급성 신우신염에서 급성 신부전이 동반된 환자들의 임상적 양상

성수아 ( Su Ah Sung ),강영선 ( Young Sun Kang ),이소영 ( So Young Lee ),김상욱 ( Sang Wook Kim ),이지은 ( Ji Eun Lee ),한금현 ( Kum Hyun Han ),서지아 ( Ji A Seo ),조원용 ( Won Yong Cho ),김형규 ( Hyoung Kyu Kim ) 대한내과학회 2003 대한내과학회지 Vol.64 No.2

목적: 급성 신우신염 환자에서 혈류량 부족, 패혈증, 약물 요법, 요로 폐쇄 등의 악화 요인 없이 급성 신부전이 동반되어 발생하는 임상 사례가 지속적으로 보고 되고 있어 저자들은 입원시 급성 신부전이 동반된 급성 신우신염 환자와 급성 신부전이 동반되지 않는 급성 신우신염 환자들의 임상상을 비교하여 급성 신우신염에서 급성 신부전과 관련된 인자를 파악하고자 본 연구를 시행했다. 방법: 1996년 1월부터 2000년 12월까지 만 5년 동안 고려대학교 안암병 Background: If acute renal failure develops in patients with acute pyelonephritis, it is most commonly due to hypovolemia, sepsis, drug therapy or urinary obstruction. But there have been reported many cases about patients of acute renal failure derived f

유지 혈액투석 중인 말기 신부전 환자에서 치료적 위내시경 후에 발생한 십이지장 근육내 혈종 및 췌장염 1 예

이소영(So Young Lee),조상경(Sang Kyung Jo),박선민(Sun Min Park),서지아(Ji A Seo),성수아(Su Ah Sung),한금현(Kum Hyun Han),조원용(Won Yong Cho),김형규(Hyoung Kyu Kim),정석인(Suk In Jung) 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.4

Intramural duodenal hematoma is a rare finding in the adult, especially when related to iatrogenic complications of ulcer treatment, it can lead to biliary obstruction and pancreatitis, which can be fatal in severe case. We report one case of intramural duodenal hematoma complicated with pancreatitis after endoscopic hemostasis in a chronic renal failure patient with maintenance hemodialysis. He had a duodenal ulcer bleeding treated with endoscopic epinephrine injection and electro-coagulation therapy, but on the second day, he complained of persistent abdominal pain, nausea and vomiting. Abdominal ultrasound showed acute, edematous pancreatitis and a mass with low echodensity in the wall of the 2nd portion of the duodenum. Symptom and laboratory findings were persistent under conservative therapy, 7 days later, gastric resection, hematoma evacuation was carried out, subsequently the patient recovered from the pancreatitis but the patient died of septic shock and multiple organ dysfunction.

복막투석 : 복막투석 환자에서 혈당 조절이 잔여신기능에 미치는 영향

이성혁 ( Sung Hyuk Lee ),성수아 ( Su Ah Sung ),황영환 ( Young Hwan Hwang ),이소영 ( So Young Lee ),김세중 ( Se Joong Kim ),정우경 ( Woo Kyung Jung ),김성균 ( Sung Gyun Kim ),오지은 ( Ji Eun Oh ),오국환 ( Kook Hwan Oh ) 대한신장학회 2008 춘계학술대회 초록집 Vol.28 No.1

배양된 인 근위세뇨관 상피세포에서 고농도의 단백질이 TGF-β와 Fas 유전자 발현에 미치는 영향

서지아 ( Ji A Seo ),조상경 ( Sang Kyung Jo ),한금현 ( Kum Hyun Han ),성수아 ( Su Ah Sung ),이지은 ( Ji Eun Lee ),이소영 ( So Young Lee ),김상욱 ( Sang Wook Kim ),차대룡 ( Dae Ryong Cha ),조원용 ( Won Yong Cho ),김형규 ( Hyun Kyu K 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.6

배 경 : 사구체신염은 다량의 단백뇨와 세뇨관간질의 규조적인 변화를 특징으로 하며 이는 말기신부전으로의 진행을 예측하는데 있어서 사구체의 변화보다 중요한 인자로 알려져 있다. 이러한 세뇨고나간질의 구조변형은 세뇨관 내에 포함된 다량의 단백이 세뇨관 상피세포에 흡수되어 대사되는 과정에서 상피세포로부터 Transforming Growth Factor-β 등의 fibrosing cytokine과 Monocyte Chemeatactant Peptide-1 등의 염증성 chemokine의 발현이 증가하고 그에 따른 각종 염증성 변화가 일어나는 것에 기인하는 것으로 알려져 있다. 이러한 염증성 변화이의에도 다량의 단백뇨에 의한 세뇨관 간질세포의 소설이 일어나는 기전으로 아포프토시스가 관여하리라는 가정 하에 고농도의 단백 및 당뇨병성 신증으로 인한 신증후군 환자의 단백뇨에 노출된 근위세뇨관 상피세포에서 아포프토시스와 연관된 Fas 유전자의 발현과 TGF-β의 발현을 관찰하였다. 방 법 : 인 근위세뇨관 상피세포를 배양한 뒤 bovine serum albumin (1, 10 ㎎/mL)과 당뇨병성 신증으로 인한 신증후군 환자의 단백뇨 (1, 10 ㎎/mL)에 노출시켰고 대조군은 약물처리를 하지 않고 배양하였다. 24시간 토출시킨 뒤 RNA를 추출하여 RT-PCR 방법으로 Fas 유전자와 TGF-β 발현을 정량하였다. 결 과 : 약물처리를 하지 않은 대조군의 TGF-β 발현은 human ribosamal protein L-19에 대한 상대값이 0.45±0.02였고 BSA 10 ㎎/mL 군에서는 0.78±0.12 (p=0.016), 단뇨병성 신증으로 인한 신중후군 환자의 단백뇨 10 ㎎/mL에 노출된 군서는 0.7±0.08 (p=0.012)로 증가하여 두 군 모두에서 통계적으로 유의한 증가를 보였다. 대조군의 Fas 유전자 발현은 human ribosomal protein L-19에 대한 상대값이 0.7±0.09였고 이에 비해 BSA 10㎎/mL 군에서는 0.97±0.09로 유의하게 (p=0.021) 증가하였으며 당뇨병성 신증으로 인한 신증후군 환자의 단백뇨 10 ㎎/mL에 노출된 군에서는 0.94±0.14(p=0.067)로 증가하였으나 통계적인 유의성은 없었다. 또한 10 ㎎/mL의 BSA좌 TGF-β에 대한 항체에 함께 노출된 군에서의 Fas 유전자 발현은 0.78±0.19로 TCF-β에 대한 항체에 노출되지 않은 군에서 보여졌던 Fas 유전자 발현의 증가가 관찰되지 않았다. 결 론 : 정상적으로는 노출되지 않는 고농도의 단백에 노출시 세뇨관 상피세포는 TGF-β 및 Fas 유전자의 발현증가로 매게되는 아포프토시스를 통한 세포사멸의 과정을 통해 세뇨관간질의 위측에 관여하는 것으로 생각된다. Background : Glomerular diseases of diverse origins are characterized by heavy proteinuria and tubulointerstitial changes in pathology. Numerous studies have recently demonstrated that interstitial fibros and tubular atrophy are better predictors of renal disease progression compared with glomerular pathology. One of the important mechanisms of these tubuloimerstitial injury is tubulointerstitial damage due to increased protein trafficking across the proximal tubular epithelial cells. We tested the hypothesis that tubular cells exposed to high concentration of protein express TGF-β, which can be related to tubulointerstitial fibrosis, and Fas antigen, which can be associated with tubular cell apoptosis. Methods : Cultured human proximal tubular cells were incubated with varying concentrations of BSA (1, 10 ㎎/mL) and nephrotic range proteinuria, due to diabetic nephropathy (1, 10 ㎎/mL), with or without inactivation of complement. After 24 hr-incubation period, the expressions of TGF-β and Fas mRNA were examined by RT-PCR. Results : The amount of expression of TGF-β was increased in BSA 10 ㎎/mL group (0.78±0.12, p=0.016) and in diabetic proteinuria 10 ㎎/mL group (0.78±0.08, p=0.012) compared to control group which was incubated in medium alone (0,48±0.02), and the amount of expression of Fas was increased in BSA 10 ㎎/mL group (0.97±0.09, p=0.021) and showed increased tendency in diabetic proteinuria 10 ㎎/mL group (0.94±0,14, p=0.067) also. Furthermore, the anti TGF-β antibody ameliorated the increased albumin-induced expression of Fas. Conclusion : Collectively, our results showed that protein overload increased the expression of TGF-β & Fas, which can play an important role in tubulointerstitial atrophy by inducing apoptosis of renal tubular cells.

투석막에 따른 염증성 싸이토카인의 생성 및 응고기전 활성화에 관한 연구

한금현(Kum Hyun Han),이지은(Ji Eun Lee),서지아(Ji A Seo),성수아(Su Ah Sung),이소영(So Young Lee),조상경(Sang Kyung Jo),조원용(Won Yong Cho),김형규(Hyung Kyu Kim) 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.5

배 경 : 혈액투석 중 혈액-투석막간의 상호작용에 의해 혈액 옹고계, 섬유소성 용해계 및 혈구성분의 활성화가 일어나는지 알아보고, 생체적합도가 다르다고 알려진 hemophan 투석막과 polysulfone 투석막에서의 차이가 있는지 알아보았다. 방 법 : 유지혈액투석을 받는 25명의 말기 신부전 환자를 hemophan 투석막 (n=13), polysulfone 투석막 (n=12)의 두 군으로 나누어 2주간 혈액투석을 시행한 뒤, 투석 전후의 혈액을 채취하여 혈청 Thrombin-antithrombin complex (TAT), D-dimer, tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), fibrinogen, aPTT를 측정하고, 이들의 혈액투석 전후의 변화와 투석막에 따른 변화율의 차이를 비교하였다. 단핵구 활성시 생성되는 염증성 싸이토카인인 TNF-α 단백의 혈청 농도로 단핵구의 활성을 평가하였다. 결 과 : 혈액투석 후 혈청 TNF-α 단백 농도의 변화가 없었으며, Hemophan군과 polysulfone군 사이에도 차이가 없었다. 혈액투석 후 PAI-1를 제외한 aPTT, fibrinogen, TAT, D-dimer, tPA의 농도는 모두 의미있게 증가되었다. Hemophan굴과 polysulfone군 사이의 aPTT, fibrinogen, D-dimer, PAI-1, tPA의 투석 친후 변화량 (Δ)은 차이가 없었으나, TAT의 변화량 (Δ)은 polysulfone군에서 의미있게 적었다. 결 론 : 혈액-투석막간의 상호작용은 혈액 응고계 뿐 아니라 섬유소성 용해계도 활성화시키며, 혈액 응고계의 활성을 적게 일으킨다는 점에서 polysulfone의 생체적합도가 hemophan에 비해 우수하다. 혈액-투석막간의 상호작용이 혈청 TNF-α 단백 농도에 변화를 주지 못했는데, 향후 연구가 필요하리라 생각된다. Background : Blood-dialyzer membrane interaction in hemodialysis has the potential to activate blood coagulation and fibrinolysis, and it might elicit production of inflammatory cytokine such as TNF-α by monocytes activation. The aim of the present study was to; ⅰ) assess changes in coagulation status, fibrinolytic activity and plasma level of TNF-α during hemodialysis; ⅱ) determine whether the extent of activation is dependent on the dialyzer material used. Methods : Twenty-five end-stage renal failure patients who had undergone maintenance hemodialysis were included in the study. Patients were randomly divided into two groups; one using hemophan dialyzer membrane (n=13) and the other using polysulfone dialyzer membrane (n=12). On sixth dialysis session, blood samples were obtained before and at the end of hemodialysis. Thrombin-antithrombin complex (TAT) and D-dimer, each reflecting in vivo thrombin generation and fibrin degradation product respectively, were measured for coagulatory and fibrinolytic activity. Tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), and fibrinogen were measured. Activated partial thromboplastin time (aPTT) was measured for efficancy of anticoagulant. Plasma level of TNF- a was also measured. Results : During hemodialysis, plasma level of TNF-α did not change. Between hemophan dialysis and polysulfone dialysis group, the change in plasma level of TNF-α (Δ TNF-α) was not different. Significant changes were observed in aPTT, fibrinogen, TAT, D-dimer, tPA during hemodialysis (p<0.05) except in PAI-1 (p=0.71). Between two groups, changes in aPTT, fibrinogen, D-dimer, PAI-1 and tPA (ΔaPTT, Δfibrinogen, ΔD-dimer, ΔPAI-1, ΔtPA) were not different (p>0.05). However, the change in TAT (ΔTAT) was significantly lower in polysulfone dialysis group (p=0.049). Conclusion : Hemodialysis enhances coagulatory activity despite the use of anticoagulant and also enhances fibrinolytic activity, which is likely the result of tPA release. In activation of coagulatory system, biocompatibility of polysulfone membrane is superior to that of hemophan membrane. Plasma level of TNF-α did not change during hemodialysis, further study should be considered.

발진열에 동반된 급성 세뇨관 간질성 신염에 의한 급성신부전 1례

부창수 ( Chang Su Boo ),고강지 ( Gang Jee Ko ),성수아 ( So Ah Sung ),조상경 ( Sang Kyung Jo ),조원용 ( Won Yong Cho ),김형규 ( Hyoung Kyu Kim ),원남희 ( Nam Hee Won ) 대한신장학회 2005 Kidney Research and Clinical Practice Vol.24 No.6

저분자량 헤파린 사용에 있어 신기능 정도에 따른 출혈경향 연구

송은주 ( Eun Ju Song ),이승엽 ( Seung Yup Lee ),정유민 ( Yu Min Jung ),노경우 ( Kyung Woo Nho ),성수아 ( Su Ah Sung ),황영환 ( Young Hwan Hwang ),이소영 ( So Young Lee ) 대한신장학회 2011 Kidney Research and Clinical Practice Vol.30 No.2

Purpose: Low molecular weight heparin (LMWH) is safe and effective in the treatment of acute coronary syndrome (ACS) and venous thromboembolism. Compared with unfractionated heparin (UFH), it is known to have less bleeding tendency in the general population. However, it is not certain whether bleeding complications are decreased by LMWH in patients with renal failure. We postulated that the use of LMWH may lead to increase in bleeding tendency in patients with renal dysfunction. Methods: We conducted a retrospective study in 486 hospitalized patients who were diagnosed as cerebral infarction or ACS, and treated with enoxaparin or nadroparin from January 2008 to December 2009. Bleeding complications were compared in 3 groups according to estimated glomerular filtration rate (GFR 60, 30-59, and <30 mL/min/1.73m ≥ 2). Age, hypertension (HTN), diabetes mellitus (DM), smoking and usage of antithrombotics were examined and the relationship of these variables with bleeding tendency was analyzed. Results: Compared with group I, the frequency of total bleeding complications increased in patients with group II (p=0.002) and III (p=0.005) regardless of adequate dose reduction. Multiple logistic regression analysis after adjustment for age, HTN, DM, and usage of antithrombotics revealed that decreased GFR groups [odds ratio (OR) of group II was 5.79 (95% confidence interval (CI), 1.23-29.97; p=0.042), OR of group III 5.92 (95% CI, 1.22-27.61; p=0.029)] and DM [OR of DM 7.88 (95% CI; 1.46-46.32, p=0.026)] were two independent factors which affect major bleeding. Conclusion: These findings suggest that renal insufficiency, even if it is mild, could affect major bleeding complications in the use of LMWH.

복막투석 환자에서 발생한 Delftia acidovorans 복막염 1예

송은주 ( Eun Ju Song ),선춘식 ( Choon Sik Seon ),박세환 ( Se Hwan Park ),정종관 ( Jong Kwan Jung ),이소영 ( So Young Lee ),성수아 ( Su Ah Sung ),황영환 ( Young Hwan Hwang ),조영욱 ( Young Uk Cho ) 대한신장학회 2011 Kidney Research and Clinical Practice Vol.30 No.3

Delftia acidovarans is aerobic, nonfermentative Gram-negative rod commonly found in soil and water. Generally it is nonpathogenic but it unusually can cause bacteremia in immunocompromised patients. We present a case of peritonitis due to D. acidovorans in a patient on continuous ambulatory peritoneal dialysis. A 75-year-old woman was admitted with abdominal pain and cloudy peritoneal effluent. She was empirically treated with intraperitoneal (IP) cefazolin and ceftazidime, and then IP ceftazidime and oral ciprofloxacin, but peritonitis did not improve. Seven days after admission, D. acidovorans was identified from the peritoneal effluent, which was sensitive to amikacin, ceftazidime, ciprofloxacin and imipenem. Catheter removal was considered with regard to poor response to adequate antibiotics; however, 4 days after changing to IP imipenem/cilastatin, abdominal pain, the leukocyte count of peritoneal effluent and C-reactive protein decreased. She was treated with imipenem/cilastatin for two weeks and discharged with the dialysis catheter intact.