HBsAg 양성 말기 신부전 환자에서의 신이식

배현호(Hyun Ho Bae),장익득(Ik Deuk Jang),김중경(Joong Kyoung Kim),윤명순(Meung Soon Yoon),이시래(Si Rhae Lee) 대한내과학회 1995 대한내과학회지 Vol.49 No.3

N/A Methods: From December 1984 to June 1991, 21 HBsAg positive and 248 HBsAg negative patients underwent living renal transplantation in Kosin Medical College. During follow up period of a mean 32.7 months in HHsAg positive group and 33.0 months in HBsAg negative group, HBsAg, HBsAb and anti HBc examinations were done by radioimmunoasssy and biochemical liver function tests were performed monthly. The liver function abnormality was diagnosed when aminotransferase values were above the normal range(50 I.U./L)in at least two consecutive determinations. The immunosupressant hepatic toxicity was taken into account when amino transferase elevation promptly returned to normal after reducing the drug dosage and was excluded in this study. Differences between HRsAg positive and negative patients were tested for statistical significance by the chi square test. Results: 1) There was no significant difference in patient and graft survival of HBsAg positive and HBsAg negative group and in the incidence of acute rejection in bath groups. 2) The significantly higher incidence of hepatic dysfunction in HBsAg positive group than HBsAg negative group was noted. Excluding chronic active hepatitis and liver cirrhosis from transplantation in HBsAg positive patients, no notable relation between pre-tansplantation histological changes and the patients and graft survival during follow up period of 32.7 months was found. 3) There was slightly better survival rate in HBsAg positive transplants than HBsAg positive hemodialysis patients. Conclusion: The hepatitis B antigenemia is not an absolute contraindication to renal transplantation, We recommend a pre transplantation liver biopsy in HBsAg positive patients, and if the histological findings suggest a benign form of liver disease, we would have no hesitation in providing a renal transplant in spite of an HBsAg positive status. To reduce the mortality from hepatic failure, the doses of immunosuppressive drugs should be lowered or with- drawn in patients who exhibit severe hepatic dysfunction.

지속성 외래 복막투석 ( CAPD ) 환자에서 영양 상태를 반영하는 지표들과 요소 동력학 모형 ( Urea Kinetic Modeling ) 및 크레아티닌 청소율과의 비교 관찰

이종명(Jong Myoung Lee),허동(Dong Hu),정유성(yu Seong Jeong),장익득(Ik Deuk Jang),배현호(Hyun Ho Bae),김지윤(Jee Yoon Kim),김중경(Joong Kyoung Kim),윤명순(Meung Soon Yoon),이시래(Si Rhae Lee) 대한내과학회 1997 대한내과학회지 Vol.52 No.3

N/A Objectives: Protein-calorie malnutrition has been shown to be prevalent among patients on chronic dialysis, And assessment of nutritional status of continuous ambulatory peritoneal dialysis(CAPD) patients has assumed greater importance because of the association of protein-calorie malnutrition with increasing morbidity and mortality. So we observed the incidence and clinical effect of protein-calorie malnutrition, and we compared the indices of nutrition with dialysis adequacy utilizing urea kinetic modeling and cretinine clearance in CAPD patients. Methods: We performed a cross-sectional study in which eight parameters, based on anthropometry, blood chemistry and subjective symptoms, were scored according to the degree of abnormalities in 82CAPD patients. A malnutrition index was derived from these scores. We also performed comparative analysis to identify significant correlations of the indices of urea kinetic modeling and creatinine clearance with the other parameters of nutritional status. Results: The malnutrition index classified 47(57%) patients as normal, 30(37%) intermediately malnourished, and 5(6%) as severely malnourished. Malnutrition index showed a significant correlation with the body mass index(BMI), triceps skinfold thickness(TSF), mid-arm circumference(MAC), mid-arm muscle area (MAMA), duration of CAPD, subjective symptoms, serum albumin, transferrin, cholesterol, and triglyceride. The malnutrition index also showed a significant correlation with residual renal function(RRF), and standardized creatinine clearance(SCCr). The TWR-Kt/V(total Kt/Vurea per week with consideration of residual renal urea clearance) was significantly lower in the severely malnourished group than in the normal group. Serum alkaline phosphatase and BUN levels were higher in the severely malnourished group than in the normal and inter- mediate groups. Conclusion: In assessing the nutrition status of CAPD patients, body weight, TSF, MAC, MAMA, subjective symptoms, serum albumin, transferrin, cholesterol, triglyceride, urea nitrogen, and alkaline phosphatase were considered useful parameters. There was a trend of increased BUN and decreased TWR-Kt/V in severely malnourished patients, and the value of SCCr was significantly lower in mal- nourished patients. However, no meaningful relationships between TW-Kt/V and malnutrition index or between NPCR(normalized protein catabolic rate) and malnutrition index were found m this cross- sectional study. As the number of patients with longer duration of CAPD or negligible RRF has increased in the malnourished patients, regular monitoring of these parameters, especially TWR-Kt/V and SCCr, may be helpful to assess dialysis adequacy to keep good nutritional status of each CAPD patient.

혈액투석 ( HD ) 과 복막투석 ( CAPD ) 환자에서 임상경과의 비교 관찰

김중경(Joong Kyung Kim),김창석,윤대현(Dae Hyun Yun),박용기(Yong Ki Park),신용훈(Yong Hoon Shin),감복규(Bok Gyu Gam),허동,장익득(Ik Deuk Jang),김미선(Mi Sun Kim),이시래(Shi Rae Lee) 대한내과학회 1998 대한내과학회지 Vol.55 No.3

N/A Objective: The selection of dialysis modalities for end-stage renal disease patient is often a complex decision process involving considerations of efficacy in terms of life maintenance, quality of life, convenience and cost. In order to facilitate informed decisions, we have compared the clinical outcome of CAPD and HD patients. Methods: From May 1992 to May 1997, we observed the followings: patients` survival rate, the causes of death in CAPD and HD patients, the frequency of CAPD peritonitis, CAPD catheter survival rate and the causes of catheter removal. Patients were categorized in the following ways: DM and non-DM, alive or expired, above and below the age of 60 years, and treatment duration of more or less than 5 years. Six items(serum albumin, serum creatinine, hemoglobin, BMI, NFCR and KT/V) were measured, their values were evaluated and compared with each group using univariated statistics. Results: The total number of patients was 508 (369 CAPD, 139 HD). 58 of them expired during the observation period. The overall 5 year patient survival rate was 81.4% for CAPD, 80.5% for HD, and 57.8% for CAPD with DM and 25% for HD with DM using the Kaplan-Meier method. In the CAPD group, the frequency of peritonitis was 0.52/pt, yt; the 5 year technical survival of the catheter was 80.5%. 42(88%) of 48 technical failures of the catheter were removed due to peritonitis. Regardless of the modes of replacement therapy used to treat DM and non-DM groups, the DM patients had longer duration of admission, older age, lower serum albumin and serum creatinine levels, and a lower 5 year patient survival rate than the non-DM group. Death in CAPD and HD was positively correlated with a long duration of admission and old age; CAPD patients who expired had lower serum albumin, smaller BMI and mare frequent peritonitis than the surviving group. Conclusion: 1. There was no significant difference in the 5 year patient survival rate between CAPD and HD(81.4% in CAPD, 80.5% in HD). 2. DM patients had lower serum albumin, creatinine and BUN levels than non-DM patients. 3. The mortality rate was positively correlated with old age and duration of admission in CAPD and HD; frequent CAPD peritonitis, lower serum albumin and small HMI in CAPD were also positively correlated with the death rate. 4. The higher the serum albumin and NPCR, the higher the survival rate for CAPD patients. 5. The serum creatinine was lower in patients above 60 years old and in those treated more than 5 years. 6. The DM group had a higher mortality rate than the non-DM group, the DM CAPD group had a higher 5 year survival rate than the DM HD group but it was not statistically significant.

Tc-99m DTPA 신장스캔을 이용한 이식신의 사구체 여과율 측정의 임상적 유용성의 평가

김미선,박용기,장익득,김중경,윤대현,신용훈,감복규,이시래,윤명순 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.1

In clinical practice, Tc-99m DTPA renal scan has been using for screening for the presence of renal dysfunction to determine the need for early treatment in kidney transplantation patients. We measured glomerular filtration rate(GFR) using Gates method during the routine Tc-99m DTPA renal scan, predicted creatinine clearance estimated by Cockcroft and Gault formula and 24-hour creatinine clearance and compared each other in 88 kidney transplantation patients simultaneously. The range of renal uptake(%) of Tc-99m DTPA was from 1.8% to 10.4% and the correlation between 24-hour creatinine clearance and renal uptake showed Y=7.176X8.975Y=creatinine clearance(ml/min), X=renal uptake(%) and the correlation coefficient was 0.771. The correlation coefficient between GFR (ml/min) using Tc-99m DTPA renal scan and predicted creatinine clearance was 0.765. The correlation coefficient between predicted creatinine clearance and 24-hour creatinine clearance was 0.850. We concluded that the measurement of GFR using Tc-99m DTPA renal scan was clinically useful in kidney transplantation patients with the advantage of simplicity, low expense, opportunity for renal imaging.

혈액투석환자에서 영양 상태를 반영하는 지표들과 요소 동력학 모형(Urea Kinetic Modeling)과의 비교 관찰

박민,김미선,박용기,서경덕,허동,장익득,김중경,윤대현,신용훈,이시래 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.3

Objectives:Protein-calorie malnutrition has been shown to be prevalent among patients on long-term hemodialysis(HD) patients. And assessment of nutritional status of HD patients has assumed greater importance because of the association of protein-calorie malnutrition with increasing morbidity and mortality. So we observed the incidence and clinical effect of protein-calorie malnutrition, and we compared the indices of nutrition with dialysis adequacy utilizing urea kinetic modeling in HD patients. Methods:We performed a cross-sectional study in which eight parameters, based on anthropometry, blood chemistry and subjective symptoms, were scored according to the degree of abnormalities in 48 HD patients. A malnutrition index was derived from these scores. We also performed comparative analysis to identify significant correlations of the indices of urea kinetic modeling with the other parameters of nutritional status. Results:The malnutrition index classified 12(25 %) patients as normal, 28(58%) intermediately malnourished, and 8(17%) as severely malnourished. Malnutrition index showed a significant correlation with the body mass index(BMI), mid-arm circumference(MAC), mid-arm muscle area(MAMA), duration of HD, total lymphocyte count,trnsferrin. The malnutrition index also showed a significant correlation with renal creatinine clearance(Ccr), alkaline phosphatase. However, malnutrition index showed no meaningful correlation with TWR-Kt/V, TW-Kt/V, BUN, cholesterol,calcium, triglyceride. The value of Ccr was significantly lower in the severely malnourished and intermediately group than in the normal group. Conclusion:In assessing the nutritional status of HD patients, body weight, MAC, MAMA, duration of HD, total lymphocyte count, transferrin, alkaline phosphatase and Ccr were considered useful parameters. No meaningful relationships between TW-Kt/V and malnutrition index or between NPCR (normalized protein catabolic rate) and malnutrition index were found in this cross-sectional study. As the number of patients with longer duration of HD or negligible Ccr has increased in the malnourished patients, regular monitoring of these parameters, especially TWR-Kt/V and residual renal function may be helpful to assess dialysis adequacy to keep good nutritional status of each HD patient.

이식신에 발생한 Polyoma Virus 간질성 신염 1예

박민,김미선,윤대현,박용기,정현주,허동,이시래,김중경,장익득,신용훈,정숙금 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.6

We report one case of renal PV infection after renal allograft transplantation leading to graft dysfunction. According to prior reports, PV induced interstitial nephritis might be a cause of graft loss. Pathologic findings show varying degrees of interstitial infiltration and tubular degenerative changes, which resemble acute cellular rejection. Therapeutic strategies have not yet been developed. Case ; A 23 years old male underwent renal transplantation from his HLA haploidentical 25 year old sister. His renal function had been good with cyclosporin, steroid and azathioprine until 9 months after transplantation, when his serum creatinine level rose to 2.2mg/dl. The renal biopsy revealed diffuse lymphocyte infiltration in the interstitium and feature of the tubulitis. Also, giant tubular epithelial cells with large, hyperchromic nuclei were present. Despite steroid pulsing and OKT3, renal function progressively deteriorated. After 10 days of OKT3 therapy, the patient suffered from high fever, dyspnea and general aches. A chest X-ray revealed interstitial infiltration in both lung fields and the cytomegalovirus PCR (polymerase chain reaction) test of serum and blood was positive. Intravenous ganciclorvir was administered and immunosuppressants were tapered. 4 months after admission, he lost his graft function and underwent hemodialysis. The aforementioned renal biopsy was retested immunohistochemically. Nuclear inclusions in renal tubular epithelial cells were shown and these inclusions were reacted positively with PV monoclonal antibodies.