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장제현,김용철,송상헌,김수진,조민우,김세중 대한신장학회 2023 Kidney Research and Clinical Practice Vol.42 No.6
Background: The medium cutoff (MCO) dialyzer increases the removal of several Background: Patients with chronic kidney disease (CKD) should be educated about their condition so that they can initiate dialysis at the optimal time and make an informed choice between dialysis modalities. Shared decision-making (SDM) empowers patients to select their own treatment and improves patient outcomes. This study aimed to evaluate whether SDM affects the choice of renal replacement therapy among CKD patients. Methods: This is a multicenter, open-label, randomized, pragmatic clinical trial. A total of 1,194 participants with CKD who are considering renal replacement therapy were enrolled. The participants will be randomized into three groups in a 1:1:1 ratio: the conventional group, extensive informed decision-making group, and SDM group. Participants will be educated twice at months 0 and 2. Videos and leaflets will be provided to all patients. Patients in the conventional group will receive 5 minutes of education at each visit. The extensive informed decision-making group will receive more informed and detailed education using intensive learning materials for 10 minutes each visit. Patients in the SDM group will be educated for 10 minutes each visit according to illness perception and item-based analysis. The primary endpoint is the ratio of hemodialysis to peritoneal dialysis and kidney transplantation among the groups. Secondary outcomes include unplanned dialysis, economic efficiency, patient satisfaction, patient evaluation of the process, and patient adherence. Discussion: The SDM-ART is an ongoing clinical study to investigate the effect of SDM on the choice of renal replacement therapy in patients with CKD.middle molecules more effectively than high-flux hemodialysis (HD). However, comparative data addressing the efficacy and safety of MCO dialyzers vs. postdilution hemodiafiltration (HDF) in Korean patients are lacking. Methods: Nine patients with chronic HD were included in this pre-post study. Patients underwent HD with an MCO dialyzer for 4 weeks, followed by a 2-week washout period using a high-flux dialyzer to minimize carryover effects, and then turned over to postdilution HDF for 4 weeks. Reduction ratios and differences in the uremic toxins before and after dialysis were calculated from the MCO dialysis, postdilution HDF, and high-flux HD. In the in vitro study, EA.hy926 cells were incubated with dialyzed serum. Results: Compared to postdilution HDF, the MCO dialyzer achieved significantly higher reduction ratios for larger middle molecules (myoglobin, kappa free light chain [κFLC], and lambda FLC [λFLC]). Similarly, the differences in myoglobin, κFLC, and λFLC concentrations before and after the last dialysis session were significantly greater in MCO dialysis than in postdilution HDF. The expression of Bax and nuclear factor κB was decreased in the serum after dialysis with the MCO dialyzer than with HDF. Conclusion: Compared with high-volume postdilution HDF, MCO dialysis did not provide greater removal of molecules below 12,000 Da, whereas it was superior in the removal of larger uremic middle molecule toxins in patients with kidney failure. Moreover, these results may be expected to have an anti-apoptotic effect on the human endothelium.
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Early Start of Dialysis Has No Survival Benefit in End-Stage Renal Disease Patients
장제현,Min Young Rim,Jiyoon Sung,고광필,김동기,정지용,이현희,정우경,김세중 대한의학회 2012 Journal of Korean medical science Vol.27 No.10
The timing for dialysis initiationis still debated. The aim of this study was to compare mortality rates, using a propensity-score approach, in dialysis patients with early or late starts. From January 2000 to June 2009, incident adult patients (n = 836) starting dialysis for end-stage renal disease (ESRD) were enrolled. The patients were assigned to either an early- or late-start group depending on the initiation time of the dialysis. After propensityscore-basedmatching, 450 patients remained. At the initiation of dialysis, the mean estimated glomerular filtration rate (eGFR) was 11.1 mL/min/1.73 m2 in the early-start group compared with 6.1 mL/min/1.73 m2 in the late-start group. There were no significant differences in survival between the patients in the early- and late-start groups (Log rank tests P = 0.172). A higher overall mortality risk was observed in the early-start group than in the late-start group for the patients aged ≥ 70 yr (hazard ratio [HR]: 3.29;P = 0.048) and/or who had albumin levels ≥ 3.5 g/dL (HR: 2.53; P = 0.046). The survival of the ESRD patients was comparable between the patients in the early and late-start groups. The time to initiate dialysis should be determined based on clinical findings as well as the eGFR.
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장제현 대한의사협회 2020 대한의사협회지 Vol.63 No.1
The kidneys are closely connected with several organs, including the liver, and can therefore be negatively affected when the liver is damaged. The most common cause of chronic liver disease is chronic viral hepatitis, resulting from either a hepatitis B virus (HBV) or a hepatitis C virus (HCV). Chronic viral hepatitis often progresses to cirrhosis and hepatocellular carcinoma. However, it can also lead to viral-associated glomerulopathies that can cause chronic kidney disease (CKD), which can then progress to end stage renal disease (ESRD). Additionally, patients with ESRD on hemodialysis are at risk for viral infections because HBV and HCV are hematogenously transmitted. Recently, treatments with oral nucleoside/nucleotide analogues and direct-acting antivirals have yielded excellent results in HBV- and HCV-infected patients with CKD. As a result, a new paradigm for the treatment of chronic viral infections in CKD patients has emerged. This review discusses viral-associated glomerulopathies, antiviral treatments of HBV and HCV infections in patients with CKD, and prevention strategies for the transmission of HBV and HCV in patients with ESRD.
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The Relationship between Coronary Artery Calcification and Renal Function in Nondialyzed Patients
장제현,김세중,성지윤,정지용,이현희,정우경,성연미 연세대학교의과대학 2012 Yonsei medical journal Vol.53 No.4
Purpose: Coronary artery calcification (CAC) has been described in individuals with chronic kidney disease (CKD), and its presence is associated with an increased risk of cardiovascular death. However, it is unclear whether there is an independent relationship between renal function and CAC. Therefore, we evaluated the association between renal function and CAC. Materials and Methods: We retrospectively reviewed 870 Korean patients who had undergone computed tomographic coronary angiography. The glomerular filtration rate (GFR) was estimated using the Modification of Diet in Renal Disease study formula with an ethnic factor for the Korean population. The CKD stages were classified using estimated GFR (eGFR) and proteinuria. Results: The mean age of the participants was 56.8±11.8 years, and the mean eGFR was 89.4±16.5 mL/min/1.73 m2. Hypertension and diabetes were noted in 41.5 and 17.0% of patients, respectively. There were 584 and 286 patients with no CAC and with CAC, respectively. After adjusting for confounding variables, late stage CKD was associated with CAC [odds ratio (OR) 2.80, 95% confidence interval (CI) 1.05-7.46]. However, early stage CKD was not associated with CAC (OR 1.61, 95% CI 0.92-2.82). Diabetes was an independent risk factor of CAC (OR 2.06, 95% CI 1.36-3.13). There was no significant association between proteinuria and CAC (OR 1.65, 95% CI 0.96-2.85). Conclusion: CAC is related to late stage CKD in nondialyzed patients. These findings emphasize that individuals with CAC should be considered a high-risk population for decreased renal function.
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장제현 ( Jae Hyun Chang ),김현욱 ( Hyun Wook Kim ),박선영 ( Sun Young Park ),김동기 ( Dong Ki Kim ),문성진 ( Sung Jin Moon ),최동훈 ( Dong Hoon Choi ),심원흠 ( Won Heum Shim ),김범석 ( Beom Seok Kim ),강신욱 ( Shin Wook Kang ) 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.4
목적: 신동맥 협착은 고혈압 및 신기능 저하와 연관되어 있고, 치료하지 않는 경우 점차 진행하며, 약물에 반응하지 않는 고혈압이나 반복적인 폐부종이 있는 경우 신장 혈관성형술의 적응증이 된다. 그러나, 시술 후 신기능의 변화에 대해서는 논란이 있어, 신동맥 협착 환자에서 스텐트 삽입술 시행 후 신기능의 변화에 대해 알아보고자 하였다. 방법: 1999년 1월부터 2005년 12월까지 연세대학교 의과대학 세브란스 병원에서 신동맥 협착을 진단받은 환자 중 스텐트 삽입술을 시행한 후 6개월 이상 추적관찰이 가능하였던 환자를 대상으로 후향적으로 분석하였다. 시술 전 MDRD 공식에 의하여 산출한 사구체 여과율에 따라 두 군으로 나누어 비교하였다 (A군: GFR ≥60 mL/min/1.73m2, B군: GFR <60 mL/min/1.73m2). 대상환자들의 성별, 나이, 동반질환, 흡연, 체질량지수, 신동맥 협착의 편측성 혹은 양측성 여부와 생화학 검사 소견을 조사하여 비교 분석하였다. 결과: 대상 환자는 66명이었고, 남자 37명, 여자 29명이었다. 평균 연령은 61±12세였으며, 평균 추적기간은 54±27개월이었다. 고혈압은 92.4%, 당뇨는 30.3%에서 동반되었고, 편측성 신동맥 협착이 73%였다. A군 (n=37)에 비하여 B군 (n=29)은 나이가 많고 (58±14 vs. 65±9세), 체질량지수가 높았다 (23±3 vs. 25±3 kg/m2). 성별, 당뇨, 고혈압, 관상동맥협착, 흡연, 신동맥 협착의 편측성 혹은 양측성 여부, 혈청 총 콜레스테롤치에는 양군간에 차이가 없었다. A군에서는 스텐트 삽입술 후 통계적으로 유의하게 신기능이 감소하였고 (시술 전: 75±11, 시술 후: 70±15 mL/min/1.73m2, p= 0.038), B군에서는 통계적으로 유의한 신기능의 변화가 없었다 (시술 전: 48±9, 시술 후: 48±15 mL/min/1.73m2). A군에서는 신기능이 호전된 환자가 3%, 유지된 환자가 70%였으며, B군에서는 신기능이 호전된 환자가 24%, 유지된 환자가 52%였다. 결론: 신기능이 저하된 환자에서 스텐트 삽입술 시술 후, 신기능의 유지 및 호전에 효과적인 것으로 보아, 신동맥 협착에서 신기능이 저하된 경우에도 스텐트 삽입술을 고려해야 할 것으로 사료된다. Purpose: Renal artery stenosis (RAS) causes or deteriorates hypertension and/or renal insufficiency, and is known as a progressive disease. The aim of this study is to reveal the change of renal function after stenting for RAS. Methods: We retrospectively analyzed 66 patients between 1999 and 2005 who had stenting for RAS. Renal function was assessed by modified MDRD equation. According to baseline glomerular filtration rate (GFR), patients were divided into subgroups with group A (n=37, GFR ≥60 mL/min/1.73m2) or group B (n=29, GFR <60 mL/min/1.73m2). Clinical parameters were compared between two groups. Results: A total of 66 patients (male:female=37:29) were studied. The mean age was 61±12 years old and the mean follow-up duration was 54±27 months. Sixty-one (92.4%) patients had hypertension, 20 (30.3%) had diabetes, and 48 (73%) had unilateral RAS. Group B was older than group A (65±9 vs. 58±14 years old). The mean body mass index of group B was higher than that of group A. In group A, there was a decrease in the MDRD GFR (from 75±11 to 70±15 mL/min/1.73m2; p=0.038). In contrast, in group B there was no significant change in the MDRD GFR (from 48±9 to 48±15 mL/min/1.73m2). In group A and group B, renal function has been improved in 3% and 24%, and stabilized in 70% and 52%, respectively. Conclusion: Stenting for RAS has renal function preserving effect in patients with renal insufficiency. Therefore, stenting should be considered as a treatment modality in RAS patients even with deteriorated renal function.
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