Clinical evaluation for 30 cases of therapeutic plasma exchange / 대한내과학회지

BACKGROUND: Therapeutic plasma exchange is the therapeutic procedure to improve clinical course by removing various antibodies, immune complexes, toxic materials or by replacing insufficient plasma elements. But there are many debates about its effects although many immunologic diseases improve their clinical courses by plasma exange. The aim of this study is to examine clinical aspects of plasma exchange. METHODS: We investigated retrospectively 30 patients who had been done a total of 128 plasma exchange procedures during the last 5 years at Korea University Anam Hospital. We judged clinical improvement according to diseases, replacing solutions and examined the changes of blood chemistries, side effects etc. RESULTS: There were 14 males and 16 females. The patients' age ranged from 8 to 76 years old and mean age was 45 years old. Total 30 patients had been carried out a total of 128 plasma exchange procedures and the mean was 4.3 times. The frequency of plasma exchange was from once up to 12 times and five times is the most frequent number carried out (27%). The most frequent diseases were multiple myeloma and myasthenia gravis which were 17% respectively and other diseases in the decreasing order of frequency were hemolytic uremic syndrome (HUS), Guillian-Barre syndrome, fulminant hepatitis etc. Double lumen catheter into femoral vein(73%) was most frequently used for the vascular access. The clinical improvement was obtained in 50% of total cases and the clinical results in myasthenia gravis and Guillian-Barre syndrome were excellent. There were 8 patients(27%) who died during treatment period, but the cause of death was not related to plasma exchange procedure itself. As a replacement solution, 5% albumin alone(23%) was used most frequently and the others were fresh frozen plasma(FFP) alone(20%), FFP plus Hartman's soultion plus albumin(20%), FFP plus albumin(17%) etc. Serum total calcium concentration was significantly decreased from 8.5 to 7.9 mg/dL(p=0.017) and platelet was also decreased from 154,666/mm3 to 100,222/mm3(p=0.02) after plasma exchange but the other chemistries were not changed. The frequent side effects were nausea, vomiting, fever, chill, hypotension, itching sensation and muscle cramps. CONCLUSION: The plasma exchange is one of the useful therapeutic procedures in some immunologic diseases especially for the myasthenia gravis and Guillian-Barre syndrome. It is a relatively safe procedure, but gastrointestinal side effects such as nausea, vomiting in early period may be a problem. And the careful monitoring of serum calcium concentration, platelet count before and after plasma exchange is required.

Usefulness of Urinary n-acetyl-beta-d-Glucosaminidase(nag) for a Predictor of Aminoglycoside Nephrotoxicity / 대한신장학회잡지

Nephrotoxicity is a major factor limiting the clinical utility of aminoglycoside antibiotics(AG). In this study, we have therefore investigated the usefulness of the renal tubular protein for a predictor of the nephrotoxicity of AG. We have also compared the nephrotoxicity among different AG. Among the simple fracture patients visiting orthopedics, for whom an AG seemed warrantable, we have sampled thirty-nine subjects--excluding those suffering from severe bleeding, taking drugs, or having renal disease which can affect the renal function. We have set three different groups by the following criteria; ten subjects in group I were given 250mg of Amikacin sulfate twice a day; fifteen subjects in GroupII were given 60mg of Micronomicin sulfate twice a day; and fourteen subjects in GroupIII were given 200mg of Isepacin sulfate twice a day. Urine from each patient was collected for 24 hours before, one week after, and two weeks after the drugs were given, and then the urinary concentrations of NAG, beta2-Microglobulin(beta2-MG), and electrolyte(Na+, K+, Cl-) were measured. The measurement of 24-hour urinary concentrations of NAG shows that, for all three groups, significant increase of the concentrations(P<0.01) is seen between the different times in the same group. The results of measurements of the 24-hour urinary concentrations of beta2-MG, and electrolyte(Na+, Ke+, Cl-) show their increase for all three groups but whithin the normal range. For the samples collected two weeks after the drugs were given, there is a significant decrease in the twenty-four-hour urinary concentrations of NAG(P<0.05) of Group III compared to Group I and II. The resulta of measurements of 24-urinary concentrations of beta2-MG, and electrolyte(Na+, K+, Cl-) show their increase for all three groups but whithin the normal range. In conclusion, we have seen that the nephrotoxicity of the AG appears for all three groups; but, when we compare the nephrotoxicity between the different antibiotics, the nephrotoxicity of Amikacin sulfate and that of Micronomicin sulfate appear stronger than that of Isepacin sulfate. Our data suggest the usefulness of sequential NAG measurements in monitoring and predicting aminoglycoside nephrotoxicity.

Relation between Diet and Metabolic Acidosis in Chronic Dialysis Patients / 대한신장학회잡지

OBJECTIVES: It has been known that the incidence of protein malnutrition is high in patients with chronic renal failure(CRF). Although the effect of uremia on protein metabolism has not been known clearly, some reports suggest that metabolic acidosis, one of the uremic manifestations, increases protein catabolism. In a steady state, acid production is mainly related to dietary protein intake. Also severe acidosis causes anorexia and may decreases protein intake. But the relationship between diet and metabolic acidosis in chronic dialysis patients has not been established. In order to investigate the relation between metabolic acidosis and diet in CRF patients, we analyzed the diet intake and the nutritional status in chronic dialysis patients with or without severe metabolic acidosis. METHODS: We selected 10 patients as an acidosis group (total CO2 17.5mEq/L) among patients who have been receiving hemodialysis. RESULTS: The mean ages and male to female ratios were similar in both groups, but in the underlying diseases of acidosis group, non-chronic glomerular nephritis (nonCGN) was more prevalent. Weekly hemodialysis time of the acidosis and the control group were 10.20, 11.45hours per week, respectively. The concentrations of pre-dialysis BUN were 89.74 vs. 71.25mg/dL and nPCR were 1.289 vs. 1.035g/kg/ day in each group.. However, the analysis of dietary protein intake showed no significant difference between both groups. The nutritional status of both groups were similar. CONCLUSION: In CRF patients, metabolic acidosis increases protein catabolism by stimulated amino acid oxidation and protein degradation in muscle. This study therefore suggests that patients with metabolic acidosis need to receive more adequate dialysis to correct the acidosis. And we recommend the indivisualization of protein intakes rather than the indiscriminate protein restriction in CRF patients with metabolic acidosis.

One Case of Henoch-Sch nelin Purpura Associated with Thrombotic Thrombocytopenic Purpura / 대한신장학회잡지

Henoch-Sch nlein purpura(HSP) is primarily a disorder of childhood and chracterized by skin rash, joint pain, abdominal pain and renal involvement. Thrombotic thrombocytopenic purpura(TTP) is a rare clinical syndrome of unknown etiology and classically presents with microangiopathic hemolytic anemia, thrombocytopenia, fluctuating neurological signs, renal dysfuncion and fever. Recently, we experienced one patient with histologically proven HSP, and manifested as a TTP like clinical feature. Patient is a 8-year-old boy who had been diagnosed one month earlier as HSP. He showed microangiopathic hemolytic anemia, renal failure and seizure during the course of his illness. Histological evaluation of renal biopsy confirmed the presence of intravascular thrombosis. Treatment with fresh frozen plasma, plasmapheresis, steroid therapy and peritoneal dialysis resulted in clinical improvement. But he expired on 130th day after admission due to aspiration pneumonia and pneumothorax.

Effect of Calcium Channel Blocker on Gene Expression of Renin after lschemic Renal Injury / 대한내과학회지

OBJECTIVES: lschemic acute renal failure(ARF) is characterized by an abrupt and sustained decline in GFR within minutes to days after renal ischemia and not immediately reversed on restoration of renal blood flow. The typical delay of a few days to a few weeks suggests reversible parenchymal damage awaiting cell regeneration for functional recovery. Many potentially cell damaging factors, such as ATP depletion, plasma membrane phospholipid degradatian and superoxide-induced membrane damage, play a central part in ischemic injury. More recently, much attention has been focused on the role of calcium, especially ischemic cell injury and the possible therapeutic role of calcium channel blockers emerged from studies conducted several years ago. In the past, it was thought that activation of renin-angiotensin system plays a role in the pathogenesis of ARF. Now the role of angiotensin in human renal ischemia also appears to be controversial. The following study was done in order to investigate the effect of a calcium channel blocker, nifedipine, on gene expression of renin during acute ischemic renal injury. METHODS: The Sprague-Dawley rats were divided into 4 groups, group I(n=3) as the control, group II (n=3) as the sham operation group, group III(n=15) as the ischemic renal injury group without nifedipine pretreatment, and group IV(n=15) as the ischemic renal injury model by right nephrectomy and left renal artery clamping for 40 minutes with systemic nifedipine pretreatment(10mg/kg), 1n ischemic renal injury model(group III and IV), rats were further divided into three subgroups according to reperfusion time of 1,24,72 hours. The non-ischemic right kidney removed at the time of initial procedure served as paired control. Total renal RNA was extracted by Chomczynskis method and electrophoresis was done in a 1% agarose gel containing 2,2M formaldehyde. Northern was performed at 42degrees C with isotope labeled renin probe for 18 hours, Autoradiographs were obtained and quantitated by a densitometer measured at 530nm. RESULTS: 1) The expression of renin gene was markedly decreased after renal ischemia and slowly recovered to one half of the control level after 72 hours of reperfusion. 2) Renin gene expression pattern of ischemic renal injury with prior nifedipine treatment was similar to the ischemic group without nifedipine pretreatment. CONCLUSION: These findings suggest that the renin gene expression was markedly decreased after renal ischemia and slowly recovered. Systemic nifedipine pretreatment does not have a significant effect on gene expression pattern of renin in ischemic renal injury.

A Case of IgA Nephropathy Associated with Anemia Induced by Persistent Gross Hematuria / 대한신장학회잡지

IgA nephropathy(IgAN) is the most frequent primary glomerular disease in many countries, including Korea. The typical clinical manifestation of IgAN is synpharygitic gross hematuria, which is usually innocuous for the renal function. Some patients who developed acute renal failure coinciding with episodes of gross hematuria are rarely observed in IgAN. We have observed a 29-year-old male patient with IgAN in whom the duration of gross hematuria(total 28 days) was clearly longer than usual, inducing anemia. We report a case of IgAN associated with anemia due to persistent gross hematuria and a brief review of the literature.

A Case of Henoch-Sch nlein Purpura Complicated with Nephrotic Syndrome and Spontaneous Bacterial Peritonitis in Patient with Stomach Cancer / 대한신장학회잡지

Henoch-Sch nlein purpura(HSP) occurs frequently in childhood and is a few occurrence in adults. The occurrence of nephrotic syndrome is rare in HSP patients and the association of renal disease with HSP is very important to prospect longterm clinical outcome. The causes of HSP have been diversely reported such as foods, drugs, sensitivity to infections, vaccination, insect bite, cold exposure etc and recently immune complex is studing as representative cause of HSP, but nothing is verified of definite mechanism of HSP until now. The occurrence of HSP associated with cancer has been rarely reported in the literature but there is no report in Korea. The patient was 31 year-old woman with stomach cancer who was operated in our hospital. 5 months after operation of stomach cancer, the massive proteinuria, generalized edema were developed and thereafter abdominal pain, generalized purpuric lesion on extremities were also occurred. We have done kidney biopsy and biopsy findings were compatible with HSP pathologically. After administration of prednisolone, spontaneous bacterial peritonitis was occurred suddenly, patient was recovered after ceasation of administration of prednisolone and proper antibiotic therapy but patient died of cachexia 3 months after diagnosis of HSP. We report a case of HSP presenting as nephrotic syndrome in patient with stomach cancer and complicated with spontaneous bacterial peritonitis.

A Clinical study of Blowout Fracture

The authors reviewed charts of 50 consecutive cases which were operated for blowout fracture on preoperative symptoms and signs, intraoperative findings, and surgical prognosis according to timing of surgery, location of fracture and size of fracture, from May 1, 1985, to April 30, 1991, respectively. Most of them had persistent diplopia, positive forced duction test and conspicuous blemish enophthalmos preoperatively. In addtion, the most common site of fracture in the orbital floor was anterior 1/3 with a size of one to two em in vertical diameter. Good prognosis may be expected in patient with anterior fracture of orbital floor, operated within 4 weeks after receiving trauma. Chemosis and lower lid retraction were encountered as an early and late postoperative complications, respectively.