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김갑현 ( Kim Gab Hyeon ),박병배 ( Park Byeong Bae ),백현정 ( Baeg Hyeon Jeong ),이준행 ( Lee Jun Haeng ),백승운 ( Baeg Seung Un ),백경란 ( Baeg Gyeong Lan ),장기택 ( Jang Gi Taeg ) 대한내과학회 2004 대한내과학회지 Vol.66 No.3
Cytomegalovirus (CMV) infections are usually reported in immunocompromised patients. However, it occurs rarely in immunocompetent individuals. A case of CMV associated with stomach ulcers and mucosal nodules is reported in a immunocompetent host. A previously healthy 27-year-old man visited our hospital with a thirty-day history of epigastric pain and a nine-day history of vomiting. The demonstration of intranuclear inclusion bodies in a few gastric glandular epithelial cells contributed to the diagnosis of CMV gastritis. Treatment with a proton pump inhibitor and ganciclovir was successful to mitigate the epigastric pain and vomiting.
전신적 항응고제 사용이 어려운 말기신부전 환자에서 헤파린 결합된 Hemophan 투석기를 사용한 혈액투석 - 7년간의 임상 경험
윤수진 ( Yun Su Jin ),김범 ( Kim Beom ),이현희 ( Lee Hyeon Hui ),이영기 ( Lee Yeong Gi ),강우헌 ( Kang U Heon ),김정아 ( Kim Jeong A ),이방훈 ( Lee Bang Hun ),여호명 ( Yeo Ho Myeong ),임영환 ( Im Yeong Hwan ),백현정 ( Baeg Hyeon 대한신장학회 2003 Kidney Research and Clinical Practice Vol.22 No.4
목 적 : 저자들은 양전하를 띤 N, N-diethyl-aminoethyl group이 부착되어 있는 Hemophan 투석기에 음전하를 떤 헤파린을 결합시키는 Gretz 등의 방법을 수정하여 출혈 위험성이 있는 말기신부전 환자에서 헤파린 결합 Hemophan을 이용한 혈액투석법 (hemodialysis using heparin bound Hemophan, HBH-HD)을 보고한 바 있다. 저자들은 지난 7년 동안 출혈 위험성이 있는 말기신부전증 환자들에서 HBH-HD를 시행하였으며 이에 그간의 결과를 종합하여 HBH-HD의 안전성과 효율성을 보고하고자 한다. 방 법 : 저자들은 1995년 4월부터 2002년 4월까지 출혈 위험성이 있는 만성혈액투석환자 159명에서, 헤파린을 결합시킨 Hemophan 투석기 (GFS plus 11, Gambro)를 사용하여 총 1,057회의 HBH-HD를 시행하였다. 투석기나 혈액관 교체가 필요할 정도의 심한 혈액응고 없이 4시간 동안 혈액투석이 가능하였던 40회 투석에서 혈액투석 전, 투석 시작 후 15분, 60분, 120분과 투석 종료 직전 (240분)에 혈중 헤파린 농도와 activated partial thromboplastin time (aPTT)을 측정하였다. 투석의 효율성을 평가하기 위하여 동일 환자에서 시행한 HBH-HD와 이후 헤파린을 전신적으로 사용한 혈액투석 (routine hemodialysis, R-HD) 간의 혈액구획용적(total blood compartment volume, TBCV) 손실과 투석기요소청소율 (K), Kt/V를 비교하였다 (n=20). 결 과 : 1,057회 투석 중 11회 (1.0%)에서는 투석 후 150분 이내에 투석기와 혈액관에 혈액 응고가 발생하어 투석을 증단하였고, 64회 (6.1%)에서는 투석 후 150분부터 230분 사이에 혈액관에 혈액응고가 발생하여 혈액관 교체가 필요하였다. 투석기나 혈액관의 교체가 필요할 정도의 심한 혈액응고 없이 4시간 동안 혈액투석이 가능하였던 982회 증 40회의 투석에서 측정된 헤파린 농도는 투석전 값 (0.11±0.06 U/mL, 평균±표준편차)에 비하여 투석 후 15분 (0.14±0.06 U/mL)에 경미한 증가를 보인 후 (p<0.05), 60분에 0.11±0.05 U/mL, 120분에 0.08±0.04 U/mL, 투석 종료 후 0.08±0.04 U/mL로 감소하였다. 투석 중 aPTT는 투석 전 (44.3±12.9초)에 비하여 투석 후 15분 (49.8±10.5초)에 증가한 후 (p<0.05), 60분에 40.8十7.1초, 120분에 36.1±5.5초, 투석 종료 후 32.1±5.3초로 감소하였다. 두 투석간의 TBCV 손실은 HBH-HD시 17.2±9.6%, R-HD시 2.8±1.2%로 유의한 차이를 보였다 (p<0.0001). 그러나, HBH-HD시 측정한 K값은 136.9±14.6 mL/min, Kt/V는 1.27±0.21로 R-HD의 137.6±18.4 mL/min와 1.20±0.22와 각각 비교하여 볼 때 유의한 차이가 없었다 (p>0.05). 결 론 : 헤파린을 결합시킨 투석막을 사용한 혈액투석법은 출혈 위험성이 있는 말기신부전증 환자들에서 시행할 수 있는 안전하고 효과적인 투석법이다. 그러나 체외 회로에 심한 혈액응고를 완전히 방지하지는 못하므로 투석 중 투석기와 혈액관에서 혈액응고 발생 여부를 감시해야 한다. Objective : Positively charged N,N-diethyl-aminoehtyl groups on Hemophan enable negative charged heparin to be bound with the dialyzer membrane and hemodialysis using heparin bound Hemophan (HBH-HD) could be a hemodialysis modality in patients at risk of bleeding. We designed simplified heparin binding technique and evaluated the bleeding risk and effciency of HBH-HD in chronic renal failure patients at risk of bleeding. Methods : During the period from April 1995 through April 2002, 159 patients at high bleeding risk received 1057 HBH-HD (dialyzer : GFS plus 11, Gambro). The duration of each HBH-HD was standardized to 4 hours at blood-flow rate of 200-250mL/min. To evaluate of HBH-HD, we measured serum heparin concentration (HC) and activated partial thromboplastin time (aPTT) at baseline, 15, 60, 120 minutes and endpoint (240 minutes) (n=40). To evaluate the dialysis effciency, HBH-HD and routine hemodialysis with systemic heparinization (R-HD) were compared for total blood compartment volume (TBCV) loss, dialyzer urea clearance (K) and Kt/V in same study group patients (n=20). Results : Clotting of dialyzer necessitating termination of dialysis occurred in 11 (1.0%) out of 1,057 dialyses at 150 minutes, and clotting requiring change of blood line occurred in 64 dialyses (6.1%) between 150 and 230 minutes. There was a slight increase in the aPTT (mean±SD, 49.8±10.5 sec) and HC (0.14±0.06 U/㎖) at 15 min, compared to predialysis levels of 44.3±12.9 sec and 0.11±0.06 U/㎖, respectively (p>0.05). But no increase in aPTT, HC was observed in measurements at 60 min, 120 min, and at the endpoint. TBCV loss was significantly higher in HBH-HD (mean±SD, 17.2±9.6%), compared to R-HD (2.8±1.2%) (p<0.0001). However, K and Kt/V value (mean±SD) were 136.9±14.6 ㎖/min and 1.27±0.21 in HBH-HD and 137.6±18.4 ㎖/min and 1.20±0.22 in R-HD, showing no significant difference (p>0.05). Conclusion : HBH-HD could be a safe and efficient HD technique in patients at high risk of bleeding. Extracorporeal clotting, however, should be observed cardfully during HBH-HD. (Korean J Nephrol 2003;22(4):389-396)
Sjogren 증후군에서 신장 가성림프종에 의한 급성 간질성신염
여호명 ( Yeo Ho Myeong ),허우성 ( Heo U Seong ),백현정 ( Baeg Hyeon Jeong ),임영환 ( Im Yeong Hwan ),김정아 ( Kim Jeong A ),이방훈 ( Lee Bang Hun ),강우헌 ( Kang U Heon ),김범 ( Kim Beom ),이현희 ( Lee Hyeon Hui ),김윤구 ( Kim Yu 대한신장학회 2003 Kidney Research and Clinical Practice Vol.22 No.6
A 65 year-old woman with SjOgren`s syndrome was found to have renal mass and acute renal failure. Immunopathologic analysis of renal biopsy specimens showed polyclonal lymphocytic interstitial infiltration. Gene rearrangement study of T cell receptor showed a polyclonal pattern. The degree of azotemia and the size of pseudolymphoma diminished dramatically with steroid therapy. This is a case of proven pseudolymphoma that was found as renal mass in SjOgren`s syndrome. (Korean J Nephrol 2003;22(6):744-748)
신성철 ( Sin Seong Cheol ),김윤구 ( Kim Yun Gu ),백현정 ( Baeg Hyeon Jeong ),임영환 ( Im Yeong Hwan ),여호명 ( Yeo Ho Myeong ),김응호 ( Kim Eung Ho ),김정아 ( Kim Jeong A ),이방훈 ( Lee Bang Hun ),강우헌 ( Kang U Heon ),김범 ( Ki 대한신장학회 2003 Kidney Research and Clinical Practice Vol.22 No.3
A 21-year-old male was presented with sudden headache, fever, petechiae and neck stiffeness. The diagnosis of meningococcal meningitis was confirmed by examination of cerebrospinal fluid. The clinical symptoms of the illness were improved after treatment of antibiotics. However the paient developed generalized edema, oliguria, azoternia, and heavy proteinuria in the recovery phas of illness. Low serum C3 level was also noted. A kidney biopsy was perfromed and showed the features of postinfectious glomerulonephritis and typical subepithelial humps on electron-microscopic examination. His sysmptoms and laboratory findings were improved, and C3 level re turned to normal range after conservative treatment. We suggest that a complement deficiency should be reled out in patients of glomerulonephritis developed during the recovery phase of meningococcal men ingitis. C3 nephritic factor detection and renal biopsy should be carefully considered in these patients. (Korean J Nephrol 2003;23(3):321-325
단백뇨가 동반되지 않은 고질소혈증으로 발현한 경쇄침착질환
임영환 ( Im Yeong Hwan ),김윤구 ( Kim Yun Gu ),백현정 ( Baeg Hyeon Jeong ),여호명 ( Yeo Ho Myeong ),신성철 ( Sin Seong Cheol ),김정아 ( Kim Jeong A ),강우헌 ( Kang U Heon ),김범 ( Kim Beom ),허우성 ( Heo U Seong ),김대중 ( Kim Da 대한신장학회 2003 Kidney Research and Clinical Practice Vol.22 No.5
A 67-year-old male was admitted to the hospital for evaluation of incidentally detected anemia and mild azotemia. Urinalysis showed no abnormal finding and 24 hr urine protein amount was clinically insignificant (270 mg/day). Urine and serum protein electrophoresis were negative for a monoclonal spike. However, urine and serum immunoelectrophoresis demonstrated the presence of monoclonal free K light chains. Renal biopsy showed the features of chronic tubulointerstitial disease and on the immunofluorescence studies, K light chain was in a linear pattern in basement membranes of glomeruli and tubules. Work-up for multiple myeloma including bone marrow biopsy showed results compatible with multiple myeloma. Treatment was started with vincristine, adriamycin and doxorubicin at monthly interval for three months followed by autologus peripheral blood stem cell transplantation. At follow -up 5 months after autologus peripheral blood stem cell transplantation, the patient is well with a serum creatinine of 2.3-2.6 mg/dL and 24 hr urine protein of 200-350 mg.
한국인에서 Iohexol의 혈장 청소율을 이용한 사구체 여과율의 측정
강우헌 ( Kang U Heon ),권태근 ( Kwon Tae Geun ),김대중 ( Kim Dae Jung ),강명재 ( Kang Myeong Jae ),백현정 ( Baeg Hyeon Jeong ),여호명 ( Yeo Ho Myeong ),임영환 ( Im Yeong Hwan ),김정아 ( Kim Jeong A ),이방훈 ( Lee Bang Hun ),김범 대한신장학회 2004 Kidney Research and Clinical Practice Vol.23 No.2
배 경 : Iohexol (Omnipaque^(?))은 혈장 청소율이 GFR과 일치하는 물질로, 서구에서는 iohexol의 배설단계의 혈장 농도와 그 반감기를 이용하여 혈장 청소율을 계산하고 이를 보정하여 GFR을 추정하고 있다 [Bro¨chner-Mortensen (B-M)법]. 그러나 아직 한국인을 대상으로 그 방법이 정립된 바 없으며 또 가장 적절하고도 편리한 혈장 농도 측정 시간 및 횟수에 대해서는 논란이 있는 실정이다. 이에 저자들은 iohexol외 혈장반감기를 이용한 위와 같은 측정법을 검체 횟수 및 시간 간격을 달리하여 한국인에 적용하였을 때 GFR 측정의 정확도 및 크레아티닌 청소율을 비롯한 여러 GFR 계측 공적들의 정확도를 다음과 같이 검증하였다. 방 법 : 신장질병이 없는 한국인을 대상으로 (n=19) iohexol 정주 후 HPLC로 측정한 14시점의 혈장 농도들을 이용하여 2구획 모델에 의한 iohexol의 혈장 청소율 (CL-T)을 구하였다. 이를 기준으로 첫째 배설단계의 8시점의 농도를 이용하여 B-M법으로 계산된 청소율 (CL-M8), 둘째 그 중 각각 3, 2시점의 농도를 가지고 같은 방법으로 계산된 청소율 (CL-M3, CL-M2), 셋째 CCr를 비롯한 여러 계측 공식들을 이용한 GFR 예측치를 비교하였다. 각 측정치의 정확도는 CL-T를 기준으로 하여 -0.1≤(측정값-CL-T)/CL-T≤0.1를 만족하는 정도 (%)로 평가하였다 (DOQI guideline). 결 과 : CL-T, CL-M8, CL-M3와 CL-M2는 각각 101.9±24.0, 101±18.7, 101.7±18.6,101.9±곤19.5 mL/min/1.73 ㎡로서 서로 차이가 없었으며 CL-M8의 정확도는 74%이었고, CL-M3, CL-M2의 정확도는 각각 84%, 79%로 상호간에 차이가 없었다. GFR 계측 공식 중에서는 MDRD 공식이 비교적 정확하였다 (47%). 결 론 : 이상에서 저자들은 신장질환이 없는 우리나라 사람을 대상으로 iohexol을 이용하여 B-M 보정법으로 사구체 여과율 측정하였을 때 2회의 검체 채취로도 정확하게 사구체 여과율을 측정할 수 있음을 확인하였으나 향후 GFR 값이 다양한 보다 많은 환자를 대상으로 추가 연구가 필요할 것으로 생각한다. Background : Plasma clearance of iohexol (Omnipaque^(?)) which used widely in radiologic procedure is considered as useful method for estimation of GFR because iohexol is neither reabsorbed nor secreted from tubule after filtered as inulin and its extrarenal clearance is negligible. Plasma clearance of iohexol can be calculated from two compartment model or one compartment model with Bro¨chner Mortensen (B-M) modification which convenient and reliable. But there were controversies about sufficient sampling numbers and times for B-M modification of iohexol clearance. Methods : Nineteen healthy Korean without renal disease underwent measurement of iohexol clearance. Iohexol was given as a single iv dose, and 14 blood sample were drawn up to 300 min. A reference GFR was iohexol clearance calculated from two-compartment model using 14 samples (CL-T). From 8, 3 and 2 samples clearances were calculated by B-M modification (CL-M8, 3 and 2 respectively). The accuracy of estimates was evaluated as percent of estimates falling within 10% above or below the reference GFR. Accuracy of CCr and equations for GFR estimation were also compared. Results : CL-T, CL-M8, CL-M3 and CL-M2 were not different (101.9±24.0, 101.9±18.7, 101.7±18.6, 101.9±19.5 mL/min/1.73 m² respectively). Accuracy of CL-M8, 3 and 2 were not different (74%, 84% and 79% respectively, p>0.05). MDRD equation had higher accuracy (47%) compared with other equations. Conclusion : These results indicate that sampling simplified method might be reduced to only two without accuracy loss in Korean without renal disease.