말기 신부전 환자에서 시행한 관상동맥 조영술 소견과 치료에 대한 고찰

김재헌(Jae Heon Kim),윤수영(Soo Young Yoon),노현정(Hyun Jeong Roh),박형천(Hyung Cheon Park),강남규(Nam Gyu Kang),최동훈(Dong Hoon Choi),강신욱(Shin Wook Kang),장양수(Yang Soo Jang),신원흠(Won Heum Shim),조승연(Seung Yun Cho),이호영(H 대한신장학회 2001 Kidney Research and Clinical Practice Vol.20 No.4

Background - Disease of the heart remains the leading cause of death in patients treated for endstage renal disease(ESRD). In contrast to person with normal renal function, coronary risk factors or indicators could not yet clearly be defined in renal insufficiency. The aim of this study is to elucidate whether conventional risk factors are valid predictors of coronary artery disease(CAD) in ESRD patients and to examine the therapeutic outcome of percutaneous transluminal coronary angioplasty(PTCA) and coronary artery bypass graft(CABG) in chronic dialysis patients. Methods: Between 1997 and 1999, 44 ESRD patients were perfomed by echocardiography and coronary angiography. Results: 31 patients showed positive results in coronary angiography. In patients with CAD, there were statistically significantly older(45.4 vs 60.6 yrs), had higher LP(a> level(18.0 vs 37.5 mg/dL), lower HDL cholesterol level(42.5 vs 33.6 mg/dL), higher BMI (20.7 vs 22.6), and lesser degree of ejection fraction on echocardiography(58.6Yo vs 42.8Yo). And there were more patients who had DM(30.8 vs 64.5Fo) and previous myocardial infarction(MI) histories(7.796 vs 38.7 96) in CAD group. Logistic regression analysis suggested that old age, high Lp(a), and previous MI history could be risk factors for coronary artery disease in ESRD patients. Among the 31 patients had CAD, 10 in HD and 3 in CAPD group experienced PTCA, and another 2 in HD and 4 in CAPD group experienced CABG. Treatment modality and mortality were not different between the two groups. Follow up angiography were performed in 4 HD patients, and 2 of them had restenosis of previously involved vessels. Conclusion: Old age, previous MI history and high Lp(a) are independent risk factors for the presence of CAD in ESRD patients.

비당뇨병성 말기신부전 환자에서 심혈관질환 발생의 예측 인자로서 아디포넥틴의 유용성

안혜림 ( Hye Rim An ),문성진 ( Sung Jin Moon ),박형천 ( Hyeong Cheon Park ),이용규 ( Yong Kyu Lee ),김좌경 ( Jwa Kyung Kim ),김범석 ( Beom Seok Kim ),김형종 ( Hyung Jong Kim ),한대석 ( Dae Suk Han ),하성규 ( Sung Kyu Ha ) 대한신장학회 2010 Kidney Research and Clinical Practice Vol.29 No.4

Purpose: Adiponectin (ADPN) has been known to protect against cardiovascular disease (CVD) in metabolic syndrome with normal renal function for its anti-inflammatory and anti-atherogenic property. However, it is still unclear whether ADPN is associated with cardiovascular outcomes in end-stage renal disease (ESRD) patients. Methods: This study included 80 non-diabetic ESRD patients [mean age, 52.8±13.7 years; dialysis duration, 67.1±52.0 months; hemodialysis (HD), 35 pts; peritoneal dialysis (PD), 45 pts] who survived for more than 3 months after the start of dialysis, and serum ADPN levels were measured at the beginning of the study. We conducted a longitudinal follow-up to evaluate the association of serum ADPN level with cardiovascular outcomes for 29.3±6.7 months. Results: ADPN was inversely correlated with fasting serum insulin (r=-0.309, p=0.006) and HOMA-IR (r=-0.321, p=0.004) in ESRD patients. In a multiple linear regression analysis adjusted for age, gender, waist to hip ratio (WHR), and HDL-cholesterol, HOMA-IR (β=-0.880, p=0.041) was an independent factor associated with serum ADPN level. Kaplan-Meier analysis revealed that patients with higher ADPN levels (≥15.8 μg/mL) had a significantly higher survival rate compared with lowers (<15.8 μg/mL) (p=0.032). Cox proportional hazard model adjusted for age, WHR, creatinine, CRP, and previous CVD history revealed that serum ADPN level (HR, 0.899; 95% CI, 0.818-0.987; p=0.026) was an independent determinant of cardiovascular outcomes. Conclusion: These findings suggest that lower ADPN levels independently predict cardiovascular events in non-diabetic ESRD patients.

지속성 외래 복막투석 환자에서 아미노산 투석액 ( Nutrineal(R) ) 의 장기간 사용이 영양상태에 미치는 영향 - 반응군과 비반응군의 비교

최소래(So Rae Choi),송영수(Yong Soo Song),윤수영(Soo Young Yoon),윤도식(Do Sik Yun),안수현(Soo Hyun Ahn),박형천(Hyung Cheon Park),이종호(Jong Ho Lee),강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),하성규(Seong Kyu Ha),이호영(Ho Yung Lee 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.5

배 경 : 복막투석 환자에서 아미노산 복약투식액 (IPAA)의 사용이 영양학적 지표를 단기적으로는 개선한다고 보고되고 있으나, 장기적으로 투여하였을 때 영양상태에 미치는 영향에 대해서는 아직 보고된 바가 없다. 이에 저자들은 IPAA의 장기간 사용이 환자의 영양상태에 미치는 영향을 평가하고, IPAA의 사용으로 영양상태의 호전을 보이는 환자들의 특성을 규명하고자 하였다. 방 법 : 영양실조 소견을 보이는 지속성 외래 복막투석 환자 46명을 대상으로 하여 아미노산 복막투석액 (Nutrineal^ )을 1일 1회 12개월간 사용하면서 영양학적 지표를 12개월 동안 측정하였으며, 크레아티닌 배설량으로부터 계산된 제지방무게 (LBMCr)가 2.0 ㎏ 이상 증가하거나 전체 체중에 대한 제지방무게의 비율 (%LIBMCr)이 5% 이상 증가한 환자들을 반웅군으로 정의하여, 반응군과 비반응군 두 군에서 여러 지표를 비교하였다. 결 과 : IPAA를 12개월 사용 후 혈청 요소질소, 크레아티닌, IGF-1은 기저치와 비교하여 지속적으로 유의하게 증가하였으며, 단백질과 알부민은 의미있는 변화를 보이지 않았다. 혈청 총 CO_2는 IPAA 투여 후 점차 감소하여 대사성산증의 정토가 심화되는 경향을 보였다. LBMCr, 표준 단백질소 발현을, 주관적 영양상태 평가, 운동 능력은 아미노산 투석액 투여 후 지속적으로 유의하게 증가하여, 영양 상태의 호전을 보여주었다. IPAA 사용 후 혈청 요소질소, 단백질소 발현을, 표준화 단백질소 발현을과 주관적 영양상태평가는 반응군과 비반응군 모두에서 기저치에 비해 유의하게 상승하였으나, 반응군에서의 상승이 비반옹군보다 더욱 현저하였다. 그러나 혈청 크레아티닌, LBMCr와 %LBMCr은 반웅군에서만 유의하게 증가하였다. 또한, 운동능력은 기저치에서부터 반응군이 비반응군에 비해 유의하게 높았으며, IPAA 사용 후 반웅군에서만 유의하게 증가하였다. IPAA 사용 이전부터 감소하는 경향을 보이던 혈청 알부민은 비반웅군에서는 계속 감하였으나, 반응군에서는 감소하는 경향이 둔화되어 안정화되는 경향을 보였다. 결 론 : 1일 1회 1.1% TPAA의 장기간 사용은 영양실조 상태의 복막투석 환자에서 영양상태의 호전을 초래하는 것으로 생각할 수 있었다. 영양실조가 진행된 환자보다 영양실조가 경한 상태에서부터, 특히 기저치 운동능력이 보전된 환자와 IPAA 사용 후에 IGF-1, LBMCr와 운동능력이 증가하는 환자에서 IPAA을 지속적으로 사용하는 것이 영양상태의 호전을 더 기대할 수 있을 것으로 예상된다. Background : IPAA provide nutritional benefit, at least in the short term. However, the long-term efficacy of IPAA in PD patients remains unclear. An attempt was made to evaluate long-term efficacy of IPAA and to ascertain possible factors associated with improved nutritional status after IPAA. Methods : The 46 malnourished CAPD patients were treated with IPAA (one exchange of Nutrineal daily) for one year. Various nutritional, boichemical variables, urea kinetic study and measurement of lean body mass based on creatinine excretion (LBMCr) were carried out at baseline, and at 3month interval thereafter. Responders was defined as those patients who had an increment of mean LBMCr more than 2.0 ㎏ and/or an increase in mean %LBMCr (LBMCr/Body weight) more than 5% during IPAA treatment. Results : After administration of IPAA, BUN, Cr, LBMCr, %LBMCr, nPNA, SGA, and exercise capacity increased significantly. But, protein and albumin level showed no significant change. Increment of GF-1 level was significant. At baseline, responders had a significantly higher hand grip and back lift strength compared to non-responders. IPAA treatment significantly increased in BUN, PNA and nPNA in both groups, but the increment of them was pronounced in responders. IPAA resulted in a significant increase in serum creatinine (10.6±2.1 vs. 11.8±2.6 ㎎/dL, p<0.05) and %LBMCr (70.8±8.9 vs. 76.4±9.2%, p<0.05), hand grip strength (23.2±7.3 vs. 24.3±7.7 ㎏, p<0.05) and back lift strength (67.0 27.4 vs. 75.3±26.6 ㎏, p<0.05) only in responders. Serum albumin level remained stable after IPAA treatment in responders. Conclusion : IPAA treatment for 12 months provided some nutritional benefits in malnourished CAPD patients. And, our data suggest that response to IPAA is more pronounced in CAPD patients with a better preserved nutritional status, `especially in those patients with higher back lift and hand grip strength at baseline.

장구균혈증의 임상양상 및 예후인자에 관한 고찰

박형천,이천균,김응,김준명 대한감염학회 1995 감염 Vol.27 No.4

목적:장구균은 일반적으로 발병력이 낮고 그로 인한 위중한 감염의 발생빈도는 비교적 낮은 것으로 고려되어 왔다. 그러나 최근 고령인구, 신생물 질환, 장기이식의 증가에 따라 장구균혈증의 빈도 및 그로 인한 사망률이 증가하는 추세임이 보고되고 있어 이의 임상양상 및 예후인자에 관해 알아보고자 본 연구를 시행하였다. 방법:1986년 1월부터 1992년 12월까지 세브란스 병원에서 장구균혈증으로 진단받은 82예중 기록검토가 가능했던 54예의 임상상 및 치료, 예후와 관련된 요소를 후향적으로 조사하였다. 장구균혈증은 체온이 38.3℃ 이상으로 상승하여 시행한 혈액 배양 검사상 2번이상 장구균이 자란 경우로 하였다. 결과: 1) 전체 연구 대상은 54예로 남녀비는 1.25:1이며 평균연령은 44.3세 (1-77세)였다. 그리고 평균 재원기간은 31.7일(1-164일)이었다. 전체대상중 59.3%인 32예가 병원내 감염이었으며 중환자실 치료를 받은 환자는 38.9%인 21예였다. 2) 혈액 배양에서 동정된 장구균의 종은 Enterococcus faecalis가 50.2%(28예), E.faecium이 27.6%(14예), E.avium은 5.6%(3예)였다. 그리고 다균혈증이 50%인 27예였는데 다균혈증에서 장구균과 병발된 균주는 E.coli가 11예로 가장 많았으며 Enterobacter(5예), Klebsiella(5예), S.epidermidis(5예), S.aureus(2예)등이었다. 3) 대부분의 환자에서 기저질환을 가지고 있었는데 신생물 질환(17예), 심장질환9예), 중추신경계 질환(6예), 그외 당뇨(2예), 만성 신부전과 신장이식(3예), 다발성외상(2예)등이 있었다. 4) 장구균의 원발병소로 28예가 확인되었는데 담도계가 25.9%(14예)가 가장 많았으며 복부 내농양이 14.8%(8예), 비뇨기계가 13.0%(6예), 피부창상이 7.5%(4예)였다. 5) 약제 감수성 검사상 배양된 모든 장구균에 ampicillin 79.1%, vancomycin 85%, teicoplanin 67.0%, ciprobloxacine 41.4%의 약제 감수성을 보였다. 6) 전체 사망률은 23예인 42.6%였으며 그중 장구균혈증 자체에 의한 사망으로 추정되는 경우는 9예인 16.7%였다. 예후인자로서의 성별, 이전 항생제 치료 여부, 다균혈증 여부, 병원내 감염여부는 사망률과 의의있는 상관관계를 관찰할 수 없었으며 기저질환이 위중한 경우에 있어서 약제치료의 적합성과 생존률사이에는 의의있는 관계가 있었다. 결론:이상으로 장구균혈증은 병원내 감염 및 다균혈증을 특징으로 하며 면역력의 약화와 관련된 숙주 방어에 변화가 초래된 환자에게서 많이 발병함을 알 수 있다. 그리고 기저질환의 정도가 심할수록 기저질환의 조절은 물론 감수성 검사에 근거한 적절한 항생제의 조기투여가 예후결정에 중요함을 알 수 있었다. Background:Enterococci belong to Lancefield group D family of Streptococci. Generally, it has bee considered that serious enterococcal infection was not so frequent because its virulence was low. However, as old age, neoplasms and organ transplantations have increased recently, the morbidity and mortality of enterococcal bacteremia have increased. This study was performed to observe the clinical outcome and prognostic factors of enterococcal bactermia. Methods:Fifty-four cases of enterococcal bacteremia diagnosed from January 1986 to December 1992 in Yonsei University College of Medicine were analysed with their clinical records retrospectively. Results: 1) Male to female ratio was 1.25:1 and mean age was 44.3 years old. Mean hospital days were 31.7 days and 32 cases(59.3%) were nosocomial infections. 2) 28 cases(50.2%) were Enterococcus faecalis. 14 cases(27.6%) were E. faecium and 3 cases(5.6%) were E. avium. 27 cases(50%) were polymicrobial infection and the associated organims were E. coli(11), Enterobacter(5), Klebsiella(5), S. epidermidis(5), and S. aureus(2). 3) Most patients had serious underlying diseases including neoplasm(17), heart disease(9), CNS disease(6), DM(2), CRF and renal allograft(3), and multiple trauma(2). 4) Probable portal of entry was identified in 28 patients : 22 cases(40.7%) were of GI origin and 6 cases(13.0%) were of GU origin. 5) In vitro susceptibility tests showed sensitivity rates of 79.1% to ampicillin, 85.0% to vancomycin, 67.0% to teicoplanin, and 41.1% to ciprofloxacine. 6) The overall mortality rate was 42.6% and the mortality rate due to enterococcal bacteremia itself was 16.7%. Gender, polymicrobial infection, nosocomial infection, and previous antibiotics therapy were not related to the mortality. But the appropriate antibiotic therapy was significantly related to the mortality in cases of the fatal underlying disease. Conclusion:Our study suggests that the nature of enterococcal bacteremia is nosocomial and polymicrobial. It is common in patients with altered host defenses secondary to serious underlying disease. Considering its morbidity and mortality, in cases of the fatal underlying disease, correction of the underlying condition and the use of appropriate antibiotic are neccessary to decrease the morbidity and mortality rates.

경추 척수병증의 수술적 치료

박향권,박동빈,박형천,신규만 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.6

Patients admitted with the clinical symptomatology of a progressive myelopathy associated with radiologic findings compatible with spondylotic degeneration of the cervical spine and who manifest appropriate neurophysiological abnormalities should be considered as candidates for surgical treatment. The authors have undertaken a study of 20 patients who had received decompressive surgicalprocedures and possible follow up studies for CSM, which was defined as a myelopathy related to osteophytic overgrowth and ossification of posterior longitudinal ligament(OPLL) in the cervical spinal canal causing impingement upon the spinal cord from Sep. 93. to Aug. 1995. It was concluded with the following results. 1) man was exclusively prevalent in most cases. 2) age at surgery : There was a signigicant negative correlation between the age at surgery and the recovery rate 3) original cause of compression : There was no signigicant difference between the CSM and OPLL 4) the involved level : three level involvement was the most common(8cases), followed by two level(6 cases), four level(3 cases), and single level(2 cases). There was no correlation between the preoperative Harsh scale and the number of the involved level. 5) recovery rate : excellent(Grade 0.1). 12 cases(60%), good(Grade Ⅱ, ⅢA). 4 cases(20%), poor(Grade Ⅲc, Ⅳ, Ⅴ) 4 cases(20%).

원발성 척수 종양의 임상적 고찰

정지현,박형천,최혜영,김명현,박향권,김성학,신규만,박동빈 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.6

With the advent of magnetic resonance image(MRI), direct visualization of the spinal cord tumors and their relationship to the surrounding structures becomes possible. A clinical analysis was done retrospectively in forty patients suffering from primary spinal tumors and were treated surgically from November 1991 to November 1995. There were 19 male and 21 female patients, peak incidence occures in the sixth decade of life. The tumor with the highest incidence was neurogenic tumor(42.5%), followed by glial tumor and meningioma. The most frequent symptom was pain. On radiological evaluation, simple plain X-ray showed abnormality in 37.5% of cases, in which the most common positive finding was pedicle erosion(20%). CT was performed in 38 cases and MRI in 31. The MRI reveals not only morphologic abnormalities but also diversities in signal intensity. These findings helped us to establish pathologic diagnosis and operative planning. Surgery was performed via anterior(5%) and posterior(95%) approaches. Total removal was possible in 70% of the cases and subtotal removal in 30%. Evaluation of the patient's symptom and neurologic deficit was done one month after operation, it was found that about 80% of the patients recovered or have their conditions improved. Complications were developed in 3 cases.