증례 : 신장 ; 급성 췌장염에 병발한 급성 신부전의 급성 복막투석 3예

황주안 ( Joo An Hwang ),문은준 ( Eun Joon Moon ),김은경 ( Eun Kyung Kim ),양민재 ( Min Jae Yang ),황재철 ( Jae Chul Hwang ),박인휘 ( In Whee Park ),김흥수 ( Heung Soo Kim ) 대한내과학회 2009 대한내과학회지 Vol.77 No.5S

Severe acute pancreatitis occurs in about 20% of patients with acute pancreatitis and can be associated with multiorgan failure. Acute renal failure caused by severe acute pancreatitis not only aggravates pancreatitis but also increases patient mortality. Peritoneal exudate contains many toxic substances such as amylase, lipase, phospholipase-A, trypsinogen, prostaglandins, kinin forming enzymes, and histamine releasing factor. Upon entering the circulation, these substances can cause complications, which are responsible for the majority of early deaths. This said, peritoneal dialysis is indicated to remove toxic materials from the peritoneal cavity and to manage acute renal failure. We report three acute peritoneal dialysis cases in acute renal failure associated with severe acute pancreatitis. (Korean J Med 77:S1246-S1252, 2009) 저자들은 급성 췌장염 환자에서 급성 신부전이 동반된 경우 복막투석으로 복강 세척 및 배액을 통해 급성 췌장염의 임상적 증상 호전 및 전신적 합병증을 감소시키고, 급성신부전의 호전으로 소변량 증가와 함께 신기능이 회복된 3예를 경험하였기에 문헌고찰과 함께 보고하는 바이다.

흰가시광대버섯 중독에 의한 급성 신부전 1예

문은준 ( Eun Joon Moon ),황주안 ( Joo An Hwang ),이다미 ( Da Mi Lee ),이민석 ( Min Suk Lee ),김순선 ( Soon Sun Kim ),김선미 ( Sun Mi Kim ),임현이 ( Hyun Ee Yim ),민영기 ( Young Gi Min ),김흥수 ( Heung Soo Kim ),신규태 ( Gyu Tae Sh 대한신장학회 2010 Kidney Research and Clinical Practice Vol.29 No.1

Mushroom poisonings are potentially fatal. Most fatalities are due to the amatoxin that causes fulminant hepatic failure and acute renal failure. We report a patient who developed acute renal failure after ingesting Amanita virgineoides, which required renal replacement therapy, despite recovery of liver injury. A kidney biopsy showed acute tubular necrosis. The patient was recovered with the supportive care and temporary hemodialysis.

논평 참조 ; 만성 간질환에서 간탄성률 측정에 영향을 미치는 요인 분석

이다미 ( Da Mi Lee ),문은준 ( Eun Joon Moon ),황주안 ( Joo An Hwang ),이민석 ( Min Suk Lee ),정재연 ( Jae Youn Cheong ),조성원 ( Sung Won Cho ),김영배 ( Yeong Bae Kim ),김동준 ( Dong Joon Kim ),황성규 ( Seong Gyu Hwang ),양진모 ( 대한간학회 2009 Clinical and Molecular Hepatology(대한간학회지) Vol.15 No.4

목적: 본 논문은 만성 간질환 환자를 대상으로 간탄성률 측정에 영향을 미치는 요인을 알아보기 위해 연구를 시행하였다. 대상과 방법: Transient elastography와 간조직검사를 시행한 만성 간질환 환자 158명을 대상으로 혈액검사 및 간조직 소견을 분석하였으며, 간조직검사 결과는 대한병리학회 기준에 따라 0~4단계로 분류하였다. 결과: 간탄성률은 간조직생검으로 확인한 간섬유화 정도와 유의한 상관관계를 보였다(P=0.636. P<0.001). 간염의 소엽 내 활성도 및 문맥역/문맥주변부 활성도가 높아질수록 간탄성률 측정치도 증가하였으며, spearman 상관계수가 각각 0.359(P<0.001), 0.448(P<0.001)로 유의하였다. 또한 간탄성률은 혈청 총 빌리루빈치, 직접 빌리루빈치, GGT 수치, INR 등과 양의 상관관계가 있었으며, 혈청 알부민치 및 혈소판치와는 음의 상관관계가 있었다. 다변량 회귀분석에서는 간섬유화(B 3.50, P=0.009) 및 간염의 소엽 내 활성도(B 3.25, P=0.047)만이 간탄성률과 관련이 있는 것으로 나타났다. 결론: 만성 간질환 환자에서 간탄성률은 간섬유화뿐만 아니라 간내 염증 활성도에 의해서도 영향을 받음을 확인하였으며, 간탄성률의 해석에 간섬유화뿐만 아니라 간내 염증 정도도 고려해야 할 것이다. Background/Aims: Transient elastography is a new noninvasive tool for measuring liver stiffness that accurately predicts significant fibrosis and cirrhosis. However, several studies have indicated that liver stiffness can be significantly influenced by major changes in aminotransferase in patients with chronic viral hepatitis. The aim of this study was to determine the factors influencing liver stiffness in patients with chronic liver disease. Methods: We studied 158 patients with chronic liver disease who underwent transient elastography and liver biopsy sampling. Histologic findings on fibrosis and necroinflammatory activity in the biopsy specimens were evaluated according to the Korean Society of Pathologists Scoring System. Routine biochemical tests were performed according to standard methods. Results: Liver stiffness was strongly correlated with liver fibrosis stage (Spearman coefficient=0.636, P<0.001), lobular activity (Spearman coefficient=0.359, P<0.001), and portoperiportal activity grade (Spearman coefficient=0.448, P<0.001). Liver stiffness was significantly associated with serum levels of total bilirubin (P=0.025), direct bilirubin (P=0.049), gamma-glutamyl transpeptidase (P=0.014), platelet count (P=0.004), albumin (P<0.001), and international normalized ratio (P<0.001). Multivariate analysis showed that fibrosis stage (B 3.50, P=0.009) and lobular activity grade (B 3.25, P=0.047) were independently associated with liver stiffness. Conclusions: Liver stiffness as measured by transient elastography is associated with the grade of necroinflammatory activity and the stage of fibrosis, irrespective of serum ALT levels. (Korean J Hepatol 2009;15:464-473)

4 cm 이하의 단일결절 간세포암종에서 고주파열치료와 경동맥화학색전술의 효과 비교

양민재 ( Min Jae Yang ),안소연 ( So Yun An ),문은준 ( Eun Joon Moon ),이민석 ( Min Suk Lee ),황주안 ( Joo An Hwang ),정재연 ( Jae Youn Cheong ),원제환 ( Je Hwan Won ),김재근 ( Jai Keun Kim ),왕희정 ( Hee Jung Wang ),조성원 ( Sung 대한간학회 2009 Clinical and Molecular Hepatology(대한간학회지) Vol.15 No.4

Carcinoma, Hepatocellular, Radiofrequency ablation, Chemoembolization, Therapeutic, 간세포암종, 고주파열치료, 경동맥화학 색전술 Background/Aims: Radiofrequency ablation (RFA) is an established curative therapeutic modality for unresectable hepatocellular carcinoma (HCC), and transarterial chemoembolization (TACE) has been used as a palliative treatment for inoperable HCC. It is still unknown whether RFA and TACE are equally effective for improving the survival of patients with unresectable HCC that is amenable to either treatment. The aim of this retrospective study was to compare the clinical impacts of two treatments, and analyze the prognostic factors for recurrence and survival. Methods: Ninety-three patients with a single HCC smaller than 4 cm who showed complete responses (complete ablation or complete lipiodol tagging) after treatment with RFA (n=43) or TACE (n=50) between January 2002 and February 2009 were investigated. Univariate and multivariate analyses were performed for 13 potential prognostic factors using the Cox proportional-hazards model. Results: The time-to-recurrence rates at 1, 2, and 3 years after treatment were 32.9%, 44.3%, and 55.4%, respectively, for the RFA group, and 42%, 68.3%, 71.7% for the TACE group. The probability of survival at 1, 2, and 3 years was 97.7%, 77.4%, and 63.1%, respectively, for the RFA group, and 95.9%, 76.1%, and 60.2% for the TACE group. The time-to-recurrence and overall survival rates did not differ significantly between the two treatment groups. A multivariate Cox proportional-hazards model revealed that a tumor size larger than 3 cm and lower serum albumin levels were independent risk factors for recurrence, and that being male, being seropositive for hepatitis B surface antigen, and having a higher serum albumin level were independent favorable prognostic factors for survival. Conclusions: TACE and RFA exhibited similar therapeutic effects in terms of recurrence and survival for patients with a single HCC smaller than 4 cm, if they could exhibited complete responses. (Korean J Hepatol 2009;15:474-485)

지속적정정맥투석요법과 지속적정정맥여과투석을 사용하는 핍뇨 환자에서 vancomycin의 약동학적 변수 관찰

박인휘 ( In Whee Park ),이선아 ( Sun A Lee ),임승관 ( Seung Kwan Lim ),유수경 ( Su Kyong Yu ),장은정 ( Eun Jung Jang ),문은준 ( Eun Joon Moon ),황주안 ( Joo An Hwang ),김흥수 ( Heung Soo Kim ),신규태 ( Gyu Tae Shin ) 대한신장학회 2010 Kidney Research and Clinical Practice Vol.29 No.5

목적: 지속적 신대체요법이 사용되고 있는 환자들에게서는 vancomycin 치료가 필요한 경우가 흔하지만 연속적 정정맥 혈액투석 (continuous venovenous hemodialysis, CVVHD) 또는 연속적 정정맥 혈액여과투석 (continuous venovenous hemodiafiltration, CVVHDF)을 받고 있는 국내 환자를 대상으로 한 약동학적 연구는 부족한 실정이다. 이에 저자들은 이러한 환자들에게서 vancomycin 의 약동학적 변수에 관하여 연구 했다. 방법: 2008년 1월 1일부터 2009년12월31일까지 CVVHD 또는 CVVHDF 치료를 받고 있고 핍뇨가 있는 환자 중 vancomycin이 항정 상태에서 혈중 농도가 측정된 23명 35예를 대상으로 일반적 특성과 약동학적 지표를 분석했다. 결과: CVVHD가 사용된 8예와 CVVHDF가 사용된 27예에서 분석이 가능 했다 신대체요법의 정도는 CVVHD군에서 17.7±4.9 mL/h/kg였고 CVVHDF군에서는 32.1±3.9mL/h/kg였다 (p=0.000). Vancomycin의 청소율은 CVVHD군에서 16.4±3.8mL/min CVVHDF에서는 16.4±3.8 mL/min, CVVHDF에서는 21.6±5.1mL/min 였다. (p=0.007). Vancomycin의 체내 제거율과CVVDH와 CVVHDF의 배액 속도간에는 의미 있는 비례 관계가 있었다. (CVVHD; r2=0.745, p=0.012, CVVHDF; r2= 0.452, p=0.000). 결론: CVVHD와 CVVDHF는 체내로 투여된 vancomycin을 효과적으로 청소시키고 있었고 vancomycin의 청소율은 지속적 신대체요법의 정도에 비례하였으므로 vancomycin 투여 용량 결정시 이를 중심으로 약동학적 관련 요소가 고려되어야 한다. Purpose: Critically ill patients receiving continuous renal replacement therapy are susceptible to infection with methicillin-resistant bacteria, which require treatment with vancomycin. However, there are limited reports regarding vancomycin pharmacokinetics in the continuous venovenous hemodialysis (CVVHD) and continuous venovenous hemodiafiltration (CVVHDF). We performed this study to investigate the pharmacokinetics of vancomycin in oliguric patients receiving CVVHD and CVVHDF. Methods: Data at steady-state obtained as part of our routine drug monitoring of vancomycin therapy in critically ill adult oliguric patients undergoing CVVHD or CVVHDF, retrospectively. Data were available for 35 cases of 23 patients assessed for 2 years. We analyzed the pharmacokinetic parameters of these cases. Results: 8 cases on CVVHD and 27 cases on CVVHDF were available. The mean intensity of CVVHD was 17.7±4.9 mL/hour/kg and that of CVVHDF was 32.1±3.9 mL/hour/kg (p=0.000). The mean clearance of vancomycin was 16.4±3.8 mL/min in the CVVHD group and 21.6±5.1 mL/min in the CVVHDF group (P=0.007). The elimination of vancomycin correlated with the intensity of CVVHD and CVVHDF (CVVHD; r2=0.745, p=0.012, CVVHDF; r2=0.452, p=0.000). Conclusion: CVVHD and CVVHDF are effective for vancomycin elimination and there is a strong dependency of the vancomycin removal on the intensity of continuous renal replacement therapy. Strategies for individualization of vancomycin therapy in patients receiving CVVHD and CVVHDF are proposed.