말기신부전 환자의 조기 사망에 대한 연구

송현용(Hyun Yong Song),박영수(Young Soo Park),강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),하성규(Sung Kyu Ha),한대석(Dae Suk Han),이호영(Ho Yung Lee) 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.4

목 적 : 의학의 발달과 노인 인구의 증가 등으로 말기신부전 환자의 수는 계속 증가하고 있으며 신대체 요법의 발달에 따른 환자의 삶의 질과 생존율은 계속 향상되고 있으나 말기신부전 환자의 사망률은 아직도 여전히 높은 편이다. 말기신부전 환자의 투석 방법에 따른 생존율의 차이에 대한 비교 연구와 장기간 투석을 시행받고 있는 환자의 예후에 대한 연구는 많으나 투석 개시 후 3개월 이내 사망한 조기 사망군에 대한 연구는 별로 없는 실정이다. 따라서 이들 조기 사망군의 특성을 이해하고 사망률을 낮춘다면 전체 말기신부전 환자의 생존율의 향상을 기대할 수 있다. 방 법 : 1994년 1월 1일부터 1999년 6월 30일까지 말기 신부전증으로 진단받고 처음 신대체 요법을 시행받은 환자 986명 중 투석 개시 후 90일 이내에 사망한 환자 66명과 투석 개시 후 1년 이상 생존한 환자 920명을 대상으로 하여 두 군간의 투석 개시시의 임상상, 동반질환, 생화학적 지표 및 사망 원인에 차이가 있는지 후향적으로 조사하였다. 결 과 : 전체 환자의 1년내 사망률은 10.4%였고 이중 조기 사망군의 사망률은 6.9%(1년내 사망 환자의 64.1%)였으며 평균 생존 기간은 28.9±23.0일이었다. 대상 환자의 평균 연령은 조기 사망군이 생존군에 비해 많았으며(47.6±15.1세 vs 64.7±13.8세, p<0.001) 남녀비는 조기 사망군 30 : 36, 생존 환자군 506 : 414로 조기 사망군에서 여성이 많았으나 통계적 유의성은 없었고 조기 사망군에서 신장내과 의사에게 투석전 적절한 전치료를 받은 조기의뢰군의 비율이 낮은 경향을 보였으나 통계적 유의성은 없었다. 투석 시작시 심전도 변화는 생존군의 경우 좌심실 비대 396예(43.0%), 허혈성변화 86예(9.3%), 부정맥 67예(7.3%), 정상 506예(55.0%)였으며 조기 사망군의 경우 좌심실 비대 24예(36.4%), 허혈성 변화 12예(18.2%), 부정맥 12예(18.2%), 정상 32예(48.5%)로 조기사망군의 경우 허혈성 변화와 부정맥의 빈도가 많았다(p<0.05). 조기 사망군의 동반 질환이 생존군에 비해 많았으며(2.7±1.4 vs 1.6±1.1, p<0.001) 특히 심혈관계 질환 및 악성종양의 동반이 통계적으로 유의하게 많았으나 당뇨 동반여부는 통계적 유의성이 없었다. 혈청 생화학적 검사상 조기 사망군의 경우 투석 전 백혈구의 증가와 림파구의 감소, 혈청 크레아티닌의 감소, 혈청 알부민의 감소, 총 콜레스테롤의 감소와 혈청 C-reactive protein(CRP)의 증가가 생존군에 비해 통계학적으로 유의한 차이를 보였다. 조기 사망군의 위험인자로 나이가 많을수록, 동반질환이 많을수록 특히 악성종양과 심부전이 동반되어 있는 경우, 혈청알부민이 저하 되어있는 경우 및 CRP가 증가되어있는 경우의 순으로 나타났으며 성별, 고혈압, 당뇨의 유무와는 상관관계가 없었다. 조기 사망군의 사망원인은 감염 32예(48.5%), 심혈관계 질환 28예(42.4%), 악성종양 4예(6.1%), 영양실조 2예(3.0%)였다. 결 론: 말기신부전 환자의 조기 사망은 투석 개시 전 감염증의 동반, 심혈관계 질환 및 악성 종양의 동반과 혈청 알부민의 저하, 총 콜레스테롤의 감소, 크레아티닌의 저하 등 영양 상태 불량과 심한 대사성 산증 및 고칼륨혈증 등 전신 상태가 나빠 응급 투석이 요하는 경우가 많으므 Background : Despite improvements in dialysis care, the mortality of patients with end-stage renal disease(ESRD) remains high. Patients who die within the first 90 days after beginning dialysis are not included in mortality rates and may be absent from incidence count. Therefore, the identification of modifiable characteristics associated with the risk of death during the first 90 days of treatment could lead to improved survival during this interval. Methods : We performed a retrospective analysis in 986 patients(at least 1 year survival from initiating dialysis were 920 patients, and 66 patients died within 90 days after dialysis) who were initiated renal replacement therapy first at Yonsei Medical Center from Jan 1994 to Jun 1999. Results : The 1 year mortality rate of total patients was 10.4%, and early death rate was 6.9%. The mean survival duration was 28.9±23.0 days. Characteristics independently associated with increased risk of early death included older age, inflammation, nutritional impairment, more comorbid condition and previous history of cardiovascular disease at starting dialysis. But Diabetes was not increased early death rate. By multivariate logistic regression analysis, old age, combined comorbid conditions, especially malignancy and congestive heart failure, low serum album and elevated C-reactive protein level were the independent risk factors affecting early death. Other variables such as sex, dyslipidemia, hypertension and diabetes mellitus were not significant risk factors. The leading cause of death in early death group was infection rather than cardiovascular accidents. Conclusion : Proper treatment of infection and improved nutritional status by adequate predialytic managements may contribute to their prolonged survival on dialysis patients.

소장천공으로 발현된 간헐적 복막투석 환자의 경화성 복막염

임동미 ( Dong Mee Lim ),황원민 ( Won Min Hwang ),윤세희 ( Se Hee Yoon ),김완호 ( Wan Ho Kim ),유기현 ( Ki Hyun Ryu ),송현용 ( Hyun Yong Song ),윤성로 ( Sung Ro Yun ),윤대성 ( Dae Sung Yoon ),정동진 ( Dong Jyn Jung ) 대한신장학회 2004 Kidney Research and Clinical Practice Vol.23 No.6

고 농도의 당 존재하에서 신 세뇨관 상피 세포의 세포외 기질 생성 조절 기전에 관한 연구

강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),송현용(Hyun Yong Song),유태현(Tae Hyun Yoo),황재하(Jae Ha Hwang),김주성(Joo Seong Kim),송영수(Young Su Song),정득림(Deug Lim Chong),김경섭(Kyung Sup 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.1

N/A Thickening of tubular basement membrane and progressive tubulointerstitial fibrosis has been reported as important components of diabetic nephropathy, In order to investigate the mechanisms of tubulinterstitial changes in diabetic nephropathy, we evaluated the effects of a high concentration of glucose(25mM; 450mg/dL) on glucose transporter GLUT1 level, fibronectin production and tissue inhibitors of metalloproteinases (TIMP)-1 concentration in renal tubular(LLC-PK₁) cells. As the effect of high glucose-induced alteration in LLC-PK< cells, the expression of facilitative glueose transporter, GLUT1 was decreased after longer than 24-hours exposure to 25mM glucose, compared to control(5.6mM). The administration of protein kinase C (PKC) inhibitor GF109203X(10μM) did not show significant effect on high glucose-induced decrease of GLUT1 level. On western blot analysis of fibronectin production, The exposure of LLC-PK cells to 25mM glucose for 48 hours significantly increasc4 fibro- nectin production, dose-dependently. The addition of GF102903X at the concentration of 10pM induced the significant increase of fibronectin level in LLC-PK₁cells under glucose-free condition, whereas there was no significant effect on the high glucose-induced increase of fibronectin production. The addition of anti-TGF-βantibody at 30μg/mL partly inhibited the high glucose-induced increase of fibronectin production. Concerning the changes of tissue inhibitor of metallo-proteinase(TIMP)-1 levels in the presence of high glucose, the exposure to high glucose for 24 and 43 hours increased TIMP-1 levels in culture supernatant of LLC-PK₁ cells, dose-dependently. The TIMP-1 levels of 48-hour exposure to 15 and 25mM glucose were also significantly higher than those of 24-hourexposure. The treatment with 10μM GF102903X or 30μg/mL anti-TGF-βantibody had no significant effects on TIMP-1 levels measured under the high glucose culture condition. In conclusion, the expression of facilitative glucose transporter, GLUT1 is inhibited and the production of fibronectin is increased in renal tubular cells cultured in the presence of high concentration of glucose, which is partly mediated by TGF-β. The TIMP-1 level is also increased under high glucose culture condition. The enhanced productions of fibronectin and TIMP-1 of renal tubular cells under high glucose concentration may contribute to tubulointerstitial fibrosis that occurs in diabetic nephropathy.

이차성 부갑상선 기능 항진증이 있는 지속성 외래 복막투석(CAPD) 환자에서 칼시트리올(칼시오) 경구 충격요법과 저용량 매일요법의 비교 연구

강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),유태현(Tae Hyeon Yoo),신석균(Sug Kyun Shin),하성규(Sung Kyu Ha),노현진(Hyun Jin Noh),류동렬(Dong Ryeol Ryu),송현용(Hyun Yong Song),황재하(Jae Ha Hwan 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.3

N/A The most widely used method for treatment of secondary hyperparathyroidism(SH) in CAPD patients has been the administration of calcitriol by oral route. In this study, we compared the efficacy and safety of daily low dose calcitriol therapy with those of intermittent high dose pulse therapy. The study group consisted of 38 patients undergoing CAPD with serum intact PTH level of more than 200pg/ mL. Twenty patients were randomly administered daily low dose calcitriol(0.25μg/day for 1 month followed by 0.5μg daily dose for the next 3 mon-ths) while 18 patients were given intermittent pulse therapy(0.5μg-0.5μg-0.75μg 3 times a week for 1 month, increased to 1.0μg-1.25μg-1.25μg 3 times a week for the next 3 months). Thirty five patients completed the study : 17 on daily oral calcitriol (M: F=0.7:1, mean age=47.3±10.6 years, mean duration of CAPD=48.9±41.1 months), and 18 on oral pulse calcitriol(M: F=1.6: 1, mean age=41.5±12.7 years, mean duration of CAPD=49.2±41.6 months). The baseline serum levels of calcium, phosphorus, i-PTH, alkaline phosphatase, and total CO₂were not different be- tween daily and pulse group(9.5±0.8 vs 9.3±0.9mg/ dL, 5.8±1.3 vs 5.1±1.2mg/dL, 443.1±162.5 vs 546±385.9pg/mL, 91.8±47.7 vs 108.9±66.5IU/L, 23.7±1.9 vs 25.5±2.0mEq/L, p>0.05, respectively). The i-PTH level decreased significantly in daily calcitriol group after 1 month(332.8±214.8pg/mL, p<0.01), and at final evaluation(180.4±254.8pg/mL, p<0.01). In pulse calcitriol group, i-PTH level also decreased signi-ficantly to 400,4±225.8pg/mL(p<0.05), 89.4±122.6 pg/mL(p<0.01), respectively. The rate of decline in i-PTH level from baseline were similar(daily=25.4±22.7 vs pulse=19.5±12.6%decline/month, p>0.05). The serum calcium increased similarly in both groups after treatment(daily=10.6±0.8 vs pulse=l0.1±1.0mg/ dL, p>0.05). Hypercalcemia(>11.0mg/dL) was rarely observed in all patients(daily=5, pulse=8 episodes). In conclusion, both daily and pulse calcitriol therapy were similarly effective and safe in control of SH.

알레르기 질환 환자에서 고양이털 항원에 대한 감작을 및 고양이털의 항원성에 관한 연구

라선영(Sun Young Rha),남동호(Dong Ho Nam),김범수(Bum Soo Kim),안중배(Joong Bae Ahn),원욱희(Wook Hee Won),송현용(Hyun Yong Song),조홍근(Hong Keun Cho),전동운(Dong Woon Jun),홍천수(Chein Soo Hong) 대한내과학회 1995 대한내과학회지 Vol.48 No.3

N/A Objectives: The cat fur allergen used in skin prick test was known to be contaminated with housedust mites. So we intended to evaluate the clinical importance of cat fur as a causative allergen in patients with allergic diseases. Methods: We performed skin prick tests with cat allergen of Torii company(Japan), Bencard company (England) and home made extracts in 387 patients, We detected specific IgE by 3M FAST-plus and ELISA method using home made cat fur allergen, developed at this class. To characterize the allergenic components, cat fur extracts were fractionated by 12 % sodium dodecyl sulfate polyacrylamide gel electrophoresis(SDS-PAGE) and then transferred onto nitrocellulose membrane and probed with sera of cat fur sensitive patients Results: 1) Out of 387 patients, 77(19.9%) showed more than 1+results on skin prick test. There were no significant differences in the rates of positive results ac- cording to the allergic diseases, but the age groups were correlated with the positive results(younger than 30: 34.5%, between 30 and 50: 14.4%, older than 50: 6.8%). 2) Cat ELISA showed specific inhibition to cat fur allergen and Cat ELISA inhibition test revealed the linear dose response curve on the added amounts of cat allergn into pooled sera. 67.7% out of Torii cat fur sensitive patients(A/H ratio≥1) showed positive results in Cat ELISA for specific IgE antibody. 3) Cat fur extracts showed 15 protein bands by SDS-PAGE, then they were transferred onto nitrocellulose membrane and probed with sera of 16 cat-fur sensitive patients, one sera pool of patients with RAST class 3, and three negative controls and with biotin-conjugated anti IgE-avidin peroxidase. Six IgE binding protein bands were detected at 94, 73, 56, 44, 28 and 21 kilodalton of molecular weight. Out of six IgE binding bands, MW 21KD concerned as major cat allergen, Fel d 1, were noted in five sera(31.3% ). Conclusion: It is suggested that cat fur can be regarded as an important allergenic fur and that we need further studies to st.andardize cat antigens for in vivo and in vitro tests.

미만성 증식성 낭창성 신염의 임상상 및 예후인자

최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),하성규(Sung Kyu Ha),류동렬(Dong Ryeol Ryu),송현용(Hyun Yong Song),신석균(Suk Kyun Shin),황재하(Jae Ha Hwang),노현정(Hyun Jung Roh),유태현(Tae Hyun Yoo),김주성(Joo Seong Kim 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.1

N/A Lupus nephritis is a major cause of morbidity and mortality arising from systemic lupus erythematous. It is generally acknowledged that the presence of diffuse proliferative lupus nephritis(DPLN) is highly predictive of a poor prognosis in terms of renal and patient out- come on survival. The objective of this study was to evaluate the clinicopathologic characteristics, renal out- come according to therapeutic regimen, and prognostic factors of biopsy-proven diffuse proliferative lupus nephritis. Among the biopsy-proven lupus nephritis patients who were admitted to Yonsei University Medical Center from January 1986 to June 1997, 36 patents who were diagnosed DPLN by renal biopsy and treated for at least 6 months and regularly followed-up for at least 12 months were included. We retrospec-tively reviewed the medical recorders. Patients were treated with steroid regimen with or without cyclo-phosphamide. According to the therapeutic response, patients were divided into two groups : a therapeutic response group(n=24), and a therapeutic non-response group<n=12). The mean age of the patients was 27.4 years and the mean follow-up duration was 51 months. Lupus nephritis developed at a mean 9.7 months after SLE diagnosis and mean duration of nephritis was 39.2 months. Mean serum creatinine was 1.6mg/ dL, 24 hour proteinuria was 4,873mg, and anti-DNA antibody was positive in 8196 of patients at the time of renal biopsy. Activity index and chronicity index were 10.4 and 2.8, respectively. Overall 5 year renal survival rate was 7596 and no difference between steroid single therapy and cyclophosphamide combination therapy was observed. Factors affecting therapeutic response included delayed development of nephritis(3.1 vs 13.8 months, p<0.05) and elevated serum creatinine level(0.9 vs 1.9mg/dL, p<0.05), which were associated with poor therapeutic response. Other clinicopathologic, biochemical and immunologic parameters were not different between the therapeutic response group and the therapeutic non-response group. In conclusion, delayed development of lupus nephritis and elevated serum creatinine at nephritis presentation are poor prognostic factors of DPLN, but further randomized prospective study{including divided cytoxan intravenous pulse therapy and oral therapy, with long-term follow-up) is necessary.

이차성 부갑상선 기능 항진증을 가진 복막투석 환자에서 경구 칼시트리올 치료 반응에 관여하는 요인

강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),신석균(Sug Kyun Shin),하성규(Sung Kyu Ha),노현진(Hyun Jin Noh),송현용(Hyun Yong Song),노현정(Hyun Jung Roh),유태현(Tae Hyun Yoo),황재하(Jae Ha Hwang) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.1

N/A Calcitriol therapy is an important treatment for the prevention and control of secondary hyperparathyroidism in continuous ambulatory peritoneal dialysis (CAPD) patients. However, this often has been limited by the associated hypercalcemia and hyperphosphatemia due to increase in intestinal calcium and phosphorus absorption. Many studies reported that these limitations could be avoided by changing routes, frequency and dose of calcitriol treatment. But, there are still controversy about each methods and the results on the PTH response to conventional calcitriol treatment in CAPD patients. This study was performed to evaluate the factors affecting the response to oral calcitriol in CAPD patients. A retrospective study was done in 92 CAPD patients with secondary hyperparathyroidism(intact PTH level >200pg/ml) on oral calcitriol treatment. After baseline study of serum calcium, phosphorus, alkaline phosphatase, BUN, creatinine and intact PTH, calcitriol therapy was begun via oral rou- te, daily. Serum calcium, phosphorus, alkaline phosphatase, BUN, creatinine, intact FI'H and other bio- chemical markers were checked at 3 month, 6 month after treatment. Parathyroid gland ultrasonography was performed to detect parathyroid hypertrophy and nodule and to measure the diameter of parathymid gland. All the patients were divided into two groups according to percent reduetion of i-PTH(initial PTH PTH after 3, 6 months)×100/initial PTH(%),△PTH during oral calcitriol therapy for 3 and 6 months(group I ; △PTH >30%, group II ; △PTH <30%). Result: 1) All 92 patients(mean age 46.5 11.3yr, M: F 45: 47, mean CAPD duration 51.3 39.4 months) were administered oral calcitriol, daily. Mean calcitriol dose during 3 month was 0.43 0.22μg and during 6month 0.43 0.24μg. 2) After 3-month treament, there were significant differences in initial i-PTH, the diameter of parathyroid gland, initial phosphorus, intial total alkaline phosphatase and duration of CAPD between group I and II(406.7±196.5 vs. 871.0±478Apglml, 6.2±2.6 vs. 13.1±5.2mm, 5.0±1.3 vs. 5.7±1.3mg/dl, 93.7±4L1 vs. 171.9±137.6IU/L, 40.1±34.9 vs. 73.5±37.8months, p< 0.05, respectively). 4) After 6-month treament, there were significant differences in initial i-PTH, the diameter of parathyroid gland, intial total alkaline phosphatase and duration of CAPD between group I and II(474.1±266.6 vs. 889.7±485.4pg/ml, 6.4±2.7 vs. 14.5±5.1mm, 107.9±80.1 vs. 180.7±121.5IU/L, 40.5± 32.9 vs. 81.8±35.3months, p<0.05, respectively). 5) The significant negative correlation was shown between △PTH and the duration of peritoneal dialysis, the diameter of parathyroid gland, initial PTH level and PTH response during 3-month and 6-month oral calcitriol treatment. The response to oral calcitriol was poor when i-PTH level more than 500pg/ml(kappa 0.429, p value <0.01), the diameter of parathyroid gland more than 10.0mm(kappa 0.641, p value<0.01), the duration of CAPD more than 55months(kappa 0.524, p value< 0.01). These data suggested that initial i-PTH level, the diameter of parathyroid gland size and the duration of CAPD were independent risk factors of the poor response to oral calcitriol therapy in CAPD patients with secondary hyperparathyroidism.

단회뇨의 protein/creatinine ratio를 이용한 일일 뇨단백량 예측에 영향을 미치는 인자

강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),유태현(Tae Hyeon Yoo),류동렬(Dong Yul Ryu),신석균(Sug Kyun Shin),하성규(Sung Kyu Ha),노현진(Hyun Jin Noh),송현용(Hyun Yong Song),황재하(Jae Ha Hwang) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.1

N/A It's well known that protein/creatinine ratio(P/C ratio) in random urine samples reflects 24-hour urine protein. However, the factors affecting accurate quantitation of proteinuria using random urine P/C ratio are not fully evaluated. The aim of this study is to evaluate factors affecting accurate quantitaion of proteinuria using random urine P/C ratio. 118 patients admitted in Yonsei university medical center during June 1998 and Dec. 1998 were assessed for the measurement of random urine protein/creatinine ratio from second voided urine. 118 patients(mean age 41.5year, male: female 2.36: 1) had mean creati-nine level 1.83±1.78mg/dL, 24-hour pmteinuria 6.06±7.64g/day and P/C ratio 4.80±4.48, All the patiient.s were divided into A, B, C, I, II, K, IV according to serum creatinine level and 24-hour proteinurim amount. The correlation coefficient(R value) between proteinuria and P/C ratio are shown that in all pa- tients is 0.875, group A(Cr≤1.4) 0.884, group B(1A <Cr≤4.0) 0.819, group C(4,0<Cr) 0.844, gmup I (24-hr pro'≤0.3) 0.8%, group II(0.3<24-hr pro≤1.0) 0.813, group III(1.0<24-hr pro≤3.5) 0.716, group IV (3.5<24-hr pro) 0.637. These R value were statisti-cally significant(p value<0.05).(Cr serum creatinine, mg/dL, 24-hr pro ' 24-hour urine protein amount, g/day). Greater amount of proteinuria in 24-hour urine less correlated in sensitivity, specificity and positive predictive value with random urine P/C ratio. To evaluate factors affecting accurate quantitation of proteinuria by P/C ratio, multiple regression analysis was performed. The factors affecting accurate quantitation of proteinuria using random urine P/C ratio was 24-hour urine protein amount, not serum creatinine. Especially, in the patients with 24-hour pro-teinuria less than 4.0g/day, the random urine P/C ratio predicted 24-hour urine protein amount most accurately. In conclusion, random urine P/C ratio was well correlated with 24-hour proteinuria in the non-ne-phrotic range proteinuria especially, under 4.0g/day, irrespective of serum creatinine level.

지속성 외래 복막투석 환자에서 염증 지표와 고해상도 B 모드 경동맥 초음파 소견의 연관성에 관한 연구

송현용,송영수,안철우,강신욱,최규헌,하성규,이현철,이호영,한대석 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.2

배 경 : 저알부민혈증 및 C-반응 단백(C-reactive protein, CRP)이 증가된 지속성 외래 복막투석 환자의 사망률이 높은 정확한 이유는 밝혀져 않다. 혈액투석 환자에서처럼 복막투석 환자에서 저알부민혈증 및 염증반응이 심혈관계 질환 위험인자 인지 알아보고자 하였다. 방 법: 비당뇨병성 말기 신부전, 지속성 외래 복막투석 환자 93명의 심혈관계 질환 위험인자들과 복막 투과 특성 및 알부민, CRP 등의 염증지표에 따라 고해상도 초음파를 이용한 경동맥내막-중간막 두께, 내막-중간막 면적, 플라크의 유무 등을 단면적으로 비교하였다. 결 과: 복막 투과 특성은 고투과막군 14명, 중간 고투과막군 38명, 중간 저투과막군 31명, 저투과막군 10명으로 각 군간의 경동맥 내막-중간막 두께, 플라크 유무 및 내막-중간막 면적의 차이는 없었다. 기존 관상동맥 질환 환자는 8예(8.6%)로 내막-중간막 두께는 관상동맥 질환이 없는 환자보다 증가되었고(0.79±0.21 vs 0.60±0.11 mm, p<0.05) 플라크 형성은 더 많이 보이나 통계적 유의성은 없었다(75.0 vs 63.5%, p>0.05). 혈청 알부민치와 경동맥 내막-중간막 면적은 역상관관계를 보였다(r=-0.27, p<0.05). 저알부민혈증 환자(혈청 알부민 <3.5 g/dL)는 정상 알부민혈증 환자보다 내막-중간막 두께가 증가되었고(0.67±0.15 vs 0.61±0.12 mm, p<0.05), 플라크도 유의하게 많았다(68.0 vs 55.8%, p<0.05). 혈청 CRP치와 경동맥 내막-중간막 면적은 양의 상관관계가 있었으며(r=0.21, p<0.05) CRP가 높은 환자(≥0.8 mg/dL, n=18)에서플라크가 많이 관찰되었으나(65.8 vs 50.0%, p<0.05) 경동맥 내막-중간막 두께 및 내막-중간막면적은 양군간에 차이가 없었다. 다변량 회귀 분석상 경동맥 내막-중간막 두께에 영향을 미치는 인자는 고령, 높은 CRP, 기존 심혈관계질환, 낮은 혈청 알부민 순이였다. 결 론 : 복막투석 환자에서 고해상도 초음파를 이용한 경동맥 내막-중간막 두께 측정은 심혈관계 질환 유무 예측의 비침습적 검사가 될 수 있고 저알부민혈증 및 높은 CRP과 같은 만성염증 지속상태가 복막투석 환자에서 죽상 동맥 경화증의 발생을 증가시킨다고 가정할 수 있다. Background : Continuous ambulatory peritoneal dialysis(CAPD) patients with low albumin(LA) and signs of inflammation reflected by increased C-reactive protein(CRP) level have an increased mortality, but the mechanism of this phenomenon is not clear yet. Methods : To answer whether LA and inflammation also enhance cardiovascular risk in CAPD patients, we performed cross sectional study measuring carotid artery intima-media thickness(IMT), calculated intima-media area(cIM area) and the presence of plaque by high-resolution B-mode ultrasonography in 93 non-diabetic CAPD patients. Results : Patients with coronary artery disease (CAD, n=8) had significantly increased IMT(0.79± 0.21 mm vs. 0.60±0.11 mm, p<0.05) and higher prevalence of carotid plaques(75.0% vs. 63.5%) compared to the non-CAD patients. Significant inverse correlation was observed between serum albumin (SA) level and cIM area(r=-0.27, p<0.05). Those patients with LA(SA <3.5 g/dL) had significantly increased IMT compared to non-LA patients(0.67±0.15 mm vs 0.61±0.12 mm, p<0.05). Prevalence of carotid plaques was also significantly higher in LA patients (68.0% vs. 55.8%, p<0.05). CRP level revealed a significant positive correlation with cIM area(r=0.21, p< 0.05). Patients with high CRP(≥0.8 mg/dL, n=18) had higher prevalence of carotid plaques (65.8% vs. 50.0%, p<0.05) compared to those patients with CRP <0.8 mg/dL, but IMT and cIMT area were not different. By multivariate logistic regression analysis, old age, high CRP, history of CAD and low SA were the independent risk factors affecting IMT. Conclusion : Our study strongly suggests that low albumin and chronic inflammatory state of CAPD patients could be associated with increasing atherosclerotic cardiovascular disease. (Korean J Nephrol 2002;21(2):285-294)

B형 간염과 연관된 신증후군 치료에 Lamivudine 단독요법과 Lamivudine 및 Steroid 병합요법의 비교

송현용,류동렬,이호영,신석균,황재하,강신욱,최규헌,한광협,하성규,한대석,노현진 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.4

Treatment of nephrotic syndrome associated with hepatitis B are controversial, but some patients may respond to interferon therapy. Steroid therapy in these patients could be limited, because it may aggravate hepatitis with the acute viral replication. Lamivudine may also be effective in reducing viral burden and may convert patients from HBsAg and HBeAg positive to negative. But there was no report for the usefulness of lamivudine in treatment of these patients. We performed a randomized comparative study to assess the usefulness of lamivudine and the effect of steroid in the use of lamivudine in treatment of B-viral associated nephrotic syndrome. Twelve patients(M:F=1:0.2, mean age 34.3 years, MCD 1, MPGN 5, MGN 6 patients) suspected to have the acute viral replication with nephrotic syndrome were included. They were randomly assigned to receive lamivudine and steroid combination therapy(group I, 150mg of lamivudine with high-dose steroid, 1mg/kg/day, orally once daily in 6 patients) or lamivudine alone therapy(group II, 150 mg of lamivudine orally once daily alone in 6 patients). The duration of lamivudine use was 6 months in both groups, and that of steroid use was 6 weeks in group I. Then, lamivudine and steroid were tapered according to the amount of proteinuria and serum HBV-DNA titer. All patients were closely monitored every 2 months with clinical, bioche mical, and serological parameters for 10 months. The rate of negative sero-conversion of HBV- DNA were 91.7%(11/12) at 2 months of lamivudine therapy in all patients, and there was no difference between group I and II(83.3% vs. 100%, p$gt;0.05). In group I, there were a significant decreases of mean serum HBV-DNA values(899.2±711.9 vs. 31.4±32.7, 12.7±27.6, and 137.2±278.1pg/ml, p$lt;0.05, respectively), proteinuria(11.0±3.6 vs. 3.9±2.3, 2.1±2.3, and 2.5±3.1g/d, p$lt;0.05, respectively), and SGPT (57.7±18.9 vs. 30.5±12.4, 23.8±10.2, and 26.0±10.4 IU/L, p$lt;0.05, respectively) measured at 2, 6, and 10months compared to before therapy, and serum albumin levels were significantly increased at 2, 6, and 10months compared to before therapy(2.2±0.5 vs. 3.1±0.5, 3.9±0.8, and 3.9±0.9g/dL, p$lt;0.05, respectively). In group II, serum HBV-DNA was significantly decreased at 2, 6, and 10 months compared to before therapy(358.8±369.3 vs. 19.1±27.0, 0.0±0.0, and 0.0±0.0pg/ml, p$lt;0.05, respectively), and proteinuria and SGPT were significantly decreased at 6 and 10 months compared to before therapy(8.5±5.5 vs. 2.6±1.3 and 2.1±2.3g/d, p$lt;0.05; 67.5±43.0 vs. 25.3±11.6 and 31.5±9.2IU/L, p$lt;0.05, respectively). Serum albumin levels were significantly increased at 10 months compared to before therapy(2.8±0.8 vs. 4.3±0.1g/dL, p$lt;0.05). Serum HBV-DNA levels rebounded in two patients of group I, but none was observed in group II. No serious adverse events were observed in all the patients. In conclusion, lamivudine and steroid combination therapy may more rapidly decrease proteinuria than lamivudine alone in B-viral associated nephrotic syndrome, but may induce the rebound of serum HBV-DNA.