Acute kidney injury in patients with acute-on-chronic liver failure: clinical significance and management

( Jeong-ju Yoo ),( Moo Yong Park ),( Sang Gyune Kim ) 대한신장학회 2023 Kidney Research and Clinical Practice Vol.42 No.3

Acute-on-chronic-liver failure (ACLF) refers to a phenomenon in which patients with chronic liver disease develop multiple organ failure due to acute exacerbation of underlying liver disease. More than 10 definitions of ACLF are extant around the world, and there is lack of consensus on whether extrahepatic organ failure is a main component or a consequence of ACLF. Asian and European consortiums have their own definitions of ACLF. The Asian Pacific Association for the Study of the Liver ACLF Research Consortium does not consider kidney failure as a diagnostic criterion for ACLF. Meanwhile, the European Association for the Study of the Liver Chronic Liver Failure and the North American Consortium for the Study of End-stage Liver Disease do consider kidney failure as an important factor in diagnosing and assessing the severity of ACLF. When kidney failure occurs in ACLF patients, treatment varies depending on the presence and stage of acute kidney injury (AKI). In general, the diagnosis of AKI in cirrhotic patients is based on the International Club of Ascites criteria: an increase of 0.3 mg/dL or more within 48 hours or a serum creatinine increase of 50% or more within one week. This study underscores the importance of kidney failure or AKI in patients with ACLF by reviewing its pathophysiology, prevention methods, and treatment approaches.

만성 신장병 환자의 하지불안증후군에 대한 작약감초탕 치험 1례

정소민,이성욱,이한결,조기호,문상관,정우상,권승원 대한한방내과학회 2023 大韓韓方內科學會誌 Vol.44 No.2

Restless leg syndrome is a nervous system disorder that causes an overpowering urge to move one’s legs. Symptoms of restless leg syndrome usually worsen when one tries to fall asleep and can prevent sufficient sleep. Restless leg syndrome is common in patients with chronic kidney failure and can be caused or worsened by chronic kidney failure and hemodialysis. Various medications can treat restless leg syndrome, though the long-term use of medications can cause augmentation and adverse effects. In addition, the use of dopamine agonists is limited in patients with chronic kidney failure. This is because the dose of administration should be controlled for patients with chronic kidney failure, and the treatment effect has not been clearly proven. This study reports the case of a 56-year-old male diagnosed with chronic kidney failure complaining of uncomfortable leg sensations. The patient underwent Korean medicine treatment using Jakyakgamcho-tang. The IRLS, NRS, and AIS scores were evaluation tools during treatment. This study suggested significantly improved symptoms through the individual interventions of Jakyakgamcho-tang in a restless leg syndrome patient with chronic kidney failure.

Relationship between serum brain natriuretic peptide and heart function in patients with chronic kidney disease

( Jae Won Yang ),( Min Soo Kim ),( Jae Seok Kim ),( Jong Myoung Yoo ),( Seung Tae Han ),( Bi Ro Kim ),( Yun Deok Kim ),( Jeong Wook Choi ),( Seung Ok Choi ),( Byoung Geun Han ) 대한내과학회 2008 The Korean Journal of Internal Medicine Vol.23 No.4

Background/Aims: Brain natriuretic peptide (BNP) levels are known to be elevated in patients with chronic kidney disease (CKD) and normal heart function. Therefore, the present study was performed to examine the effectiveness of BNP level in diagnosing heart failure in patients with CKD and to determine its effects on survival rate and prognosis. Method: A total of 182 patients with CKD who visited the hospital due to dyspnea of NYHA class II were included in the study. BNP levels were measured and echocardiography was performed to divide the subjects into groups with and without heart failure. Their BNP levels, clinical courses, and survival rates were analyzed retrospectively. Results: When BNP level was ≥858.5 pg/mL in CKD patients, heart failure could be diagnosed with sensitivity and specificity of 77% and 72%, respectively. Survival rate of the group with BNP levels of ≥858.8 pg/mL was significantly lower than that of the group with BNP level below this threshold (p=0.012) and multivariate analysis showed that BNP level, age, and sex affected survival rate in the group with BNP level ≥858.8 pg/mL. Conclusions: BNP levels of patients with CKD showed a positive correlation with creatinine levels, and the critical point of BNP level for diagnosis of heart failure was 858.5 pg/mL. As the survival rate in patients with BNP level above the critical point was significantly low, this level was a useful indicator for predicting their prognosis. Care should be taken in interpreting BNP level because patients with stage 5 CKD may show a high concentration of BNP without heart failure.

복막투석 중인 말기신부전 환자에서 지속적인 midazolam 정주에 의한 진정 상태의 지연 회복

조영일 ( Young Il Jo ),최혜진 ( Hye Jin Choi ),김소영 ( So Young Kim ),최혜진 ( Hae Jin Choi ),박현식 ( Hyun Sik Park ),윤선웅 ( Seon Ung Yun ),배병주 ( Byeong Joo Bae ),박정환 ( Jung Hwan Park ),이종호 ( Jong Ho Lee ) 대한신장학회 2010 Kidney Research and Clinical Practice Vol.29 No.6

Purpose: Midazolam, a benzodiazepine derivatives, is widely used in intensive care unit for sedation of patients who require mechanical ventilation. Although midazolam has a short acting time, it might cause a prolonged sedation, especially in patients with renal failure. We report the case of a 76-year-old man who received peritoneal dialysis and showed prolonged sedation after stopping continuous infusion of midazolam. The patient who has received maintenance hemodialysis for five months admitted in intensive care unit to manage pneumonia and severe congestive heart failure. In ICU, hemodialysis was transferred to peritoneal dialysis due to severe cardiac dysfunction. He was treated with mechanical ventilation under sedation with midazolam. However, even though stopping midazolam, deep sedation by midazolam was not restored. The patient completely recovered from sedation after 280 hours.

Effects of Dietary Salt Restriction on the Development of Renal Failure in the Excision Remnant Kidney Model

김기혁,김상윤,강용주,맹원재,김교순,Kim Kee-Hyuk,Kim Sang-Yun,Kang Yong-Joo,Maeng Won-Jae,Kim Kyo-Sun Korean Society of Pediatric Nephrology 1999 Childhood kidney diseases Vol.3 No.2

목적 : 만성신부전유발 백서에서 식이 sodium 제한이 만성신부전의 진행속도 및 혈압조절에 어떠한 영향을 주는지, 또한 항고혈압제제 (enalapril: E, nicardipine: N)와 병행 투여하였을 매 항고혈압제제 단독투여보다 만성신부전의 진행속도 및 혈압조절에 어떠한 영향을 주는 지를 연구하였다. 방법 : 5/6 신절제술로 만성신부전을 유발시킨 백서를 수술 제 7일부터 무작위로 0.49% sodium 식이군, 0.25% sodium 식이군, 0.49% sodium 식이 enalapril군, 0.49% sodium 식이 nicardipine군, 0.25% sodium식이 enalapril군, 0.25% sodium식이 nicardipine군으로 나누고 신절제술 4주, 12주, 16주 혹은 24주에 혈압, 24시간 단백뇨의 변화, 신 조직의 mesangial expansion score(MES) 및 사구체용적의 변화를 비교 분석하였다. 곁 과 : 1) 0.25% sodium 식이군은 0.49% sodium 식이군보다 혈압의 감소를 보였고 0.25% sodium 식이 enalapril군, 0.25% sodium 식이 nicardipine군, 0.49% sodium 식이 enalapril군, 0.49% sodium 식이 nicardipine 군에서는 혈압의 감소가 관찰되었다. 2) 16주째 0.25% sodium 식이 enalapril군, 0.25% sodium 식이 nicardipine군, 0.49% sodium 식이 enalapril군, 0.49% sodium 식이 nicardipine 군은 0.49% sodium 식이군보다 의의있는 단백뇨의 감소를 보였다 (P<0.05). 0.25% sodium 식이군의 16주째 뇨단백은 $78{\pm}16$ mg 이었고 0.25% sodium 식이 enalapril 군, 0.25% sodium 식이 nicardipine군은 각각 $35{\pm}9mg,\;41{\pm}15mg$으로 enalapril, nicardipine 에 의해 뇨단백의 감소를 관찰할 수 있었고, 0.25% sodium 식이군의 24주째 뇨단백은 $82{\pm}10$ mg 이었고 0.25% sodium 식이 enalapril 군,0.25% sodium 식이 nicardipine군은 각각 $54{\pm}3mg,\;76{\pm}11mg$으로, enalapril 에 의해서만 24 시간 단백뇨의 의의있는 감소를 관찰할 수 있었다. 3) 24주째 백서를 희생하여 크레아티닌 청소률을 관찰한 결과 심한 신부전은 관찰되지 않았고, 0.25% sodium 식이 대조군에 비해 0.25% sodium 식이 enalapril군에서 사구체여과율이 증가됨을 관찰할 수 있었다. 4) 신절제술후 남아 있는 신조직무게를 비교하여 보면 24주째 0.25% sodium 식이군, 0.25% sodium 식이 enalapril군, 0.25% sodium 식이 nicardipine군에서 16주째 0.49% sodium 식이군, 0.49% sodium 식이 enalapril군, 0.49% sodium 식이 nicardipine 군보다 의의있게 신조직무게가 증가됨을 관찰할 수 없었다. 5) 0.25% sodium 식이군은 0.49% sodium 식이군과 비교하여 MES의 현저한 감소를 보였고 (0.25% sodium식이군: 12주; $1.97{\pm}0.02$, 24주; $2.06{\pm}0.03$ vs. 0.49% sodium 식이군: 12주; $2.29{\pm}0.09$, 16주; $2.55{\pm}0.16$, P<0.05) 12주 이후에 관찰한 MES는 0.25% sodium 식이군, 0.25% sodium 식이 enalapril군, 0.25% sodium 식이 nicardipine군 세군간의 통계적인 차이는 없었다. 6) 24주에 시행한 0.25% sodium 식이군의 사구체용적은 16주에 시행한 0.49% sodium 식이군의 사구체용적보다 현저하게 감소되어있었다 (0.25% sodium 식이군:24주; $1.58{\pm}0.18{\times}10^6{\mu}m^3$ vs. 0.49% sodium 식이군:16주; $1.98{\pm}0.18{\times}10^6{\mu}m^3$, P<0.05). 24주 0.25% sodium 식이 enalapril군의 사구체용적($1.51{\pm}0.08{\times}10^6{\mu}m^3$)은 16주 0.49% sodium 식이 enalapril군의 사구체용적($1.81{\pm}0.22{\times}10^6{\mu}m^3$)과 비교하여 현저한 감소를 보였다. 12주, 24 주에 관찰한 0.25% sodium 식이군, 0.25% sodium 식이 enalapril군, 0.25% sodium 식이 nicardipine군의 사구체용적은 세군간에 의의있는 차이는 없었다. 결론 : 식이 sodium 제한은 대상성 신비대의 감소를 통해 신손상을 감소시켰고 혈압의 감 Purpose: To evaluate whether or not sodium restriction had its own beneficial effect and increased the efficiency of the anti-hypertensive drugs on the progression of renal failure. Methods: We studied using the excision remnant kidney model. Treatment groups were as follows: 5/6 nephrectomy and a 0.49% (normal-high) sodium diet (NN); 5/6 nephrectomy and a 0.25% (normal-low) sodium diet (LN); 5/6 nephrectomy, a 0.49% sodium diet and enalapril (NNE); 5/6 nephrectomy, a 0.49% sodium diet and nicardipine (NNN); 5/6 nephrectomy, a 0.25% sodium diet and enalapril (LNE); 5/6 nephrectomy, a 0.25% sodium diet and nicardipine (LNN). Both diets were isocaloric and had the same content of protein, phosphorus and calcium. Proteinuria, remnant kidney weight, mesangial expansion scores, and glomerular volume were assessed. Results: Blood pressure tended to be lower in LN compared to NN (P<0.05). NN developed progressive hypertension. LNE, LU, NNE, and NNN reduced blood pressure. LNE, LNN, NNE, NNN, and LN had significantly less proteinuria than NN at 16 weeks (P<0.05). At 24 weeks, LN developed proteinuria (82 mg/day), which were lessened in LNE (54 mg/day) and not lessened in LNN (76 mg/day). Mesangial expansion scores were significantly less in LN rats compared to those in NN rats. Glomerular volumes at 24 weeks in LN rats were significantly less compared to those at 16 weeks in NN rats. Mesangial expansion scores and glomerular volumes at 4, weeks, 12 weeks, and 24 weeks were not different among LN, LNE, and LNN groups. Conclusion: Dietary salt restriction lessens renal damage, at least in part, by inhibiting compensatory renal growth and reducing blood pressure. Enalapril was particularly successful in reducing proteinuria and glomerular injury when combined with dietary salt restriction.

동정맥 이식편을 통해 혈액투석치료를 받는 환자에서 발생한패혈성 폐색전증

이강욱 ( Kang Wook Lee ),권오경 ( Oh Kyung Kwon ),배홍진 ( Hong Jin Bae ),장원익 ( Won Ik Jang ),정사라 ( Sa Rah Chung ),최대은 ( Dae Eun Choi ),나기량 ( Ki Ryang Na ),신영태 ( Young Tai Shin ) 대한신장학회 2010 Kidney Research and Clinical Practice Vol.29 No.6

Purpose: Septic pulmonary embolism (SPE) is different from non-infectious thromboembolism in that it causes pulmonary arterial obstruction and inflammation by infectious emboli from various sources. There are increased risks of SPE in patients with chronic kidney disease because of decreased immunity and frequent venous puncture with the use of indwelling venous catheters or arterio-venous graft (AVG). However, SPE related with AVG infection in end-stage renal failure patient is very rare. Recently, we experienced a typical case of septic pulmonary embolism occurring in a 57-year-old man with infected AVG during hemodialysis. The patient had started hemodialysis 10 years ago due to diabetic end stage renal failure. Due to functional failure of the arterio-venous fistula, hemodialysis had been performed through an AVG on the upper left arm 3 years before admission. One week before admission, the patient complained of fever, chill, and painful swelling on the AVG site. Chest x-ray and computerized tomography showed variable sized multiple nodules and some cavity formation, suggestive of septic pulmonary embolism on both lung fields. Methicillin-resistant Staphylococcus aureus (MRSA) was identified from blood and wound culture studies. The AVG was removed along with continued use of vancomycin administration for 8 weeks. Complete clinical and radiological recovery was attained 2 months after initiation of antibiotic treatment.

Cell-based therapy for kidney disease

정현철,고인갑,Anthony Atala,James J. Yoo 대한비뇨의학회 2015 Investigative and Clinical Urology Vol.56 No.6

The prevalence of renal disease continues to increase worldwide. When normal kidney is injured, the damaged renal tissue undergoes pathological and physiological events that lead to acute and chronic kidney diseases, which frequently progress to end stage renal failure. Current treatment of these renal pathologies includes dialysis, which is incapable of restoring full renal function. To address this issue, cell-based therapy has become a potential therapeutic option to treat renal pathologies. Recent development in cell therapy has demonstrated promising therapeutic outcomes, in terms of restoration of renal structure and function impaired by renal disease. This review focuses on the cell therapy approaches for the treatment of kidney diseases, including various cell sources used, as well recent advances made in preclinical and clinical studies.

혈액투석중인 만성신부전 환자의 뇌내 대사물질의 변화: 수소자기공명분광 소견

백혜원,유현,유수정,김기현 대한영상의학회 2007 대한영상의학회지 Vol.57 No.2

Purpose: We wanted to evaluate the cerebral metabolites in patients with chronic renal failure (CRF) and who were undergoing hemodialysis by performing proton MR spectroscopy and we wanted to evaluate the correlation between the changes in the cerebral metabolite ratios and the duration after starting the initial hemodialysis. Materials and Methods: Proton MR spectroscopy was performed in 15 patients with CRF and who were undergoing hemodialysis and in ten healthy volunteers. The changes in N-acetylaspartate (NAA), choline-containing compounds (Cho), myo-inositol (Myo), glutamine/glutamate complex (Glx), and creatine (Cr) were analyzed. MR spectroscopy was performed before and after hemodialysis. Results: For the patients with CRF before hemodialysis, the Cho/Cr ratio in the gray matter (p<0.001) and the Myo/Cr ratio in both the gray and white matter (p<0.01) were significantly elevated compared with those in the control subjects. For the patients with CRF after hemodialysis, their Cho/Cr ratios were significantly reduced in both the gray and white matter compared with that before hemodialysis (p<0.05). There was a significant positive correlation between the Cho/Cr ratio and serum Cr in the gray matter of CRF patients after hemodialysis (r=0.54, p<0.05). The cerebral metabolite ratios were not significantly correlated with the duration after starting the initial hemodialysis. Conclusion: The cerebral metabolite patterns are significantly different between the patients with CRF and who are undergoing hemodialysis and the normal controls. The cerebral metabolite ratios are not significantly correlated with the duration after starting the initial hemodialysis. 목적: 수소 자기공명분광검사를 이용하여 혈액투석을 받는 만성신부전 환자의 뇌내 대사물질들의 변화를 알아보고 혈액투석을 처음 시작한 이후부터 시간이 지남에 따라 뇌내 대사물질들도 의미 있게 변하는지 알아보고자 하였다. 대상과 방법: 15명의 혈액투석중인 만성신부전 환자와 10명의 정상인을 대상으로 자기공명분광검사를 실시하였다. 자기공명분광검사는 화적소를 마루엽의 회색질과 백색질에 위치시키고 실시했으며 NAA, Cho, Myo, Glx, 및 Cr을 측정하였다. 자기공명분광검사는 혈액투석 전과 후에 각각 시행하였다. 결과: 혈액투석 이전의 만성신부전 환자의 회색질에서는 Cho/Cr 비가( p < 0.001), 백색질과 회색질에서는 Myo/Cr 비가(p < 0.01) 각각 정상 대조군 보다 유의하게 높게 관찰되었다. 혈액투석 후의 만성신부전환자에서는 혈액투석 전과 비교하여 Cho/Cr 비가 회색질과 백색질 모두에서 유의하게 감소하였다( p < 0.05). 혈액투석 후의 만성신부전 환자의 회색질에서 얻은 Cho/Cr비는 혈청 Cr 수치와 유의한 상관관계를 보였다(r=0.54, p < 0.05). 뇌내 대사물질들의 비는 첫 혈액투석을 시작한 이후부터 검사 시점까지의 경과 시간과는 유의한 상관관계가 없었다. 결론: 만성신부전 환자의 뇌내 대사물질들은 정상 대조군과 비교하여 유의한 차이를 보였다. 혈액투석을 처음 받기 시작한 이후부터 지나간 시간과 뇌내 대사물질들의 변화 사이에는 유의한 상관관계가 없었다.

만성 신부전 환자와 신이식 환자에서 혈장 총 호모시스테인과 엽산의 농도

김범(Beom Kim),하경원(Kyoung Won Ha),이윤하(Yoon Ha Lee),김혜영(Hye Young Kim),허우성(Woo Seong Huh),김대중(Dae Joong Kim),김윤구(Yoon Goo Kim),오하영(Ha Young Oh) 대한내과학회 1998 대한내과학회지 Vol.55 No.1

N/A Background: A few articles reported that the plasma total homocysteine(tHcy) concentration of renal transplant recipients(RTR) was higher than that of normal controls, but lower than that of patients with chronic renal failure. But renal function of the RTR was variable, and plasma tHcy concentration of RTR with normal renal function was unknown. We compared plasma tHcy concentration of RTR with norrr1 renal function to normal controls and evaluated the relation between folate concentration, the independent factor of plasma tHcy concentration, and plasma tHcy in patients with chronic renal failure in predialysis, hemodialysis(HD) and continuous ambulatory peritoneal dialysis(CAPD), Methods We measured fasting plasma level of total homocysteine by high-performance liquid chromatography and folate concentration in 36 predialysis CRF patients(Ccr<25mlu'min), 37 HD patients, 28 CAPD patients, 41 RTR(serum creatinine≤1.4mg/dL) and % healthy controls. Results : 1)Mean(±SD) tHcy concentration in pre- dialysis CRF(21.93 ±14.33 μ mol/L), HD(18.24±8.73μmol /L) and CAPD(17.16±7.8μmol/L) patients was significantly higher than that in controls (8.91±4.11μmol/L, P<0.05) but tHcy concentration of RTR group(8.99±3.99 μmol/L)had no difference from that of normal controls 2)In predialysis patients, CAPD patients, and HD patients showed a significant negative correlation between serum folate and plasma tHcy concentrations (r=-0.18, p<0.05). 3)In predialysis, HD and CAPD patients, mean plasma folate concentratirin in patients with 1mg/ day-folate supplementation(20.41±15.65ng/ml.) was higher than patients without 1mg/day-folate supplementation (10.20±8.24ng/mL)(p<0.05) and mean plasma tHcy concentration in patients with 1mg/day-folate supplementation (17.87±7.94μmol/L) was lower than patients without 1mg/day-folate supplementation(21.87±13.35μmol/L)(p<0.05). Conclusion: Plasma tHcy concentration in RTR with normal renal function had no difference with that in normal controls. In predialysis, HD, and CAPD patients, plasma tHcy had negative correlation with plasma folate concentration and plasma tHcy in patients with 1mg folate supplementation, usual dose in chronic renal failure, was higher than that in patients without folate supplementation and lower than that in normal controls.

Applications of acoustic radiation force impulse quantification in chronic kidney disease: a review

Liang Wang 대한초음파의학회 2016 ULTRASONOGRAPHY Vol.35 No.4

Acoustic radiation force impulse (ARFI) imaging is an emerging technique with great promise in the field of elastography. Previous studies have validated ARFI quantification as a method of estimating fibrosis in chronic liver disease. Similarly, fibrosis is the principal process underlying the progression of chronic kidney disease, which is the major cause of renal failure. However, the quantification of tissue stiffness using ARFI imaging is more complex in the kidney than in the liver. Moreover, not all previous studies are comparable because they employed different procedures. Therefore, subsequent studies are warranted, both in animal models and in clinical patients, in order to better understand the histopathological mechanisms associated with renal elasticity and to further improve this imaging method by developing a standardized guidelines for its implementation.