독사교상후 발생한 급성신부전에 대한 임상적 고찰

백진기(Jin Ki Paek),유병우(Byung Woo Yu),안영수(Young Soo An),김종봉(Jong Bong Kim),김태준(Tae Jun Kim),김홍수(Hong Soo Kim),최태명(Tae Jun Kim),양동호(Dong Ho Yang),홍세용(Sae Yong Hong),양승하(Seung Ha Yang),이현순(Hyun Soon Lee) 대한내과학회 1994 대한내과학회지 Vol.46 No.4

Objectives: The pathogenesis of acute renal failure developed after snake bite has been variously attributed to the direct renal damage by the venoms, and the secondary effects of disseminated intravascular coagulation, shock, intravascular hemolysis, the defibrination syndrome, and myoglobinuria. We analysed the thirteen cases of renal involvement after snake bite to elucidate possible causes and clinical characteristics of acute renal failure. Method: We reviewed the clinical symptoms, physical examination, laboratory data, and renal biopsies (two cases) in the 13 cases of acute renal failure developed after snake bite among 195 cases during the recent 10 years, Results: 1) The sex ratio of the patients with acute renal failure after snake bite (man: woman) was 1:5.5, presenting female predominance. Most of the cases were over 50 years of age covering more than 90% of the total snake bite cases 2) As respects to the time elapse from the snake bite to the hospital care, four cases were within 1 hour, two cases were within 1~2 hours, two cases were within 3~12 hours, and the rest of them (ten cases) were within 24 hours. 3) The systemic symptoms and signs of snake bite are as follows: nausea, vomiting, dyspnea, macroscopic hematuria, dizziness, headache, altered consciousness, and visual disturbance. Most of the patients complained of localized edema and pain around the wound of snake bite. Oliguria was noted in four patients, and it lasted for 13 days in average. 4) On admission, urinalysis of the patients with acute renal failure showed proteinuria (ten cases) and hematuria (six cases). Most of the patients with renal failure had hyperkalemia, hypocalcemia, elevated SGOT and LDH. The serum BUN and creatinine levels were elevated (more than 2.0 mg/dl and 4.2 mg/dl, respectively) above the normal range. 5) Renal biopsy performed in two cases of convalescent stage showed the findings of acute tubular necrosis with intact glomeruli. 6) Hemodialysis was performed in six patients out of thirteen cases of acute renal failure. 7) Of the thirteen patients with renal failure after snake bite, eight patients improved. But five patients were discharged against our will. All but one (self discharged) of the six patients with hemodialysis were discharged with clinical improvement. Conclusions: Acute renal failure caused by snake bite is not uncommon in Korea. We analysed the thirteen cases of snake bite with acute renal failure that revealed direct renal tubular necrosis on biopsy. And we speculate that the renal damage may be caused by the nephrotoxin of the venom. It is suggested that immediate intervention and preventive measures for renal failure after snake bite are needed.

뇌부종이 있는 뇌경색 환자들에서 만니톨과 신부전의 연관성

추인성,봉정빈,안성환,김후원,김진호,강현구 대한신경집중치료학회 2016 대한신경집중치료학회지 Vol.9 No.2

Background: Renal failure is one of the most common side effects of mannitol. However, very little is known regarding the cause, incidence, risk factors, and outcome of mannitol-induced renal failure. The goal of this study is to determine the predicting factors of mannitol-induced renal failure. Methods: We retrospectively reviewed the medical records of all ischemic stroke patients who were treated with mannitol due to brain edema from January 2008 to December 2010 at Chosun university hospital. From among 125 patients, 25 patients who received mannitol for less than 3 days were excluded and 100 patients were selected. Furthermore, 15% or 25% mannitol was administered intravenously as an intermittent bolus and the maximum dose was less than 200 g/day. Renal failure was defined as an increase in the creatinine level of > 0.5 mg/dL if the baseline value was < 2 mg/dL or an increase in the creatinine level of > 1 mg/dL if the baseline value was > 2 mg/dL. Results: Fourteen patients (14%) were diagnosed as having mannitol-induced renal failure. Glucose level before the use of mannitol and peak osmolality during mannitol treatment were associated with renal failure in univariate analysis. In logistic regression analysis of suspected factors (P<0.1), independent predictive factors of mannitol-induced renal failure were glucose level before the use of mannitol, (odd ratio, 1.01; 95% CI, 1.00–1.03; P<0.043) and peak osmolality (odds ratio, 1.04; 95% confidence interval, 1.01–1.08, P=0.01). Conclusions: Strict glucose control before mannitol treatment may reduce the rate of occurrence of renal failure. However, the rate of recovery from renal failure was not confirmed in our study because of the short follow up period.

미니돼지에서 허혈성 신장 손상의 조기진단

김세은,고아라,배춘식,박수현,한호재,심경미,강성수 한국임상수의학회 2011 한국임상수의학회지 Vol.28 No.1

Acute renal injury induced by ischemia is a major cause of high morbidity and mortality in hospitalized patients and a common complication in hospitalized patients. Thus, the work with acute renal failure and renal ischemia has been studied for many years. Although serum creatinine concentration that is widely used as an index of renal function performs fairly well for estimating kidney function in patients with stable chronic kidney disease, it performs poorly in the setting of acute disease. Thus, an ideal biomarker for acute kidney injury would help clinicians and scientists diagnose the most common form of acute kidney injury in hospitalized patients, acute tubular necrosis, early and accurately, and may aid to risk-stratify patients with acute kidney injury by predicting the need for renal replacement therapy, the duration of acute kidney injury, the length of stay and mortality. In this study, renal ischemia and reperfusion were performed by clapming and un-clamping right renal artery in miniature pigs. Plasma blood urea nitrogen (BUN)and creatinine were examined at pre- clamping, after-clamping at 0, 1 and 3 hours. And we searched initial indicators in these samples. Also, renal tissue was collected and searched the initial indicator by PCR and western blotting. As a result, hypoxia inducible factor 1α (HIF1α), nuclear factor kappa-B (NFκB), IκB, erythropoietin (EPO), erythropoietin receptor (EPOR), angiopoietin-1 and vascular endothelial growth factor (VEGF) were showed significant changes among the renal protein. HIF1α, EPO, and EPOR were showed significant changes among the renal gene. Thus, these markers will be used as initial diagnosis of acute renal failure.

중증 급성 신부전의 원인의 되었던 급성 국소성 세균성 신염

윤정민 ( Jung Min Yoon ),윤선애 ( Sun Ae Yoon ),김영옥 ( Young Ok Kim ),김미정 ( Mi Jung Kim ),차현민 ( Hyun Min Cha ),곽승기 ( Sung Ki Kwak ),김해림 ( Hae Rim Kim ),최영진 ( Young Jin Choi ),방병기 ( Byung Kee Bang ) 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.6

Urinary tract infection is one of the causes of acute renal failure. But it has been reported rarely, so we must consider another etiologies before diagnoses. Abdominal ultrasonogram is a good non-invasive technique for radiologic diagnosis or for differential diagnosis, but it`s possible that tiny abscesses and small lesions of focal bacterial nephritis might be missed CT is the best radiologic method to diagnose renal lesion, especially acute bacterial nephritis. Nevertheless, CT has several problems, including contrast-induced nephropathy, exposure to radiation. We experienced a severe form of anuric acuric acute renal failure secondary to acute bacterial nephritis due to E, coli infection, The patient`s renal lession was not visualized on the ultrasonogram and his uremic symptom was severe. So we decided to do a kidney biopsy to find another possible cause of acute renal failure. The renal biopsy finding showed acute bacterial nephritis, and abdominal CT reconfirmed it. His serum creatinine increased to a maximum 8.5 ㎎/dL, but decreased to 1.24 ㎎/dL through continuous antibiotic therapy. We emphasize that urinary tract infection is not a rare cause of acute renal failure any more, and that positive diagnositic approaches, including kidney biopsy, are important for accurate and early diagnosis.

증례 : 신장 ; 급성 췌장염에 병발한 급성 신부전의 급성 복막투석 3예

황주안 ( Joo An Hwang ),문은준 ( Eun Joon Moon ),김은경 ( Eun Kyung Kim ),양민재 ( Min Jae Yang ),황재철 ( Jae Chul Hwang ),박인휘 ( In Whee Park ),김흥수 ( Heung Soo Kim ) 대한내과학회 2009 대한내과학회지 Vol.77 No.5S

Severe acute pancreatitis occurs in about 20% of patients with acute pancreatitis and can be associated with multiorgan failure. Acute renal failure caused by severe acute pancreatitis not only aggravates pancreatitis but also increases patient mortality. Peritoneal exudate contains many toxic substances such as amylase, lipase, phospholipase-A, trypsinogen, prostaglandins, kinin forming enzymes, and histamine releasing factor. Upon entering the circulation, these substances can cause complications, which are responsible for the majority of early deaths. This said, peritoneal dialysis is indicated to remove toxic materials from the peritoneal cavity and to manage acute renal failure. We report three acute peritoneal dialysis cases in acute renal failure associated with severe acute pancreatitis. (Korean J Med 77:S1246-S1252, 2009) 저자들은 급성 췌장염 환자에서 급성 신부전이 동반된 경우 복막투석으로 복강 세척 및 배액을 통해 급성 췌장염의 임상적 증상 호전 및 전신적 합병증을 감소시키고, 급성신부전의 호전으로 소변량 증가와 함께 신기능이 회복된 3예를 경험하였기에 문헌고찰과 함께 보고하는 바이다.

신성 저요산 혈증 환자에서 운동 후 유발된 급성신부전증

최성철,김윤구,김정아,도정호,이영기,이현희,윤수진,허우성,김대중,오하영,김보현 대한신장학회 2002 Kidney Research and Clinical Practice Vol.21 No.2

We have described a male patient with a episode of acute renal failure after strenuous exercise. He was found to have low serum uric acid(0.6 mg/dL, after recovery) and normal 24 hour urinary excretion in the steady state. The possibility of other diseases that cause hypouricemia could be excluded, acute renal failure associated with idiopathic renal hypouricemia was diagnosed in this case. A renal computed tomography showed the delayed wedge shaped contrast enhancement, these findings suggested that the cause of acute renal failure could be renal vasoconstriction rather than obstruction by uric acid crystals. Hypouricemia appear to play a crucial role in this reperfusion oxygen free radical induced acute renal failure. We have suggested that the renal hypouricemia should be suspected in the case of acute renal failure associated with exercise when the patient's uric acid level was within or slight alone normal range at the time of acute renal failure. (Korean J Nephrol 2002;21(2):312-316)

정상 Glucose-6-Phosphate Dehydrogenase 환자에서의 A형 간염 후 발생한 용혈성 빈혈 및 급성 신부전증 1예

정현연,김형수,김희준,이운주,김광렬 중앙대학교 의과대학 의과학연구소 2015 中央醫大誌 Vol.40 No.1

Viral hepatitis A is considered to be a self-limited disease without clinical sequel. Among the extrahepatic complication of acute viral A hepatitis, severe hemolysis and acute renal failure have been rarely reported. In Korea, a hemolytic anemia after hepatitis A infection was reported in a glucose-6-phosphate dehydrogenase (G6PD) deficiency patient, but the hemolytic anemia in a normal G6PD patient has not been reported yet. G6PD deficiency is the most common enzyme deficiency and it causes a spectrum of disease including neonatal hyperbilirubinemia, acute hemolysis, and chronic hemolysis. We describe a normal G6PD patient with acute hepatitis A who developed severe hemolytic anemia and acute renal failure. A 42-year-old male patient was transferred to our hospital for treatment of severe anemia and acute renal failure. He did not have any underlying disease and did not take a medication. Laboratory results were compatible with hemolytic anemia, however the additional studies for differential diagnosis of hemolytic anemia including glucose-6-phosphate dehydrogenase status, showed normal results. He was diagnosed with acute hepatitis A complicated by severe hemolytic anemia and acute renal failure, and recovered spontaneously with only supportive care. We recently experienced the normal G6PD patient with acute hemolytic anemia and acute renal failure, therefore, we report a case of such experience.

횡문근 융해증이 발생한 농약중독 환자에서 급성 신부전 발생의 연관요인

강창우,이경우,정진희,강태신,김동훈,김성춘,박인성,Kang, Chang-Woo,Lee, Kyung-Woo,Jung, Jin-Hee,Kang, Tae-Shin,Kim, Dong-Hoon,Kim, Sung-Choon,Park, In-Sung 대한임상독성학회 2009 대한임상독성학회지 Vol.7 No.2

Purpose: Rhabdomyolysis is one of the most important complications of pesticide intoxication. It affects a patient's clinical prognosis and can cause acute renal failure. It is important that patients diagnosed with pesticide intoxication receive an accurate initial diagnosis and proper treatment to prevent significant complications. This study's objective was to investigate and confirm related factors causing acute renal failure by verifying clinical observations and laboratory findings collected following pesticide intoxication. Methods: A retrospective analysis was made of 734 patients who presenting to our emergency medical center after ingesting pesticides between January 2006 and December 2008, Of these, 513 patients were selected for the study. Two hundred and twenty-one patients were excluded because of paraquat intoxication, age (if under 18), or chronic renal failure. Seventy-four patients were diagnosed with rhabdomyolysis, based on serum creatinine phosphokinase levels were > 1,000U/L. Acute renal failure was diagnosed when creatinine levels were > 2.0 mg/dL. Results: Among the 74 patients diagnosed with rhabdomyolysis, 26 (35.1%) experienced acute renal failure. The most meaningful related factor in the prediction of acute renal failure was initial arterial pH and creatinine level. Conclusion: Initial arterial pH and creatinine level are predictors of complications such as acute renal failure in patients with rhabdomyolysis.

Glycerol-유도 급성신부전에서 표피성장인자 발현 및 조직학적 변화에 관한 스쿠알렌의 효과

최영복,김영호,이준행,김종세,Choi, Young-Bok,Kim, Young-Ho,Lee, Jun-Heung,Kim, Jong-Se 한국현미경학회 2004 Applied microscopy Vol.34 No.4

신장은 독성물질, 빈혈, 재관류-유도 상해, 급성신부전에 회복 기능을 가지고 있다. 뇨 표피성장인자(EGF)는 신장 사구체연접장치에서 생산된다. 신장은 EGF를 축적하거나 배설한다. 신장 질환의 경우에는 EGF 배설이 감소한다. 본 연구에서는 glycerol-유도 급성신부전에서 스쿠알렌의 효과를 연구하였다. In vitro에서 RT-PCR를 통해 EGF 발현을 관찰하였다. 근위세뇨관 세포를 분리한 후, glycerol (1, 2, 4 mM) 혹은 스쿠알렌(0.1, 0.05 or 0.1%)을 첨가하였다. In vivo에서 BUN, creatine, 조직학적 변화를 관찰하였다. 실험군은 다음과 같다. 실험군 1은 정상군, 실험군 2는 glycerol (50%, 8 ml/kg) 처치 후, 스쿠알렌을 처치하지 않은 군, 실험군 3은 glycerol (50%, 8 ml/kg) 처치 후, 스쿠알렌(180 mg/kg)을 함께 처치한 군으로 각 실험군 당 생쥐 7마리를 사용하였다. 실험 결과, glycerol이 신장에 손상을 주어 EGF mRNA 발현이 감소됨을 확인할 수 있었다. 그러나, 스쿠알렌을 처치한 군에서는 EGF mRNA 발현이 증가함을 관찰할 수 있었다. 또한, BUN과 creatine 수치의 빠른 회복이 관찰되었다(P<0.01). 조직학적 관찰에서도 실험군 2는 사립체의 심한 손상이 관찰되었는데, 실험군 3의 경우 사립체의 빠른 회복이 관찰되었다. 결론적으로, 스쿠알렌이 glycerol-유도 급성신부전에 회복 효과가 있을 것으로 사료된다. Kidney had recovery functions against toxicants, ischemia, reperfusion-induced damage, acute-renal failure (ARF). Urinary epidermal growth factor (EGF) is produced by the juxtaglomerular apparatus. Kidney accumulates or excretes the EGF. In case of renal diseases, excreted EGF was decreased. The aim of this study is to evaluate the effects squalene (SQ) on the prevention of experimental acute renal failure induced by glycerol. In case of in vitro study, we investigated the expression of EGF by RT-PCR. After the proximal tubular cells was isolated, glycerol (1, 2, 4 mM) or glycerol plus squalene (0.1, 0.05 or 0.1%) was added. In case of in vivo study, we investigated the changes of BUN, creatine, and ultrastructure. Experimental groups were divided into four groups. Group 1 was normal mouse. Group 2 was injected with SQ only (180 mg/kg). Group 3 was not treated with squalene after intraperitoneal contamination of glycerol (50%, 8 ml/kg). And, Group 4 was treated with squalene (180 mg/kg) after intraperitoneal contamination of glycerol (50%, 8 ml/kg). All groups were used to 7 mice. In the results, we investigated the glycerol induced renal failure. The expression of EGF mRNA was decreased in renal proximal tubules when treated with only glycerol. SQ increased the mRNA expression of EGF in renal proximal tubules. SQ also quickly recovered the levels of BUN and creatine compared with those of mice treated with only glycerol (P<0.01). In case of ultrastructure, group 3 had heavily damaged mitochondria, but, mitochondria in group 4 had evidences of the recovery. It was concluded that SQ had the recovery effects for the glycerol-induced acute renal failure.

급성신부전을 동반한 외상성 횡문근 융해증 2례

최옥경,박인철,장석준,김승호 대한응급의학회 1994 대한응급의학회지 Vol.5 No.1

Rhabdomyolysis may be defined as a reversible or irreversible skeletal muscle injury with release of muscle cell contents into the plasma. The classic description of rhabdomyolysis presented by Bywater and Beall in 1941 includes the clinical presentation of traumatic skeletal muscle injury, pigmented urine and acute renal failure. The major clinical and fatal sequalae of rhabdomyolysis is associated with acute renal failure. Therefore, early recognition and prompt management are essential. We feel that a lack of familiality with the syndrome may contribute to delay in diagnosis and treatment and reduce the chances for functional neuromuscular recovery. We report 2 cases demonstrating acute renal failure associated with traumatic rhabdomyolsis. A 65-year old male and a 36-year old female patient were admitted to our Department of Emergency Medicine because of pain and swelling in lower extremities as a result of mild trauma. Metabolic features including hyperkalemia, hypercalcemia, acute renal failure with myoglobinuria has developed. In male patient peritoneal dialysis was initiated. On the 40th hospital day, he was discharged, having regained virtually normal renal function. The female patient was treated with conservative manner and was discharged with normal renal function on the 30th hospital day.