주초와 주중 혈액 투석 전 혈색소를 기준으로 조혈호르몬 용량 조절 시 평균 혈색소의 변화

장은희 ( Eun Hee Jang ),강우헌 ( Woo Hun Kang ),최소연 ( So Yeon Choi ) 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.3

목적: 혈액 투석 환자의 가장 적절한 목표 혈색소 농도는 11-12 g/dL이다. 조혈호르몬 (EPO) 치료 기준으로서 주초 혈액 투석 전 혈색소 (day1 preHD Hb)는 과도한 체중 증가로 인해 평균 혈색소를 저평가하여 과치료를 유발하고 둘째 혈액 투석 전 혈색소 (day3 preHD Hb)는 평균 혈색소를 잘 반영한다고 한다. 저자들은 국내보험 기준하의 일정한 EPO 프로토콜을 적용하여 다른 날짜의 투석 전 혈색소를 기준으로 EPO용량을 조절하였을 때 평균 혈색소의 변화를 관찰하고자 하였다. 방법: 제주대학교 병원에서 3개월 이상 투석과 EPO 치료를 받고 있는 환자 총20명을 대상으로 무작위로 두 군으로 나누어 A군 (n=11)은 day1 preHD Hb을 기준으로 B군 (n=9)은 day3 preHD Hb을 기준으로 정해진 지침에 따라 EPO를 8주간 투여한 후 이후 8주간은 cross over하였다. 연구 기간 동안 Transferrin saturation >20%, ferritin >100 pg/mL로 유지하였으며 mean Hb은 Day1 predialysis Hb+ (Day3 postdialytic Hb-Day3 predialytic Hb)/3으로 계산하여 2주 간격으로 측정하였고, 4주 간격으로 철분상태를 평가 보충하였다. EPO의 부작용으로 투석 전 평균 혈압을 비교하였고 항고혈압약제의 증량 또는 추가 빈도를 관찰하였다. 결과: 각 군에서 평균 연령과 성별, 평균 투석기간은 유의한 차이가 없었다. 각각 기저치, 8주, 16주째 EPO 프로토콜 적용 후 평균 혈색소는 A군에서 10.05±0.60, 10.10±1.2, 10.11±1.03 g/dL, B군에서 9.93±0.62, 9.72±0.99, 10.30±1.13 g/dL으로 유의한 차이가 없었다. 기저치, 0-8주간, 8-16주간 EPO 요구량은 A군에서 107.2±74.7, 110.9±37.0, 71.8±41.9 IU/kg/week, B군에서 95.4±94.6, 76.58±45.4, 85.6±35.7 IU/kg/week으로 유의한 차이는 없었다. 투석 전 평균 혈압은 시험 전, 8주, 16주째 두군 모두 차이가 없었으나 (107±12 vs 107.0±9, 108±8 vs 101±15, 101±6 vs 96±9 mmHg), 항고혈압제 증량이 각각 day1 preHD 기준시 3명에서 필요했다. 결론: 본 연구에서 주초, 주중 투석 전 혈색소 수치를 기준으로 EPO용량을 조절했을 때 EPO투여량 및 평균 혈색소에는 차이가 없었다. Purpose: The time average hemoglobin concentration (Hb-Tac) is more likely to represent hemodialysis (HD) patients` true hemoglobin due to variable hemoglobin concentration. This study was performed to evaluate the effect of erythropoietin adjustment on the Hb-Tac according to the Hb of different hemodialysis days. Methods: A controlled, randomized, cross-over study, where 20 stable hemodialysis patients (7 males, 13 females, mean age 57.8±3.0 year, mean HD duration 973±707 days) acted as their own controls. EPO adjustment was performed by protocol and according to preHD Hb of the first HD session (group A) or the second HD session (group B) in cross over for each 8 weeks. Serial Hb-tac were calculated by equation [mid week preHD Hb+[midweek pre HT [midweek preHD Hb+(midweek postHD Hb-preHD Hb)/3] every two weeks during the entire study periods. Their iron status were monitored and maintained adequately as K/DOQI guidelines. Results: There was no significant difference in clinical parameters except age during the entire study period. Mean hemoglobin at randomization and after 8, 16 weeks were 10.0±0.60, 10.10±1.19, 10.1±1.03, respectively, in group A compared with 9.93±0.62, 9.72±1.00, 10.3±1.12 g/dL in group B. Mean weekly epoetin alfa dosage at randomization and after 8, 16 weeks were 107.2±74.7, 123.2±43.1, 123.0±85.0 IU/kg/week, respectively in group A compared with 95.4±94.7, 107.4±60.7, 125.5±85.0 IU/kg/week in group B. There were no significant differences in Hb-tac and EPO dosage. Addition of antihypertensive occurred in three patients during EPO adjustment to preHD Hb of the first session. Conclusion: EPO dose adjustment according to the different day preHD Hb does not affect the Hb-tac and total EPO.

신장 ; 서울 서남부지역 혈액투석 환자의 빈혈 및 칼슘-인 대사 현황

이영기 ( Young Ki Lee ),김소윤 ( So Yoon Kim ),백수진 ( Soo Jin Baek ),김성남 ( Seong Nam Kim ),강우헌 ( Woo Hun Kang ),강나리 ( Na Ree Kang ),김기원 ( Kiwon Kim ),전용덕 ( Yong Deok Jeon ),손승환 ( Seung Hwan Son ),김대중 ( Dae J 대한내과학회 2013 대한내과학회지 Vol.85 No.4

목적: 혈액투석 환자와 인공신장실은 해마다 늘고 있으며 대한신장학회에서는 2009년부터 말기신부전 환자에 대한 의료서비스의 질 관리 및 건전한 인공신장실 운영을 위하여 인공신장실 인증시범사업을 시행하고 있다. 저자들은 인공신장실 인증제도 시범사업 결과를 분석하여 서울 서남부 혈액투석 환자들의 빈혈, 칼슘, 인 대사장애에 대한 관리 실태를 알아보고자 하였다. 방법: 인공신장실 인증제도 1차 시범사업에 참여한 25개 의료기관의 혈액투석 환자 1,524명에서 빈혈, 철저장능, 혈청 칼슘, 인 수치를 조사하였고, 철분 부족 환자에서 철분주사 투여율을 분석하였다. 또한 인증기관(12개)과 불인증기관(13개)에 따라 각 항목을 비교하였다. 결과: 대상 환자의 평균 혈색소 수치는 10.5 ± 1.5 g/dL였으며 혈색소 10 g/dL 이하인 빈혈 환자 비율은 27.4%이었고, 철 부족 환자는 25.2%였다. 그리고 철 부족 환자에서 철분주사의 투여율은 48.1%로 조사되었다. 평균 혈청 인 수치는 5.1 ± 1.9 mg/dL이었으며 혈청 칼슘-인 농도의 곱이 55mg2/dL2 미만인 환자 비율은 70.7%로 나타났다. 빈혈과 철저장능 충족률, 혈청 칼슘-인 농도는 인증기관과 불인증기관이 비슷하였으나 철 부족 환자에서 철분주사의 투여율은 인증기관(65.6%)이 불인증기관(30.9%)보다 더 높았다. 결론: 서울 서남부 혈액투석 환자들의 빈혈, 칼슘, 인 대사장애는 비교적 잘 관리되었으나 일부 기관에서는 좀 더철저한 철분 관리가 필요하다. 우리나라 투석 환자의 빈혈,칼슘-인 대사 이상 및 사망률에 대해 전향적으로 데이터를 추적하여 결론을 도출하려면 인증사업을 활성화할 필요가 있을 것으로 생각한다. Background/Aims: The number of hemodialysis patients and dialysis centers is increasing each year, but there are no quality standards for facilities. Thus, the Korean Society of Nephrology carried out a pilot project regarding a hemodialysis center accreditation system. This study was aimed at surveying the prevalence of anemia and abnormalities of calcium or phosphorus metabolism in hemodialysis patients in southwestern Seoul. Methods: We investigated anemia, serum calcium, and phosphorus levels in 1,524 patients in 25 hemodialysis units. The rate of iron injections in patients with iron deficiency was also evaluated. Each item was compared between accredited (n = 12) and non-accredited centers (n = 13). Results: The mean hemoglobin in subjects was 10.5 ± 1.5 g/dL. The prevalences of anemia and iron deficiency were 27.4% and 25.2%, respectively. The rate of iron injection in patients with iron deficiency was 48.1%. The mean phosphorus level was 5.1 ± 1.9 mg/dL and the proportion of patients with Ca × P < 55 mg2/dL2 was 70.7%. The prevalence of anemia, iron deficiency, and Ca × P were similar between accredited and non-accredited centers. The rate of iron injection in iron deficiency was higher in accredited (65.6%) than non-accredited centers (30.9%). Conclusions: Management of anemia and levels of calcium or phosphorus were acceptable in hemodialysis patients in southwestern Seoul, although some facilities should make more efforts to improve iron deficiency. The availability of data from a hemodialysis center accreditation system allowed us a unique opportunity to further explore the relationships between anemia, abnormalities of mineral metabolism, and outcomes. (Korean J Med 2013;85:378-384)

복막 투석 환자에서 혈청 Leptin 농도의 변화

오하영,오동진,김대중,강우헌,이방훈,김범,이숭구,허우성 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.3

Elevated serum leptin concentration can contribute to anorexia and poor nutrition in patients with chronic renal failure, since leptin is elevated in chronic renal failure patients with or without dialysis, especially in chronic ambulatory peritoneal dialysis(CAPD) patients. The aim of this study to find whether leptin can be removed by peritoneal dialysis(PD) and to analyze factors that can affect serum leptin concentration after start of CAPD by observing the changes of serum leptin shortly after start of CAPD and their correlations with body mass index(BMI), serum insulin concentration and residual renal function(Creatinine clearance+Urea clearance/2). Twenty patients who started CAPD during the observation periods were studied. Serum leptin concentration was measured before start of CAPD, 3-5 days and 1, 3 months after start of CAPD by RIA method. Simultaneously, body weight, serum insulin concentration and residual renal function were measured. Removal of leptin was assessed by measuring dialysate leptn concentration divided by average serum leptin concentration before and after peritoneal equilibration test(PET) to compensate for the circardian rhythm of leptin. Leptin was eliminated by PD with dialysate to serum ratio of leptin to be 0.16±0.07 which was comparable to removal of β2-microglobulin(0.14±0.06). The mean serum leptin concentration did not decrease after 3-5 days of CAPD(8.4±13.1±11.9±18.0) despite its removal by PD and increased markedly 189%, 260% of basal serum leptin concentration on 1 month and 3 months after start of PD, respectively. Correlation coefficients(Spearmann's) between changes of serum leptin concentration and changes of BMI, serum insulin concentration, residual renal function were 0.267(P$gt;0.05, n=20), 0441(P$gt;0.05, n= 16), 0.706(P$gt;0.05, n=8) respectively. Leptin was removed by peritoneal dialysis. Serum leptin concentration did not decrease in 5 days after start of PD despite its removal by PD, and increased markedly 3 months after start of PD. We could not find signi correlation between changes of serum leptin concentration and changes of BMI. Factors other than fat mass gain can stimulate leptin increase shortly after start of PD.