IgA Nephropathy의 임상 및 병리학적 고찰

윤견일 梨花女子大學校 醫科大學 醫科學硏究所 1995 EMJ (Ewha medical journal) Vol.18 No.4

목 적 : IgA 신증은 한국에서 가장 흔한 사구체 신염의 하나로 육안적 혈뇨, 현미경적 혈뇨, 단백뇨 및 배통 등으로 발현하고, 초기에는 비교적 양성 경과를 취하나 환자의 30%정도에서는 20 년에서 30 년 사이에 말기 신부전증으로진행되는 것으로 되어 있다. 하지만 IgA 신증의 정확한병태 생리 및 치료 방법에 따른 예후에 대해서는 연구자마다 다른 결과를 보고하고 있는 상태이다 이에 저자는한국에서의 IgA 신증의 임상 양상과 병리 소견의 특징을조사하고 추적 검사시의 신기능의 변화를 관찰하여 환자치료에 도움을 받고자 하였다. 방법 : 1988년 1월 부터 1995년 10월까지 이화여자 대학교의과대학 부속 병원 내과에서 신포직 검사를 받았던 총224예 중 IgA 신증으로 진단된 37예를 대상으로 환자의임상적 특성, 검사소견 및 병리학적 소견을 관찰하고, 외래를 통한 추적 검사가 가능했던 19예에서 추적 기간 중의 신장 기능을 포함한 각종 검사 소견을 조사하였다. 결과 : 전체 신조직 검사 224예중 16.5%인 37예에서 IgA 신증으로 진단되었다. 30대의 남자 환자에서의 발병률이 가장 높았고 육안적 혈뇨(27%), 단백뇨를 동반한 현미경적혈뇨(24%)가 가장 흔한 임상 양상이었고, 신증후군으로발현한 경우는 22% 였다. 전체 대상 환자에서 일일 단백뇨의 정도는 3.5±4.9g/day 이었고 creatinine 청소률은62.3±38.Iml/min 이었다. 병리 소견에서는 mesangial expansion(41%)와 mesangial cell proliferation(41%)이 가장 흔한 소견으로 WHO 분류에 의한 classⅡ의 빈도가 가장 높았다. 면역 형광 검사에 의한 사구체내의 IgA 침착 정도와 환자의 혈압, creatinine 농도 및24시간 단백뇨의 정도에는 의의있는 차이가 없었다. 평균22.4개월 간의 추적 검사 기간 동안 환자의 혈중 creatinine농도는 의의 있게 증가되는 소견을 보였고 3예의 환자는 말기 신부전증으로 진행되어 투석 치료를 받게 되었다. 이들 3예는 모두 진단 당시 신증후군으로 발현 하였고이들의 단백뇨는 Steroid에 대해 반응하지 않았다. 3예중2예에서는 진당 당시 조직 검사 소견상 이미 심한 사구체경화 소견과 crescent formation을 보였다. 결 론 : IgA 신증은 이전에 보고된 것처럼 양성 경과만을 취하는 것으로 생각할 수 없으며 특히 신증후군으로 처음 발현한 경우 Steroid 치료에 잘 반웅하지 않고 신부전증으로 진행될 가능성이 높다. 따라서 이들 환자에서 신기능이 악화되는 것을 막기위한 보다 적극적인 치료에 관한장기적이고 전향적인 연구가 요구된다. 0bjectives : Immunoglobulin A nephropathy(IgA nephropathy) Is one of the most prevalent glomerulonephritis in Korea, and nearly one third of them progress to end stage renal disease(ESR:D) over 20 to 30 years. The exact pathogenesis and therapeutic modality to inhibit theprogress of IgA nephropathy into BSRD are still uncertain in spite of lots of reports on beneficial effects of several therapeutic strategy. The present study was undertaken to know the incidence of IgA nephropathy, the mode of presentation, the characteristic pathologic findingsand the course of disease with the possible prognostic factor. Methods : I reviewed the medical records including the pathologic reports of 37 cases of IgAnephropathy who performed renal biopsy between Jan. 1988 and Oct. 1995. The initialpresenting sypmtoms and laboratory finding, pathologic characteristic and follow-up data werealso investigated with the relationship between the initial laboratory or pathologic findings andthe deterioration of renal function. Results : The incidence of IgA nephropathy was 16.5%. IgA nephropathy was more prevalent in male in their 3rd decade. Gross hematuria (27%) and microscopic hematuria with significant proteinuria (24%) were the most common clinical symptoms/signs. The incidence ofneprotic syndrome among IgA nephropathy was 22%. The amount of proteinuria in total 37subjects was 3.5±4.9g/day. Mesangial expansion (41%) and hypercellularity (41%) were themost common light microscopic finding. We couldn't find any statistically significant differencein initial blood pressure, serum creatinine and proteinuria according to the extent of mesangialIgA deposition. With the follow-up of mean duration of 22.4±0.8 months, serum creatinineincreased significantly with the development of ESRD in 3 cases of subjects. These cases ofESRD all presented nephrotic syndrome initially, and did not respond to steroid therapy. Thepathologic findings in 2 of them were global glomerular sclerosis and crescent formation. Conclusion : IgA nephropathy is no longer the unusual and benign disease. Further prospective, controlled study is necessary to know which is the best therapeutic modality to inhibitor slow-down the progression of IgA nephropathy.

혈액투석 환자에서의 생존율 및 사망에 관한 연구

윤견일 梨花女子大學校 醫科大學 醫科學硏究所 1991 EMJ (Ewha medical journal) Vol.14 No.3

We reached the following conclusions from analyzing survival rates and causes of death of 71 patients who received hemodialysis at our hemodialysis center from January 1983 to December of 1990 using life-table method. 1) The 5-year survival rate of the whole patients was 52%. 2) The survival rate decreased significantly with increasing age after 3 years from commencement of dialysis. The 5-year survival rate of patients under the age of 30 was 89%, the rate of patients between the age of 31 and 50 was 70% . and the rate of patients above the age of 51 years was 30%. 3) Diabetes Mellitus had no slgnificant influence on survival rate in patients over the age 51. 4) The survival rates according to sex revealed no significant difference. 5) The leading cause of death was cardiovascular disease including cerebrovascular accident amounting 47.6% and next was infectious disease 23.8%. Additional study on survival rate in age group over 51 with or without Diabetes Mellitus is required in the future.

위암에 속발한 발작성야간혈색소뇨증 : 양의 골수섬유증 1예 Like Secondary Myelofibrosis with Gastric Cancer

윤견일 梨花女子大學校 醫科大學 醫科學硏究所 1982 EMJ (Ewha medical journal) Vol.5 No.4

A case of PNH-like secondary myelofibrosis associated gastric cancer is presen-ted with brief literal view. This 45 years old Korean male who had gastric cancer, was admitted to Ewha University hospital with marked pallor and bone pain. On hematologic examination, hemoglobin 4.0 gm/dl, hematocrit 8%, and RBC count was 92×10^4/㎣. WBC count was 16,200/㎣, with normal differentiation and platelet count was 18,000/㎣. Reticulocyte count was 5%. Peripheral blood smear showed anisocytosis, poikilocytosis and schistocytes including tear-drop cell. Two attempts of bone marrow biopsy disclosed island-shape of gastric cancer call infiltration and reticulin strands. After transfusion with 4 units of whole blood over the night, his early morning urine color was dark reddish-brown. The HAM test was positive and the value of the leukocyte alkaline phosphatase was very high. But there was no specific change of urine after administration of Iron-dextran. The author assure that this case was accompanied by Paroxysmal Nocturnal Hemoglobinuria-like red cell defect rather than microangiopathic hemolytic anemia.

식도정맥류의 내시경적 관찰

윤견일 梨花女子大學校 醫科大學 醫科學硏究所 1983 EMJ (Ewha medical journal) Vol.6 No.4

The purpose of this study was to observe the correlation between the severity of esophageal varices and various clinical findings. Thirty-four patients with esophageal varices were selected for the study from Jan. 1981 to Sept. 1983 at the Ewha Womans University Hospital. The varices were classified by the Sesoko's method into 3 grades according to severity. The grade Ⅰ or mild varices are those with unequivocal distension and tortuosity of the vein forming fold-like elevations. The grade Ⅱ or moderate varices look like hemispherical or nodular prominance in some parts of the elevated structure below the 2nd narrowing. The grade Ⅲ or severe varices are the longitudinally aligned, nodular or beads-like bulging of highest degree of veins, usually throughout the entire length of the esophagus. The observed results are summerized as follows. 1) The ratio between male and and female was 4:1. In age ditribution, the incidence was most prevalent in 4th to 5th decade. 2) Underlying liver diseases were liver cirrhosis(23 cases), carcinoma of the liver(9 cases) and chronic hepatitis(2 cases). 3) Esophagoscopy is good method for observing the variceal morphology, number, location, degree and bleeding sites in this study. Esophagoscopy is the far better method in the diagnosis of esophageal varix than esophagography. Almost the mild varices were not demonstrated by esophagography and one third of moderate varices were not detected by the routine esophagography. 4) There was no significant correlation between the size, number, location or color of the varices and variceal bleeding. 5) There was no correlation between the severity of esophageal varices and hepatomegaly. But there was a tendency for some correlation among the severity of esophageal varices, splenomegaly and ascites.

새해 맞이를 위한 지난해 돌아보기

윤견일,Yun, Gyeon-Il 대한병원협회 2005 대한병원협회지 Vol.34 No.1

胃疾患 1,272例의 胃內觀鏡所見에 對한 硏究

尹堅一 梨花女子大學校 韓國生活科學硏究院 1983 韓國生活科學硏究院 論叢 Vol.32 No.-

성인병 중에서 위질환은 그 빈도에 있어서 가장 수위를 점하고 있다. 위질환의 진단은 병력, 이학적소견 및 위 X-선검사가 있으나 현재 위내시경검사는 신속함과 정확도에 있어서 가장 유용한 진단방법의 하나이다. 더우기 위점막의 미세한 병변이나 조기위암을 초기에 발견될 수 있음은 위내시경의 발전에 있다고 하겠다. 저자는 과거 4년간(1979.1∼1982.12) 위내시경으로 진단된 각종 위질환의 연구분석 결과 다음과 같은 결론을 얻었다. 1. 각종 위질환 및 십이지장궤양으로 확진된 1,272예중 남자는 826예(64%), 여자는 446(36%)였고, 40대, 30대, 50대의 순으로 많았다. 2. 질환별 분포는 위염이 555예(43.7%)로 가장 많았고, 위궤양과 십이지장궤양은 257 및 250예로서 거의 비슷한 분포를 나타났다. 3. 위염의 남녀비는 각각 1.2:1로 비슷하였으며 호발연령은 30대와 40대에서 가장 많았으며 표층성위염이 63%로서 수위를 차지하였다. 4. 위궤양의 남녀비는 각각 2.6:1로서 남자가 많았고 호발연령은 40대, 50대였으며 단발성이 70%로 훨씬 많았다. 5) 위암은 총 1,272예중 195예 였으며 남녀비는 각각 2.4:1로서 남자가 많았고, 호발연령은 50대 35%, 60대 30%순으로 많았고, 호발부위는 위체부로서 50.8%를 차지하였고, BⅣ형이 114예(58%)로서 가장 많았다. 6) 십이지장궤양의 남녀비는 각각 3.5:1로서 남자가 월등히 많았다. A clinical analysis was carried out on1272 patients taken gastrofiberscopy who were considered to have various stomach diseases clinically, from January 1976 to December 1982 in Dept. of Internal Medicine, Ewha Womans University Hospital. The results were as follows; 1) Of the tota 1272 cases, 826(64%) cases cases were male and 446(36%) cases were female. 22.8% of the cases were of the 4th decade, 3th decade(21.5%) and 5th decade (20.6%) in order. 2) The distribution of Upper G-I disease on endoscopic finding was gastritis; 555(43.7%) cases, gastric ulcer; 257(20.1%) cases, ducdenal ulcer; 250(19.6%) cases and gastric cancer; 195(15.4%) cases in order. 3) Of the 555 patients with gastritis, 301(54.2%) cases were male and 254(45.8%) cases were female. The peak incidence of gastritis was 3th decade (28%), 4th decade (26%) and 5th decade (18%) in order. The most frequent type of gastritis was superficial gastritis (63%). 4) Of the 257 cases of benign gastric ulcer, 186(72%) cases were male and 71(28%) cases were female. The endoscopic finding revealed that single ulcer was 180 (70%) cases and multiple ulcer was 29(11%) cases. 5) Of the 195 cases of gastric cancer, 137(70%) cases were male and 58(30%) cases were female. The peak incidence was 5th decade (35%) and next was 6th decade (30%). The most frequent type of gastric cancer was type Ⅳ in Borrmann's classification (58%), and the most frequent occurrence site was gastric body (50.8%). 6) Of the 250 cases of duodena ulcer, 195(78%) cases were male and 55(22%) cases were female, male to female ratio was 3.5:1.

낭창성 신염 환자에서 혈중 및 요중 Endothelin-1의 의의

윤견일 梨花女子大學校 醫科大學 醫科學硏究所 1993 EMJ (Ewha medical journal) Vol.16 No.3

Endothelin is a 21-residue peptide vasoconstrictor produced by endothelium. The exact roleof endothelin in the pathophysiology of renal disease has not yet been extensively demonstrated.Thus, to elucidate the pathophysiological significance of plasma and urinary endothelin-1 (ETI) in patients with lupus nephritis. we studied 7 patients diagnosed as lupus nephritis bykidney biopsy and 7 healthy volunteers. Serum and urinary biochemical studies includingcreatinine and ET-1 were done, and urinary excretion of N-acetyl-β-D-glucosaminidase(NAG)was also measured. The results were as follows ; 1) Patient poop and control group showed no significant differences in their clinical characteristics, basic biochemical studies, serum creatinine, plasma ET-1, urinary excretion of protein.NAG and creatinine and ET-1 clearance. Of 7 lupus nephritis patients, only 2 patients showedabnormal serum complement and anti-dsDNA. 2) In lupus nephritis patients, plasma ET-1 level showed no correlation with serum creatinine,complement and anti-dsDNA(p>0.05). 3) ET-1 clearance showed no significant correlaticn with creatinine clearance rate, complement anti-dsDNA ana urinlary NAG excretion. Plasma ET-1 level and its clearance rate could not reflect the lupus nephritis activity. Butour study included small number of patients and only 2 patients of pathologically provenlupus nephritis showed active disease, biochemically and clinically, ana the majority of patientshas alreday been in remission state after treatment Above factors probably acted as a biasagainst the results, leading to statistical limitations. In further studies, we should broaden oursubject group in number and to other renal diseases than limiting to lupus nephritis andprospective long term follow up study is indicated to further investigate the role of urinaryexcretion of ET-1 and their mechanism of action on renal disease.

고혈압에 의한 신질환

윤견일 대한신장학회 1992 추계학술대회 초록집 Vol.1992 No.-

膵臟炎患者에 있어서의 Amylase-Creatinine Clearance Ratio에 관한 硏究

尹堅一 梨花女子大學校 韓國生活科學硏究院 1978 韓國生活科學硏究院 論叢 Vol.21 No.-

혈청 amylase치의 상승은 급성취장염 이외에도 장폐쇄, 간장질환, 난관질환, 소화성 궤양의 천공 및 담도질환 등에서도 나타날 수 있으므로 급성취장염의 정확한 진단의 척도가 될 수는 없다. 1969년 Levitt, Rapoport 및 Cooperband는 급성취장염에서 amylase의 renal clearance와 creatinine의 renal clearance 비가 정상이나 다른 질환에 비해 특별히 높다는 것을 발견한 이래 많은 연구가 계속도어 왔다. 1975년 Warshaw와 Fuller는 급성취장염에서 amylase-creatinine clearance비가 증가되는 현상은 신장에서 amylase의 투과성이 상승되는 때문이라고 설명하였다. 저자는 정상인 16예, 급성취장 염환자26예, 만성취장염환자 3예 및 기타 질환 16예를 대상으로 amylase-creatinine clearanceratio(C^Am/C_Cr비)를 측정하여 비교한 결과, 급성취장염에서만 C^Am/C_Cr치가 1.5∼2배 이상 높다는 것을 관찰하였다. 또한 혈청 amylase치는 급성취장염의 발병 초기에만 증가하여 시간이 경과함에 따라 2∼3일 이내에 가소하여 정상으로 유지되지만, 급성취장염의 C^Am/C_Cr치는 발병 10일까지도 계속 증가되어 있음을 알 수 있었다. 이상과 같은 결과로 C^Am/C_Cr 비는 급성취장염의 진단에는 물론, 혈청 amylase치가 상승될 수 있는 급성취장염 이외의 질환들과의 감별진단에도, 가치가 있음을 입증하게 되었다. The value of an elevated serum amylase as an indicator of acute pancreatitis is limited because elevations also occur with intestinal obstruction and inflammation, liver trauma and heaptitis, acute salpingitis and ruptured ectopic pregnancy, peptic ulcer diseases, and common-duct stones. In 1969 Levitt, Rapoport, and Cooperband showed that renal clearance of amylase, expressed as a percentage of simultaneous creatinine clearance to minimize irrelevant changes due to variations in renal function, rises in acute pancreatitis to levels several times higher than normal. In 1975 Warshaw and Fuller showed that the clearance ratio was abnormally high only in acute pancreatitis, and suggested that this phenomenon was due to an effect on the kidney rather than to different clearances of different forms of amylase. The present investigation reports an analysis of serum amylase, urinary amylase and derived C /C ratio in 16 normal controls, 26 patients with acute pancreatitis, 3 with chronic pancreatitis and 16 with non-pancreatic disease (6 with acute cholecystitis, 4 with stomach cancer, 3 with liver disease and 3 with peptic ulcers) at the Ewha Uni-versity Hospital, from March, 1977 through December, 1977. The level of serum and urine amylase was measured by Somogyi units. The C /C ratio in each group is as follows: a) Normal control: 23.2±0.9% Acute cholecystitis: 2.15±0.73% Stomach cancer: 1.62±0.5% Liver disease: 1.53±0.17%, Peptic ulcer: 2.19±0.58%. This results were within normal limits. b) Acute pancreatitis from onset to the 2nd day: 3.36±0.86%, from 2nd day to the 4th day of onset: 3.62±0.94%, from 4th day to 10th day of onset: 4.79±1.33%. (p±0.05) This results reached 1.5 to 2 times the normal data. In chronic pancreatitis, C /C ratio remained within normal limits although there were significantly high serum and urine amylase levels.

혈액투석 환자에서 혈중 Endothelin-1(ET-1)및 Lipoprotein(a)(Lip(a)) 농도에 동정맥루 폐쇄의 상관 관계에 관한 연구

윤견일,강걷희 대한신장학회 1996 Kidney Research and Clinical Practice Vol.15 No.4

Reliable vascular access has been described as the Achilles heel of modern hemodialysis (HD) patients. In spite of the improved technology in vascular surgery, vascular access occlusion (VAO) by thrombosis and stenosis has been a constant problem, accounting for 10-40% of all hospital admissions of dialysis patients. Runoff vein stenosis due to vascular smooth muscle (neointimal') hyperplasia has been found to be one of the most common pathologic findings in cases with anatomic lesions of VAO. ET-1 is a naturally occurring vasoactive substance which has an intense mitogenic effect on cultured vascular smooth muscle cells and Lp(a) is known to be an independent predictor of coronary risk and coronary bypass stenosis. However, the clinical significance of the increased ET-1 and Lp(a) in relation to VAO is uncertain in HD patients. The present study was undertaken to evaluate the clinical significance of Lp(a) and ET-1 as a possible risk factor for VAO in 50 HD patients (male:'female 29:21, mean age 48 years, mean HD duration 47 months). The frequency of VAO in entire subjects was 0.47±1.03 episodes/patient-year. The median value of Lp(a) was 10.8mg/dl (1.9-87.6mg/dl) and the median value of ET-1 was 8,3 pg/ml (3.2-29.3 pg/ml). Fourteen patients (28% of subjects) were found to have at least one episode of VAO. There was no statistically significant difference in sex, age, blood pressure, % of patients receiving rHuEpo between VAO and non-VAO group. Biochemical parameters including Lp(a) & ET-1 were not different between VAO and non-VAO group. Six out of 50 patients (12%) had increased levels of ET-1 above mean±2SD. In those patients with increased ET-1, the frequency of VAO was higher (1.83±1.65 vs. 0.38±0.54 episodes/patient-year, p$lt;0.05). The median survival of vascular access for this high ET-1 group was 14.5 months, which was significantly lower compared to 77.8 months in patients whose ET-1 level was below 16pg/mL However, there was no significant difference in vascular access survival according to thvel of Lp(a). In conclusion, the level of ET-1 can affect the event free vascular access survival in HD patients, while the Lp(a) level seems to be unrelated to the VAO in our Korean HD patients. Further prospective studies are necessary to know the exact clinical significance of increased ET-1 and Lp(a) in the occurrence of access occlusion in maintenance HD patients.