A case of acute eosinophilic myocarditis as a complication of the hypereosinophilic syndrome / 대한내과학회지

The hypereosinophilic syndrome (HES) is a leukoproliferative disorder, marked by sustained blood eosinophilia of greater than 1,500/mm3, for longer than 6 months and predilection to damage specific oragans. Any organ system may be affected in HES, but the most severe clinicopathophysio-logical involvements are of the heart and nervous system. We report a case of a 48-year-old man with acute eosinophilic myocarditis combined with hypereosinophilic syndrome who was successfully treated with steroids.

An Analysis of the Factors which Influence UF during Peritonitis in PD Patients / 대한신장학회잡지

No abstract available.

The Effects of Catheter Revision and Mupirocin on Exit Site Infection/Peritonitis in CAPD Patients / 대한신장학회잡지

BACKGROUND: Exit site/tunnel infection causes con-siderable morbidity and technique failure in CAPD patients. We presently use a unique revision method for the treatment of refractory ESl/TI in CAPD patients and mupirocin prophylaxis for high risk patients. MTEHODS: We reviewed one hundred-thirty nine CAPD patients about the ESI/TI from Qctober 1993 to February 1999 at Yeungnam University Hospital. At the beginning of the ESI, we usually started medications with rifampicin and ciprofloxacin and then changed the antibiotics according to the sensitivity test. If the ESI had persisted and there were TI symptoms(purulent discharge, abscess lesion around exit site), we performed catheter revision(external cuff shaving, disinfection around tunnel and new exit site on opposit direction) with a combination of proper antibiotics. We applied local mupirocin ointment at the exit site three times per week to the 34 patients who had the risk of ESI starting from October 1998. RESULTS: The total follow-up was 2401 patient months (pt.mon). ESI occurred on 105 occasions in 36 out of 139 patients, and peritonitis occurred on 112 occasions in 67 out of 139 patients. Cumulative incidence of ESI and peritonitis was 1 per 23.0 pt.mon and 1 per 21.6 pt.mon. The most common organism responsible for ESI was Staphylococcus aureus (26 of 54 isolated cases, 43%), followed by Methicillin resistant S. aureus (MRSA)(13 cases, 24%). Seven patients (5: MRSA, 2: Pseudomonas) had to be treated with a revision to control infection. Three patients experienced ESI relapse after revision. One of them improved with antibiotics, while another needed a second revision and the remaining required catheter removal due to persistent MRSA infection with reinsertion at the same time. But, there was no more ESI in these 3 patients who were received management to relapse (The mean duration : 14.0 months) The rates of ESI were more reduced after using mupirocin than before (l per 12.7 vs 34.0 pt.mon, p<0.01). CONCLUSION: In summary, revision technique can be regarded as an effective method for refractory ESI/TI before catheter removal. Also local mupirocin ointment can play a significant role in the prevention of ESI.

Intraperitoneal Vancomycin Induced Chemical Peritonitis in CAPD Patients / 대한신장학회잡지

BACKGROUND: Intraperitoneal(IP) vancomycin has been widely used for the treatment of peritonitis or exit-site infection associated with continuous ambulatory peritoneal dialysis(CAPD). However, some previous reports in the literature have suggested that IP administration of certain vancomycin may be associated with chemical peritonitis in CAPD patients. METHODS: Between 1 February 1994 and 1 February 1997, 35 consecutive CAPD patients requiring treatment with intraperitoneal vancomycin for either exit-site infection or peritonitis in the Yeungnam University Hospital were recruited retrospectively into the study. We compared retrospectively the incidence of chemical peritonitis after using two different preparations of vancomycin from different pharmaceutical companies, namely vancocin CP(R) and vancomycin(R). RESULTS: Thirty-three cases(all 26 cases given vancocin CP(R) and 7 out of the 9 cases given vancomycin(R)) showed improvement. None of them developed fever, abdominal pain or cloudy dialysate. Out of the 9 cases given IP vancomycin(R), two who currently did not have abdominal pain and cloudy dialysis effluent develolped these symptom and sign at 5 and 6 hours after administration of IP vancomycin. The chemical peritonitis may be secondary to prolonged contact of the peritoneal membrane with one or more of the impurities present in vancomycin preparation. CONCLUSION: In summary, it is necessary for the nephrologists to be aware of the possible chemical peritonitis which can be caused by the impurities of certain brand of vancomycin.

Analysis of the Timing of PET and Factors Influencing PET Results / 대한신장학회잡지

The peritoneal equilibration test(PET) is used as a tool for determining the characteristics of the peritoneal membrane. Initial PET is recommended at least 1 month after peritoneal dialysis, but PET after 1 month may be difficult to perform on an out- patients basis. Two standard PETs(D/P4Cr) were per- formed in 60 CAPD patients(DM:non DM=22:38). Initial PETs, within one week after starting CAPD and follow up PETs, at least 3 months after CAPD were performed. The initial PET values were compared with subsequent PET values. Clinical data (age, sex, body surface area, BMI, presence of diabetes mellitus, ascites) and laboratory indices(serum albumin, dialysate creatinine clearance, KT/V, protein catabolic rate) were compared with the results of the PETs. In initial PET result, there was negative correlation between D/P4Cr and serum albumin(r=-0.522, p<0.001 N=60). There was no significant difference between initial and follow up(mean+/-S.D.:8.84+/-5.2months after CAPD) D/P4Cr(0.68+/-0.14 vs 0.68+/-0.13). But with passage of time, delta D/P4Cr and delta serum albumin were also negatively correlated (r=-0.459, p<0.001). According to the linear regression analysis, the factor significantly associated with D/P4Cr was serum albumin(coefficients -0.111). In conclusion, serum albumin level is the most important predictor of the peritoneal membrane transport characteristics, and it seems that the timing of PET does not matter, rather the changes of with time are strongly correlated with the changes of the serum albumin level.

A Case of Disseminated Nocardiosis in Kidney Transplant Recipient / 대한신장학회잡지

Nocardiosis is a rare infection seen most commonly in immunocompromized patients. Most patients have pulmonary involvement, but some develop disseminated infection. A 52-year-old man, treated with immunosuppressive drugs for 3 months after kidney transplantation, developed pulmonary nocardiosis and disseminated infection involving brain, skin, and both uvea. The diagnosis was made by open lung biopsy specimens showing characteristic weak acid fastness with modified Ziel-Neelsen stainig and histologic examination. Immunosuppressive therapy was continued and combination of surgical drainage of brain abscess and chemotherapy with Minocycline were successful. With the increasing number of allograft recipients and concomitant immunosuppression, the possibility of an increase in Nocardia opportunistic infections exists.

The Characteristics of Blood Pressure Control in Chronic Renal Failure Patients Treated with Peritoneal Dialysis / 영남의대학술지

BACKGROUND AND METHODS: In order to evaluate characteristics and modulatory factors of blood pressure in peritoneal dialysis(PD), studies were conducted on the 69 patients who had underwent peritoneal equilibration test(PET). RESULTS: The results were as follows: 1) All patients received an antihypertensive drug before PD, but, 15 of 69 patients successfully quit taking the antihypertensive drug after peritoneal dialysis. 2) During peritoneal dialysis, mean arterial pressure(MAP) was significantlydecreased for the first 3 months, and this lasted for 1 year, and antihypertensive drug requirements were significantly decreased continuously up to 9 months(p<0.005). 3) After changing the modality from hemodialysis to peritoneal dialysis. MAP(mmHg, from 107.1+/-4.5 to 98.6+/-8.8, p<0.05), antihypertensive drug requirements(from 5.6+/-2.6, to 2.0+/-2.5, p<0.01) and erythropoietin dosages(Uint/week, from 4600+/-2660 to 2000+/-1630, p<0.05) were decreased. 4) Multiple logistic regression analysis showed that MAP(p<0.01) and daily ultrafiltration volume(p<0.05) can contribute to the determination of antihypertensive drug requirements. However the relationship between antihypertensive drug requirements and PET results or dialysis adequacy indices(weekly Kt/V. weekly creatinine clearance) was not revealed. CONCLUSION: In conclusion, the prescription of antihypertensive drugs should be considered according to daily ultrafiltration volume, especially during first year after initiating PD, and follow-ups for over a year may be needed.

The Effects of Catheter Revision and Mupirocin on Exit Site Infection/Peritonitis in CAPD Patients / 영남의대학술지

BACKGROUND: Exit site/tunnel infection causes cosiderable morbidity and technique failure in CAPD patients. We presently use a unique revision method for the treatment of refractory ESI/TI in CAPD patients and mupirocin prophylaxis for high risk patients. MATERIALS AND METHODS: We reviewed 139 CAPD patients about the ESI/TI from October 1993 to February 1999 at Yeungnam University Hospital. At the beginning of the ESI, we usually started medications with rifampicin and ciprofloxacin and then changed the antibiotics according to the sensitivity test. If the ESI had persisted and there were T1 symptoms(purulent discharge, abscess lesion around exit site), we performed catheter revision(external cuff shaving, disinfection around tunnel and new exit site on opposit direction) with a combination of proper antibiotics. We applied local mupirocin ointment at the exit site three times per week to the 34 patients who had the risk of ESI starting from October 1998. RESULTS: The total follow-up was 2401 patient months(pt. mon). ESI occurred on 105 occasions in 36 out of 139 patients, and peritonitis occurred on 112 occasions in 67 out of 139 patients. The total number of incidences of ESI and peritonitis was 1 per 23.0 pt.mon and 0 per 21.6 pt.mon. The most common organism responsible for ESI was Staphylococcus aureus(26 of 54 isolated cases, 48%), followed by the Methicillin resistant S. auresu(MRSA) (13 cases, 24%). Seven patients(5: MRSA, 2: Pseudomonas) had to be treated with a revision to control infection. Three patients experienced ESI relapse after revision. One of them improved with antibiotics, while another needed a second revision and the remaining required catheter removal due to persistent MRSA infection with re-insertion at the same time. But, there was no more ESI in these 3 patients who were received management to relapse (The mean duration: 14.0 months). The rates of ESI were significantly reduced after using mupirocin than before(1 per 12.7 vs 34.0 pt.mon, p<0.01). CONCLUSION: In summary, revision technique can be regarded as an effective method for refractory ESI/T1 before catheter removal. Also local mupirocin ointment can play a significant role in the prevention of ESI.

Nonimmunological Factors Influencing Serum Creatinine on Discharge after Kidney Transplantation / 대한신장학회잡지

There are two factors which influence the long term outcome of renal transplantation. One is the immunological factor such as HLA typing, the other is the nonimmunological factor such as physiologic match of the donor kidney to the recipient. We analyzed the relation between serum creatinine on the day of discharge which is known as a good predictor of long term graft survival and several nonimmunological factors influencing long term outcome of renal transplantation. One hundred fourteen renal transplanted patients in Yeungnam university hospital for 3 years after 1994 were included except the patients had experienced rapid deterioration of renal function like acute graft rejection. Several indices(KW/R.BSA, KW/R.BW, KW/ R.BMI, D.BSA/R.BSA, D.BW/R.BW : KW=kidney weight, R=recipient, D=donor, BSA=body surface area, BMI=body mass index, BW=body weight) representing relative kidney size to recipient were significantly correlated with serum creatinine on the day of discharge(KW/R.BSA : r=-0.30, KW/R.BW : r=-0.35, KW/R.BMI : r=-0.41, D.BSA/R.BSA : r=-0.47, D.BW/R.BW : r=-0.44). Serum creatinine levels on the day of discharge were lower at the male kidney donated to female recipient than the female kidney donated to male recipient (0.89 vs. 1.22mg%, P<0.05). The age of donors had positive correlation with serum creatinine on the day of discharge (r=0.28). That was, when donor is more younger person, renal function after transplantation is better. But several indices by renal scan(effective renal plasma flow, perfusion index, peak renal uptake, T1/2) done after transplantation, urine output of the next day after transplantaton, renal function of donor before transplantation(creatinine level) were not correlated with serum creatinine on the day of discharge. In conclusion, nonimmunological factor such as nephron mass size, age, gender should be considered when selecting renal donor, and the more actual, new criteria for kidney transplantation and long term prognosis should be worked out by further study.

Long-term Effect of Desferrioxamine to rHuEPO Regident Anemia in Hemodialysis Patients / 영남의대학술지

There are several factors concerning to anemia in chronic renal failure patients. But when rHuEPO is used, most of these factors can be overcome, and the levels of hemoglobin are increased, However, about 10% of the renal failure patients represent rHuEPO-resistant anemia eventhough high dosage of rHuEPO. For these cases, desferrioxamine can be applied to correct rHuEPO resistnacy, and many mechanism og DFO are arguing. So we are going to know whether DFO can applied to correct anemia of the such patients, how long its effect can continued. The seven patients as experimental group(DFO+EPO) who represent refractoriness to rHuEPO and the other seven patients as control group(EPO) were included. Experimental group has lower than 9 g/dL of hemoglobin levels despite high rHuEPO dosage (more than 4000U/Wk) and showed normochromic anemia. There were no definitive causes of anemia such as hemorrhage or iron deficiency. Control group patients has similar characteristics in age, mean dialysis duration but showed adequate response to rHuEPO. DFO was administered to experimental group for 8 weeks along with rHuEPO(the rHuEPO individual mean dosage had been determined by mean dosage of the previous 6 months. Total mean dosage; 123.5 U/Kg/Wk). After 8 weeks of DFO administration, the hemoglobin and rHuEPO dosage levels were checked for 15 consecutive months. It should be noted that the patients determined their own rHuEPO dosage levels according to hemoglobin levels and economic status. In control group, rHuEPO was administered by the same method used in experimental group without DFO through the same period. Fifteen months of ovservation period after DFO trial were divided as Time I(7 months after DFO trial) and Times II(8 months after Time I). The results are as follows: Before DFO trial, mean hemoglobin level of experimental group was 7.8 g/dL, which is similar level(p>0.05) to control group(mean Hb; 8.2 g/dL). But in experimental group, significantly(p<0.05) higher dosages of rHuEPO(mean; 123.5 U/Kg/Wk) than control group (mean;41.6 U/Kg/Wk) had been used. It means resistancy to rHuEPO of experimental group. But after DFO trial, the hemoglobin levels of the experimental group were increased significantly(p<0.05), and these effect were continued to II.(Time I; mean 8.6g/dL, Time II; mean 8.6g/dL) The effects of DFO to hemoglobin were continued for 15 months after DFO trial with simiral degree through Time I, Time II. Also, rHuEPO dosage used in the experimental group were decreased to simiral levels of the control group after DFO trial and these effect were also continued for 15 months(Time I; mean 48.1 U/Kg/Wk. Time II; mean 51.8 U/Kg/Wk). In the same period, hemoglobin levels and rHuEPO dosages used in the control group were not changed significantly. Notibly, hemoglobin increment and rHuEPO usage decrement in experimental group were showed maxilly in the 1st month after DFO trial. That is, after the use of DFO, erythropoiesis was enhanced with a reduced rHuEPO dosage. So we think rHuEPO reisistancy can be overcome by DFO therapy. In conclusion, the DFO can improve the anemia caused by chronic renal failure at least over 1 year, and hence, can reduce the dosage of rHuEPO for anemia correction. Additional studies in order to determined the mechanism of DFO on erythropoiesis and careful attention to potential side effects DFO will be needed.