비대상성 간경변증 환자의 예후지표로서 Model for End-stage Liver Disease와 간정맥압차의 비교

이성화 ( Sung Hoa Lee ),박승하 ( Seung Ha Park ),김고운 ( Go Woon Kim ),이우진 ( Woo Jin Lee ),홍원기 ( Won Ki Hong ),류명신 ( Myeong Shin Ryu ),박규태 ( Kyu Tae Park ),이민영 ( Min Young Lee ),이찬우 ( Chan Woo Lee ),김진호 ( Jin 대한간학회 2009 Clinical and Molecular Hepatology(대한간학회지) Vol.15 No.3

목적: 비대상성 간경변증 환자에서 3개월과 12개월 시점의 간정맥압차와 MELD의 사망예측 정확도를 비교하여, HVPG의 예후인자로서의 역할을 확인하고자 하였다. 대상과 방법: 2006년 1월부터 2008년 6월까지 한림대학교부속 춘천성심병원에서 136명의 비대상성 간경변증 환자를 대상으로 HVPG를 측정하였다. 생존분석의 1차 결과 변수로서 3개월과 12개월에서의 사망 여부를 확인하였다. 결과: Cox 회귀분석 결과, MELD와 HVPG 모두 독립적인 예후인자로 확인되었다[각각 hazard ratio는 1.11(95% CI, 1.04 to 1.20)과 1.12(95% CI, 1.08 to 1.16)]. 두 변수의 ROC곡선의 AUC를 비교해 볼 때, 3개월에서 유의하진 않지만 MELD는 HVPG보다 사망예측에 있어서 정확도가 8% 정도 더 높게 보였다[0.76(95% CI, 0.62 to 0.89) 대 0.68(95% CI, 0.52 to 0.84), P=0.22]. 12개월에서는 MELD와 HVPG 모두 비슷한 사망예측의 정확도를 보였다[0.72(95% CI, 0.61 to 0.83) 대 0.73 (95% CI, 0.61 to 0.84), P=0.45,]. 결론: MELD와 HVPG는 비대상성 간경변증 환자에서 사망과 관련된 독립적인 예후인자로서 사망예측의 정확도에 있어서 유의한 차이를 보이지 않는다. 하지만 HVPG는 침습적이고 소수의 의료기관에서만 시행된다는 점에서 사망예측인자로서 HVPG의 역할은 제한적이라 판단된다. 그러나 HVPG의 다양한 예후인자로서의 임상적 역할을 규정하기 위해서는 폭넓은 환자군(원인, 성별, 지역, 등)을 대상으로 하는 전향연구가 필요하다. Backgrounds/Aims: This study compared the prognostic values of the Model for End-stage Liver Disease (MELD) and the hepatic venous pressure gradient (HVPG) in the prediction of death within 3 and 12 months in patients with decompensated liver cirrhosis. Methods: We used data from 136 consecutive patients with decompensated cirrhosis who underwent HVPG between January 2006 and June 2008. Cox regression analysis was used to investigate the independent relationships with death of MELD and HVPG. The prognostic accuracies of MELD and HVPG were analyzed by calculating the area under the receiver operating characteristic curve (AUROC) for the occurrence of death within 3 and 12 months. Results: Both MELD and HVPG were independent predictors of death [hazard ratio (HR)=1.11 and 1.12, respectively; 95% confidence interval (CI)=1.04~1.20 and 1.08-1.16]. Analysis of the AUROC demonstrated that the prognostic power did not differ between MELD and HVPG for predicting the 3-month survival (HR=0.76 and 0.68, respectively; 95% CI=0.62~0.89 and 0.52~0.84; P=0.22) or the 12-month survival (HR=0.72 and 0.73, 95% CI=0.61~0.83 and CI=0.61~0.84). Conclusions: Both MELD and HVPG are independent prognostic factors of death within 3 and 12 months in patients with decompensated liver cirrhosis, and their accuracies are similar. However, HVPG has a limited role in the prediction of death in decompensated cirrhosis due to its invasiveness and limited use. (Korean J Hepatol 2009;15:350-356)

Calcium Polystyrene Sulfonate 복용으로 유발된 급성 대장 괴사의 1예

이성화 ( Sung Hoa Lee ),김성중 ( Sung Jung Kim ),김고운 ( Go Eun Kim ),이우진 ( Woo Jin Lee ),홍원기 ( Won Ki Hong ),백광호 ( Gwang Ho Baik ),최영희 ( Young Hee Choi ),김동준 ( Dong Joon Kim ) 대한소화기학회 2010 대한소화기학회지 Vol.55 No.4

A 63-year-old woman was admitted due to right upper quadrant abdominal pain. She was going through hemo-dialysis due to end stage renal disease and taking calcium polystyrene sulfonate orally and rectally due to hyperkalemia. Colonoscopy showed a circular ulcerative mass on the proximal ascending colon. Biopsy specimen from the mass showed inflammation and necrotic debris. It also revealed basophilic angulated crystals which were adherent to the ulcer bed and normal mucosa. These crystals were morphologically consistent with calcium polystyrene sulfonate. She was diagnosed with calcium polystyrene phosphate induced colonic necrosis and improved with conservative treatment. (Korean J Gastroenterol 2010;55:261-265)

ALT<80 IU/L인 만성 B형 간염 환자의 중등도 이상 간섬유화 유병률

이우진 ( Woo Jin Lee ),박승하 ( Seung Ha Park ),김동준 ( Dong Joon Kim ),이성화 ( Sung Hoa Lee ),이찬우 ( Chan Woo Lee ),박규태 ( Kyu Tae Park ),정재연 ( Jae Youn Cheong ),조성원 ( Sung Won Cho ),황성규 ( Seong Gyu Hwang ),이연재 대한내과학회 2010 대한내과학회지 Vol.78 No.1

Background/Aims: The aims of this study were to investigate the prevalence of significant fibrosis in patients with chronic hepatitis B (CHB) virus infections and alanine aminotransferase (ALT) <80 IU/L, and to develop a noninvasive predictive model for significant fibrosis. Methods: The 136 patients with CHB who underwent liver biopsy were recruited from six tertiary hospitals. The diagnostic value of predictors was judged using multivariate logistic modeling and the area under the receiver operating characteristic (AUROC) curve. Results: Significant fibrosis was diagnosed in 97 patients (71.3%, 95% CI, 63.7~78.9%). In the training set (n = 85), the most important clinical data for predicting significant fibrosis were age and aspartate aminotransferase (AST). The AUROC of this model was 0.86 (95% CI, 0.78~0.94). The validation set (n=51), obtained from another institute, yielded similar results [AUROC: 0.90 (95% CI, 0.78~0.99)]. Conclusions: A high prevalence of significant fibrosis in CHB patients with ALT <80 IU/L was observed. A simple model that includes age and AST provides an easily applicable tool for physicians to guide the decision-making process regarding the need to perform a liver biopsy in individual patients. However, additional studies are needed to explore the model`s performance in larger, independent patient populations. (Korean J Med 78:68-74, 2010)

가을철 유행하는 급성열성질환의 폐침범과 CRP와의 연관관계

김고운 ( Go Woon Kim ),이우진 ( Woo Jin Lee ),홍원기 ( Won Ki Hong ),이성화 ( Sung Hoa Lee ),이창률 ( Chang Youl Lee ),이명구 ( Myung Goo Lee ),현인규 ( In Gyu Hyun ),정기석 ( Ki Suck Jung ) 대한결핵 및 호흡기학회 2009 Tuberculosis and Respiratory Diseases Vol.66 No.2

연구배경: 쯔쯔가무시병, 렙토스피라병, 신증후출혈열은 우리나라에서 흔한 급성열성질환으로 최근 발병과 유행성의 보고가 있음에도 불구하고 열성질환에 있어서 폐 침범에 대한 연구는 부족한 상태이다. 열성질환에 있어서 폐합병증이 있을 때 임상적으로 더 심한 경과를 보이고 CRP 수치도 더 높게 측정되는 경우가 있어 입원 시 측정한 CRP값이 조기에 적극적인 치료 대상에 대한 예측인자가 될 수 있는지 알아보고자 하였다. 방법: 2002년 1월부터 2008년 5월까지 한림대학교 춘천성심병원에서 혈청학적 검사에서 양성이거나 임상적으로 진단을 받았던 환자를 대상으로 후향적 연구를 하였다. 결과: 총 105명의 환자가 대상이 되었고 쯔쯔가무시병 63명(63%), 신증후출혈열 32명(30.5%), 렙토스피라병 10명(9.5%)이었고 폐침범은 42명(40%)에서 관찰되었으며 폐부종 20명(19%), 가슴막삼출 20명(19%), 간질폐렴 2명(2%)이었다. CRP는 평균 8.87±7.29 mg/dl였고 20 mg/dl 이상의 높은 값을 보였던 환자도 8명 있었고 폐침범 중 간질폐렴 형태에서 가장 높은 평균값을 보였다(p=0.027). 폐합병증을 보였던 환자군에서 임상적으로 심한 경과를 보였으며 중환자실 입원치료와 인공호흡기 치료를 동반하고 있었고 더 높은 CRP값을 보였다(p=0.0073). 결론: 급성열성질환에 있어서 폐합병증을 보인 군에서 더 높은 CPR 수치가 측정되었으며 입원 시 CRP측정을 통해 조기에 더 적극적인 치료가 필요한 환자군을 선택할 수 있고 폐침범에 의한 사망률과 치명률의 감소에도 도움이 될 것으로 추정된다. Background: Tsutsugamushi, leptospirosis and hemorrhagic fever with renal syndrome (HFRS) are the prevalent diseases among the acute febrile illnesses in Korea. Pulmonary involvement in the patients with these diseases remains poorly recognized in endemic regions, and this is despite reports of recent outbreaks and epidemic episodes. Pulmonary involvement and a higher CRP level as clinical manifestations show a more severe form of infection. The aim of this study is to analyze the correlation of pulmonary involvement and the CRP level in patients with acute febrile illnesses. Methods: We retrospectively reviewed the clinical records of 105 patients who were diagnosed with tsutsugamushi, HFRS and leptospirosis from January 2002 to May 2008 in Chuncheon Sacred Heart Hospital. The radiographic images were retrospectively analyzed by two radiologists. We analyzed the pulmonary complications of the patients with these febrile diseases and we checked the CRP level at admission. Results: The study included 105 patients who were diagnosed with febrile diseases. Of these patients, 32 patients had hantaan, 10 patients had leptospirosis and 63 patients had tsutsugamushi disease. 42 (40%) patients had pulmonary complications, 20 patients had pulmonary edema, 20 patients had pleural effusion and 2 patients had interstitial pneumonitis. The patients with pulmonary involvement showed a more severe form of infection and a higher CRP level than that of those patients without pulmonary involvement (p=0.0073). Conclusion: Pulmonary involvement in patients with acute febrile diseases might be correlated with a higher CRP level. Identification of this factor on admission might provide useful selection criteria for the patients who need early intensive care.

급성심근경색증으로 체외막산소화장치 치료 중 Futhan을 사용한 예

홍원기 ( Won Ki Hong ),김고운 ( Go Woon Kim ),이성화 ( Sung Hoa Lee ),이우진 ( Woo Jin Lee ),윤덕형 ( Duck Hyoung Yoon ),김형수 ( Hyoung Soo Kim ),한상진 ( Sang Jin Han ) 대한내과학회 2010 대한내과학회지 Vol.79 No.2

It is essential during extracorporeal membrane oxygenation (ECMO) to extend the activated clotting time (ACT) using anticoagulants to prevent blood clot formation. Traditionally, heparin has been used as an anticoagulant during ECMO. Hemorrhaging due to systemic heparinization is considered a major complication of ECMO. A 48-year-old man was admitted due to cardiogenic shock with acute myocardial infarction. ECMO was instituted because of recurrent ventricular tachycardia and refractory shock. We used nafamostat mesilate (Futhan) as an anticoagulant to reduce hemorrhagic complications. The total bypass time was 153 h. The average dose of nafamostat mesilate was 2.64±1.11 mg/kg/h; the average ACT was 128.68±21.24 seconds. Only a few units were transfused, and there was no oxygenator failure or hemorrhagic complications. Thus, nafamostat mesilate may reduce the need for transfusions and hemorrhagic complications during ECMO. (Korean J Med 79:181-186, 2010)