, anthropometric data, biochemical parameters, urea kinetic data and comorbidity in 106 stable CAPD patients. Results: 1) There were 50 men and 56 women with a mean CAPD duration of 43 months and mean age of 49 years. The mean concentration of SA was 3.9±0.5 (range 2.5-5.3) g/dl and weekly Kt/Vurea 2.0±0.4 (range 1.32-3.79) 2) Twenty-one patients(20%) were classified as group I(SA<3.5g/dl)and the remaining patients(80%) as group II(SA≥3.5g/dl) 3) Group I patients were significantly older(55±11 vs 47±11 years, p<0.05%) and had significantly higher comorbidity score(1.5±0.8 vs 0.7±0.9, p<0.05), C-reactive protein (4.5±0.9 vs 0.5±0.1 mg/dl, p<0.05%), 24-hr dialysate-to-plasma creatinine(D/PCr) ratio(0.84±0.1 vs 0.76±0.1, p<0.05), 24-hr dialysate protein (7167±2031 vs 5471±1515 mg, p<0.05) and had significantly lower residual renal function(RRF)(0.2±03 vs 0.7±1.2 ml/min, p<0.05), BUN(48±14.8 vs 55.6±14.9 mg/dl, p<0.05), serum creatinine(10.4±2.8 vs 12.6±3.5 mg/dl, p<0.05), IGF-1(186±99 vs 260±131 ng/ml, p<0.05), serum phosphorus(4.1±1.2 vs 5.0±1.3 mg /dl, p<0.05) than group II. 4) SA showed positive correlation with anion gap (r=0.43, p value=0.001), transferrin(r-0.41, p value=0.001) phosphorus(r=0.31, p value=0.001) and negative correlation with 24-hr dialysate protein loss(r=-0.51, p value=0.001), 24-hr D/PCr ratio(r=-0.49, p value=0.001), comorbidity score(r=-0.36, p vluue=0.001). NPCB(r=0.22, p vaiue=0.023), IGF-1(r=0.30, p value=0.002), BUN(r=0.23, p ualue=0.016) weakly correlated with SA. 5) By stepwise multiple logistic regression analysis, age, CRP, 24-hr D/PCr ratio and RBF independently influenced SA level. Conclusion: SA level seems to be affected by non-nutritional factors such as age, peritoneal membrane transport characteristics, residual renal function and presence of acute phase protein response manifested by CRP elevation, in addition to nutritional factors.

IgA 신병증에서 혈청 면역글로불린 A 의 유용성

김명성(Myeong Sung Kim),신규태(Gyu Tae Shin),임현이(Hyun Ee Yim),김승정(Seung Jung Kim),신승수(Seung Soo Sheen),마경애(Kyoung Ai Ma),조남한(Nam Han Cho),최영일(Young Il Choi),김흥수(Heung Soo Kim),김도헌(Do Hun Kim) 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.1

배 경 : 면역글로불린 A (Immunoglobulin A, 이하 IgA) 신병증은 가장 흔한 사구체신염으로 알려져 있다. IgA 환자의 30- 50%에서 혈청 IgA 농도가 증가하지만 혈청 IgA 측정이 갖는 IgA 신병증 진단의 유용성에 대해서는 잘 밝혀져 있지 않다. 방 법 : 1994년 6월부터 1998년 12월까지 아주대학교병원에 내원하여 신조직 검사를 시행한 전체환자 333명 중 혈청 IgA 농도를 측정한 270명을 후향적으로 조사하였다. 결 과 : 혈청 IgA 농도의 정상치의 상한 값인 365 ㎎/dL를 초과하는 환자 수는 IgA 신병증 환자들에서는 80명 중에 32.5%인 26명이었으며, 나머지 환자들에서는 190명 중에 8.9%인 17명이 혈청 IgA치가 365 ㎎/dL를 초과하였다(p<0.001). 혈청 IgA 농도 증가에 따라 IgA 신병증 진단에 대한 민감도는 감소하며, 특이도는 증가하는 관계를 나타내었다. 혈청 IgA농도 1 ㎎/dL에 대해 IgA 신병증으로 진단 받을 위험도(Risk ratio)는 1.0025였다(p- value 0.0043). 또한 혈청 보체치가 저하되지 않은 환자만을 대상으로 하였을 경우 이러한 위험도는 1.0079로 더욱 상승하였다. 그러나 혈청 IgA 농도와 신조직 면역형광 소견과는 상관관계가 없는 것으로 나타났다. 결 론 : 혈청 IgA 농도 측정이 IgA 신병증 진단 추정에 유용함을 보여 주었고, 이러한 결과는 특히 신 조직 검사가 적합하지 않은 환자에서, 혈청 IgA 농도, 보체 등을 이용하여 IgA 신병증 진단을 추정하는데 임상적으로 도움을 줄 수 있다. Background : Immunoglogulin A (IgA) nephropathy is the most common primary glomerular disease throughout the world. 30-50% of patients with IgA nephropathy (IgAN) have high serum IgA concentrations. However, we do not know if the degree of elevation in IgA level increases the likelihood of having IgAN. Neither do we know if the IgA level has any association with pathological findings of IgAN. Methods : We analyzed the relationships between IgAN and the levels of serum IgA which has been a routine part of the study in all patients with glomerulonephritis in our institution for the last 4 years. We reviewed 270 patients in whom the pathological diagnosis and the results of their IgA levels were both available. Results : Of 80 patients who were IgA nephropathy, 26 patients (32.5%) had higher than normal cutoff value of serum IgA (385 ㎎/dL). In contrast, 8.9% of patients with other types of glomerulonephropathies showed the values above normal(p<0.0001). The risk ratio for an increase of one unit of the IgA level was 1.0025(logistic regression, p=0.0043), which was increased to 1.0079 when patients with low complement levels were excluded from the analysis. The data were also analyzed according to the immunofluorescence microscopic findings of IgAN, which were found to have no significant correlation with IgA concentrations. Conclusion : The IgA level is a risk factor for IgAN throughout the whole range. However, it does not correlate with the IgA deposition in the renal tissue. We believe that this study will help understanding the interpretation of IgA levels in patients with IgAN.

고유량 고효율 혈액투석막 재사용의 임상경험

조현경(Hyeon Kyeong Cho),김승정(Seung Jung Kim),임병국(Byong Kook Im),정혁준(Hyuck Joon Chung),최영일(Young Il Choi),마경애(Kyoung Ai Ma),신규태(Gyu Tae Shin),김흥수(Heung Soo Kim),김도헌(Do Hun Kim) 대한신장학회 2001 Kidney Research and Clinical Practice Vol.20 No.3

N/A N/A

IgA 신증 환자들에서 신조직내GF-β와 TNF-α의 유전자발현에 대한 ACE Ihibitor의 영향

김승정,신규태,마경애,김흥수,김도헌 대한신장학회 2000 대한신장학회잡지 Vol.19 No.4

백혈병으로 전환된 림프종 환자에서 발생한 유산산증(Lactic Acidosis)

김현수,김도헌,마경애,신규태,서유진,김승정,김명성,안성균,정혁준,현봉학 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.3

Occurence of lactic acidosis with adequate tissue oxygenation(type B lactic acidosis) has been described in association with leukemia, lymphoma, small cell carcinoma and breast cancer. However, no such case has been reported in Korea. Therefore, we report a case of type B lactic acidosis in a man with rapidly progressing acute lymphoblastic leukemia which had been transformed from lymphoma.

고용량 항암요법후 말초혈액 자가조혈모세포 이식환자에서의 감염 양상

구성현,최소연,조요한,한동석,마경애,김현수,김효철 대한조혈모세포이식학회 1996 대한조혈모세포이식학회지 Vol.1 No.1

목적: 동종골수이식이나 자가골수이식, 말초혈액 자가조혈모세포이식에서 공통적으로 이병률과 사망률에 관여하는 중요한 인자중의 하나가 항암 치료후 발생하는 감염이다. 감염의 발생빈도 및 정도에 대해서 확실히 알수 있고, 위험인자를 감별해 낼수 있다면 고용량 항암요법 후에 발생하는 이병률과 사망률을 줄여 더 나은 결과를 얻을수 있다고 사료되어 저자 등은 고용량 항암요법을 시행한 환자들을 대상으로 후향적인 연구를 통해 감염 및 그로 인한 합병증을 발생빈도, 정도 및 감염과 관련된 위험인자를 규명하려고 하였다. 방법: 1995년 11월부터 96년 8월까지 아주대학교병원에서 고용량 항암요법후에 말초혈액 자가조혈모 세포이식을 시행한 33명의 환자를 대상으로 하여 나이, 성별, 진단명, 조혈모세포이식 날짜, 사용한 항암제의 종류, 방사선 치료 유무 여부, 호중구 감소증 기간, 사망여부, 사망원인을 분석하였다. 결과 33명의환자에서 37회(4명은 2번 항암치료)의 고용량 항암 요법을 시행한 결과를 분석하였다. 1) 기존에 가지고 잇는 질환을 종류별로 보면, non-Hodgkin's lymphoma(n=13), Hodgkin's disease(n=1), breast cancer(n=5), stomach cancer(n=14)이었으며 모든 환자가 기존의 항암 치료에 불응하는 악성 종양이었다. 2) 대상환자의 평균 연령은 42세이었으며 여자가 18명이었고, 평균 호중구 감소기간은 9.62일 이었다. 3) 37회 고용량 항암 요법후 8회를 제외한 29회 (78.3%)에서 열이 있었으며, 29회의 발열 중 8예(21.6%)에서 감염이 균 검출로 증명되었거나 임상적으로 확실히 의심되었다. 8회의 감염중 Staphylococcus epidermidis가 1예, E coli가 2예, Bacteroides fragilis가 1예 있었다. 4) 33명의 환자중 모두 10명이 현재까지 추적관찰중 사망하였는데 이중 2명이 고용량 항암요법후 호중구가 감소되어있는 기간에 발생한 패혈증으로 사망하여 사망원인이 고용량 항암요법에 의한 합병증과 직접적인 연관이 있었다. 5) 감염에 연관되는 위험인자를 알아보기 위하여 나이, 성별, 방사선치료유부, 호중구 감소증 기간, 악성종양 종류 등을 감염군과 비감염군으로 나누어 비교하였는데 모든 항목에서 감염군과 비감염군 사이에 통계적으로 의미있는 차이를 찾을수 없었다. 결론: 고용량 항암요법후 감염이 가장 중요한 이병률 및 사망률의 원인이 되고 있는데 현재 말초혈액 자가조혈모 세포이식후 조혈촉진인자를 사용하여 감염 발생률을 많이 줄이기는 하였으나 앞으로 좀더 많은 환자를 오랜기간 추적 관찰하여 감염으로 인한 문제점을 찾아 개선해 나가야 하겠다. Objectives: Infection is one of the most important factor in the morbidity and mortality of both allogenic and autologous bone marrow transplantation, and peripheral blood stem cell transplant patients. Therefore, an accurate knowledge of the incidence, severity, and risk factors can lead to reduction in the morbidity and mortality. We performed a retrospective analysis in patients with high dose chemotherapy to clarify these infections and also the incidence of complication, severity and associated risk factors. Methods: The subjects of our study were patients who had been admitted at Ajou University Hospital from November 1995 to August 1996 and received autologous peripheral blood stem cell transplantation(PBSCT) after high dose chemotherapy. There were 33 patients in all and the following were analyzed : age, sex, disease diagnosis, date of PBSCT, the duration of neutropenia, and the cause of death. Results: The results of 37 trials (4 patients had two trials) of high dose chemotherapy in 33patients were analyzed. ① The diagnosis included non-Hodgkin's lymphoma(n=13), Hodgkin's disease(n=1), breast cancer(n=5), stomach cancer(n=14). All of the patients were refractory to the conventional chemotherapy. ② The average age was 42years, 18 of the patients were female and the mean duration of netropenia was 9.62days. ③ 29 out of37trials was associated with fever. In 8 out 29case, infection was diagnosed by detection of bacteria or clinically suspicious. Staphylococcus aureus was detected in 4case, Staphylococcus epidermidis in 1 case, E coli in 2 case, and Bacteroides fragilis 1 case. ④10patients died during follow up. 2 case died of sepsis during the period of neurtropenia. Therefore 2 death were directly related to the complications of high dose chemotherapy. ⑤The following factors were analyzed in both infected and non-infected group to determine if there any significant different: age, sex, radiation therapy, duration of neutropenia, disease. There was no significant different between the 2 groups. Conclusion: Infection is the most important cause of morbidity and mortality in high dose chemotherapy. The rate of infection has been largely reduced as a result of rapid marrow engraftment following autologous PBSCT. A longer duration of follow up must be done on more patients to find and improve the problems after autologous PBSCT.

사구체 신염 환자들에게 말초혈액 단핵세포의 Cytokine들의 유전자 발현에 대한 ACE Inhibitor의 영향

김홍수,김상돈,이한민,김승정,마경애,신규태,지석배,김도헌 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.1

Angiotensin II(ANG II) has been known to induce systemic and glomerular hypertension, which leads to renal tissue injury and progressive fibrosis of kidney. Some effects of ANG II may be mediated by its effect on the cytokine synthesis. In the present study, we investigated the effect of ANG II inhibition on the expression of various cytokines implicated in the pathogenesis and progression of the kidney disease. Blood samples of 11 patients with glomerulonephritis were obtained before the ACE inhibitor therapy and then while they were taking ACE inhibitors. Using peripheral blood mononuclear cells(PBMC) harvested from the samples, RT-PCR was performed to evaluate the changes in mRNA expression of TGF-β1, IL-6, TNF-α and IL-10. The ratios of target cytokines and β-actin were calculated. TGF-β1 mRNA expression was decreased in five pat ients after ANG II inhibition with ACE inhibitors, while it was increased in the remaining six patients. ACE inhibitors consistently decreased IL-6 mRNA expression in all 11 patients. IL-10 expression was decreased in 4 patients, and increased in 3 patients after ANG II inhibition. It was not expressed in 4 patients. TNF-α expression was increased in 8 patients, and decreased in only 1 patient. In two patients, it was not changed while on ACE inhibitors. Conclusion:ACE inhibitors attenuate IL-6 expression consistently in all 11 patients. This is the first-time demonstration of the in vivo inhibitory effect of ACE inhibitors on IL-6 mRNA expression in humans. The lack of significant suppression of TGF-β1 in PBMC suggests that the in vivo attenuating effect of ACE inhibitors on TGF-β1 may be derived from renal hemodynamic changes. The tendency of heightened expression of TNF-α confirms the previous investigations in which IL-6 was shown to down regulate TNF-αexpression.

혈뇨 환자에서 방광경 검사의 유용성

김영수,김홍수,김상돈,정도영,이한민,김도헌,김승정,마경애,신규태,지석배,안현수 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.1

Hematuria is a common presentation of bladder cancer. As medical examinations for health screening are becoming more popular, increasing number of patients are found to have hematuria. When to refer these patients to urologists for cystoscopy is a common problem to nephrologists and a matter of debate as well. In fact, many authors differ in their opinions on this issue, especially in cases of microscopic hematuria. Given the fact that the incidence of bladder cancer varies between countries, it will be reasonable that the investigation strategy for Koreans should be determined according to the studies on Korean people. In the present study, we retrospectively analyzed 349 patients who underwent cystoscopic examinations in our institution to investigate causes of microscopic or gross hematuria. Bladder cancer was detected on cystoscopy in 35(15.9%) of 220 patients with gross hematuria, in contrast to patients with microscopic hematuria in whom 2(1.6%) of 129 patients were found to have bladder cancer. Eighty nine percents of cancer patients were male. Bladder cancer was detected even in relatively young patients with gross hematuria, while no bladder cancer was found in patients with microscopic hematuria below 60 years of age. Urine cytology was revealing in 59.5% of cancer patients. Bladder cancer was detected in 71.4% and 76.2% of cancer cases by sonography and IVP, respectively. Urine protein by dipstick was unreliable in predicting the presence of cancer. In conclusion, decision on cystoscopy in patients with asymptomatic microscopic hematuria younger than 50-60 years of age should be made conservatively, while more aggressive diagnostic work up is necessary in patients with gross hematuria regardless of their age.

고유량 고효율 혈액투석막 재사용의 임상경험

조현경,김승정,임병국,정혁준,최영일,마경애,신규태,김흥수,김도헌 대한신장학회 2001 대한신장학회잡지 Vol.20 No.3

다양한 고염투석액을 이용한 혈액투석시 혈액량의 변화 및 부작용 발생의 관찰

김홍수,김상돈,김도헌,김헌종,고광현,김승정,마경애,김명성,정철권,이한민,지석배,신규태 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.3

Chronic hemodialysis patients frequently experience hemodialysis(HD)-related side effects caused by excessive ultrafiltration and abrupt change of osmolality. Sodium ramping in HD is known to reduce ultrafiltration-related side effects, but it frequently induces symptoms related to sodium overload. We wanted to know the relationship between blood volume changes and the side effects related to ultrafiltration during hemodialysis and whether we can individualize various sodium ramping methods according to the effect of change in blood volume( BV) and side effects of sodium ramping. We studied 9 hypotension-prone patients during HD. The duration of the study lasted for 5 weeks, each week using different sodium ramping protocols: protocol 1; dialysate [Na+] of 140mEq/L, protocol 2; dialysate [Na?] same as the predialysis serum [Na+], protocol 3; dialysate [Na+] was 20mEq/L greater than that of the patient's serum for 1hr, 10mEq/L greater than patient's serum [Na+] for 2hr and then the same as patient's serum] for the last 1hr, protocol 4; at the beginning of dialysis, dialysate sodium was ramped to 20mEq/L above the patient's serum sodium and then on a straight linear fashion lowered to the predialysis serum [Na+] at the end of dialysis, protocol 5; sodium was constantly ramped to 10 mEq/L above serum [Na+]. We measured the BV with Crit-Line IIR(In-Line Diagnostics, Corp., Riverdale, USA), the blood pressure during each HD and interdialytic weight gain. We documented subjective symptoms which occurred during the 5 treatment protocols by patient's questionnaire after each HD. The results were as follows. 1) The mean age of the patients(M:F=3:6) was 54.1years and 6 patients were diabetics. 2) There was no significant difference in the BV among the 5 protocols in both whole study population and individual. Neither was there a statistically significant difference in the BV with respect to hypotension during HD. 3) There were no episodes of hypotension(P value $lt;0.001) with protocols 3, 4, 5 compared to protocs 1 and 2. 4) Three patients during protocols 4 and 5 experienced more thirst after HD than during protocol 1 and one patient during protocol 4, 5 had more interdialytic weight gain than the protocol 1. As a whole, patients while on protocol 4 & 5 experienced more thirst than protocol 1 but patients during protocol 3 experienced the same degree of thirst as protocol 1. In summary, sodium ramping reduced HD-related side effects but this benefit could not be explained on the basis of blood volume change measured by the Crit-Line IIR. Protocol 3 may be more appropiate sodium ramping method in 4 of the 9 patients. These data suggest that protocol 3 may be used before protocol 4, 5 when we apply sodium ramping to the patients who frequently have hypotension during HD.