만성 신부전환자에서 섬유소 용해력의 변화

홍세용 ( Hong Se Yong ),양동호 ( Yang Dong Ho ) 대한내과학회 1993 대한내과학회지 Vol.44 No.6

Background : Recently we described that in the physiologic state, urokinase concentration is higher in the renal vein than in the renal artery which is suggests that kidney is the essential organ providing urokinase to the systemic circulation. In ESRD patients, urokinase provided by the kidney may be decreased and this might be the cause of decreased systemic fibrinolytic activity seen in ESRD. Method : To study this possibility, we measured fibrinolytic profiles including urokinase, t-PA and fibrinolytic activity in euglobulin fraction from ESRD patients and compared the results with the of two control groups consisting of renal transplant patients, and age and sex matched healthy control group. Results : The euglobulin fibrinolytic activity was 92.2±14.8 BAU in the ESRD group, 108.7±13.5 BAU in the KT group and 101.5±8.0 BAU in the healthy control group. Although It was lower in the ESRD group than in KT group (p<0.005) and the healthy control group (p<0.005), there was no difference between the KT group and the healthy control group. t-PA ag was 1.2±1.3ng/ml in the ESRD group, 3.5±1.7ng/ml in the KT group and 3.1±2.1ng/ml in the healthy control group. It was lower in the ESRD group compared to the KT group (p<0.001) and the healthy control group (p<0.001) but there was no difference between the KT group and the healthy control group. Urokinase ag was 0.6±0.2ng/ml in the ESRD group, 2.0±1.5ng/ml in the KT group and 2.6±0.3ng/ml in the healthy control group. It was lower in the ESRD group compared to the KT group (p<0.001) and the healthy control group (p<0.001) but there was no difference between KT group and healthy control group. Conclusion : The total fibrinolytic activity in euglobulin, t-PA and urokinase were lower in ESRD than the control group and it became normalized after successful renal transplantation. These results might offer some information on the relatively frequent thrombosis related complications, in spite of bleeding tendency, seen in ESRD.

말기신부전환자와 고혈압환자에서의 심박수 변이도 비교

오준석 ( Joon Seok Oh ),배우형 ( Woo Hyung Bae ),이화목 ( Hwa Mock Lee ),김현주 ( Hyun Ju Kim ),김남식 ( Nam Sik Kim ),윤성한 ( Sung Han Yun ),이승은 ( Seung Eun Lee ),박용기 ( Yong Ki Park ),신용훈 ( Yong Hoon Shin ),김중경 ( Joo 대한내과학회 2008 대한내과학회지 Vol.75 No.1

목적: 심박수는 운동, 호흡, 대사변화 그리고 육체적 또는 정신적 긴장 등 여러 가지 요인에 영향을 받으며, 기본적인 심박수와 그 조절은 일차적으로 자율신경계의 활성도 즉 교감신경계와 부교감신경계 각각의 균형에 의해 이루어진다. 현재까지 말기 신부전으로 혈액투석을 받고 있는 환자에 있어서 심박수 변이도 변화에 대한 연구는 비교적 드문 실정이다. 이에 저자들은 말기 신부전이 자율 신경계의 기능 장애와 관련이 있는지 알아보기 위해 24시간 활동 심전도를 이용하여 심박수 변이도를 조사하였다. 방법: 2006년 1월 1일부터 2007년 6월 30일까지 김원묵기념 봉생병원 신장내과에 내원한 환자 중 말기 신부전으로 진단받고 혈액투석을 시행받고 있는 30명을 대상으로 24시간 활동 심전도를 시행하고 심박수 변이도를 조사하였다. 당뇨병성 신증으로 말기 신부전에 이른 환자의 경우는 대상에서 제외하였다. 연령과 성별이 유사한 64명의 일반고혈압 환자를 대조군으로 하여 같은 검사를 시행하였다. 심박수 변이도 분석 지표는 시간 계열 분석(time domain analysis)과 주파수 계열 분석(frequency domain analysis)으로 산출 하였다. 결과: 연구대상 환자는 30명으로 남자가 17명, 여자가 13명이었고 평균 나이는 51.17±11.91이고, 범위는 30~75세였다. 또한 연령과 성별이 유사한 대조군은 64명으로 남자는 30명, 여자는 34명이었고, 평균 연령은 55.02±13.72세였으며 범위는 23~77세였다. 심박수 변이도 분석 지표 중 SDNN, HRV index, VLF, LF의 normalized unit 그리고 LF/HF가 환자군에서 대조군에 비해 통계적으로 유의하게 낮았고(p<0.05), HF의 normalized unit가 높았다(p<0.05). 결론: 말기 신부전으로 혈액투석을 받고 있는 환자들은 일반 고혈압 환자들에 비해 전반적인 자율신경계의 활성이 감소한 가운데 상대적으로 교감신경계의 활성은 감소하였고, 부교감신경계의 활성이 증가했다. Background/Aims: Heart rate variability (HRV) can be used to assess the effects of drugs and other interventions, including exercise, respiration, metabolic changes, and psychological or physical stressors, on cardiac autonomic tone. HRV is regulated by the balance of sympathetic and parasympathetic tone. Few studies pertaining to HRV in end stage renal disease (ESRD) patients have been performed in Korea. Thus, autonomic nervous system activity as indicated by HRV was investigated in patients on hemodialysis due to ESRD. Methods: We compared the pattern of cardiac sympathetic and parasympathetic activity through time- and frequency-domain analyses of HRV with 24-hour Holter monitoring in 30 ESRD patients and 64 hypertensive control subjects. The ESRD patients had undergone hemodialysis therapy at the Bongseng Hospital between January 2006 and June 2007. Results: The mean age of ESRD patients and hypertensive controls was 51.17±11.91 and 55.02±13.72 years, respectively. In the ESRD group, all time- and frequency-domain HRV measures, including the standard deviation of all normal sinus R-R intervals over 24 hours (SDNN), the HRV index, the very low-frequency (VLF) normalized unit of low-frequency (LFnorm), and the ratio of low-frequency power to high-frequency power (LF/HF), were reduced; the normalized unit of high frequency (HFnorm) was increased in the ESRD patients compared with the control group. Conclusion: The autonomic tone in ESRD patients on hemodiaysis was decreased compared with hypertensive patients. The parasympathetic tone in ESRD patients on hemodyalysis was dominant over the sympathetic tone. (Korean J Med 75:54-59, 2008)

말기 신부전 환자의 중성구에서 활성 산소 대사

최혜정 ( Choe Hye Jeong ),권진경 ( Kwon Jin Gyeong ),문교철 ( Mun Gyo Cheol ),장은주 ( Jang Eun Ju ),곽춘식 ( Gwag Chun Sig ),한승엽 ( Han Seung Yeob ),황은아 ( Hwang Eun A ),박성배 ( Park Seong Bae ),김현철 ( Kim Hyeon Cheol ) 대한신장학회 2004 Kidney Research and Clinical Practice Vol.23 No.3

목적 : 말기 신부전 환자에서는 감염에 대항하는 중성구의 기능장애 기전을 밝히고자 하였다. 방법 : 혈액투석을 하는 말기 신부전 환자 50명과 정상인 40명에서 중성구를 분리한 후 superoxide 음이온, 과산화수소의 농도 및 malondialdehyde 농도, 항산화 효소인 superoxide dismutase (SOD), catalase, glutathione peroxidase 및 myeloperoxidase의 농도를 측정하였으며, SOD의 조효소인 구리와 아연 이온의 농도를 측정하고, SOD에 대한 역전사 중합효소 연쇄 반응을 실시하였다. 결과 : 말기 신부전 환자의 중성구에서는 정상인에 비해 superoxide 음이온, catalase, glutathione peroxidase, malondialdehyde가 증가하였으며, SOD, 과산화 수소의 양, 아연 이온의 농도는 감소하였다. 또한 말기 신부전 환자에서는 SOD의 유전자 발현이 억제되었으며 glutathione peroxidase의 활성은 유의한 변동이 없었다. 결론 : 말기 신부전 환자의 중성구에서는 유전자 발현 억제 및 조효소의 양적 감소에 의해 SOD의 활성이 저하되며, 이로 인한 superoxide 음이온의 증가는 중성구의 산화적 손상을 유발하는 것으로 생각된다. 또한 SOD의 활성 저하와 catalase의 활성 증가는 과산화 수소를 감소시켜 myeloperoxidase에 의해 전환되는 차아염소산의 감소를 초래함으로서 중성구 기능 장애 원인 중의 일부로 작용할 수 있음을 시사한다. Background: The present study was aimed to know the cause of impaired bactericidal activity, especially the metabolism of oxygen free radicals in neutrophils from patients with end-stage renal disease (ESRD). Methods : We measured the amount of superoxide anion, the activity of three antioxidant enzymes, myeloperoxidase, copper ion level, zinc ion level and the amount of malondialdehyde in neutrophils from patients with ESRD before and after hemodialysis. Reverse transcription-polymerase chain reaction (RT-PCR, for superoxide dismutase (SOD) was also done. Results : The malondialdehyde level, the amount of superoxide anion, catalase, and myeloperoxidase levels in the neutrophils from the patients with ESRD were higher than those from healthy controls. SOD activity, hydrogen peroxide level and zinc level were lower in ESRD patients. On the RT-PCR, the relative index, which is defined the ratio of the band densities for SOD to glyceraldehyde 3-phosphate dehydrogenase, was decreased in neutrophils from patients with ESRD. Glutathione peroxidase activity in the neutrophils from ESRD patients did not show any significant change. Conclusion : These results indicate that there are some alterations in metabolism of oxygen free radicals including lower levels of hydrogen peroxide which exerting a direct germicidal ability, due to decreased gene expression and mineral levels. And these alterations might be one of the major mechanisms of impaired microbicidal activity in patients with ESRD. (Korean J Nephrol 2004;23(3):429-438)

신이식후 갑상선 기능변화에 대한 장기간 추적관찰

류미숙(Mee Sook Ryu),홍성표(Seong Pyo Hong),이태원(Tae Won Lee),임천규(Chun Gyoo Ihm),김명재(Myung Jae Kim) 대한내과학회 1997 대한내과학회지 Vol.53 No.4

Background: Thyroid status in uremia is still inconclusive due to the complexicity of the system. No single pathogenetic event may explain the thyroid function abnormalities in end stage renal disease (ESRD). Defects at all levels of the hypothalamic-pituitary-thyroid axis have been identified. Regarding the thyroid dysfunction in ESRD it is well recognized that the TSH response to TRH is blunted and serum concentrations of thyroid hormones are decreased in patients with ESRD. Whether or not on maintenance hemodialysis. Restoration of renal function with renal transplantation resulted in normalization of all parameters of thyroid function with exception of blunted TSH response to TRH. We evaluated the long-term changes of the thyroid function in 10 patients to know whether the thyroid function and the hypothalamo-pituitary axis were improved with the recovery of the renal function under maintenance low-dosage steroid administration after renal transplantation. Methods: These tests were performed during the morning in the fasting state in 10 ESRD patients before, 1 month and 6 years after renal transplantation (RT). Thyroid function tests. Serum T3, T4 were measured by RIA kit and serum TSH was measured by IRMA kit. TRH stimulation test. Serum blood samples were obtained 0, 30, 60, 90, 120 min after TRH (400㎍) administration. Statistical analysis. All grouped data were expressed as mean±SD. Student t-test was used to assess the statistical difference between any two means. Results: 1) The mean basal level of serum T3 was reduced in ESRD patients (53.6±33.2ng/dL) and increased to the low normal level 1 month after RT (87.8±25.4ng/dL), improved to the normal level 6 years after RT (116.3±28.8ng/dL). 2) The mean basal level of T4 was within normal range before RT (5.9±1.1㎍/dL), after 1 month (6.2±1.2㎍/dL) and after 6 years (6.5±1.4㎍/dL) of RT. 3) The mean basal level of TSH was within normal range before RT (2.0±1.2μU/mL), after 1 month (1.1±0.7μU/mL), and after 6 years (0.7±0.5μU/mL) of RT. Rut the mean TSH level of 6 years of RT was significantly decreased within the normal range. 4) In ESRD the TSH response to TRH was blunted, had a diminished peak and delayed fall before RT. After 1 month of RT, the TSH response to TRH was persistently blunted, however showed more rapid fall of TSH. After 6 years of RT, the TSH response to TRH normalized, but the absolute level of TSH and the peak level of TSH to TRH were less than before and after 1 month of RT. Conclusions: The abnormalities of thyroid hormones in uremic patients were improved partially after 1 month of RT and almost completely after 6 years of RT. But the level of T3H and the peak level of TSH to TRH were low within normal range, these results may be a direct consequence of low-dosage and long-term glucorcorticoid administration.

지속적 외래복막투석 환자에서의 정상분만 1 예

최승옥(Seung Ok Choi),김승률(Sung Rul Kim),여경구(Kyong Gu Yoh),홍희승(Hee Seung Hong),원영준(Young Jun Won),이광훈(Kwang Hoon Lee),정인배(In Bae Cheong) 대한내과학회 1993 대한내과학회지 Vol.45 No.5

Advances medical cares for end-stage renal disease(ESRD), CAPD and renal transplatation have led to an extended life span for patients with ESRD. Despite these advanced, patients with ESRD have an exceeding- ly poor reprductive capacity. There are high incidence of infertilities, spontaneous abortions and still births. CAPD has been increasingly popular management tool for patient with ESRD and has advantages over hemodialysis in the management of pregnant patient. The fetus faces a more constant uterine environment without rapid shifts in fluids, solutes and electrolytes. The patients as a population have higher hematocrits and hypotensive episodes are less frequent. Recently we had experienced a case of successful pregnancy in patient with ESRD undergoing CAPD. This is the first case in Korea. A 25-year-old woman had been undergoing CAPD for 5 months became pregnant. Her blood pressure was controlled in the 144±11mmHg systolic and 97±8 mmHg diastolic range with 40 mg/day of hydralazine and 500 mg/day of methyldopa. Her mean serum BUN and creatinine during pregnancy were 31±10 mg/dl and 3.7±1.1 mg/dl, respectively. A female infant was delivered by normal spontaneous vaginal delivery at 37 weeks gestation with APGAR score of 7 and 9 at 1 and 5 minutes, respetively and birth weight was 2.1 Kg. There was no obstetric or neonatal complication. At the 3 months fallow-up the baby's growth and development are normal.

혈액투석 환자에서 발생한 속립성 폐결핵과 동반된 결핵성 간농양 1 예 및 투석환자의 결핵에 대한 문헌고찰

문계혁(Gae Hyuk Moon),송준호(Joon Ho Song),이승우(Seoung Woo Lee),이경주(Kyong Ju Lee),박현신(Hyun Sin Park),김문재(Moon Jae Kim) 대한신장학회 2001 Kidney Research and Clinical Practice Vol.20 No.2

The impairment of host defense mechanisms, particularly of cellular immunity, causes high incidence of mycobacterial infections in the patients with ESRD. Extrapulmonary mycobacterial infections are more frequent in ESRD patients compared to general population. However, there has been rarely reported on the occurrence of hepatic tuberculous abscess as an extrapulmonary mycobacterial infection in ESRD patients. We present a case of ESRD patient manifesting miliary tuberculosis and hepatic tuberculous abscess, which have successfully resolved after antituberculous medications. A 44 years old male admit- ted with fever, general weakness, night sweating, and cough. Chest X-ray and abdominal CT revealed pulmonary miliary tuberculosis and a solitary tuberculous abscess at S7 of right hepatic lobe with multiple periportal and celiac lymphadenopathy. After the administration of anti-tuberculous medications(isoniazid, rifampicin, ethambutol - eight month, pyrazinamide - two month), miliary tubuculosis disappeared. The size of hepatic tuberculous abscess and lymphadenopathy were reduced in abdominal CT six month later. The patient is followed in outpatient without noticeable symptoms after eight month treatment.

Decreased Circulating Klotho Levels in Patients Undergoing Dialysis and Relationship to Oxidative Stress and Inflammation

Oh, Hyung Jung,Nam, Bo Young,Lee, Mi Jung,Kim, Chan Ho,Koo, Hyang Mo,Doh, Fa Mee,Han, Jae Hyun,Kim, Eun Jin,Han, Ji Suk,Park, Jung Tak,Yoo, Tae-Hyun,Kang, Shin-Wook,Han, Dae-Suk,Han, Seung Hyeok International Society for Peritoneal Dialysis 2015 Peritoneal dialysis international Vol.35 No.1

<P>♦ <I>Introduction:</I> It has been reported that klotho deficiency is associated with oxidative stress and inflammation in experimental kidney disease models. Patients with endstage renal disease (ESRD) are particularly characterized by increased oxidative stress and inflammation. However, little is known about the relationship between these features and klotho in patients with ESRD.</P><P>♦ <I>Methods:</I> We conducted a single-center, cross-sectional study of 78 patients receiving peritoneal dialysis (PD). Serum concentrations of klotho, high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and 8-isoprostane were measured by enzyme-linked immunosorbent assay. To define factors independently associated with klotho, we determined Spearman’s correlation coefficients for between co-variates and conducted multiple linear regression analyses.</P><P>♦ <I>Results:</I> Patients were classified by median concentration of klotho. In patients with klotho levels > 329.6 pg/mL, serum 8-isoprostane and IL-6 levels were significantly higher than in those with klotho levels < 329.6 pg/mL. In correlation analyses, log 8-isoprostane (γ = –0.310, <I>p</I> = 0.006) and log IL-6 (γ = –0.343, <I>p</I> = 0.002) were inversely correlated with log klotho. After adjustment for age, gender, mean arterial pressure, log intact parathyroid hormone, and log IL-6, log 8-isoprostane was independently associated with log klotho (β = –0.158, <I>p</I> = 0.040). However, the significant relationship between klotho and IL-6 was not seen in an adjusted model.</P><P>♦ <I>Conclusions:</I> This study showed that circulating klotho levels were significantly associated with 8-isoprostane levels in patients undergoing PD, suggesting a potential link between klotho deficiency and enhanced oxidative stress in ESRD patients.</P>

한국어판 말기신부전 환자의 치료순응도 측정 도구의 타당도와 신뢰도 검증

김영미,박영미 병원간호사회 2012 임상간호연구 Vol.18 No.2

Purpose: The purpose of this study was to develop and test psychometric properties the Korean version of the End-Stage Renal Disease Adherence Questionnaire (KESRD-AQ). The ESRD-AQ, a 46-item, multidimensional, self-administrated questionnaire which was developed to assess treatment adherence to hemodialysis (HD) attendance, medications, fluid restrictions, and diet prescription among patients on maintenance hemodialysis, has been validated. Methods: The KESRD-AQ was developed by performing both translation and backtranslation. The content validity and test- retest reliability of the KESRD-AQ were evaluated by establishing item-level content validity index (I-CVI) and intra-class correlation coefficients (ICC), respectively. Construct validity was assessed by adopting a known-group analysis comparing adheres and non-adherers using Mann- Whitney U Test. Results: 41 Korean-American patients with ESRD on HD from 3 outpatient dialysis centers in California participated in the study. The KESRD-AQ showed excellent content validity (average I-CVI=.96) and test-retest reliability (ICC=.917, p=.004). The construct validity indicated that the KESRD-AQ distinguished adheres and non-adheres (p=.02~.047). Conclusion: The KESRD-AQ is a valid and reliable instrument to measure treatment adherence.

인슐린 비의존성 당뇨병에 의한 말기 신부전증 환자에서 iPTH치 및 골밀도에 관한 연구

이강욱,김종학,황평주,송민호,김영건,노흥규,신영태 충남대학교 의과대학 지역사회의학연구소 1999 충남의대잡지 Vol.26 No.1

The patients with diabetic ESRD have been reported to be suffered from more serious morbidity and mortality than other ESRD patients. In order to define if there are certain differences in the clinical parematers including bone metabolism, such as bone mineral density (BMD), serum iPTH level and Tc-99m MDP whole body bone scan between diabetic and nondiabetic ESRD, we evaluated 52 patients with ESRD (20 diabetic ESRD and 32 non-diabetic ESRD) beginning first hemodialysis or peritoneal dialysis at the Department of Internal Medicine in Chungnam National University Hospital, from January to December, 1998. The results were as follows : 1. Twenty patients with diabetic ESRD have been suffered from non-insulin dependent diabetes mellius and diabetic nephropathy. The causes of ESRD of 32 non-diabetic ESRD patients were hypertension (56%), chronic glomerular nephritis (26%), chronic interstitial nephritis (3%), and others (15%), respectively. 2. Serum creatinine, albumin, and phosphorus levels of diabetic ESRD patients were significantly lower than those of non-diabetic ESRD patients(all p<0.05), and creatinine clearance was also significantly higher in diabetic ERSD patients than non-diabetic ESRD patients (p<0.05) at the beginning of renal replacement therapy. 3. There was no significant difference in BMD, serum calcium, iPTH, alkaline phosphatase, 24 hours urine protein excretion, hemoglobin, and Tc-99m MDP whole body bone scan score between diabetic and non-diabetic ESRD patients (all p>0.05). 4. On the multivariable linear regression analysis, there was no statistically significant influence of patient's age, presence or absence of diabetes, iPTH, calcium, phosphorus, ALP, albumin, creatinine and ferritin levels on t-score of bone densitometry. In conclusion, we speculate that diabetic ESRD patients begin renal replacement therapy earlier than other ESRD patients although there was no significant difference in bone metabolism parameters, such as iPTH and bone mineral density.

Immunogenicity of COVID-19 Vaccination in Patients With End-Stage Renal Disease Undergoing Maintenance Hemodialysis: The Efficacy of a Mix-and-Match Strategy

Joon-Sung Park,Dohsik Minn,Susie Hong,Saeyoung Jeong,Soohyun Kim,Chang Hwa Lee,Bongyoung Kim 대한의학회 2022 Journal of Korean medical science Vol.37 No.23

Background: The objective of this study was to evaluate the immunogenicity of coronavirus disease 2019 (COVID-19) vaccination in patients with end-stage renal disease (ESRD) on hemodialysis. Methods: ESRD patients at the hemodialysis center of a tertiary-care university-affiliated hospital and healthy employees at the clinical laboratory center were prospectively recruited between March and June 2021. For severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) antibody analysis, blood samples were collected serially on days 0, 14, 28, and 56 after the first vaccine dose, and on days 7 and 50 after the second dose. Antibodies against the SARS-CoV-2 spike protein were quantified, and SARS-CoV-2 neutralizing antibodies were measured in the serum and plasma. Results: Thirty-one ESRD patients and 55 healthy employees were regularly monitored. Twenty-five (80.6%) ESRD patients on hemodialysis received a mix-and-match strategy with ChAdOx1-BNT162b2 (AZ–Pf group) and six (19.4%) received two doses of ChAdOx1 (AZ–AZ group). ESRD patients on hemodialysis showed lower binding antibody titers and neutralizing antibody activities compared to healthy participants following the first vaccination with ChAdOx1. After the second dose, AZ-Pf group had higher immunogenicity than healthy people on days 7 and 50. The binding antibody titer and neutralizing antibody activities on days 7 and 50 were significantly higher in the AZ–Pf group than in the AZ–AZ group. Conclusion: ESRD patients on hemodialysis receiving the mix-and-match strategy (ChAdOx1–BNT162b2) have COVID-19 vaccine immunogenicity comparable to healthy individuals receiving two doses of ChAdOx1.