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고유량 혈액투석에서 온라인 혈액여과투석법으로 전환 후 임상 소견과 beta 2-microglobulin 및 oxidized LDL의 변화
신준암 ( Jun Am Shin ),장은희 ( Eun Hee Jang ),백현정 ( Hyun Jeong Baek ),최소연 ( So Yeon Choi ),김민옥 ( Min Ok Kim ),이정은 ( Jung Eun Lee ),허우성 ( Woo Seong Huh ),김대중 ( Dae Joong Kim ),오하영 ( Ha Young Oh ),김윤구 ( Yoon 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.1
목적: 온라인 혈액여과투석법은 고유량 혈액투석법과 혈액여과법을 병합한 치료법으로, 정수 처리된 투석액을 세균학적으로 초정제하여 만든 다량의 보충액을 온라인을 통해 환자의 혈액 내로 주입하여 노폐물 제거 효율을 높인 투석 방법이다. 본 연구에서는 고유량 혈액투석법에서 온라인 혈액여과투석법으로 전환 후 임상소견과 beta 2-microglobulin, oxidized LDL (OxLDL) 변화를 알아보고자 하였다. 방법: 최소 6개월 이상 안정적으로 주 3회 고유량 혈액투석 치료를 받고 있는 환자들 중에 고유량 혈액투석법에서 온라인 혈액여과투석법으로 전환한 14명의 만성신부전 환자들을 대상으로 하였다. 이후 환자의 주관적 증상, 헤모글로빈 수치, 적혈구생성인자 사용용량, Kt/V, 요소의 투석 중 감소율, beta 2-microglobulin, OxLDL, CRP의 변화를 3개월 간격으로 12개월 동안 관찰하였다. 결과: 피로감, 가려움증, 수면장애, 식욕 등의 증상들이 유의하게 호전 되었다 (p<0.05). 적혈구생성인자 사용용량의 변화는 없었음에도 헤모글로빈 수치는 유의하게 증가하였다 (10.6±1.3 vs. 11.4±1.0, p<0.05). Kt/V (1.63±0.17 vs. 1.77±0.24, p<0.05)와 요소의 투석 중 감소율 (75.1±3.2 vs. 77.2±3.9%, p<0.05)이 유의하게 개선되었다. Beta 2-microglobulin 청소율 (17.7±4.4 vs. 21.9±6.1 mL/min, p<0.05)이 유의하게 개선되었으나, 투석 전 beta 2-microglobulin 수치는 유의한 변화가 없었다. OxLDL의 투석 중 감소율은 변화가 없었으나, 투석 전 OxLDL 수치는 유의하게 감소하였다 (32.36±6.03 vs. 26.05±6.00 U/L, p<0.05). 투석 전 CRP 수치는 유의한 변화가 없었다. 결론: 온라인 혈액여과투석법을 통해 환자의 주관적 증상, 빈혈, 소분자 용질 및 beta 2-microglobulin의 청소율 등이 개선되고, OxLDL의 생성량도 줄일 수 있을 것으로 사료된다. Purpose: Hemodiafiltration with the on-line regeneration of ultrafiltrate (on-line hemodiafiltration, OLHDF) provides better clearance of both small and large solutes than high-flux hemodialysis (HFHD) and may reduce inflammation and oxidative stress. The purpose of this observational study was to ascertain whether OL-HDF improves clinical markers after switching from HFHD to OL-HDF in patients with end-stage renal disease. Methods: Fourteen stable patients on HFHD for at least 6 months were switched to OL-HDF. We observed changes in subjective symptoms, the levels of hemoglobin, erythropoietin dose, Kt/V, URR, beta 2-microglobulin, plasma oxidized LDL (OxLDL) and CRP for twelve-months period. Results: There were improvements in subjective symptoms including fatigue, anorexia, insomnia and itching sensation (p<0.05). There were significant increases in Kt/V (1.63±0.17 vs. 1.77±0.24, p< 0.05) and URR (75.1±3.2 vs. 77.2±3.9%, p<0.05). Even though erythropoietin dose was not changed, hemoglobin level was increased (10.6±1.3 vs. 11.4±1.0, p<0.05). Beta 2-microglobulin clearance was significantly increased (17.7±4.4 vs. 21.9±6.1 mL/min, p<0.05). However, the pre-dialysis level of beta 2-microglobulin was not significantly reduced. The pre-dialysis level of CRP was not changed. OxLDL reduction ratio was not changed. On the other hand, the pre-dialysis plasma level of OxLDL was significantly reduced (32.36±6.03 vs. 26.05±6.00 U/L, p<0.05). Conclusion: OL-HDF improved several subjective symptoms, anemia, the clearance of small solute, beta 2-microglobulin level and reduced plasma OxLDL after switching from HFHD. Less OxLDL may be generated in OL-HDF compared with HFHD.
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)
양선 ( Sun Yang ),오성욱 ( Sung Ook Oh ),신준암 ( Jun Am Shin ),박신실 ( Sin Sil Park ),오영재 ( Young Jae Oh ),장기택 ( Kee Taek Jang ),이규택 ( Kyu Taek Lee ) 대한내과학회 2007 대한내과학회지 Vol.72 No.2
저자들은 복통으로 내원한 환자에서 원위부 간외 담도 내의 종괴를 발견하였으나, 방사선학적 검사 및 수술 중 동결절편 검사에서도 악성종양과 감별되지 않아, 광범위 절제술을 시행한 후 진단한 총담관에 발생한 선근종 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Adenomyoma is a nonneoplastic lesion that can be found anywhere in the gastrointestinal tract, but it`s rarely found in the extrahepatic bile duct. To the best of our knowledge, it is a completely benign lesion, but making a clear distinction from malignancy on preoperative evaluation is very difficult. Its clinical importance mainly lies in the possibility that they may be confused with carcinoma, leading to unnecessarily extensive surgical resections. We report here on a case of distal common bile duct adenomyoma that presented with right upper quadrant abdominal pain, and the preoperative examinations could not reveal whether the tumor was benign or malignant. It was finally diagnosed by histological examination after performing pylorus preserving pancreaticoduodenectomy. (Korean J Med 72:217-221, 2007)
임태규 ( Tae Kyu Lim ),엄지은 ( Ji Eun Uhm ),신준암 ( Jun Am Shin ),정혜숙 ( Hae Suk Cheong ),장은희 ( Eun Hee Jang ),박철근 ( Cheol Keun Park ),박준오 ( Joon Oh Park ) 대한내과학회 2006 대한내과학회지 Vol.71 No.5
원발성 간세포암이 난소에 전이하는 경우는 드물다. 이에 저자들은 간세포암 진단을 받고 경간동맥 항암화학 색전술 및 고주파 열치료를 시행받았던 환자에서 간 내에 간세포암의 재발을 보이지는 않았으나 지속적인 알파태아단백 상승이 있던 중 난소에서 발견된 전이성 간세포암 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Primary hepatocellular carcinoma with metastasis to the ovary is a rare malady. To the best of our knowledge, approximately eight cases in the English literature and two cases in the Korean literature have been reported. We report here a case of hepatocellular carcinoma with metastasis to the ovary in a 40-year-old woman who presented with a month long history of lower abdominal discomfort and a palpable mass. She had been diagnosed with hepatocellular carcinoma (HCC) four years prior and subsequently underwent a several courses of transarterial chemoembolization and radio-frequency ablation. The patient had then been seen regularly and was generally well until 4 month ago, when the alpha fetoprotein (AFP) level began to rise to 425 ng/mL. After that time she had been seen and examined every month, however, the AFP level rose to 2,150 ng/mL without evidence of recurrence on the computed tomography (CT) scan of liver, the heapatic artery angiography, PET and so on. On admission, a pelvis MRI revealed mainly solid masses of both ovaries and multiple peritoneal and omental nodules. Transvaginal core biopsy was performed and the histologic examination of the specimen revealed metastatic hepatocellular carcinoma. We report here on one case of ovarian metastasis from hepatocellular carcinoma together with a brief review of the literature.(Korean J Med 71:573-576, 2006)
증례 : 급성 폐렴으로 발현한 Mycobacterium intracellulare 폐질환
이유지 ( Yu Ji Lee ),고원중 ( Won Jung Koh ),박혜윤 ( Hye Yun Park ),신재욱 ( Jae Uk Shin ),신준암 ( Jun Am Shin ),강나리 ( Na Ree Kang ),정혜원 ( Hae Won Jung ) 대한내과학회 2006 대한내과학회지 Vol.71 No.6
MAC NTM 폐질환을 일으키는 가장 흔한 원인균으로 만성폐쇄성폐질환 등 만성 호흡기질환을 가진 환자, 혹은 고령의 여성에서 많이 발생한다. 증상이 서서히 진행하는 경과와 함께 방사선학적으로는 상엽에 공동을 보이거나 기관지확장증에 동반된 다발성 결절이 특징적이다. 저자들은 만성폐쇄성폐질환의 기왕력이 있는 환자에서 급성 폐렴으로 발현한 M. intracellulare 폐질환 증례를 경험하여 이를 보고하는 바이다. The Mycobacterium avium-intracellulare complex (MAC) is the most common pathogen in pulmonary disease Caused by a nontuberculous mycobacteria. Patients with MAC pulmonary disease tend to be older, are more likely to have underlying lung disease than tuberculosis patients. The insidious nature of MAC pulmonary disease has been emphasized in many reports because symptoms may be present for months or years before a diagnosis can be made. Most patients experience chronic coughing, which is usually productive of purulent sputum. A MAC pulmonary infection is rarely accompanied by acute respiratory symptoms and lobar pneumonic consolidation on chest radiography. We report a very rare case of M. intracellulare pulmonary disease Presenting as acute pneumonia. (Korean J Med 71:678-682, 2006)