급성 신우신염 환자에서 패혈성 쇼크와 관련 있는 신장 전산화단층촬영 소견

권순성,진상찬,최우익,김성진 대한중환자의학회 2013 Acute and Critical Care Vol.28 No.4

Background: Clinical findings, medical history and laboratory findings in patients with acute pyelonephritis are insufficient to predict the occurrence of septic shock and to assess its severity and prognosis. Early imaging may not only aid in diagnosing acute pyelonephritis,but also help in assessing the risk factors associated with septic shock. Methods: In this retrospective study, we reviewed the medical records and collected the data of 200 patients from January to December,2011. All patients were over 18 years old; showed symptoms of fever, chills, muscle pain and flank pain; demonstrated more than 10white blood cells in urinalysis; and were diagnosed with acute pyelonephritis after computed tomography (CT) scan. Patients were classified into two groups: patients with septic shock (group 1) and patients without septic shock (group 2), and the clinical, laboratory and CT findings of the two groups were then compared. Results: Out of all 200 patients, there were 32 patients (16%) who had acute pyelonephritis with septic shock. The acute pyelonephritis with septic shock group (group 1) showed increased bacteremia compared with the other group (53.1% vs. 24.4%, p = 0.002). Laboratory findings showed that group 1 patients had higher serum creatinine (1.67 ± 1.03 mg/dl vs. 1.14 ± 0.98 mg/dl, p = 0.022)and hsCRP (8.36 ± 5.29 mg/dl vs. 5.27 ± 3.53 mg/dl, p = 0.000) than group 2 patients. The findings of kidney CT showed statistically significant differences in global renal enlargement (31.3% vs. 18.7%, p = 0.005), pelvicalyceal wall thickening (37.5% vs. 13.1%, p = 0.005) and poor excretion of contrast (25% vs. 2.4%, p = 0.000). The results of the logistic regression test showed that there were significant differences in bacteremia serum creatinine, C-reactive protein, pelvicalyceal wall thickening and poor excretion of contrast. Conclusions: Computed tomography can predict the possibility of septic shock by identifying the range of renal lesions in patients with acute pyelonephritis. It can therefore allow initial aggressive treatment that can contribute to decreases in mortality and morbidity in patients with acute pyelonephritis.

정상 및 급성 신우신염 소아에서 요 Transforming Growth Factor-β1/Creatinine 비에 관한 연구

한혜원 ( Han Hye Won ),이준호 ( Lee Jun Ho ),엄은영 ( Eom Eun Yeong ),하일수 ( Ha Il Su ),정해일 ( Jeong Hae Il ),최용 ( Choe Yong ) 대한신장학회 2003 Kidney Research and Clinical Practice Vol.22 No.5

목 적 : 소아에서 만성 신부전의 원인 중 신우신염이 중요한 인자이며 transforming growth factor-β1 (TGF-β1)은 신 섬유화를 초래하는 인자임이 확인되어 있다. 본 연구는 소아의 급성 신우신염에서 요 TGF-β1/creatinine 비의 변화를 확인하고 신반흔 혹은 농뇨와의 연관성을 검증하기 위해 시행되었다. 방 법 : 정상 소아 67명과 급성 신우신염 환자 25명의 요를 채취하여 ELISA법으로 TGF-β1을 정량하였다. 요 creatinine은 alkaline picrate법으로 측정하였다. 환자의 요 TGF-β1,/creatinine 비를 대조군과 비교하고 치료후 변화를 관찰하였다. 요 TGF-β1/creatinine 비와 농뇨의 정도, 신 반흔 존재와의 연관성을 검증하였다. 결 과 : 정상 소아의 요 TGF-β1/creatinine 비는 연령이 증가함에 따라 유의하게 감소하였다 (p<0.05). 대조군에 비해 급성 신우신염 군에서 요 TGF-β1/creatinine 비는 현저히 높고 (p<0.05) 치료 후 감소하였으며 농뇨의 정도나신 반흔 발생과는 연관이 없었다. 결 론 : 소아에서 요 TGF-β1/creatinine 비는 연령별 참고치를 기준으로 평가하여야 한다. 급성 신우신염 초기의 요 TGF-β1의 증가는 가역적이고 농뇨의 정도나 신 반흔의 존재와는 무관하다. Background : Pyelonephritis is one of the major causes of chronic renal failure in children, and the transforming growth factor- R 1 (TGF-β 1) is a molecule with pivotal roles in fibrogenesis. This study was performed to investigate the alteration and clinical implications of urinary TGF- R llcreatinine ratio in children with acute pyelonephritis. Methods: Urine was collected from 67 normal children and 25 children with acute pyelonephritis. After routine urinalysis, urine TGF P 1 was quantitated by ELISA method and creatinine was measured by alkaline picrate method. Urinary TGF-β l/ creatinine ratios in children with pyelonephritis were compared with those of age-matched controls, and sequential changes of the ratios in pyelonephritic children were traced after antibiotic treatment. Correlation of urinary TGF-β 1/ creatinine ratio with the degree of pyuria and renal scar was analyzed each. Results : Neonates showed higher urinary TGF-β l/creatinine ratios than older children. The ratio increased in acute pyelonephritis and gradually returned to the control level two days after antibiotic treatment. Urinary T G F Rl/creatinine ratio in acute pyelonephritis was not correlated with the degree of pyuria and renal scar. Conclusion: The age should be considered in evaluation of urinary TGF- β l/creatinine ratio in children. The ratio increases in acute pyelonephritis, and is independent of the degree of pyuria or renal scarring.

Serum levels of interleukin-6 and interleukin-8 as diagnostic markers of acute pyelonephritis in children

Mahyar, Abolfazl,Ayazi, Parviz,Maleki, Mohammad Reza,Daneshi-Kohan, Mohammad Mahdi,Sarokhani, Hamid Reza,Hashemi, Hassan Jahani,Talebi-Bakhshayesh, Mousa The Korean Pediatric Society 2013 Clinical and Experimental Pediatrics (CEP) Vol.56 No.5

Purpose: Early diagnosis and treatment of acute pyelonephritis in children is of special importance in order to prevent serious complications. This study was conducted to determine the diagnostic value of serum interleukin (IL)-6 and IL-8 in children with acute pyelonephritis. Methods: Eighty-seven patients between 1 month to 12 years old with urinary tract infection (UTI) were divided into 2 groups based on the result of 99m-technetium dimercapto-succinic acid renal scan: acute pyelonephritis (n=37) and lower UTI (n=50) groups. White blood cell (WBC) count, neutrophil (Neutl) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) concentration, platelet count, and serum IL-6 and IL-8 concentrations of both groups were measured and compared. Results: There was a significant difference between two groups regarding WBC count, Neutl count, ESR, and CRP concentration (P<0.05). In addition, the difference between the two groups regarding serum IL-6 and IL-8 concentrations was not significant (IL-6, 60 and 35.4 pg/mL and IL-8, 404 and 617 pg/mL, respectively). The sensitivity and specificity of serum IL-6 and IL-8 for diagnosis of acute pyelonephritis were 73%, 42% and 78%, 32%, respectively. Sensitivity, specificity, negative and positive predictive values of serum IL-6 and IL-8 were less than those of acute phase serum reactants such as CRP. Conclusion: This study showed that there was no significant difference between acute pyelonephritis and lower UTI groups regarding serum IL-6 and IL-8 levels. Therefore, despite confirming results of previous studies, it seems that IL-6 and IL-8 are not suitable markers for differentiating between acute pyelonephritis and lower UTI.

Serum levels of interleukin-6 and interleukin-8 as diagnostic markers of acute pyelonephritis in children

Abolfazl Mahyar,Parviz Ayazi,Mohammad Reza Maleki,Mohammad Mahdi Daneshi-Kohan,Hamid Reza Sarokhani,Hassan Jahani Hashemi,Mousa Talebi-Bakhshayesh 대한소아청소년과학회 2013 Clinical and Experimental Pediatrics (CEP) Vol.56 No.5

Purpose: Early diagnosis and treatment of acute pyelonephritis in children is of special importance in order to prevent serious complications. This study was conducted to determine the diagnostic value of serum interleukin (IL)-6 and IL-8 in children with acute pyelonephritis. Methods: Eighty-seven patients between 1 month to 12 years old with urinary tract infection (UTI)were divided into 2 groups based on the result of 99m-technetium dimercapto-succinic acid renal scan:acute pyelonephritis (n=37) and lower UTI (n=50) groups. White blood cell (WBC) count, neutrophil (Neutl)count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) concentration, platelet count,and serum IL-6 and IL-8 concentrations of both groups were measured and compared . Results: There was a significant difference between two groups regarding WBC count, Neutl count,ESR, and CRP concentration (P<0.05). In addition, the difference between the two groups regarding serum IL-6 and IL-8 concentrations was not significant (IL-6, 60 and 35.4 pg/mL and IL-8, 404 and 617 pg/mL, respectively). The sensitivity and specificity of serum IL-6 and IL-8 for diagnosis of acute pyelonephritis were 73%, 42% and 78%, 32%, respectively. Sensitivity, specificity, negative and positive predictive values of serum IL-6 and IL-8 were less than those of acute phase serum reactants such as CRP. Conclusion: This study showed that there was no significant difference between acute pyelonephritis and lower UTI groups regarding serum IL-6 and IL-8 levels. Therefore, despite confirming results of previous studies, it seems that IL-6 and IL-8 are not suitable markers for differentiating between acute pyelonephritis and lower UTI.

급성 신부전을 동반한 급성 신우신염과 단순 급성 신우신염의 임상적 특징 비교

김성진 ( Sung Jin Kim ),권은희 ( Eun Hoe Kwon ),손정민 ( Jung Min Son ),김정희 ( Jung Hee Kim ),이동원 ( Dong Won Lee ),이수봉 ( Soo Bong Lee ),곽임수 ( Ihm Soo Kwak ),나하연 ( Ha Yeon Rha ) 대한신장학회 2003 Kidney Research and Clinical Practice Vol.22 No.2

목적 : 급성 신우신염이 급성 신부전을 일으키는 경우는 드물며 1992년 Jones에 의해 12예가 보고된 바 있다. 당뇨, 요로계 폐쇄, 만성 신부전 등 기저 질환이 없는 상태에서 요로 감염은 만성적인 신 손상을 주지 않는다. 부산대학교병원에 내원한 급성 신우신염 환자 중 합병증으로 급성 신부전이 동반된 경우를 분석하여 임상적 특징과 상관인자에 대해 알아보고자 하였다. 방법 : 부산대학교병원에서 1995년 1월부터 2001년 5월까지 기저질환이 없는 환자 중 내원시 급성 신부전을 동반한 급성 신우신염 환자 8명을 조사하였다. 대조군으로 같은 기간에 합병증이 동반되지 않은 급성 신우신염 환자 20명을 임으로 선정하였고 양군의 의무기록을 후향적으로 비교 검토하였다. 결과 : 평균 연령은 단순 신우신염군이 49.2±14.4세, 급성 신부전 동반군에서는 56.3±16.4세로 보다 높은 연령에서 발생하였다. 성별은 단순 신우신염군에서는 여성 90% (18/20), 남성 10% (2/20)이고 급성 신부전 동반군에서는 여성 62.5% (5/8), 남성 37.5% (3/8)이였다 (p=ns). 내원시 체온은 단순 신우신염군이 37.5±1.14℃, 급성 신부전 동반군은 36.62±0.32℃로 통계적으로 의미 있게 낮았다 (p=0.003). 요 백혈구 지속기간, 늑골 척주각 압통 지속기간, 입원 기간 등이 급성 신부전 동반군에서 의미있게 연장되었다. 내원시 호소하는 늑골 척추각 압통부위는 단순 신우신염군에서는 편측인 경우가 65%로 많았으나 급성 신부전 동반군에서는 양측인 경우가 65%로 많았다. 24시간 요단백 배설량은 급성 신부전 동반 군이 2.99±2.89 g/day, 단순 신우신염군이 0.15±0.48 g/day로 통계적으로 의미 있는 차이를 보였다 (p=0.001). 급성 신부전 동반군의 요 크레아티닌 청소율은 24.04±15.98 mL/min이고 FEm-Na는 2.80±2.68이였다. 양군의 급성 신우신염 환자에서 급성 신부전과 통계적으로 의미있는 상관관계를 보인 것은 요 백혈구 지속기간 (r=0.579, p<0.01), 늑골 척추각 압통 지속기간 (r=0.461, p<0.05), 내원시 혈중질소요소/크레아티닌(r=0.644/0.722, p<0.01), 24시간 요 단백 (r=0.854, p<0.01), 입원기간 (r=0.694, p<0.01) 등으로 양의 상관관계를 보였고 내원시 체온은 음의 상관관계를 보였다 (r=0.402, p<0.05). 결론 : 급성 신부전을 동반한 급성 신우신염 환자는 단순 급성 신우신염 환자에 비해 요 백혈구 지속기간, 늑골 척추각 압통 지속기간이 길었고 체온은 낮았으며 보다 많은 24시간 요 단백이 검출되었다. 결론적으로 급성 신우신염은 급성 신부전의 드문 원인이지만 반드시 감별진단으로 고려해야 하며 즉각적인 항생제 치료에 의한 적절한 세균감염의 치료는 신기능의 완전 회복에 도움을 줄 것으로 판단된다. Background : Acute pyelonephritis (APN) is an unusual cause of acute renal failure (ARF) in patients without urinary obstruction and other perdisposing conditions. Therefore, in the differential diagnosis of ARF, APN is rarely considered. Methods : We retrospectively analyzed the data from the patients with ARF secondary to APN (ARF group, n=8) with normal renal anatomy and no known predisposing conditions which lead to ARF during the course of acute bacterial pyelonephritis, and investigated the differences of clinical parameters to the patients with uncomplicated APN (control group, n=20). Results : Female were predominant in both groups. The mean age was 49.2±14.4 years in control group and 56.3±16.4 years in ARF group. On admission, the body temperature was 37.5±1.14℃ in control group and 36.62±0.32℃ in ARF group (p=0.003). The days of pyuria, duration days of costovertebral angel (CVA) tenderness and hospitalization days were significantly prolonged in ARF group. CVA tenderness was unilateral in 65% of control group and bilateral in 65% of ARF group. Amounts of daily urine protein excretion were 0.15±0.48 gm/day in control group and 2.99±2.89 gm/day in ARF group (p=0.001). Creatinine clearance and Femna were 24.04±15.98 mL/min and 2.80±2.68 in patients group, respectively. Development of ARF had positive correlation with the duration of pyuria (γ0.579, p<0.04), amounts of daily urine protein excretion (γ=0.461, p<0.05) and had a negative correlation with body temperature (γ=-0.402, p<0.05). Conclusion : APN is a rare but important cause of acute renal failure. Patients with ARF secondary to APN seems to have more prolonged period of pyuria and CVA tenderness, apyrexia and excrete more protein in urine than patients with uncomplicated APN. Adequate treatment of the bacterial infection by prompt antibiotic treatment may lead to full recovery of renal function.

루푸스 환자에서 급성 신우신염에 의해 합병된 급성 신부전과 허혈성 장질환

최윤석,김영옥,조재형,김정선,현영근,서정필,민준기,윤선애,방병기 대한신장학회 2000 대한신장학회잡지 Vol.19 No.4

양측성 신우신염에 동반된 급성 신부전 1예

김병하,탁우택,최유식,조종태,윤성철 대한내과학회 2002 대한내과학회지 Vol.62 No.3

Acute renal failure is a rare complication of acute pyelonephritis. Therefore, acute pyelonephritis is not usually considered in the differential diagnosis of acute renal failure. However, it is important to consider this entity because of potential for recovery of renal function if appropriate early antibiotics are instituted. We report a case of biopsy proven acute pyelonephritis which was manifested as acute renal failure. A 38 year old women was admitted to this hospital owing to abdominal distension and generalized edema. On admission she was started on hemodialysis because of severe hyperkalemia and marked uremic sypmtoms. She had pyuria and hematuria, but no organism was isolated at urine. We initially don't know the cause of renal failure. She was improved with antimicrobial therapy and hemodialysis. A kidney biopsy was performed on the 26th hospital day because of persistent proteinuria. Microscopic examination revealed focal tubular atrophy, necrosis or loss with heavy infilteration of leukocytes and histocytes in interstitium. Atrophic tubules contain pus casts. The patient was treated with ciprofloxacin for 4 weeks. At about 2 month follow up, proteinuria completely disappeared and serum creatinine level decreased to 1.0 mg/dL.(Korean J Med 62:297-301, 2002) 저자들은 발열, 오한, 옆구리 통증등의 급성 신우신염의 전형적인 임상소견 없이 급성 신부전으로 내원하였고, 수 차례의 혈액투석을 필요로 할 정도로 요독증이 심하였으며, 신장의 기저질환이나 패혈증의 증거가 없었던 환자에서 신장기능이 회복된 후에도 단백뇨와 농뇨가 지속적으로 검출되어 신조직 생검을 시행한 결과 급성 신우신염으로 확진된 증례를 경험하였기에 문헌고찰과 함께 보고하는 바이다.

지역사회 획득 급성 신우신장염 여성환자에서 검출된 원인균의 항균제 감수성 및 항균제의 사용

위성헌,최수미,이동건,김수영,김상일,유진홍,신완식,강문원 대한감염학회 2002 감염 Vol.34 No.6

The Diagnostic Value of Clinical and Radiologic Findings in Children after the First Episode of Acute Pyelonephritis

김지혜,김미정,최병민,유기환,홍영숙,이주원,Kim Ji Hae,Kim Mi Jung,Choi Byung Min,Yoo Kee Hwan,Hong Young Sook,Lee Joo Won Korean Society of Pediatric Nephrology 2005 Childhood kidney diseases Vol.9 No.2

목 적 : 본 연구에서는 급성 신우신염으로 진단 받은 환아에서 여러 임상 증상 및 검사 결과와 방사선학적 검사에서 확인된 신실질 손상의 관계를 알아보기 위하여 DMSA 신 스캔, 신장 초음파, IVP, VCUG 등의 방사선학적 검사의 유용성과 방사선학적 검사의 결과에 따른 환아들의 임상 증상 및 검사 소견을 비교 분석하였다. 방 법 : 1998년 1월부터 2002년 12월까지 열성요로 감염으로 처음 진단되어 입원 치료받았던 환아 115명을 대상으로 연구를 실시하였다. 이들은 DMSA 신 스캔, 신장 초음파, IVP, VCUG를 포함한 방사선학적 검사를 시행하였으며 각 검사의 양성률을 통하여 그 유용성을 비교하였다. 또한, 환아들의 연령, 성별, 발열 기간, 원인 균, 혈액학적 소견(백혈구 수, CRP, ESR)을 방사선학적 검사 결과와 비교 분석하였다. 연령에 따라 1군(1세 미만)과 2군(1세 이상)으로 분류하였으며, 각 군간의 검사 양성률 비교를 위해 chi-square test를 이용하여 통계 분석하였다. 결 과 : 방사선학적 검사 중 DMSA 신 스캔이 가장 높은 양성률을 보였다(DMSA 신 스캔 46$\%$, 신장 초음파 32$\%$, IVP 28$\%$, VCUG 22$\%$, P<0.05). 환아의 발열 기간, 백혈구 수, 원인균은 방사선학적 검사 결과와 관련이 없었으나 CRP, ESR이 DMSA 신 스캔의 양성률과 밀접한 관계를 보였다. 연령별로 비교했을 때 1군에 비해 2군에서 DMSA 신 스캔 양성률이 증가하였으며 (1군 40$\%$, 2군 79$\%$, P<0.05), VCUG 역시 2군에서 녹은 양성률을 보였다(1군 16$\%$, 2군 50$\%$, P<0.05). 그러나 신장 초음파와 IVP는 각 군간 유의한 차이를 보이지 않았다. 성별로 비교했을 때 남아에 비하여 여아에서 DMSA 신 스캔 및 VCUG의 양성률이 높았으나(DMSA; 남아 39$\%$, 여아 67$\%$, VCUG; 남아 15$\%$, 여아 43$\%$, P<0.05) 신장 초음파와 IVP는 성별에 따른 유의한 차이를 보이지 않았다. 결 론 : 급성 요로 감염에 이환된 환아는 신손상 여부의 확인을 위하여 DMSA 신 스캔을 시행하는 것이 가장 도움이 되며, DMSA 신 스캔과 VCUG의 이상은 여아와 2세 이상에서 양성률이 높으므로, 이와 같은 경우에는 이 두 가지 검사를 반드시 시행하여야 할 것으로 사료된다. Purpose : Acute pyelonephritis is one of the most common causes of unexplained fever in children. It may lead to the development of progressive renal damage. However, the deteclion of acute pyelonephritis can be difficult, especially in infants. The objective of this study was to evaluate the diagnostic value of various lab tests and imaging studies for acute renal parenchymal changes in children with APN. We correlated the clinical and laboratory manifestations of acute pyelonephritis with the Imaging studies. Methods : We reviewed the records of 115 children (85 males and 30 females) who were hospitalized Outing the period of January 1998 to December 2002 with initial clinical symptoms suggestive of pyelonephritis. The patients' age, sex, duration of fever, laboratory findings, and causative organisms were compared with the findings of imaging studies (Technetium-99m dimercaptosuccinic acid renal scan, renal ultrasonography, intravenous pyelography, voiding cystourethrography). Results : No significant relation between the number of febrile days, leukocyte count, causative organism, and the renal abnormalities in the imaging studies were observed. On the other hand, both C-reactive protein and erythrocyte sedimentation rate levels were significantly elevated in children with positive dimercaptosuccinic acid renal scan. Furthermore, females and children older than 1 year presented with significantly higher rate of abnormal dimercaptosuccinic acid renal scan findings and vesicoureteral reflux presented by voiding cystourethrography. Conclusion : We recommend females and children older than 1 year who are suspected of acute pyelonephritis be evaluated carefully for renal involvement by performing imaging studies including dimercaptosuccinic acid renal scan and voiding cystourethrography. (J Koroan Soc Pediatr Nephrol 2005;9:201-212)

급성 신우신염 환자의 치료기간에 영향을 주는 요인 분석

정재민,김성주,성병주,김한석,이상돈,최성 고신대학교의과대학 2007 고신대학교 의과대학 학술지 Vol.22 No.1

[Background] We analyzed the clinical aspects of acute pyelonephritis patients who received hospitalization treatment and the factors to effect a therapy session. [Methods] We evaluated 108 patients with acute pyelonephritis who underwent hospitalization treatment between January 2003 and May 2006. The patients were divided into two groups by history taking, radiological and laboratory finding : group A consisted of 60 patients without co-morbid condition and group B consisted of 48 patients with co-morbid conditions. Comparisons of the two groups were made using independent t-tests with hospitalized durations, uropathogen types, clinical improvement durations, laboratory improvement durations and co-morbid conditions. [Results] The analysis included 108 patients with a male to female sexual ratio of 1 : 7.3, a mean age of 51.3±16.8 years and a mean number of hospitalized days of 9.7±9.2 days. The co-morbid conditions were hypertension in 18 patients (16.7%), LUTS in 16 patients (14.8%), and diabetes mellitus in 15 patients (13.9%). The hospitalized durations of two groups were 7.4±3.3 and 10.5±6.2 days in group A and B. The uropathogen types were all E. coli in group A, whereas E. coil, Pseudomonas and Enterococcus were isolated in group B. Clinical and laboratory improvement duration of group A was significantly shorter than group B. The longer hospitalized duration of group B was seen in chronic renal failure and diabetes mellitus patients for 10.4±5.4 and 14.0±4.3 days and the longer laboratory improvement duration of group B was seen in chronic renal failure and diabetes mellitus patients for 5.3±5.2 and 5.9±5.5 days. [Conclusion] We concluded that the acute pyelonephritis with co-morbidity conditions need longer hospitalized days than that without co-morbidity conditions. Two variables (diabetes mellitus, chronic renal failure) that predicted a poor response after therapy for acute uncomplicated pyelonephritis. The more variable uropathogen were identified in a urine culture with co-morbidity conditions.