Plasma Neutrophil Gelatinase-Associated Lipocalin as a Marker of Tubular Damage in Diabetic Nephropathy

BACKGROUND: An increase in neutrophil gelatinase-associated lipocalin (NGAL) indicates tubular injury. Diabetic nephropathy causes typical changes in the kidney, characterized by glomerulosclerosis and eventual tubular damage. We validated the usefulness of plasma NGAL (pNGAL) as a biomarker of tubular damage in patients with diabetic nephropathy. METHODS: We included 376 patients with diabetes mellitus (260 patients with chronic renal insufficiency who had not received hemodialysis and 116 hemodialyzed due to diabetic nephropathy) and 24 healthy controls. Patients with chronic renal insufficiency were divided into three groups according to urinary albumin excretion (UAE) levels. pNGAL levels were measured using the Triage NGAL test (Alere, San Diego, CA, USA) and were compared between groups. We also examined whether pNGAL level was related to the degree of albuminuria and cystatin C-based glomerular filtration rate (GFR). RESULTS: Mean pNGAL levels of the healthy controls, chronic renal insufficiency patients with diabetes mellitus, and hemodialyzed patients were 61.9±5.3 ng/mL, 93.4±71.8 ng/mL, and 1,536.9±554.9 ng/mL, respectively. pNGAL level increased significantly in patients with severe albuminuria (P < 0.001) and had a moderate correlation with the degree of albuminuria (r=0.467; P < 0.001) and GFR (r=0.519; P < 0.001). Multivariate regression analysis showed that the pNGAL level was associated with tubular damage independent of patient age, sex, and GFR. CONCLUSIONS: pNGAL level independently reflects the degree of tubular damage in patients with diabetic nephropathy. Measurement of pNGAL, combined with UAE, would enable simultaneous, highly reliable assessments of tubular damage for such patients.

Use of fludrocortisone for intradialytic hypotension

Intradialytic hypotension during dialysis adversely affects a patient's prognosis and increases mortality. We report a case in which intradialytic hypotension that persisted after the administration of midodrine was relieved after the use of fludrocortisone. Administration of 0.2 mg of fludrocortisone occurred 30 minutes before dialysis. We compared 45 sessions of dialysis without fludrocortisone administration and 45 sessions of dialysis with fludrocortisone administration in one patient. The number of times in which systolic blood pressure became lower than 80 mmHg and the number of early terminations of dialysis due to a decrease in systolic blood pressure were higher in the sessions without fludrocortisone administration than in the sessions with fludrocortisone administration (P < 0.05). Fludrocortisone may be helpful for the treatment of intradialytic hypotension that does not respond to midodrine administration.

Altitude Stress During Participation of Medical Congress / 신경중재치료의학

Medical congresses often held in highlands. We reviewed several medical issues associated with altitude stress especially while physicians have participated medical congress held in high altitude. Altitude stress, also known as an acute mountain sickness (AMS), is caused by acute exposure to low oxygen level at high altitude which is defined as elevations at or above 1,200 m and AMS commonly occurs above 2,500 m. Altitude stress with various symptoms including insomnia can also be experienced in airplane. AMS and drunken state share many common features in symptoms, neurologic manifestations and even show multiple microbleeds in corpus callosum and white matter on MRI. Children are more susceptible to altitude stress than adults. Gradual ascent is the best method for the prevention of altitude stress. Adequate nutrition (mainly carbohydrates) and hydration are recommended. Consumption of alcohol can exacerbate the altitude-induced impairments in judgment and the visual senses and promote psychomotor dysfunction. For prevention or treatment of altitude stress, acetazolamide, phosphodiesterase inhibitors, dexamethasone and erythropoietin are helpful. Altitude stress can be experienced relatively often during participation of medical congress. It is necessary to remind the harmful effect of AMS because it can cause serious permanent organ damage even though the symptoms are negligible in most cases.

Staphylococcus-associated Glomerulonephritis / 대한내과학회지

A 64-year-old woman was admitted with vertebral osteomyelitis and polyarthritis (both knees and the right shoulder). She had had no health problems before these conditions developed. Joint culture grew methicillin-resistant Staphylococcus aureus. During hospitalization, hematuria, proteinuria, azotemia, and decreased C3 were reported. The renal biopsy showed mesangial proliferative glomerulonephritis with C3 and IgA co-dominant deposits on immunofluorescence staining. Following incision and drainage of the right shoulder and right knee, and intravenous vancomycin for 15 weeks, the C-reactive protein, proteinuria, hematuria, and C3 level all normalized. Here, we report a case of Staphylococcus-associated glomerulonephritis with a brief review of the literature.

Prophylactic Effect of Erythropoietin Injection to Prevent Acute Mountain Sickness: An Open-Label Randomized Controlled Trial

This study was performed to evaluate whether increasing hemoglobin before ascent by prophylactic erythropoietin injections prevents acute mountain sickness (AMS). This open-label, randomized, controlled trial involved 39 healthy volunteers with hemoglobin or =3 were present. Immediate descent criteria followed US Army recommendations. Two groups differ in hemoglobin levels on day 29 (15.4+/-1.1 vs 14.2+/-1.0 g/dL, P=0.001). At ABC, erythropoietin group had a significantly lower mean LLS, AMS incidence, and number of subjects who met immediate descent criteria. Multiple logistic regression analysis showed that SaO2<87% and control group, but not hemoglobin<15.0 g/dL, independently predicted satisfaction of immediate descent criteria. Erythropoietin-related adverse effects were not observed. In conclusion, erythropoietin may be an effective prophylaxis for AMS.(Clinical Trial Registry Number; NCT 01665781).

Effect of Efonidipine on Proteinuria in Patients with Chronic Kidney Disease Receiving RAS Blockade / 대한신장학회지

PURPOSE: Efonidipine, which inhibits both T- and L-type calcium channels, has been shown to be effective in reducing proteinuria and preserve renal function. This study was conducted to compare the effects of efonidipine versus amlodipine on the management of hypertension and proteinuria in patients with chronic kidney disease (CKD) receiving ACE inhibitors or ARB. METHODS: This study included 41 CKD patients who were at stages 2-4 and had a urine spot protein/ creatinine ratio of >0.5. Patients were administered amlodipine (5 mg/day) and efonidipine (40 mg/ day) for 3 months in a cross-over design. Blood pressure and spot urine protein/creatinine ratio were compared before and after the cross-over treatment. RESULTS: There were 24 male patients and 17 female patients. The mean age of the patients was 55.9+/-12.9 years. When the patients' medication was changed to eponidifine, we obtained the following results. First, there were no significant changes in blood pressure and serum creatinine. Second, the urine spot protein/creatinine ratio was significantly decreased (before the cross-over, 2.9+/-2.6; after the cross-over, 2.3+/-1.9 g/g; p=0.02). Finally, the reduction rate of proteinuria was significantly higher in patients with CKD at stages 2-3 than in those with CKD at stage 4 after the cross-over (stage 2, - 26.1%; stage 3, -17%; stage 4, +12.8%; p=0.03). CONCLUSION: It is concluded that efonidipine may significantly decrease proteinuria compared with amlodipine in CKD patients receiving ACE inhibitors or ARB. Further double-blind clinical trials with a larger sample size are needed to confirm our results.

Comparison of Drug-Eluting Stent and Bare Metal Stent in Reducing Adverse Cardiac Event after Coronary Stenting in Hemodialysis Patients / 대한신장학회지

PURPOSE: The patients treated with hemodialysis have been known to have a high 1-year mortality rate after percutaneous coronary intervention (PCI). We evaluated the clinical benefits of drug-eluting stent (DES), compared to bare-metal stent (BMS) in Korean hemodialysis patients. METHODS: We studied 72 hemodialysis patients (M:F=49:23, age 60+/-11 years) treated with percutaneous coronary intervention (PCI) from January, 1999 to February, 2006. Forty four patients (M:F=28: 16, age 60+/-11 years) treated with DES and 28 patients (M:F=21:7, age 60+/-12 years) with BMS were enrolled. A composite of major adverse cardiac and cerebral endpoints (MACCE) was defined as all-cause death, myocardial infarction, stroke, and target-vessel revascularization (TVR). We compared the incidence of MACCE between DES and BMS group. RESULTS: A composite of MACCE occurred in none in DES group (n=44) and 4 in BMS group (n=28) within 3 months after coronary stenting (Kaplan-Meier survival analysis: 0% vs 14%, respectively, p= 0.02). After 3 months, there was no difference in the incidence of primary end points between two groups. Multi-vessel disease (OR 2.47, 95% CI 1.02-6.11, p<0.05) was associated with a significant increase in the incidence of MACCE within 18 months after coronary artery stenting CONCLUSION: DES may be superior to BMS in reducing adverse cardiac outcome at early period after coronary stenting in HD patients. However, this study showed no significant difference with the lapse of time.

Neurotoxicity Induced by Cefepime in a Patient with Minimal Change Disease / 대한신장학회지

A 71-year-old woman with minimal change disease visited our clinic complaining of pleuritic chest pain. Cefepime was given under the impression that she had pneumonia. Three days after cefepime administration, she became unconscious. A brain MRI scan was non-revealing and an EEG showed triphasic waves. As there was no evidence of septic, uremic or hepatic encephalopathy, we suspected cefepime-induced neurotoxicity. Cefepime was stopped and she underwent hemodialysis to decrease the blood levels of the drug. Following hemodialysis, she regained consciousness.

A Case of Familial Atypical Hemolytic Uremic Syndrome Associated with Complement Factor H Mutation in Adults / 대한신장학회지

The hemolytic uremic syndrome is a clinical syndrome defined by the presence of thrombocytopenia, microangiopathic hemolytic anemia and acute renal failure. Atypical hemolytic uremic syndrome (aHUS) which is not usually associated with prodromal symptoms, especially diarrhea, has a higher mortality rate and a stronger tendency to progress to chronic renal failure. In approximately 30-50% of patients with aHUS, mutations have been detected in complement factor H, membrane cofactor protein or factor I. Mutations in the complement regulator factor H are the most frequent and have a very poor prognosis, with most patients developing ESRD. We have experienced a 33-year-old man with a family history of renal failure diagnosed as aHUS resulted from factor H mutation, for whom we carried out hemodialysis, plasmapheresis and other conservative management.

Direct Inoculation in BACTEC Culture Media is Superior to Thioglycollate Broth and Solid Culture Medium Method after Centrifugation in Identifying Gram Positive Microorganism in Peritoneal Dialysis Peritonitis Patients / 대한신장학회지

PURPOSE: Peritonitis remains one of most important complications of long-term peritoneal dialysis. This study was prospectively performed to compare the ability of identifying the causative organism for continuous ambulatory peritoneal dialysis (CAPD) peritonitis between bedside inoculation into BACTEC culture bottles and method involving centrifugation of effluent followed by plating into solid and liquid media. METHODS: We studied 38 patients with CAPD peritonitis (M:F=21:17, age 53+/-13 years) between July, 2005 and May, 2006. They had 50 episodes of CAPD peritonitis during the study period. From each peritonitis patient, two aliquots of peritoneal effluent were obtained at the same time. One aliquot was inoculated into two BACTEC culture bottles (aerobic and anaerobic, each 10 mL). The other aliquot was inoculated into thioglycollate broth (TGB, 10mL) and also spread on solid culture media (SCM) after centrifuge 50 mL of effluents. We compared positive-culture results, time from inoculation to identification of growth, and causative organism between these two culture methods. RESULTS: The BACTEC culture method was superior to the TGB & SCM culture method in identifying microorganisms (80% vs. 56%, respectively, p=0.01). Especially, there was significant difference in identifying the gram-positive bacteria between the BACTEC culture method and the TGB & SCM culture method [52% (26/50) vs 36% (18/50), p=0.001]. CONCLUSION: This study indicated that direct inoculation in BACTEC culture media is superior, especially for the gram-positive bacteria, to TGB & SCM in identifying the causative organisms in CAPD peritonitis patients.

Effects of ezetimibe on lipid profiles and hemostatic markers in end-stage renal disease / 대한내과학회지

BACKGROUND/AIMS: Dyslipidemia is one of the major causes of cardiovascular disease in end-stage renal disease (ESRD) patients. Most of them are dyslipidemic despite the use of lipid-lowering agents. Ezetimibe is a novel chemical entity that inhibits the intestinal absorption of dietary and biliary cholesterol. This study evaluated the effects of ezetimibe on the lipid profile, inflammation markers, endothelial injury, and thrombogenesis in ESRD patients. METHODS: Sixty-five patients with serum low-density lipoprotein (LDL)-cholesterol levels > or =100 mg/d were recruited: 33 patients were on hemodialysis and 32 patients were on peritoneal dialysis. They were assigned randomly to the ezetimibe (10 mg) monotherapy group and the ezetimibe (10 mg) plus simvastatin (10 mg) combination therapy group. Both drugs were administered for 8 weeks. RESULTS: There were no significant differences in the baseline demographic and laboratory characteristics between the two groups. In the monotherapy group, the total and LDL-cholesterol levels were reduced by 14.7 and 21.9%, respectively. There were no changes in the high-density lipoprotein (HDL)-cholesterol or triglyceride levels. Fibrinogen increased significantly (p=0.04). In the combination therapy group, the total and LDL-cholesterol levels were reduced by 29.8 and 42.4%, respectively. There was an additional 15.1% reduction in total cholesterol and an additional 20.5% reduction in LDL cholesterol compared with monotherapy. Several patients complained of minor adverse effects and only one patient in the ezetimibe monotherapy group discontinued medication, because of diarrhea. CONCLUSIONS: In ESRD patients, ezetimibe used as combination therapy with a statin is more effective than ezetimibe monotherapy in ESRD patients.

SIADH and Guillain-Barre Syndrome Associated with Pulmonary Tuberculosis / 대한신장학회지

Hyponatremia is one of the most common electrolyte disturbances in nephrologic clinical setting. SIADH is one of the causes of hyponatremia and can be accompanied with various conditions such as malignancies, infections and nervous system diseases. Guillain-Barre syndrome is an acute inflammatory polyneuropathy. It is reported that SIADH can be accompanied with Guillain-Barre syndrome although the mechanism is unclear. Symptoms of Guillain- Barre syndrome such as general weakness, decreased consciousness, and seizure are similar to those of hyponatremia. Thus the diagnosis of Guillain-Barre syndrome can be delayed if they coexist. Because Guillain-Barre syndrome leads to severe respiratory failure in its disease course and mechanical ventilatory assistance is mandatory for such cases, early diagnosis and treatment is critical. Korea is still endemic area for tuberculosis and clinicians often experience pulmonary tuberculosis in practice. But pulmonary tuberculosis-associated SIADH and Guillain-Barre syndrome were not reported in Korea. So far, 2 cases of gastrointestinal infection-associated SIADH and Guillain-Barre syndrome were reported. Hence, authors report here the case of SIADH associated Guillain-Barre syndrome associated with pulmonary tuberculosis.

A Case of Interstitial Pneumonitis Associated with Sirolimus Treatment in Renal Transplantation Recipient / 대한신장학회지

Sirolimus is a promising immunosuppressive drug for renal transplantation to avoid nephrotoxicity of calcineurin inhibitor. However, it has been associated with uncommon but, important pulmonary toxicity. We present a case of sirolimus related dyspnea with abnormal chest radiographic finding in a 63 year old male renal transplantation recipient. There was no evidence of bacterial, fungal, or viral infection. Dose reduction of sirolimus resulted in a significant improvement of the symptoms and chest radiographic finding.

Coronary artery calcification and serum markers / 대한내과학회지

Coronary artery calcification is associated with the increased cardiovascular mortality and the extent of atheromatous plaque, especially in the hemodialysis patients. Vascular calcification was in the past considered a passive process, a degenerative consequence of aging or the result of disrupted mineral balance in the patients with chronic renal failure. It is now understood that calcium deposition in the vasculature is an active and regulated process similar to bone formation. In this issue of JKMS, Kim et al. investigate the clinical association between osteoprotegerin, an osteoclast inhibitory factor which was reported to be associated with coronary artery calcification, and fetuin-A, a systemic ectopic calcification inhibitory factor, with coronary artery calcification (CAC) score obtained from multi-slice CT. They showed that the high serum osteoprotegerin level is associated with increased CAC score and serum fetuin-A level is significantly lowered in the severe CAC score group. These results show that serum osteoprotegerin or fetuin-A level might be used as serum markers for the determination of the severity of coronary artery calcification. However, the role of serum osteoprotegerin in the formation of vascular calcification is uncertain and the pathophysiologic mechanism is not uncovered yet. Some studies suggested that the osteoprotegerin level is associated with vascular stiffness. Lower fetuin-A level is known to be a prognostic factor of cardiovascular disease mortality from several epidemiologic studies and a confirmed anti-calcifying agents in vitro experiments. In interpreting this issue of Kim et al., it is important that increased serum osteoprotegerin level might be associated with not vascular calcification but other vascular malfunction such as arterial stiffness. In conclusion, more sophisticated study needed for the clarification of the role of calcification-associated serum markers in the process of vascular calcification.

Calcium-Sensing Receptor Gene Polymorphism is Associated with the Parathyroid Response to Low Calcium Dialysate in Hemodialysis Patients with Low Parathyroid Hormone Secretion / 대한신장학회지

PURPOSE: Low level of parathyroid hormone (PTH) is a risk factor that might cause hip fracture in dialysis patients. Low calcium dialysate (LCD) has been suggested as an approach to increase PTH level. The calcium-sensing receptor (CaSR) polymorphism is known to be associated with the sensitivity to extracellular calcium. METHODS: We prospectively investigated the role of genetic polymorphism of CaSR codon 990 as one cause of the different parathyroid responses to LCD in maintenance hemodialysis (HD) patients. 48 patients, using 3.5 mEq/L calcium dialysate, with intact PTH below 100 pg/ml for the last one year underwent HD sessions on 2.5 mEq/L calcium dialysate for 12 weeks. Serum intact PTH, total calcium, phosphorus, alkaline phosphatase (ALP) and bone-specific ALP (BAP) were measured monthly. The CaSR gene from peripheral lymphocytes was amplified to confirm the genotype by polymerase chain reaction. RESULTS: According to the CaSR genetic polymorphism, subjects were divided into 3 groups, A/A (14.6 %), A/G (45.8%) and G/G (39.6%). Twelve weeks later, intact PTH (48.5+/-25.4 to 89.0+/-49.4 pg/mL, p<0.01), and ALP (78.7+/-25.7 to 87.4+/-27.2 IU/L, p<0.01) increased significantly in G/G group, but not in non-G/G groups. However, BAP significantly increased in both G/G group (24.3+/-11.9 to 29.5+/-10.6 U/L, p<0.01) and in non-G/G groups (21.4+/-4.5 to 26.1+/-9.1 U/L, p<0.01). During the study period, levels of corrected total calcium and phosphorus were not significantly changed. CONCLUSION: The CaSR polymorphism, G/G genotype, strongly influenced the responsiveness of parathyroid gland to LCD, compared with non-G/G genotypes. However, bone formation may occur actively on LCD, irrespective of CaSR genetic polymorphism.

A Case of Acute Renal Failure with Wernicke's Encephalopathy and Beriberi due to Severe Hyperemesis Gravidarum / 대한신장학회지

Severe hyperemesis gravidarum (HG) is a rare but potentially devastating complication of pregnancy. It can cause dehydration, electrolyte imbalance, malnutrition (especially, thiamine deficiency), and compromised renal function. We report a case of acute renal failure (ARF) with Wernicke's encephalopathy and beriberi due to severe HG. A 35-year-old woman at 16 weeks of gestation presented with confused mentality, quadriparesis, nystagmus, peripheral neuropathy, and tachycardia after prolonged nausea and vomiting. Her initial serum creatinine and blood urea were 2.6 mg/dL and 100 mg/dL, respectively. FLAIR image of the initial MR examination demonstrated bilateral symmetric high signal intensities in the medial and dorsal thalami. Echocardiography showed left ventricular dilatation and dysfunction. We thought that ARF, Wernicke's encephalopathy and beriberi were resulted from dehydration and thiamine deficiency due to HG. She was managed with intravenous fluid and 100-200 mg of parenteral thiamine. ARF was improved within one week and echocardiographic findings were normalized within 1 month. MR examination at the 21st week of pregnancy showed a decreased size of the lesion. After 4 months, her neuroloic status was recovered.

The Attack of Ventricular Arrhythmia Caused by Low Potassium Level in Hemodialysis Patients / 대한신장학회잡지

ESRD patients have higher cardiovascular mortality risk than the general population. Increased QT dispersion has been shown to be a risk factor for cardiac arrhythmia in chronic hemodialysis patients with diabetes or arterial disease. It is known that QT dispersion is significantly prolonged in postdialysis than in predialysis. It is associated with a decrease in serum potassium. During hemodialysis, serum potassium is decreased and QT dispersion increases. Therefore ventricular arrhythmia frequently occurs in the latter half of dialysis. We report 2 cases of ventricular arrhythmia caused by potassium removal during dialysis in chronic hemodialysis patients.

Distribution of Cardiac Troponin T in Continuous Hemodialysis Patients and Clinical Characteristics of Patients with Elevated Cardiac Troponin T / 대한신장학회잡지

PURPOSE: The leading cause of death of end-stage renal failure is cardiovascular disease. Elevated cardiac troponin T (cTnT) is associated with the high incidence and prevalence of cardiovascular disease and increased mortality and morbidity. Therefore the aim of this study was to examine the distribution of cTnT in continuous hemodialysis patients and clinical significance of elevated cTnT. METHODS: We studied 183 asymptomatic patients who were undergoing chronic continuous hemodialysis treatment. Predialysis blood samples also used to measure hematocrit, albumin, total cholesterol. We evaluated the history of coronary artery disease and the etiologies of renal disease using chart reviews and patients interviews and cardiac status were determined by electrocardiography, two-dimensional echocardiography and coronary angiography. Predialysis cTnT was measured by a second-generation assay, Elecsys 1010 and we considered patients with serum cTnT>0.1 ng/mL as positive. RESULTS: Forty two patients (23%) had cTnT greater than 0.1 ng/mL. Ischemic heart disease was observed in 18.6% (34/183), diabetes mellitus (DM) in 53.6% (98/183), hypertension in 92.3% (169/183) and left ventricular hypertrophy in 67.2% (123/183). cTnT revealed significantly higher level in the patients with age over 60, male, DM, pulse rate over 60 mmHg, ischemic heart disease (IHD), hematocrit under 36% and albumin under 3.7 g/dL. cTnT levels significantly correlated to ischemic heart disease, DM and male. CONCLUSION: In hemodialysis patients, cTnT level is related to age, sex, DM, pulse rate, IHD, hematocrit and albumin. A prospective study is necessary to provide information on the effect of correcting the controllable factors on cTnT level and cardiovascular mortality in maintenance hemodialysis patients.

Low Dose Intravenous Iron Sucrose Maintenance Therapy in Hemodialysis Patients with Adequate Iron Storage / 대한신장학회잡지

BACKGOUND: In addition to recombinant human erythropoietin (rHuEPO) adequate iron replacement is essential to treatment of anemia in hemodialysis (HD) patients, and intravenous iron therapy has been recommended recently. But, low dose (100-200 mg/ month) intravenous iron sucrose regimen as a "maintenance therapy" in HD patients with adequate iron storage has not been established well. METHODS: We included the 40 of HD patients with serum ferritin of 200-500 ng/mL receiving rHuEPO therapy. During 4 months of study period, 100-200 mg/month of iron sucrose was administrated. rHuEPO doses were titrated to maintain target hematocrit (Hct) of 30%. To evaluate efficacy of iron sucrose, we compared serum ferritin, TSAT and rHuEPO requirements before and after iron sucrose therapy. RESULTS: Thirty-nine patients [mean age 61+/-13 yrs, M:F=20:19] completed this study. After low dose intravenous iron sucrose maintenance therapy, serum ferritin and TSAT significantly increased (370+/-84 vs. 518+/-155 ng/mL, p800 ng/mL was observed during the study. CONCLUSION: Low dose intravenous iron sucrose maintenance therapy is effective and safe in the HD patient receiving rHuEPO therapy with adequate iron storage.

Clinical Significance of Continuous Veno-Venous Hemodiafiltration as an Initial Renal Replacement Therapy for Acute Renal Failure after Cardiovascular Surgery / 대한신장학회잡지

BACKGOUND: Although continuous venovenous hemodiafiltration (CVVHDF) has many therapeutic advantages, previous studies did not report the improvement of survival rate by CVVHDF compared to that by hemodialysis (HD). It could be attributed to that they did not analyze the results under the appropriate stratification of severity and to multiorgan failure. METHODS: We performed retrospective study to compare the outcomes of 88 patients with acute renal failure after major cardiovascular surgery(s). Among them, 48 patients (M:F=32:16, Age 58+/-11 years) were treated by CVVHDF and 40 patients (M:F=27:13, Age 59+/-10 years) were treated by HD. The severity of illness was estimated by APACHE III score system at the initiation of renal replacement therapy (RRT) and we also evaluated renal outcome and survival. RESULTS: There was no significant difference between two groups in baseline characteristics, cause of surgery, survival rate and renal outcome. However, compared with those of HD group, CVVHDF group showed longer period of application with mechanical ventilator (p=0.001), longer period of vasopressor use (p<0.001), longer stay in intensive care unit (p=0.004) and higher APACHE III score at the initiation of renal replacement therapy (p=0.009). Among those with APACHE III scores over 90, survivors existed in CVVHDF group with the survival rate of 50%. In contrast, there was no one who survived in HD group (p=NS). CONCLUSION: Although this study revealed that CVVHDF could be more useful than HD as an initial RRT for the patients with renal failure after major cardiovascular surgery, the randomized prospective study will be required to accept clinical usefulness of CVVHDF.