Age-related Changes in the Sirtuin1-NFE2-related Factor 2 Signaling System in the Kidney / 대한내과학회지

BACKGROUND/AIMS: Renal aging-related changes are characterized by oxidative stress. SIRT1 regulates cellular conditions by activating Nrf2. The present study investigated the processes of renal changes by antioxidant enzymes and the relationship between SIRT1 and Nrf2. METHODS: We used male 2-, 12-, and 24-month-old C57BL/6 mice. We measured renal function, histological changes, oxidative stress, and expression of SIRT1–Nrf2 signaling in the kidneys. RESULTS: 24-month-old mice exhibited increased albuminuria and serum creatinine. Creatinine clearance was decreased in 24-month-old mice compared with 12-month-old mice. There were increases in mesangial volume and tubulointerstitial fibrosis in 24-month-old mice. Moreover, oxidative stress marker, 3-Nitrotyrosine, expression and apoptosis were increased in 24-month-old mice. The 24 h urinary 8-isoprostane and 8-hydroxy-deoxyguanosine excretion increased with aging. The levels of expression of SIRT1 and nuclear Nrf2 were decreased in 24-month-old mice. The antioxidant enzymes HO-1 and NQO-1 were down-regulated in 24-month-old mice. Another antioxidant enzyme, SOD2, was decreased in 24-month-old mice. CONCLUSIONS: Our results demonstrated that SIRT1 was down-regulated with aging, and this may be related to changes in the expression of target molecules including Nrf2. As a result, oxidative stress was induced. The pharmacological targeting of these signaling molecules may reduce the pathological changes associated with aging in the kidney.

Erratum: Age-related Changes in the Sirtuin1-NFE2-related Factor 2 Signaling System in the Kidney / 대한내과학회지

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Posterior nutcracker phenomenon with Down syndrome

No abstract available.

Risk Factors and Reversibility of Renal Failure in Patients with Newly Diagnosed Multiple Myeloma / 대한내과학회지

BACKGROUND/AIMS: Multiple myeloma (MM) is frequently accompanied by renal insufficiency, which has been regarded as a poor prognostic factor for MM. It is known that the incidence and characteristics of MM in Asia differ from those in Western countries. The aim of this study was to evaluate risk factors for renal impairment and to investigate reversible factors for renal failure in patients with MM. METHODS: Patients newly diagnosed with MM from 2005 to 2008 were included. We investigated factors associated with renal insufficiency and those related to recovery from renal dysfunction after 12 weeks of treatment of MM. RESULTS: Renal failure was recognized in 86 (39%) of 221 patients at diagnosis. In the binary logistic regression analysis, low hemoglobin (odds ratio [OR], 0.813; p = 0.02), high beta2microglobulin (OR, 1.006; p < 0.01), and use of angiotensin-converting enzyme inhibitors (ACEi) (OR, 2.783; p < 0.04) at initial presentation were independent risk factors for renal failure in patients with multiple myeloma. After 12 weeks of treatment, 25 of 86 (29%) patients with renal failure had recovered renal function. Good response to chemotherapy (OR, 6.044; p < 0.01) and higher eGFR (OR, 1.084; p < 0.01) were associated with renal function recovery. CONCLUSIONS: Levels of hemoglobin and beta2microglobulin, and use of ACEi were independent risk factors for the development of renal failure in MM patients. The response to chemotherapy and eGFR at diagnosis significantly influenced recovery of renal function.

Risk Factors and Reversibility of Renal Failure in Patients with Newly Diagnosed Multiple Myeloma / 대한내과학회지

BACKGROUND/AIMS: Multiple myeloma (MM) is frequently accompanied by renal insufficiency, which has been regarded as a poor prognostic factor for MM. It is known that the incidence and characteristics of MM in Asia differ from those in Western countries. The aim of this study was to evaluate risk factors for renal impairment and to investigate reversible factors for renal failure in patients with MM. METHODS: Patients newly diagnosed with MM from 2005 to 2008 were included. We investigated factors associated with renal insufficiency and those related to recovery from renal dysfunction after 12 weeks of treatment of MM. RESULTS: Renal failure was recognized in 86 (39%) of 221 patients at diagnosis. In the binary logistic regression analysis, low hemoglobin (odds ratio [OR], 0.813; p = 0.02), high beta2microglobulin (OR, 1.006; p < 0.01), and use of angiotensin-converting enzyme inhibitors (ACEi) (OR, 2.783; p < 0.04) at initial presentation were independent risk factors for renal failure in patients with multiple myeloma. After 12 weeks of treatment, 25 of 86 (29%) patients with renal failure had recovered renal function. Good response to chemotherapy (OR, 6.044; p < 0.01) and higher eGFR (OR, 1.084; p < 0.01) were associated with renal function recovery. CONCLUSIONS: Levels of hemoglobin and beta2microglobulin, and use of ACEi were independent risk factors for the development of renal failure in MM patients. The response to chemotherapy and eGFR at diagnosis significantly influenced recovery of renal function.

IgG4-Related Tubulointerstitial Nephritis Accompanied by Henoch-Schonlein Purpura / 대한내과학회지

Tubulointerstitial nephritis is one of the common manifestations of immunoglobulin G (IgG)4-related disease; however, among all cases of tubulointerstitial nephritis undergoing renal biopsies, IgG4-related tubulointerstitial nephritis seems to be relatively rare because of its trivial urinary findings. A previously healthy 54-year-old man was referred to our clinic with a 4-week history of lower leg purpura and renal dysfunction. A kidney biopsy was planned because of bilateral renomegaly, by imaging studies, and elevated serum creatinine levels. Pathological findings in the kidney showed prominent infiltration of IgG4-postive plasma cells in the tubulointerstitium, but not the glumeruli. A skin biopsy revealed leukocytoclastic vasculitis, accompanied by deposition of IgA and C3 in the vascular wall, indicating Henoch-Schonlein purpura (HSP). Although cases of combined IgG4-related disease and microvasculitis, including HSP, are extremely rare, the possibility of an association between two diseases deserves attention.

Very-Late Onset Diffuse Large B-cell Lymphoma with CD3 Coexpression in a Kidney Transplant Patient / 대한신장학회지

B-lineage non-Hodgkin lymphoma may aberrantly coexpress T-cell markers. In general population, however, cases of diffuse large B-cell lymphomas with CD3 co-expression are rare because the CD3 marker is the most lineage specific T-cell antigen. We report a case of CD3 coexpressed diffuse large B-cell lymphoma in a 47-year-old male patient presented with dyspepsia who had transplanted a kidney 17 years ago. An esophagogastroduodenoscopy displayed an ulcerated mass in the gastric antrum. The pathology of the mass was monomorphic post-transplant lymphoproliferative disorder - specifically, CD20- and CD3-positive diffuse large B-cell lymphoma. Resection of the mass and postop chemotherapy were performed. A follow-up computerized tomography showed disapperance of tumor. No recurrence was observed until 7 month after treatment. Nevertheless, the patient's renal function gradually aggrevated and progressed to end stage renal disease. As far as we know, this is the first case of diffuse large B-cell lymphoma with CD3 coexpression after kidney transplant.

Status of Initiating Pattern of Hemodialysis: A Multi-center Study

This study was to evaluate the status of initiating pattern of hemodialysis (HD). Five hundred-three patients in 8 University Hospitals were included. Presentation mode (planned vs. unplanned), and access type (central venous catheters [CVC] vs. permanent access) at initiation of HD were evaluated, and the influence of predialysis care on determining the mode of HD and access type was also assessed. Most patients started unplanned HD (81.9%) and the most common initial access type was CVC (86.3%). The main reason for unplanned HD and high rate of CVC use was patient-related factors such as refusal of permanent access creation and failure to attend scheduled clinic appointments. Predialysis care was performed in 57.9% of patients and only 24.1% of these patients started planned HD and 18.9% used permanent accesses initially. Only a minority of patients initiated planned HD with permanent accesses in spite of predialysis care. To overcome this, efforts to improve the quality of predialysis care are needed.

The Treatment of Post Transplant Tuberculosis: Rifampin Sparing Regimen / 대한이식학회지

BACKGROUND: Rifampin reduces the blood levels of cyclosporin (CsA) and steroids by increasing the activity of hepatic cytochrome P450 system and the inclusion of rifampin in the anti-tuberculosis treatment protocol increases the risk of acute allograft rejection and mortality due to its interaction with cyclosporine. We report the successful treatment outcome of post-renal transplant tuberculosis patients who were treated with quinolone substituted for rifampin in anti-tuberculosis regimen. METHODS: This was a retrospective study of 14 patients with tuberculosis diagnosed among 218 transplant recipients from Feb. 1988 through Dec. 2003 at Daejeon St. Mary's hospital of catholic university of Korea and 6 patients with tuberculosis who underwent transplantation in other hospital and followed up in our hospital. RESULTS: The incidence of post-renal transplant tuberculosis was 6.4%. The mean time to diagnosis of tuberculosis after transplantation was 58.6 months (3.3~180.7). 9 were pulmonary and 11 were extrapulmonary tuberculosis. The graft failure was not occurred in quinolone group (0/15) and 2 of 3 in rifampin group. The serum creatinine levels before tuberculosis were not different to that of post-treatment in quinolone group. (P=0.58) The CsA levels before tuberculosis were not also different to that of posttreatment in quinolone group (P=0.68). CONCLUSIONS: The treatment of post-renal transplant tuberculosis with rifampin sparing anti-tuberculosis regimen was successful. Rifampin, although a mainstay drug in the treatment of tuberculosis, can be avoided in patients receiving cyclosporine, thus avoiding the risk of precipitating allograft rejection.

The Preconditioning with AICAR Protects Against Subsequent Renal Ischemia Reperfusion Injury / 대한신장학회지

PURPOSE:Preconditioning due to activation of AMPK might reduce ischemia-reperfusion (I/R) injury in the kidney, based on the key role of AMPK in preserving ATP. To evaluate this possibility, the effect of preconditioning with 5-aminoimidazole-4-carboxamide ribonucleoside (AICAR), AMPK activator, before sustained ischemia was investigated. METHODS:Adult male Sprague-Dawley rats weighing approximately 220-250 g were used. To induce renal ischemia, a laparotomy was performed under ketamine and xylazine hydrochloride, and the blood supply to both kidneys was interrupted by placement of vessel clamps at the level of the renal pedicles. Reflow was initiated by removing the clamps. The following experimental groups were defined 1. Acute renal ischemia 0 sec, 10 min, 15 min, 2. AICAR treatment, 3. Sham group (S), 4. Ischemia/ Reperfusion group (I/R), 5. AICAR+I/R group (A+I/R), 6. AraA (Adenine-9-b-D-arabinofuranoside, an AMPK) inhibitor+AICAR+I/R group (AraA+A+I/R) RESULTS:There was only faint AMPK phosphorylation in the sham group. After 10 minutes of ischemia, or AICAR preconditioning however, Thr172 phosphorylation of AMPK was increased (p<0.05). The serum levels of BUN and creatinine were significantly decreased in AICAR preconditioning group (A+I/R). (128.0+/-7.33 mg/dL, 4.18+/-0.27 mg/dL vs. 90.2+/-11.13 mg/dL, 2.58+/-0.7 mg/dL, p<0.05), but these effects were attenuated by AMPK inhibitor, AraA (AraA+A+I/R group). In quantitative analysis of tubular injury, tubular injury score in AICAR preconditioning group significantly decreased (p<0.05). CONCLUSION:The AMPK activator AICAR has a protective effect against renal I/R injury.

A Case of Hypermagnesemia with Cardio-respiratory Failure in a Patient with Chronic Renal Failure / 대한신장학회지

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.

Association of Arterial Stiffness with the Decrease of Post-Dialysis Blood Pressure in Maintained Hemodialysis Patients / 대한신장학회지

PURPOSE: Cardiovascular disease is one of the leading causes of mortality and morbidity in hemodialysis patients. Arterial stiffness is known to be associated with vascular calcification in HD patients. Post-dialysis hypotension is a risk factor for cardiovascular mortality. We evaluated the relation between arterial stiffness and post-dialysis blood pressure in maintained HD patients. METHODS: 72 HD patients were enrolled in this study. They had been under maintenance HD for more than 3 months. We checked the biochemical data, including the troponin T, CRP and OPG (osteoprotegerin) levels before their dialysis session and the baPWV (brachio-ankle pulse wave velocity) after the session. We defined post-dialysis BP decrease as a drop of BP of more than 5% of the average MAP for 2 weeks (6 sessions). RESULTS: There were 34 and 38 patients with and without post-dialysis BP decrease, respectively. The BP decrease group had higher CRP, troponin T and OPG levels (p<0.05, 0.01 and 0.01, respectively). The PWV was higher in the BP decrease group (p<0.001). The CRP and troponin T levels were positively correlated with the PWV (r=0.26, p<0.05; r=0.31, p<0.01, respectively). The OPG level was positively correlated with the PWV (r=0.44, p<0.001). Age, pre-dialysis pulse pressure and drops in the patients MAP were correlated with the PWV (r=0.33, p<0.05; r=0.31, p<0.05; r=0.30, p<0.05, respectively). On multivariate analysis, PWV was the independent factor related to the drops in the MAP of the patients (beta=0.311, p=0.021). CONCLUSION: Arterial stiffness is associated with post-dialysis blood pressure decrease.

Ultrasound Measurements of Kidney Size in the Elderly without Renal Disease / 대한신장학회지

PURPOSE: Kidney size (KS) is used to diagnose the patients with renal disease. When the length of a kidney is measured under 9 cm, it is considered to indicate an irreversible disease. Because glomerular filtration rate (GFR) decreases with age, the normal range of KS in the elderly is indefinite. Therefore, we measured KS in adults older than 80 years old and investigated correlated factors. METHODS: One hundreds six adults (51 men, 55 women: mean age 83+/-0.3) without renal disease were included. Their serum creatinine (Scr) levels did not exceed 1.3 mg/dL, and the calculated GFR were over 60 mL/min/1.73m2. Abdominal ultrasonography were performed to all of them and their body indexes (BI) were measured. RESULTS: 1) The mean length of kidney was 9.9+/-0.07 cm. 2) KS in the early eighties was larger than that of adults over ninety. 3) KS showed negative correlations with age and Scr, but a positive correlation with body surface area . 4) The calculated GFR showed correlations with the surface areas of both kidney (BK) by C-G equation and with the size of BK by MDRD equation. 4) The GFR calculated by MDRD and C-G equation presented inverse correlations with Scr, but only MDRD equation showed a statistic significance. CONCLUSION:In the elderly, KS may be smaller than that of younger adults. Other factors such as either surface area or volume of BK and BI should be considered to estimate the individual KS to decide whether the size is within normal range.

Two cases of hypokalemic rhabdomyolysis due to thiazide treatment / 대한내과학회지

Hypokalemia is a common metabolic cause of rhabdomyolysis. Although treatment with thiazide causes hypokalemia frequently, hypokalemic rhabdomyolysis after administration with thiazide is very rare. Here we report two cases of hypokalemic rhabdomyolysis due to thiazide treatment. A 50-year-old woman who had been treated with thiazide for hypertension was admitted due to quadriplegia. The patient had a potassium level of 1.5 mEq/L, a creatinine phosphokinase (CPK) level of 21,346 IU/L, and a lactic dehydrogenase level (LDH) of 2,389 IU/L. An 80-year-old man who had been treated with thiazide for hypertension was admitted due to generalized weakness. His potassium level was 1.9 mEq/L, CPK was 29,000 IU/L, and LDH was 2,393 IU/L. There were no any other causes of rhabdomyolysis except hypokalemia due to thiazide treatment for both patients. With adequate hydration and potassium replacement, hypokalemic rhabdomyolysis recovered completely without sequele.

A Case of Post-Streptococcal Glomerulonephritis with Diffuse Alveolar Hemorrhage

Acute post-streptococcal glomerulonephritis (PSGN) is characterized by an abrupt onset of edema, hypertension, and hematuria. Life-threatening diffuse alveolar hemorrhage (DAH) is rarely associated with acute PSGN. There have been only two reported cases worldwide, and no case has been reported previously in Korea. Here, we present a patient who clinically presented with pulmonary-renal syndrome; the renal histology revealed post-infectious glomerulonephritis of immune complex origin. A 59-yr-old woman was admitted with oliguria and hemoptysis two weeks after pharyngitis. Renal insufficiency rapidly progressed, and respiratory distress developed. Chest radiography showed acute progressive bilateral pulmonary infiltrates. The clinical presentation suggested DAH with PSGN. Three days after treatment with high-dose steroids, the respiratory distress and pulmonary infiltrates resolved. Electron microscopy of a renal biopsy specimen sample revealed diffuse proliferative glomerulonephritis with characteristic subendothelial deposits of immune complex ("hump''). The renal function of the patient was restored, and the serum creatinine level was normalized after treatment.

Successful Resolution of Left Renal Artery Stenosis by Interventional Renal Angioplasty with Stent in a Patient with Renal Insufficiency Underlying Ischemic Nephropathy / 대한신장학회잡지

Ischemic nephropathy is defined as renal dysfunction due to renal hypoperfusion mainly through renal artery stenosis. It is a common cause of chronic renal failure in old patients with atherosclerosis and is also a potentially correctable cause of renal failure if diagnosed earlier. We experienced a case of sudden Rt. main renal artery occlusion and renal failure after femoral artery angioplasty in an aged male patient with underlying atherosclerotic bilateral renovascular stenosis associated with ischemic nephropathy. He received successful Lt. renal artery angioplasty with stenting and restored Lt. renal artery blood flow. His blood pressure was more easily controlled with fewer antihypertensive drugs after renal artery revascularization. His renal function was recovered to his baseline level and became stabilized thereafter. Early diagnosis of ischemic nephropathy with MRA and timely renal angioplasty with stenting are beneficial to avoiding progression to irreversible renal failure.

A Case of Poststreptococcal Glomerulonephritis Representing Rapidly Progressive Glomerulonephritis in an Elderly Patient / 대한신장학회잡지

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.

The Impact of Intima-media Thickness of Radial Artery on Early Failure of Radiocephalic Arteriovenous Fistula in Hemodialysis Patients

This study was performed to investigate the impact of intima-media thickness (IMT) of radial artery on early failure of radiocephalic arteriovenous fistula (AVF) in hemodialysis (HD) patients. Ninety uremic patients undergoing radiocephalic AVF operation were included in this study. During the operation, 10-mm long partial arterial walls were removed with elliptical form for microscopic analysis. Specimens were stained with trichrome and examined by a pathologist blinded to the clinical data. And then AVF patency was followed up for 1 yr after the operation. Of the total 90 patients, 31 patients (34%) had AVF failure within 1 yr after the operation. Mean IMT was thicker in failed group (n=31) than in patent group (n=59) (486+/-130 micrometer vs. 398+/-130 micrometer, p=0.004). The AVF patency rate within 1 yr after the operation was lower in patients with IMT > or = 500 micrometer (n=26) than in patients with IMT <500 micrometer (n=64) (p=0.017). Age was an independent risk factor of IMT. Diabetes mellitus tended to be independent risk factor but not statistically significant. Our data suggest that increased radial artery IMT is closely associated with early failure of radiocephalic AVF in HD patients.

Accuracy of Physical Examination in Detecting Arteriovenous Fistula Dysfunction in Hemodialysis Patients : Comparison with Venographic Findings / 대한신장학회잡지

BACKGROUND: Physical examination is a simple method detecting arteriovenous fistula (AVF) dysfunction in hemodialysis (HD) patients but its accuracy is not well-known. We evaluated the accuracy of physical examination in detecting AVF dysfunction by comparison with venographic findings. METHODS: This study enrolled 46 HD patients receiving native AVF operation. Mean age was 55+/-13 years and the number of male was 20. Physical examination of AVF was performed for 1 month after the operation by a skilled nurse. And then venography was performed. We compared physical findings with venographic findings. RESULTS: Of the total 46 patients, 28 patients showed abnormal physical findings. Abnormal findings included poor maturation (n=18), difficult palpation of vein (n=5), palpation of stenotic lesion (n= 3), weak thrill (n=1). Incidence of abnormal venographic findings was higher in the patients with abnormal physical findings than those in the patients with normal findings (75% vs. 5.5%, p<0.001). CONCLUSION: This study suggests that physical examination is an accurate and useful method in detecting early AVF failure.

Accuracy of Physical Examination in Detecting Arteriovenous Fistula Dysfunction in Hemodialysis Patients : Comparison with Venographic Findings / 대한신장학회잡지

BACKGROUND: Physical examination is a simple method detecting arteriovenous fistula (AVF) dysfunction in hemodialysis (HD) patients but its accuracy is not well-known. We evaluated the accuracy of physical examination in detecting AVF dysfunction by comparison with venographic findings. METHODS: This study enrolled 46 HD patients receiving native AVF operation. Mean age was 55+/-13 years and the number of male was 20. Physical examination of AVF was performed for 1 month after the operation by a skilled nurse. And then venography was performed. We compared physical findings with venographic findings. RESULTS: Of the total 46 patients, 28 patients showed abnormal physical findings. Abnormal findings included poor maturation (n=18), difficult palpation of vein (n=5), palpation of stenotic lesion (n= 3), weak thrill (n=1). Incidence of abnormal venographic findings was higher in the patients with abnormal physical findings than those in the patients with normal findings (75% vs. 5.5%, p<0.001). CONCLUSION: This study suggests that physical examination is an accurate and useful method in detecting early AVF failure.