이차성 부갑상선 기능 항진증을 가진 복막투석 환자에서 경구 칼시트리올 치료 반응에 관여하는 요인

강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),신석균(Sug Kyun Shin),하성규(Sung Kyu Ha),노현진(Hyun Jin Noh),송현용(Hyun Yong Song),노현정(Hyun Jung Roh),유태현(Tae Hyun Yoo),황재하(Jae Ha Hwang) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.1

N/A Calcitriol therapy is an important treatment for the prevention and control of secondary hyperparathyroidism in continuous ambulatory peritoneal dialysis (CAPD) patients. However, this often has been limited by the associated hypercalcemia and hyperphosphatemia due to increase in intestinal calcium and phosphorus absorption. Many studies reported that these limitations could be avoided by changing routes, frequency and dose of calcitriol treatment. But, there are still controversy about each methods and the results on the PTH response to conventional calcitriol treatment in CAPD patients. This study was performed to evaluate the factors affecting the response to oral calcitriol in CAPD patients. A retrospective study was done in 92 CAPD patients with secondary hyperparathyroidism(intact PTH level >200pg/ml) on oral calcitriol treatment. After baseline study of serum calcium, phosphorus, alkaline phosphatase, BUN, creatinine and intact PTH, calcitriol therapy was begun via oral rou- te, daily. Serum calcium, phosphorus, alkaline phosphatase, BUN, creatinine, intact FI'H and other bio- chemical markers were checked at 3 month, 6 month after treatment. Parathyroid gland ultrasonography was performed to detect parathyroid hypertrophy and nodule and to measure the diameter of parathymid gland. All the patients were divided into two groups according to percent reduetion of i-PTH(initial PTH PTH after 3, 6 months)×100/initial PTH(%),△PTH during oral calcitriol therapy for 3 and 6 months(group I ; △PTH >30%, group II ; △PTH <30%). Result: 1) All 92 patients(mean age 46.5 11.3yr, M: F 45: 47, mean CAPD duration 51.3 39.4 months) were administered oral calcitriol, daily. Mean calcitriol dose during 3 month was 0.43 0.22μg and during 6month 0.43 0.24μg. 2) After 3-month treament, there were significant differences in initial i-PTH, the diameter of parathyroid gland, initial phosphorus, intial total alkaline phosphatase and duration of CAPD between group I and II(406.7±196.5 vs. 871.0±478Apglml, 6.2±2.6 vs. 13.1±5.2mm, 5.0±1.3 vs. 5.7±1.3mg/dl, 93.7±4L1 vs. 171.9±137.6IU/L, 40.1±34.9 vs. 73.5±37.8months, p< 0.05, respectively). 4) After 6-month treament, there were significant differences in initial i-PTH, the diameter of parathyroid gland, intial total alkaline phosphatase and duration of CAPD between group I and II(474.1±266.6 vs. 889.7±485.4pg/ml, 6.4±2.7 vs. 14.5±5.1mm, 107.9±80.1 vs. 180.7±121.5IU/L, 40.5± 32.9 vs. 81.8±35.3months, p<0.05, respectively). 5) The significant negative correlation was shown between △PTH and the duration of peritoneal dialysis, the diameter of parathyroid gland, initial PTH level and PTH response during 3-month and 6-month oral calcitriol treatment. The response to oral calcitriol was poor when i-PTH level more than 500pg/ml(kappa 0.429, p value <0.01), the diameter of parathyroid gland more than 10.0mm(kappa 0.641, p value<0.01), the duration of CAPD more than 55months(kappa 0.524, p value< 0.01). These data suggested that initial i-PTH level, the diameter of parathyroid gland size and the duration of CAPD were independent risk factors of the poor response to oral calcitriol therapy in CAPD patients with secondary hyperparathyroidism.

단회뇨의 protein/creatinine ratio를 이용한 일일 뇨단백량 예측에 영향을 미치는 인자

강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),유태현(Tae Hyeon Yoo),류동렬(Dong Yul Ryu),신석균(Sug Kyun Shin),하성규(Sung Kyu Ha),노현진(Hyun Jin Noh),송현용(Hyun Yong Song),황재하(Jae Ha Hwang) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.1

N/A It's well known that protein/creatinine ratio(P/C ratio) in random urine samples reflects 24-hour urine protein. However, the factors affecting accurate quantitation of proteinuria using random urine P/C ratio are not fully evaluated. The aim of this study is to evaluate factors affecting accurate quantitaion of proteinuria using random urine P/C ratio. 118 patients admitted in Yonsei university medical center during June 1998 and Dec. 1998 were assessed for the measurement of random urine protein/creatinine ratio from second voided urine. 118 patients(mean age 41.5year, male: female 2.36: 1) had mean creati-nine level 1.83±1.78mg/dL, 24-hour pmteinuria 6.06±7.64g/day and P/C ratio 4.80±4.48, All the patiient.s were divided into A, B, C, I, II, K, IV according to serum creatinine level and 24-hour proteinurim amount. The correlation coefficient(R value) between proteinuria and P/C ratio are shown that in all pa- tients is 0.875, group A(Cr≤1.4) 0.884, group B(1A <Cr≤4.0) 0.819, group C(4,0<Cr) 0.844, gmup I (24-hr pro'≤0.3) 0.8%, group II(0.3<24-hr pro≤1.0) 0.813, group III(1.0<24-hr pro≤3.5) 0.716, group IV (3.5<24-hr pro) 0.637. These R value were statisti-cally significant(p value<0.05).(Cr serum creatinine, mg/dL, 24-hr pro ' 24-hour urine protein amount, g/day). Greater amount of proteinuria in 24-hour urine less correlated in sensitivity, specificity and positive predictive value with random urine P/C ratio. To evaluate factors affecting accurate quantitation of proteinuria by P/C ratio, multiple regression analysis was performed. The factors affecting accurate quantitation of proteinuria using random urine P/C ratio was 24-hour urine protein amount, not serum creatinine. Especially, in the patients with 24-hour pro-teinuria less than 4.0g/day, the random urine P/C ratio predicted 24-hour urine protein amount most accurately. In conclusion, random urine P/C ratio was well correlated with 24-hour proteinuria in the non-ne-phrotic range proteinuria especially, under 4.0g/day, irrespective of serum creatinine level.

이차성 부갑상선 기능 항진증이 있는 지속성 외래 복막투석(CAPD) 환자에서 칼시트리올(칼시오) 경구 충격요법과 저용량 매일요법의 비교 연구

강신욱(Shin Wook Kang),최규헌(Kyu Hun Choi),이호영(Ho Yung Lee),한대석(Dae Suk Han),유태현(Tae Hyeon Yoo),신석균(Sug Kyun Shin),하성규(Sung Kyu Ha),노현진(Hyun Jin Noh),류동렬(Dong Ryeol Ryu),송현용(Hyun Yong Song),황재하(Jae Ha Hwan 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.3

N/A The most widely used method for treatment of secondary hyperparathyroidism(SH) in CAPD patients has been the administration of calcitriol by oral route. In this study, we compared the efficacy and safety of daily low dose calcitriol therapy with those of intermittent high dose pulse therapy. The study group consisted of 38 patients undergoing CAPD with serum intact PTH level of more than 200pg/ mL. Twenty patients were randomly administered daily low dose calcitriol(0.25μg/day for 1 month followed by 0.5μg daily dose for the next 3 mon-ths) while 18 patients were given intermittent pulse therapy(0.5μg-0.5μg-0.75μg 3 times a week for 1 month, increased to 1.0μg-1.25μg-1.25μg 3 times a week for the next 3 months). Thirty five patients completed the study : 17 on daily oral calcitriol (M: F=0.7:1, mean age=47.3±10.6 years, mean duration of CAPD=48.9±41.1 months), and 18 on oral pulse calcitriol(M: F=1.6: 1, mean age=41.5±12.7 years, mean duration of CAPD=49.2±41.6 months). The baseline serum levels of calcium, phosphorus, i-PTH, alkaline phosphatase, and total CO₂were not different be- tween daily and pulse group(9.5±0.8 vs 9.3±0.9mg/ dL, 5.8±1.3 vs 5.1±1.2mg/dL, 443.1±162.5 vs 546±385.9pg/mL, 91.8±47.7 vs 108.9±66.5IU/L, 23.7±1.9 vs 25.5±2.0mEq/L, p>0.05, respectively). The i-PTH level decreased significantly in daily calcitriol group after 1 month(332.8±214.8pg/mL, p<0.01), and at final evaluation(180.4±254.8pg/mL, p<0.01). In pulse calcitriol group, i-PTH level also decreased signi-ficantly to 400,4±225.8pg/mL(p<0.05), 89.4±122.6 pg/mL(p<0.01), respectively. The rate of decline in i-PTH level from baseline were similar(daily=25.4±22.7 vs pulse=19.5±12.6%decline/month, p>0.05). The serum calcium increased similarly in both groups after treatment(daily=10.6±0.8 vs pulse=l0.1±1.0mg/ dL, p>0.05). Hypercalcemia(>11.0mg/dL) was rarely observed in all patients(daily=5, pulse=8 episodes). In conclusion, both daily and pulse calcitriol therapy were similarly effective and safe in control of SH.

산증후군환자에 대한 사이크로스포린의 유효성 및 안전성 평가를 위한 16주 공개 다기관 제 3상 임상시험

김도현,신규태,임천규(Chun Gyoo Ihm),조동규(Dong Kyu Cho),이태원(Tae Won Lee),김명재(Myung Jae Kim),김흥수(Heung Soo Kim),이호영(Ho Yung Lee),신석균(Sug Kyun Shin),홍성표(Seong Pyo Hong),노현진(Hyunjin Noh),김용림(Young Lim Kim) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.2

N/A A multicenter prospective study was done in four-university hospital to evaluate the efficacy and safety of cyclosporin A(CyA, Cipol-N) in 64 patients with adult nephrotic syndrome mean age 34.8 years, male:female 2.4:1, duration of disease 38.0±40.9months, 31 patients with MCD, 33 patients with Non-MCD(8 FSGS, 14 MGN, 7 MPGN, 2 lupus nephritis, 1 HBsAg associated GN)]. The prior steroid responses of these patients were 17 steroid dependent, 9 frequent relapser, 4 steroid resistant and 1 other in MCD patients, and 5 steroid dependent, 5 frequent relapser, 22 steroid resistant and 1 other in Non-MCD patients. After a 2-week steroid(predni-solon 10mg/day or deflazacort 12mg/day) run-in period, CyA 5mg/kg/day and prednisolone 10mg/day (or deflazacort 12mg/day) were administered for up to 16 weeks. Of the 64 patients enrolled, ll patients were dropped out prematurely due to adverse events or protocol violation. Of the 53 patients who completed the study, 27 had MCD and 26 had Non- MCD. High response(CR and PR) rate of 68%(36/53) were obtained with CyA treatment in all patients. Although the response rate in MCD was significantly higher than that in Non-MCD(89 vs. 46%, p<0.05) and response rates were significantly different according to the previous steroid responses by univariate analysis, only previous steroid responses affected the response to CyA significantly by Logistic multiple regression analysis(p=0.03, RR 7.08); responses were 84%(27/32) in steroid dependent and frequent relapser patients, and 37%(7/19) in steroid resistant patients. 24-hr proteinuria significantly decreased after 2 weeks and serum albumin and cholesteroi increased significantly after 4 weeks of treatment compared to baseline level. The serum creatinine level was not changed during the study. No serious and unexpected side event was observed. In conclusion, cyclosporine therapy is a safe and effective mode of treatment in patients with ne-phrotic syndrome, especially in those who need pro- longed administration of steroids with resulting in unavoidable steroid complications such as frequent relapser and steroid dependent type. The patients with steroid resistant type and contraidications of steroid administration such as DM, aseptic bone neerosis etc. can also be candidates for this treatment.

필수 아미노산의 ketoanalogs 보충을 동반한 단백 제한 식이가 만성 신질환의 진행에 미치는 영향

김동기 ( Dong Ki Kim ),강이화 ( Ea Wha Kang ),유태현 ( Tae Hyun Yoo ),김범석 ( Beom Seok Kim ),최규헌 ( Kyu Hun Choi ),이호영 ( Ho Yung Lee ),한대석 ( Dae Suk Han ),신석균 ( Sug Kyun Shin ) 대한신장학회 2008 춘계학술대회 초록집 Vol.28 No.1

담낭 선종증을 동반한 Gardner 증후군

김원호(Won Ho Kim),박찬일(Chan Il Park),김태승(Tai Seung Kim),김남규(Nam Kyu Kim),유효민(Hyo Min Yoo),임현이(Hyun Ee Yim),신석균(Sug Kyun Shin),김희성(Hee Sung Kim) 대한소화기학회 1993 대한소화기학회지 Vol.25 No.6

Gardner's syndrome is a rare hereditary disorder transmitted by autosomal dominant inheritance and charactrized by multiple adenomatous polyps throughout large intestine associated with multiple osteomas, epidermal cysts, fibromas, etc. Extracolic tumors such as periampullary carcinoma, papillary carcinoma of the thyroid gland, adrenal adenoma/carcinoma and tumors of the CNS have been reported to be associated with Gardner's syndrome. The authors report a case of Gardner's syndrome in a 53-year-old male who presented colorectol polyposis with osteoma of the frontal bone, schwannoma of neck and multiple adenomas of the gallbladder. A review of literature with empha.'is on the association of adenomata of the gallbladder was made. The colorectum was carpeted by multiple sessile and pedunculated polyps with microscopic foci of adenocarcinoma confined to the submucosa. The gallbladder was stuffed with multiple polyps, which were histologically adenomas with varying degrees of atypical change from mild dysplasia to carcinoma in situ.

지속성 외래 복막투석 환자에서 갑상선 기능의 변화

이현희 ( Hyun Hee Lee ),김대중 ( Dae Jung Kim ),김정아 ( Jung Ah Kim ),이영기 ( Young Ki Lee ),윤수진 ( Su Jin Yoon ),허우성 ( Woo Seong Huh ),김윤구 ( Yoon Goo Kim ),오하영 ( Ha Young Oh ),김용림 ( Yong Lim Kim ),신석균 ( Sug Kyu 대한신장학회 2003 Kidney Research and Clinical Practice Vol.22 No.1

목적 : 말기신부전으로 투석 중인 환자에서 C반응단백 (C-reactive protein, CRP)은 이환률과 사망률의 주요한 원인으로 알려진 관상동맥질환을 예견하는 지표로 알려져 있으며, 최근 여러 연구에서 맥압의 증가가 정상인에서 심혈관 질환과 사망률의 위험인자로 대두되고 있다. 따라서 본 연구는 복막투석 환자에서 이 두 가지 지표를 함께 측정하여 관상동맥질환의 위험도를 예견하는 지표로서의 가치를 알아보고자 시행되었다. 방법 : 복막투석을 시행하는 환자 중 thallium single photon emision computed tomography (thallium SPECT)를 시행하고 6개월 이상 추적관찰이 가능하였던 총 71명의 환자 (남자 42명, 여자 29명)를 대상으로 하였다. 나이, 성별, 흡연, 당뇨, 고혈압, 맥압, 체질량 지수에 대하여 조사하였으며 혈중 알부민, 총 콜레스테롤, 섬유소원, lipoprotein (a), C반응단백을 검사 하였다. 결과 : Thallium SPECT 양성군과 음성군으로 분류하여 비교한 결과 thallium SPECT 양성군에서 C반응단백, 맥압, 흡연율, 섬유소원의 값이 의의있게 높았다 (p<0.05). 맥압이 1 mmHg 증가시 관상동맥질환의 상대 위험도는 1.017배 (95% 신뢰구간 1.011-1.023), C반응단백이 0.01 mg/dL 증가시 관산동맥질환의 상대 위험도는 1.014배 (95% 신뢰구간 1.008-1.019) 증가하였다. 다증회귀분석 결과 C반응단백과 맥압이 심근 허혈에 영향을 주는 독립인자였다. Log C반응단백과 맥압간에는 양의 상관관계가 있었다. (p<0.01>. 결론 : 복막투석 환자에서 C반응단백과 맥압은 모두 관상동맥 질환을 예측하는데 유용한 지표로 이용할 수 있을 것으로 기대된다. 그러므로 복막투석 환자에서 뚜렷한 원인 없이 지속적으로 C반응단백과 맥압이 상승되어 있는 경우 허혈성 심질환에 대하여 검사가 이루어져야 할 것으로 생각된다. Background : Atheroclerotic vascular disease is the major cause of morbidity and mortality in dialysis patients. C-reactive protein (CRP) appears to be clinically useful in prediction of coronary heart disease. Elevated pulse pressure has been associated with an increased risk of cardiovascular disease among apparently healthy adults. Therefore, we evaluated the association between a persistent elevation of C-reactive protein level, pulse pressure and the presence of ischemic heart disease in patients with continuous ambulatory peritoneal dialysis (CAPD). Methods : A total of 71 CAPD patients (42 males 29 females) who underwent thallium SPECT and followed up more than 6 months were included. We collected the data about age, sex, smoking, diabetes, hypertension, pulse pressure and body mass index. Blood levels of albumin, total cholesterol, fibrinogen, lipoprotein (a) and C-reactive protein were measured. Results : The values of C-reactive protein, pulse pressure, smoking and fibrinogen were significantly higher in thallium SPECT positive group (p<0.05). A 0.01 mg/dL increase in C-reactive protein was associated with a 1.014 increase in the odds of having an elevated risk of coronary artery disease (95% confidence interval 1.008-1.019) and a 1 mmHg increase in pulse pressure was associated with a 1.017 increase in the odds of having an elevated risk of coronary artery disease (95% confidence interval 1.011-1.023). By multivariate logistic regression analysis, C-reactive protein and pulse pressure were independent risk factors for ischemic heart disease. Log CRP level was positively correlated with pulse pressure level (p<0.01). Conclusion : The baseline level of CRP and pulse pressure independently predicts the risk of coronary heart disease in CAPD patients. For patients who have a persistent elevation of CRP and pulse pressure without an apparent cause, we recommend a workup for ischemic heart disease.

B형 간염과 연관된 신증후군 치료에 Lamivudine 단독요법과 Lamivudine 및 Steroid 병합요법의 비교

송현용,류동렬,이호영,신석균,황재하,강신욱,최규헌,한광협,하성규,한대석,노현진 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.4

Treatment of nephrotic syndrome associated with hepatitis B are controversial, but some patients may respond to interferon therapy. Steroid therapy in these patients could be limited, because it may aggravate hepatitis with the acute viral replication. Lamivudine may also be effective in reducing viral burden and may convert patients from HBsAg and HBeAg positive to negative. But there was no report for the usefulness of lamivudine in treatment of these patients. We performed a randomized comparative study to assess the usefulness of lamivudine and the effect of steroid in the use of lamivudine in treatment of B-viral associated nephrotic syndrome. Twelve patients(M:F=1:0.2, mean age 34.3 years, MCD 1, MPGN 5, MGN 6 patients) suspected to have the acute viral replication with nephrotic syndrome were included. They were randomly assigned to receive lamivudine and steroid combination therapy(group I, 150mg of lamivudine with high-dose steroid, 1mg/kg/day, orally once daily in 6 patients) or lamivudine alone therapy(group II, 150 mg of lamivudine orally once daily alone in 6 patients). The duration of lamivudine use was 6 months in both groups, and that of steroid use was 6 weeks in group I. Then, lamivudine and steroid were tapered according to the amount of proteinuria and serum HBV-DNA titer. All patients were closely monitored every 2 months with clinical, bioche mical, and serological parameters for 10 months. The rate of negative sero-conversion of HBV- DNA were 91.7%(11/12) at 2 months of lamivudine therapy in all patients, and there was no difference between group I and II(83.3% vs. 100%, p$gt;0.05). In group I, there were a significant decreases of mean serum HBV-DNA values(899.2±711.9 vs. 31.4±32.7, 12.7±27.6, and 137.2±278.1pg/ml, p$lt;0.05, respectively), proteinuria(11.0±3.6 vs. 3.9±2.3, 2.1±2.3, and 2.5±3.1g/d, p$lt;0.05, respectively), and SGPT (57.7±18.9 vs. 30.5±12.4, 23.8±10.2, and 26.0±10.4 IU/L, p$lt;0.05, respectively) measured at 2, 6, and 10months compared to before therapy, and serum albumin levels were significantly increased at 2, 6, and 10months compared to before therapy(2.2±0.5 vs. 3.1±0.5, 3.9±0.8, and 3.9±0.9g/dL, p$lt;0.05, respectively). In group II, serum HBV-DNA was significantly decreased at 2, 6, and 10 months compared to before therapy(358.8±369.3 vs. 19.1±27.0, 0.0±0.0, and 0.0±0.0pg/ml, p$lt;0.05, respectively), and proteinuria and SGPT were significantly decreased at 6 and 10 months compared to before therapy(8.5±5.5 vs. 2.6±1.3 and 2.1±2.3g/d, p$lt;0.05; 67.5±43.0 vs. 25.3±11.6 and 31.5±9.2IU/L, p$lt;0.05, respectively). Serum albumin levels were significantly increased at 10 months compared to before therapy(2.8±0.8 vs. 4.3±0.1g/dL, p$lt;0.05). Serum HBV-DNA levels rebounded in two patients of group I, but none was observed in group II. No serious adverse events were observed in all the patients. In conclusion, lamivudine and steroid combination therapy may more rapidly decrease proteinuria than lamivudine alone in B-viral associated nephrotic syndrome, but may induce the rebound of serum HBV-DNA.

지속성 외래 복막투석 환자에서 저칼슘 복막투석액의 임상적 유용성

한대석,강신욱,최규헌,이호영,신석균,노현진 대한신장학회 1998 Kidney Research and Clinical Practice Vol.17 No.5

Hypercalcemia is a common complication in CAPD patients treated with calcium-containing phosphate binders and using the standard dialysate(SCD) calcium concentration of 3.5mEq/L. We performed a retrospective study in 25 CAPD patients to determine whether a low calcium dialysate(LCD) containing 2.5mEq/L calcium would reduce the incidence of hypercalemia with adequate control of serum inorganic phosphate levels and diminish the need to use aluminum-containing phosphate binders. All patients had previously used SCD before converting to LCD. The incidence of hypercalcemia(more than 2 episodes of corrected serum calcium?10.5mg/dL) tended to be lower after converting to LCD?0.27 (0-2.76) vs. 0(0-1.97) episodes/patient-year?. Intact PTH level increased from 38.8(0.1-1599.3)pg/mL to 70.6(9.5-1540.0)pg/mL after conversion, but there was no statistical sifnificance. Serum calcium, inorganic phosphate, alkaline phosphatase and bicarbonate levels did not change after converting to LCD. We were able to reduce aluminum roxide dosage〔1.09 (0-10.88) vs. 0(0-3.26)g/day/patient〕and increase calcium carbonate dosage(1.95-+0.92 vs. 2.98-+2.14g/day/ patient) after conversion significantly(P$lt;0.05). The frequency of peritonitis was similar in LCD and SCD period. In conclusion, low calcium dialysate is useful in diminishing aluminum-containing phosphate binder dosage and increasing calcium carbonate dosage to maintain a similar phosphate value. Its effects on renal osteodystrophy remain to be assessed.

제2형 당뇨병 환자에서 알부민뇨와 심혈관계 질환의 유병율에 대한 연구

강태수,최소래,김영아,박흥수,서정건,황학진,윤세정,신석균,강신욱,최규헌,이호영,한대석,허애정,하성규 대한신장학회 2000 대한신장학회잡지 Vol.19 No.5