상염색체우성 다낭신에서 질병진행 예측인자로서 요중 안지오텐시노겐의 유용성

박혜인조 ( Hayne Cho Park ),황진호 ( Jin Ho Hwang ),백선하 ( Seon Ha Baek ),한미연 ( Mi Yeun Han ),윤유경 ( Yu Kyoung Yun ),윤명옥 ( Myeong Ok Yoon ),오국환 ( Kook Hwan Oh ),구자룡 ( Ja Ryong Koo ),김형직 ( Hyung Jik Kim ),노정우 ( 대한신장학회 2011 Kidney Research and Clinical Practice Vol.30 No.5

Purpose: The renin-angiotensin-aldosterone system activation has been suggested as a potential risk factor for renal progression in autosomal dominant polycystic kidney disease (ADPKD). This study was performed to evaluate urinary angiotensinogen as a biomarker of renal progression in ADPKD. Methods: Patients with estimated glomerular filtration rate (eGFR) 30 mL/min/1.73m≥2 were enrolled in the study. Specimens (blood and urine) and computed tomography (CT) were taken from each subject. The eGFR was calculated by 4-variable MDRD equation and total kidney volume (TKV) was measured from CT images by modified ellipsoid method. Urinary angiotensinogen (AGT) and neutrophil gelatinaseassociated lipocalin (NGAL) were measured by ELISA. The concentration of AGT was adjusted with random urine creatinine (Cr). The association between urinary biomarkers, TKV and eGFR were evaluated. Results: A total of 59 (M:F=31:28) subjects were enrolled in the study and their mean age was 46 years. The eGFR and TKV at the enrollment were 77.3±15.6 mL/min/1.73m2 and 1389.8±925.1 mL, respectively. Log AGT/Cr was associated with TKV (r2=0.11p=0.01) in the earlier stage of disease (TKV<000 mL). However, it did not show significant correlation with eGFR. Log NGAL was not associated with either TKV or eGFR. Urinary AGT/Cr was closely related to the number of anti-hypertensive medication, TKV, and the presence of albuminuria, although there was no correlation with plasma renin activity or aldosterone level. Conclusion: Urinary angiotensinogen may be a useful biomarker of disease progression in ADPKD patients.

장 유착 박리술 후 현저히 호전된 피막성 복막 경화증

윤현배 ( Hyun Bae Yoon ),박혜인조 ( Hayne Cho Park ),이하정 ( Ha Jeong Lee ),한승석 ( Seung Suk Han ),박규주 ( Kyu Joo Park ),문주영 ( Ju Young Moon ),안규리 ( Cu Rie Ahn ),오국환 ( Kook Hwan Oh ) 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.3

Encapsulating peritoneal sclerosis (EPS) is a rare but fatal complication of continuous ambulatory peritoneal dialysis (CAPD). There are some reports on the effect of immunosuppressant therapy including steroid, but the results have not always been promising. Recently, owing to the advance of surgical techniques, there are some reports of the EPS cases significantly improved after successful surgery. A 30-year old man developed EPS after 9 years of peritoneal dialysis, and switched to hemodialysis. In spite of repetitive conservative management and immunosuppressant therapy, there was no improvement. His body weight decreased from 50 kg to 40 kg (BMI 14.2 kg/m2) due to severe malnutrition, so we decided to perform surgery. Total intestinal enterolysis was done successfully without concomitant enterectomy, and his general condition improved dramatically. Four months after surgery, the serum albumin concentration increased from 3.1 g/dL to 4.3 g/dL, cholesterol from 92 mg/dL to 208 mg/dL, and hemoglobin from 9.2 g/dL to 12.5 g/dL. His body weight increased to 61 kg (BMI 21.6 kg/m2), and there was not any fluid collection or bowel obstruction seen on the abdominal CT scan. We experienced a case of EPS which was significantly improved after enterolysis. We report this case with review of the literature.

최근 18년간 단일 기관 진료 자료를 바탕으로 분석한 복막투석 환자의 생존율 및 예후 인자 탐색

윤현배 ( Hyun Bae Yoon ),박혜인조 ( Hayne Cho Park ),이하정 ( Ha Jeong Lee ),한승석 ( Seung Suk Han ),김세중 ( Se Joong Kim ),주권욱 ( Kwon Wook Joo ),김연수 ( Yon Su Kim ),안규리 ( Cu Rie Ahn ),한진석 ( Jin Suk Han ),김성권 ( Suhn 대한신장학회 2009 Kidney Research and Clinical Practice Vol.28 No.1

목적: 복막투석은 말기신부전증의 신대체요법으로 널리 사용되고 있으나, 국내 생존 관련 자료가 부족한 실정이다. 이에 저자들은 1990년 이후 서울대병원에서 시행한 복막투석 환자의 생존 및 복막염 관련 자료를 분석함으로써, 향후 진료와 연구에 기초 자료로 활용하고자 하였다. 방법: 1990년 1월 1일부터 2007년 6월 30일 사이에 서울대병원에서 복막투석을 시작한 15세 이상의 환자 가운데, 3개월 이상 복막투석을 시행한 670명을 대상으로, 2007년 12월 31일까지 관찰하였다. 이들의 성별, 나이, 신부전의 원인, 당뇨병, 심혈관 질환, Davies Comorbidity Score, 사망이나 복막투석 중단의 원인, 그리고 복막염에 대한 자료를 분석하였다. 생존율은 Kaplan-Meier 방법으로 분석하였고, 생존율에 영향을 미치는 독립적인 인자들을 구하기 위하여 multivariate Cox proportional hazard model을 이용하였다. 결과: 말기신부전증의 원인은 당뇨병이 33.7%로 가장 많았고, 심혈관계 질환은 20.4%에서 동반되었다. 사망 원인을 알 수 있는 58명 중, 심혈관계 질환이 24명 (41.3%), 감염이 20명 (34.4%)이었으며, 복막투석 중단의 원인으로는 복막염이 66.1%로 가장 많았다. 1995년부터 2007년까지 전체 연간 환자당 복막염 발생률은 0.270회였고, 1995년부터 1999년까지 0.365회인 반면, 2000년부터 2007년까지의 발생률은 0.230회로 감소한 것으로 나타났다. 복막염의 원인균은 그람 양성균이 42.6%로 가장 많았고, 그람 음성균이 23.8%, 균이 동정되지 않는 경우는 26.9%를 차지하였다. 평균 생존 기간은 107.5±4.2개월이었고, 5년 환자 생존율은 71.7%, 10년 생존율은 48.2%이었다. 한편, 평균 복막투석 기간은 106.5±4.3개월이었고, 5년 기술 생존율은 72.8%, 10년 기술 생존율은 43.8%였다. 복막투석 환자 사망에 영향을 미치는 독립적인 인자는 당뇨 (HR 1.973, p=0.001), 심혈관 질환 (HR 2.040, p<0.001), 복막투석을 시작할 당시 나이인 것으로 나타났으며, 40세 미만에 비하여 40세 이상 60세 미만의 위험도는 2.427 (p=0.016), 60세 이상의 위험도는 7.397 (p<0.001)이었다. 한편, 기술 실패에 영향을 미치는 독립적인 인자는 60세 이상의 나이 (HR 1.791, p=0.025)와 0.270회/년보다 높은 복막염 발생률 (HR 2.361, p<0.001)이었다. 결론: 서울대병원에서 시행한 복막투석의 환자 및 기술 생존율과 복막염 발생률은 국내외 보고에 비하여 비슷하거나 우수하였고, 당뇨병, 심혈관계 질환, 그리고 복막투석 시작 당시 나이가 환자 생존율에 영향을 미치는 독립적인 인자로 나타났으며, 나이와 복막염 발생률이 기술 생존율에 영향을 미치는 독립적인 인자로 나타났다. Purpose: We investigated the survival rate, factors associated with survival, and peritonitis incidence in PD patients who commenced PD at our center since 1990. Methods: We investigated 670 patients who started PD between January 1990 and June 2007. Data for sex, age, etiology of ESRD, comorbidities, follow-up duration, cause of death, and peritonitis were analyzed. Kaplan-Meier method was used to determine patient survival and technique survival rate. Results: The most common cause of death was cardiovascular disease, while peritonitis was the main reason for technique failure. The overall incidence of peritonitis between 1995 and 2007 was 0.270 episodes per patient-year, and there was a significant drop of peritonitis rate from 1995-1999 (0.365) to 2000-2007 (0.230). Patient survival after 5 and 10 years was 71.7% and 48.2% respectively. Technique survival after 5 and 10 years was 72.8% and 43.8%. Older age (age 40-59: HR 2.427, p=0.016; age≥60: HR 7.397, p<0.001), diabetes (HR 1.973, p=0.001), and cardiovascular disease (HR 2.040, p<0.001) were the independent risk factors of mortality, while older age (age≥60: HR 1.791, p=0.025) and higher peritonitis rate (HR 2.361, p<0.001) were the independent risk factors of technique failure. Conclusion: The patient survival, technique survival and peritonitis incidence of PD patients in our center showed outcomes comparable to other centers worldwide. Older age, diabetes, and cardiovascular disease were associated with lower patient survival, while older age and higher peritonitis rate were associated with higher technique failure.

임상 연구 : 입원 환자에서 발생한 중증 저나트륨혈증의 임상상 및 경과 분석; 간질환 유무에 따른 비교

김효상 ( Hyo Sang Kim ),이하정 ( Ha Jeong Lee ),박혜인조 ( Hayne Cho Park ),정지용 ( Ji Yong Jeong ),손민정 ( Min Jeong Son ),오국환 ( Kook Hwan Oh ),김연수 ( Yon Su Kim ),안규리 ( Cu Rie Ahn ),한진석 ( Jin Suk Han ),김성권 ( Suhng 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.6

목적: 간질환은 저나트륨혈증의 가장 흔한 원인 중 하나이며, 저나트륨혈증의 정도가 심할 경우 적절한 치료가 이루어지지 않으면 심각한 합병증이 발생할 수 있다. 이에 저자들은 중증 저나트륨혈증 환자의 발생 빈도와 임상상을 간질환의 유무에 따라 알아보고자 하였다. 방법: 2005년 1년 동안 3차 단일 의료 기관에 입원한 환자 중 저나트륨혈증이 관찰된 12,729명의 환자를 대상으로 후향적 연구를 진행하였다. 저나트륨혈증은 혈청 나트륨이 135 mmol/L 미만인 경우로, 중증 저나트륨혈증은 2회 이상 125 mmol/L 이하인 경우로 정의하였다. 결과: 저나트륨혈증이 확인된 12,729명의 환자 중 711명 (0.13%)에서 중증 저나트륨혈증이 관찰되었으며, 중증 저나 트륨혈증 환자 중 290명 (40.8%)은 간질환 환자였다. 중증 저나트륨혈증의 주된 원인은 간질환 환자군에서는 간부전 (69.7%)이었으며, 간질환이 없는 환자군에서는 과도한 저장성 수액 공급 (37.3%)이었다. 양 군 모두에서 고장성 식염수를 투여하는 것이 가장 흔히 사용된 치료 방법이었다. 간질환 환자군에서 입원과 퇴원 시 혈청 나트륨이 간질환이 없는 환자들보다 낮았으며 (입원 시 128.8±7.1, 퇴원 시 127.1±8.4 vs 132.1±7.5, 131.5±8.3 mmol/L), 중증 저나트륨혈증의 지속 시간도 간질환 환자군에서 더 길었다 (5일 vs 3일). 중증 저나트륨혈증에 대해 치료를 받은 589명의 환자 중 261명이 정상 나트륨 수준으로 교정되었으며, 교정된 비율은 간질환 환자군이 간질환 없는 환자들에 비해 낮았다. 결론: 간부전은 입원 환자에서 발생한 중증 저나트륨혈증의 가장 흔한 원인이었다. 간질환 환자에서 발생한 중증 저나트륨혈증은 간질환이 없는 환자들에 비해 나쁜 임상상을 보였다. Purpose: Liver disease is one of the most common causes of hyponatremia and improper management of severe hyponatremia may result in serious complications. We evaluated the prevalence and clinical characteristics of severe hyponatremic patients according to the presence of liver disease in hospitalized patients. Methods: We studied 12,729 hyponatremic patients during hospitalization in single tertiary referral hospital for 1 year. Hyponatremia was defined as serum sodium level <135 mmol/L and severe hyponatremia as ≤125 mmol/L at least twice. Results: Of 12,729 hyponatremic patients, 711 (0.13%) patients had severe hyponatremia and 290 (40.8%) patients with severe hyponatremia had liver disease. The main cause of severe hyponatremia was liver failure (69.7%) in patients with liver disease and excessive administration of hypotonic fluid (37.3%) in non-liver disease patients. The administration of hypertonic saline was the most common treatment both in liver and non-liver disease group. In severe hyponatremic liver disease patients, the serum sodium level was lower (128.8±7.1 at admission, 127.1±8.4 at discharge vs 132.1±7.5, 131.5±8.3 mmol/L) and the duration of severe hyponatremia (5 days vs 3 days) was longer than those in non-liver disease group. Of 589 patients with severe hyponatremic patients who had been treated for the sodium correction, 261 patients were recovered from severe hyponatremia to normal range of serum sodium, and lower correction rate was observed in liver disease group. Conclusion: Liver failure was the most common cause of severe hyponatremia in hospitalized patients. Severe hyponatremia in patients with liver disease had poor clinical outcomes.

스테로이드를 투여 받는 환자에서 발생한 Nocardia farcinica 뇌 종양 1예

심성훈,박혜인조,김충종,전재현,김의종,오명돈,김남중,최강원 대한감염학회 2008 감염과 화학요법 Vol.40 No.5

Nocardiosis occurs mostly in the immunocompromised patients. N. farcinica is known to have resistance to some antibiotics and significant increase in morbidity and mortality in patients requiring long-term treatment. Nocardia farcinica infection, especially brain abscess, has not been reported in Korea. Here, we report a case of N. farcinica brain abscess in a patient receiving steroid treatment. The patient was a 64 year-old male with gouty arthritis, He received steroid for more than two months, because of allopurinol-hypersensitivity syndrome with skin rash. After three months of steroid therapy, he visited other hospital with mild fever and left thigh pain and was diagnosed of intramuscular abscess due to gram positive bacilli. One month later, he visited our hospital with right side weakness and was diagnosed as brain abscess. The causative organism turned out to be N. farcinica, which was confirmed by means of 16S rRNA sequencing. Antibiotics were selected by E-test results and treatment was successful.