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당뇨병성 신부전의 관리와 최신 치료 ; 당뇨병성 신증의 최신 치료 -새로운 약제를 중심으로-
박철휘 ( Cheol Whee Park ) 대한내과학회 2009 대한내과학회지 Vol.77 No.6
Prevention, early detection, and treatment of renal disease in diabetic patients are becoming major healthcare issues. It is well known that hyperglycemia is a major risk factor for the development and progression of diabetic nephropathy. Therapeutic options such as strict glycemic control and early antihypertensive treatment effectively prevent or slow the progression of renal disease in both types of diabetes, depending on the clinical manifestations. The mainstay of diabetic nephropathy therapy is good glycemic control and maintaining optimal blood pressure with angiotensin converting enzyme (ACE) inhibitors and/or angiotensin receptor blockers (ARBs). Additionally, correction of dyslipidemia and cessation of smoking are additional important factors to prevent and slow the progression of diabetic nephropathy. Biochemical and hemodynamic hypotheses have been proposed and are supported by animal models as the principal causes of the development and progression of diabetic nephropathy. This review discusses new insights into the recent trend focusing on new therapies, including hemodynamic agents and biochemical agents for preventing and delaying the progression of diabetic nephropathy. (Korean J Med 77:686-694, 2009)
박철휘 ( Cheol Whee Park ) 대한신장학회 2009 Kidney Research and Clinical Practice Vol.28 No.4
1. 만성 투석환자의 가장 흔한 심혈관 합병증은 고혈압이다. 투석 환자에서의 고혈압은 체액 저류가 가장 중요한 원인이다. 투석환자에서 혈압조절의 K/DOQI 권장치는 투석 전 혈압 140/90 mmHg 미만, 투석 후 혈압 130/80 mmHg 미만을 목표로 한다. 그러나, 투석 중에 혈압 저하가 없는 범위 내에서 가능한 낮은 수치가 좋다는 의견이 있다. 투석 환자의 생존율에 관한 역학조사에서 U 커브 현상이 나타나, 과도한 혈압 저하도 생존율을 악화시킨다는 보고도 있다. 2. 투석 환자에서 저혈압의 가장 흔한 요인은 한외여과에 의한 혈액용적의 감소에 대한 혈역동학적으로 불충분한 보상 에 의한다. 투석 중의 저혈압은 원인을 알아내고, 이에 대한 예방과 치료를 시행하는 것이 중요하다고 하겠다. 특히 부정맥 또는 허혈성 심질환 등 심혈관계 이상에 의한 투석 중 저혈압은 투석 후 환자 급사와 관련이 있으므로 주의를 기울여야 한다. 3. 투석 환자에서 일반인에 비해 부정맥이 더 흔한 것으로 알려져 있고, 이는 심장비후, 판막증, 허혈성 심질환 등에 합병된 것, 요독증과 관련된 대사 및 전해질의 변화 및 혈액투석의 영향에 의한 것 등 원인이 매우 다양하다. 가장 흔한 부정맥은 심방세동으로 심방세동이 생기거나 있는 환자는 없는 환자에 현저한 사망률의 증가를 보인다. 투석 환자에서 흔한 부정맥과 치료가 필요한 부정맥의 발견 및 원인에 대한 치료가 동시에 필요하다. 4. 심근경색을 포함한 허혈성 심질환은 투석 환자에서 흔하며, 심근경색 후 1년 생존율은 50% 미만이다. 무통성 허혈성 심질환이 많으므로 주의하여야 하고 투석 시 원인 불명의 혈압 저하나 심부전이 있는 경우 심근경색을 포함한 허혈성 심질환을 의심하고 검사를 시행하여야 한다. 적극적인 심혈관 질환에 대한 위험인자의 개선과 병변 발생 시 적절한 중재술을 통한 치료가 이루어져야 한다.
박철홍 ( Cheol Hong Park ),임창훈 ( Chang Hoon Lim ),장형진 ( Hyoung Jin Chang ),손상원 ( Sang Won Son ),정성진 ( Sung Jin Jung ),박철휘 ( Cheol Whee Park ),장윤식 ( Yoon Sik Chang ) 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.2
A 46-year-old woman with chronic renal failure due to polyarteritis nodosa was referred to the hospital for evaluation of abdominal pain. She had been treated with cathartics (magnesium oxidate 2.0 g/day) for constipation for several days. One day before the admission, the patient had been taken magnesium enema twice at another hospital. On admission, she was comatose, suffering from lethargy and respiratory failure. Her serum magnesium and amylase concentrations were markedly elevated (8.2 mg/dL and 1,698 IU/L respectively), and plain abdominal image and abdominal computed tomography revealed acute pancreatitis and non-obstuctive ileus. Thereafter, aggressive cardiopulomonary support with mechanical ventilation and continuous renal replacement therapy using continuous veno-venous hemofiltration (CVVH) applied due to cardio-respiratory failure and hypermagnesemia. After 3 days of CVVH treatment, the concentration of serum magnesium was normalized to 3.2 mg/dL, and respiratory failure and abdominal ileus were markedly improved. Four days after aggressive treatment, her hemodynamic and gastroenteric symptoms stabilized. Therefore, we report the case of hypermagnesemia with acute pancreatitis, severe hypotension and respiratory failure after cathartic ingestion and enema containing magnesium oxidate treated with CVVH.
복막투석 중단없이 성공적으로 치료한 복막투석 치료 중인 당뇨병성 만성신부전 환자에서 발생한 고삼투압성 혼수 2 예
강형주(Hyong Ju Kang),박철휘(Cheol Whee Park),이소연(So Yeon Lee),최현철(Hyun Cheul Choi),이정록(Jeong Rok Lee),손장명(Jang Myung Son),신영신(Young Shin Shin),장윤식(Yoon Sik Chang),방병기(Byung Kee Bang) 대한신장학회 2001 Kidney Research and Clinical Practice Vol.20 No.3
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일차진료에서 흔히 접하는 수분 전해질 문제 ; 안지오텐신 전환효소 억제제/안지오텐신 수용체 차단제 사용과 고칼륨혈증
정성진 ( Sung Jin Chung ),박철휘 ( Cheol Whee Park ) 대한내과학회 2011 대한내과학회지 Vol.80 No.1
Therapeutic manipulation of the renin-angiotensin-aldosterone system (RAAS) is an important strategy for improving hypertension, diabetes, cardiovascular disease, and chronic kidney disease. Development of hyperkalemia after the administration of RAAS inhibitors is of particular concern because patients at highest risk for this complication are often the same patients who derive the greatest cardiovascular or renoprotective benefit. Based on an overview of the incidence of hyperkalemia during treatment with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers alone and in combination, this review suggests approaches for monitoring, detecting, and managing hyperkalemia in patients treated with RAAS inhibitors. Although the incidence of hyperkalemia with RAAS inhibitors is generally low, hyperkalemia can be associated with increased mortality. When using RAAS inhibitors, it is important to monitor on-treatment electrolyte levels and renal function parameters in patients with a high risk for hyperkalemia. (Korean J Med 2011;80:20-30)
노인에서 상기도 감염후 발생한 급성감염후 급속진행성 사구체신염
오병선 ( Byoung Sun Oh ),박철휘 ( Cheol Whee Park ),장세나 ( Se Na Jang ),정현정 ( Hyun Jung Jung ),김경희 ( Kyoung Hee Kim ),박건우,정현화 ( Hyun Wha Chung ),한상우 ( Sang Woo Han ),장윤식 ( Yoon Sik Chang ) 대한신장학회 2006 Kidney Research and Clinical Practice Vol.25 No.6
Postinfectious streptococcal glomerulonephritis (PSGN) presenting as a rapidly progressive glomerulonephritis (RPGN) and nephrotic syndrome (NS) is a rare disease in elderly patients. Here we report a case of PSGN with RPGN and NS in an elderly male patient with a complete recovery from his illness. A 73-year-old man was admitted for dyspnea, oliguria and generalized edema appearing after acute upper respiratory infection. On admission, he presented nephrotic range of proteinuria, decreased renal function with elevated ASO, and decreased C3 and CH50 concentrations. The renal biopsy showed marked cellular crescents in the glomeruli with collapsed glomerular tufts and inflammatory cell infiltration. There were prominent and various sizes of humps in subepithelial areas in electron microscopy. Under the diagnosis of PSGN with RPGN, we successfully treated the patient with steroid pulse therapy and hemodialysis. We would suggest that early diagnosis and aggressive steroid therapy should be indicated in the treatment of PSGN with RPGN. (Korean J Nephrol 2006;25(6):1025-1028)