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간경변증이 동반된 말기신부전환자에서의 지속성 외래복막투석
김용림(Yong Lim Kim),권태환(Tae Hwan Kwon),조동규(Dong Kyu Cho) 대한내과학회 1996 대한내과학회지 Vol.51 No.2
Objectives: The spontaneous tendency to arterial hypotension in cirrhotic patients makes adequate hemodialysis therapy extremely difficult. Hemodialysis in these patients may produce intradialytic hypotension, limiting the amount of ultrafiltration. These patients are also at high risk for gastrointestinal bleeding, which can be exacerbated by anticoagulation, Recently peritoneal dialysis has been suggestad for the management of this population. Methods: Seven patients with chronic renal failure and liver cirrhosis treated by CAPD are described. Six of the seven patients were complicated by ascites on starting CAPD. Hepatocellular carcinoma was identified in one patient. Three had been transferred from hemodialysis for hemodynamic intolerance, one for vascular access problem. All PD catheters were surgically placed. Results: The hemodynamic tolerance was excellent in all patients. Four patients developed bleeding immediately after catheter insertion, Two patients developed early leaks and one patient late leak. Four patients had a decline in serum albumin level of 0.5 gm/dL or more during the course of chronic PD, Peritonitis occurred on average at 8.7 month interval. Three episodes of catheter removal occurred in 148 patient-months of PD(0.24 per patient-year). Four patients died while maintained on PD; three deaths were due to hepatic encephalopathy on PD for duration of 4 to 60 months and the fourth was due to peritonitis after 24 months of PD. One patient died due to malnutrition after 2 months on switching to hemodialysis because of peritonitis after 32 months of PD. Conclusion: Early mechanical complications after catheter insertion(bleeding, leak) were more common than usual. But CAPD was better tolerable than hemodialysis and may be a reasonable choice with an acceptable survival rate in end-stage renal disease patients with preexisting liver cirrhosis.
김용림(Yong Lim Kim),조동규(Dong Kyu Cho),김준철(Jun Chul Kim),백미영(Mi Young Baek),조영준(Young Jun Cho),박선희(Son Hee Park),이동욱(Dong Wook Lee) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.2
N/A Exit-site infection(ESI) is a troublesome catheter related complication of CAPD that may lead to peri-tonitis and require catheter removal, ESI is variably defined and classified. The rate of ESI and the out-come of treatment are also variably reported in literature. We conducted a retrospective study of 58 episodes of ESI(40 patients) between August 1997 and February 1999, and evaluated the episodes and types of ESI, organism isolated from ESI and their sensitivity, outcome of ESI, number and reason for catheter loss, and the current modality. The mean age was 48.9±11.5 years(31-70) and the male to female ratio was 22:18. The mean dura-tion of CAPD before ESI was 34.1±29.6 months (1.5-114.2), and diabetic nephropathy was the cause of ESRD in 17.5% of cases. The types of catheter were two-cuff, coiled Tenckhoff in 17 patients, two- cuff, coiled swan-neck in 10 patients, two-cuff, straight swan-neck in 10 patients, and two-cuff, straight Tenckhoff in 3 patients. According to Twardowski's classification, acute infection in 33 patients and chronic infection in 25 patients were noted. Causative organisms of ESI were S. aureus, S. epidermidis, Pseudomonas, and E. cali in diminishing order of frequency. S. aureus was the most common organism in acute infection, and S. epidermidis was the most common organism in chronie infection. The mean duration of CAPD before ESI was 27.6±27.2 months in acute infection, and 42.8±30.8 in chronic infection (p<0.05). The duration of antibiotic treatment was 19.9±14.4 days in acute infection, and 42.7±27.2 days in chronic infection(p<0.05). In acute infection, peri-tonitis developed in 2 patients and 1 catheter was removed. In chronic infection, peritonitis developed in 1 patient and the catheter was removed. Three patients had the external cuff shaved due to persistent ESI which was unresponsive to antibiotics and local care. By the end of the study, 36 patients(90%) were still on CAPD, 2 patients(5%) had transferred to hemodialysis, and 2 patients(5%) had died. The cause of death was peritonitis in 1 patient, and cachexia in the other patient. In conclusion, exit-site infection responded rela-tively well to conservative treatment. However, exit- site infection is one of the major causes of catheter failure in CAPD. Therefore, careful exit-site care and examinations are needed.
컴퓨터화 된 요소 역동학 모델 ( Urea Kinetic Modeling ) 을 이용한 지속성 외래 복막투석 환자의 투석용량에 따른 투석적절도 연구
김용림(Yong Lim Kim),김준철(Jun Chul Kim),김찬덕(Chan Duck Kim),김준홍(Jun Hong Kim),조동규(Dong Kyu Cho) 대한내과학회 1999 대한내과학회지 Vol.57 No.3
The DOQI guidelines recommend that the delivered PD dose should be a total weekly Kt/Vurea and Ccr values of at least 2.0 and 60 L/week/1.73 m2 for CAPD patients. To achieve these recommended guidelines, the standard regime of four 2-L daily exchanges may not be sufficient even for Oriental patients whose body size are relatively smaller than those of Westerners. However, the option of a two-and-a-half liter bag (2.5L) and a simple automated overnight exchange device for a fifth exchange are not available in some countries. In order to evaluate the percentage of CAPD patients who receive dialysis meeting DOQI guidelines in different dialysis prescriptions, 110 Korean patients, treated for over a 3 month on CAPD, with a mean age of 46.912.6 years and dialysis duration of 37.6±28.1 months (range 3-116), were studied. Methods : Baseline urea kinetic data from a 24-hour dialysate collection was obtained and analyzed using the computerized urea kinetic model of peritoneal urea transport (PACK-PD, vers 1.01, Fresenius). The potential Kt/Vurea and Ccr values using four 2L and 2.5L daily exchanges were calculated with the PC program. Results : The mean weekly Kt/Vurea and Ccr values were 2.01±0.67 and 66.4±29.6 L/week/1.73 m2 respectively, with a median body surface area (BSA) of 1.61 m2 (75th percentile 1.73 m2). The mean 24 hour dialysate-to-plasma creatinine ratio was 0.75±0.16. Fourty-five of the 110 patients (41%) had no residual renal function. Upon logistic regression analysis, Kt/Vurea was independent factor affecting serum albumin and NPCR. 1) In forty-eight (44%) of the 110 patients, both Kt/Vurea and Ccr values with four 2-L daily exchanges were adequate. In twenty-two (20%), one of Kt/Vurea and Ccr values with four 2-L daily exchanges was inadequate. In fourty (36%), both Kt/Vurea and Ccr values with four 2-L daily exchanges were inadequate. 2) In eighty-four (77%) of the 110 patients, both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were adequate. In nineteen (17%), one of Kt/Vurea and Ccr values with four 2.5-L daily exchanges was inadequate. In seven (6%), both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were inadequate. 3) In three (7%) of the fourty-five anuric patients, both Kt/Vurea and Ccr values with four 2-L daily exchanges were adequate. In eleven (24%), one of Kt/Vurea and Ccr values with four 2-L daily exchanges was inadequate. In thirty-one (69%), both Kt/Vurea and Ccr values with four 2-L daily exchanges were inadequate. 4) In twenty-seven (60%) of the fourty-five anuric patients, both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were adequate. In thirteen (29%), one of Kt/Vurea and Ccr values with four 2.5-L daily exchanges was inadequate. In five (11%), both Kt/Vurea and Ccr values with four 2.5-L daily exchanges were inadequate. Conclusion : The anuric Korean patients may need four 2.5L daily exchanges for acceptable adequacy target. Special attention must be given to those patients with no residual renal function. (Korean J Med 57:313-322, 1999)