Paraquat 중독 환자에 대한 hemoperfusion 과 continuous veno-venous hemofiltration 의 치료 효과

노희종(Hee Jong Noh),구자룡(Ja Ryong Koo),이정열(Jeong Yeol Lee),주민하(Min Ha Joo),전만조(Man Jo Jeon),김진철(Jin Cheol Kim),김근호(Gheun Ho Kim),전노원(Rho Won Chun),김형직(Hyung Jik Kim),채동완(Dong Wan Chae),노정우(Jung Woo Noh) 대한내과학회 2000 대한내과학회지 Vol.59 No.6

N/A Background : In Korea, paraquat accounts for most of fatal poisoning with 500 or more deaths per year. It has been known that patients who ingested more than 1/2 mouthful of 20% concentrate paraquat usually die of multiorgan failure and pulmonary fibrosis. But the effect of charcoal hemoperfusion which can enhance elimination of paraquat remains controversial. Because acute paraquat poisoning is also characterized by multiorgan failure including kidney and marked rebound in plasma paraquat level after hemoperfusion, Continuous veon-venous hemofiltration(CVVH) may have theoretical benefits in the treatment of paraquat poisoning. So we evaluated the effect of early charcoal hemoperfusion and prophylactic CVVH after hemoperfusion in patients with paraquat poisoning. Methods : There were 80 patients with paraquat poisoning admitted within 24 hours after ingestion (August 1996 - March 1998). All of them were treated with hemoperfusion (duration of hemoperfusion, 6.4±3.0 hours) within 24 hours of ingestion. The amount of ingestion was 2.1±1.0 mouthful (as 20% concentrate) and 78 (98%) were urine sodium dithionite test positive which is a poor prognosis factor. Forty-four patients received hemoperfusion only and 36 were followed by CVVH (duration, 50.4±20.9 hours; ultrafiltration volume, 33.8±3.9 L/day) after hemoperfusion. Results : There was no difference between the hemoperfusion group and hemoperfusion+CVVH group in age, sex, initial serum creatinine, arterial oxygen saturation, severity of poisoning (as assessed by serum paraquat level determined by HPLC and amount of ingestion), or in the time elapsed from ingestion to the beginning of hemoperfusion. The total mortality was 65% (52/80) with no difference between the hemoperfusion group (64%, 28/44) and hemoperfusion+CVVH group (67%, 24/36). The mortality according to amount of ingestion was as follows: 〈 1 mouthful, 0% (0/5); 1 mouthful, 53% (8/15); 2 mouthful, 65% (11/17); ≥ 3 mouthful, 82% (27/33); unknown, 60% (6/10). Conclusion : Early hemoperfusion can be effective in reducing mortality in patients who ingest less than 2 mouthful. Even though prophylactic CVVH after hemoperfusion has no additional benefit in reducing mortality in paraquat poisoning, it prolonged the time to death after ingestion.(Korean J Med 59:651-656, 2000)

Cytochrome P450 2E1 유전자의 다형성이 알코올성 간경변증 환자의 간손상에 미치는 영향

고문수(Moon Soo Koh),이정열(Jeong Yeol Lee),주민하(Min Ha Joo),전만조(Man Jo Jeon),노희종(Hee Jong Noh),김진봉(Jin Bong Kim),김동준(Dong Jun Kim),김정아(Jung A Kim),정영화(Young Hwa Chung) 대한내과학회 2001 대한내과학회지 Vol.60 No.3

N/A Background : There is an individual variation in the hepatic injuries following alcohol abuse, which may be partly caused by the diverse activities of enzymes participating in the degradation of alcohol. Polymorphism of cytochrome P450 2E1 (CYP2E1) gene has been reported to affect the degradating activity of the enzyme, which may be eventually associated with the severity of alcoholic liver disease. In this study we were to evaluate the effects of genetic polymorphism of CYP2E1 on hepatocellular injury or fibrosis. Methods : We analyzed the relationship of CYP2E1 genotypes to the biochemical and clinical characteristics as well as TGFβ1 expressions in a total of 33 patients (M:F=32:1) with advanced alcoholic liver cirrhosis. CYP2E1 genotypes were determined by RFLP using RsaI and PstI. The amounts of serum TGFβ1 were measured by ELISA (TGFβ1 ELISA system, Promega, USA). Results : Out of 33, 23 (70%) had the CYP2E1 of genotype A and all of the remaining 10 (30%) were type B; there was no one who had type C. The serum albumin levels of patients with type A of CYP2E1 gene were lower than those with type B (p=0.01); the Child-Pugh scores were also higher in patients with type A than B (p=0.03). However, there was no difference between the two groups in the serum AST, ALT, γ-GTP and bilirubin levels. The patients expressed similar amount of serum TGFβ1 regardless of their CYP2E1 genotypes. Conclusion : Our data indicates that the most common genotype of CYP2E1 is type A (70%) in patients with advanced alcoholic liver cirrhosis in Korea. It is also suggested that patients with genotype A of CYP2E1 may be associated with more advanced alcoholic liver cirrhosis compared to those with type B.(Korean J Med 60:222-227, 2001)

복부 대동맥류에서 발치 후 발생한 범발성 혈관내 응고증 1 예

안종호 ( Jong Ho Ahn ),이정열 ( Jeong Yeol Lee ),노희종 ( Hee Jong Noh ),주민하 ( Min Ha Joo ),전만조 ( Man Jo Jeon ),윤병인 ( Byung In Yun ),장흥문 ( Heung Moon Chang ) 대한내과학회 2001 대한내과학회지 Vol.61 No.5

N/A Disseminated intravascular coagulation (DIC) is the result of a severe underlying disorder thatinitiates massive activation of the coagulation system. We report an unusual case of 79- year - old man who developed DIC after tooth extraction in abdominal aortic aneurysm. He was referred to our hospital because of persistent bleeding after tooth extraction. Physical examination indicated a pulsating mass in abdomen. Abdominal computerized tomography (CT) scan revealed 70 mm diameter aneurysm of the abdominal aorta, extending from the renal infrahilar level to the common iliac artery, and his coagulation profile showed the features of DIC by revealing thrombocytopenia, hypofibrinogenemia, and increased level of fibrinogen degradation product (FDP). After he had received blood component therapy including fresh frozen plasma and continuous intravenous heparin infusion (4,800 U/day), the bleeding diathesis and coagulopathy improved. He refused to have definitive surgery for the aneurysm. (Korean J Med 61:572- 576, 2001)

말기신부전 환자에서 Epoetin Alfa (에스포젠) 주 1회 요법과 주 2-3회 피하투여의 효과 비교

이영기 ( Young Ki Lee ),이형석 ( Hyung Seok Lee ),주민하 ( Min Ha Joo ),김성균 ( Seong Gyun Kim ),서장원 ( Jang Won Seo ),오지은 ( Ji Eun Oh ),윤종우 ( Jong Woo Yoon ),구자룡 ( Ja Ryong Koo ),김형직 ( Hyung Jik Kim ),노정우 ( Jung 대한신장학회 2007 Kidney Research and Clinical Practice Vol.26 No.2

목적: 말기 신부전 환자에서 에리스로포이에틴 (epoietin)을 주 2-3회 피하 주사 하는 방법은 자주 주사해야 하는 번거로움 뿐만 아니라 주사할 때마다 매번 통증이 발생하기 때문에, 고용량의 epoetin를 일시에 투여하여 투여 간격을 늘리는 주 1회 요법이 시도되고 있다. 본 연구에서는 혈액투석을 받는 말기 신부전 환자에서 고용량 epoetin alfa의 주 1회 요법을 주 2-3회 피하 투여와 비교하여 그 효과와 안전성을 시험하였다. 방법: Epoetin을 피하 투여 중인 혈액투석 환자 83명을 주 1회 투여군 (n=44) 또는 주 2-3회 투여군 (대조군, n=39)으로 무작위 분류하였다. 각 군의 환자는 총 10회 방문 (스크리닝 2회, 이후 8회)하여 12주간 치료 반응을 관찰하였다. 주 1회 투여군은 10,000 IU의 주사를 사용하여 정해진 용량의 epoetin alfa를 주 1회 투여하고, 대조군은 4,000 IU의 주사를 사용하여 정해진 용량의 epoetin alfa를 주 2-3회로 나누어 투여하고 혈색소 수치가 9.0-12.0 g/dL 유지하도록 용량을 조정하였다. 결과: 투여 시작시, 4주, 8주, 12주에 혈색소는 주 1회 투여군은 10.7, 11.1, 11.3, 11.0 g/dL, 대조군은 10.5, 11.3, 11.5, 11.3 g/dL로 유의한 차이가 없었다. 투여 시작시, 4, 8, 12주의 epoetin alfa의 평균 투여량은 주 1회 투여군은 142.8, 123.0, 116.7, 112.3 IU/kg/week이며, 대조군 128.4, 119.3, 103.5, 101.2 IU/kg/week으로서 주 1회 투여군에서 다소 많은 경향을 보였으나 통계적인 유의성은 없었다. Epoetin alfa의 용량을 증가시키지 않고 혈색소 수치가 유지된 환자의 비율도 주 1회 투여군 95.5%, 대조군 92.3%으로 차이가 없었다. 결론: 고용량 epoetin alfa의 주 1회 요법은 목표 혈색소를 유지하는데 있어 epoetin alfa를 2-3회 나누어 투여하는 방법과 효과와 안정성 면에서 비슷하였다. 따라서 안정적인 혈액투석 환자에서 고용량 epoetin alfa의 주 1회 요법이 효과적인 방법으로 생각된다. Purpose: Compared with the practice of administrating subcutaneous erythropoietin injection two or three times a week in end-stage renal failure, a weekly administration reduces the frequency of injection and the workload in renal units. We investigated whether subcutaneous epoetin alfa administered weekly was as effective as the same weekly dosage given in two or three divided doses. Methods: Eighty-three patients were randomized to treatment with subcutaneous epoetin alfa either once a week (n=44), or to their original dosage two or three times a week (control, n=39) for 12 weeks. If hemoglobin was out of range (9.0-12.0 g/dL), the dosage was changed. Results: Mean hemoglobin levels at randomization and after 4, 8 and 12 weeks were 10.7, 11.1, 11.3 and 11.0 g/dL, respectively, in the once weekly group compared with 10.5, 11.3, 11.5 and 11.3 g/dL, respectively, in the control group. The mean weekly epoetin alfa dosage at randomization and after 4, 8 and 12 weeks were 142.8, 123.0, 116.7 and 112.3 IU/kg, respectively, in the once-a-week group compared with 128.4, 119.3, 103.5 and 101.2 IU/kg, respectively, in the control group. No statistically significant differences between the groups were apparent in changes in hemoglobin levels or epoetin alfa dosages at week 12. There was no significant difference between the groups in number of patients who maintained stable hemoglobin levels without epoetin alfa dose increases. Conclusion: This study demonstrates that a weekly subcutaneous administration of epoetin alfa is as effective and safe as injecting it two or three times a week administration in maintaining hemoglobin levels in stable hemodialysis patients.

폐섬유화를 보인 paraquat 중독의 치료 2 예

김진철,이정열,구자룡,윤종우,채동완,김근호,전노원,노정우,김형직,노희종,주민하,전만조 대한내과학회 2001 대한내과학회지 Vol.60 No.5

Paraquat, a very potent herbicide, has produced many fatalities through indiscriminate usage and suicides. It is known that with ingestion of more than one mouthful of 20% paraquat, death usually occurs by pulmonary fibrosis. We experienced two cases of successful outcome in patients with paraquat poisoning complicated with pulmonary fibrosis through active, intensive treatment from the early phase after ingestion. They swallowed one to two mouthfuls of the 20% commercial paraquat, and received hemoperfusion within 2-3 hours after ingestion. Then, combination therapy with steroid, vitamin C, D-penicillamine, allopurinol, colchicine was administered from the early phase. They showed moderate to severe hypoxemia and pulmonary fibrosis on chest HRCT during hospital course, but recovered from hypoxemia and remained very well on follow up over 3 months and 12 months after ingestion, respectively. We report these cases with literature review on treatment and prognosis of paraquat poisoning. (Korean J Med 60:490-495, 2001)