Chul-Woo Yang

Comparison of Clinical Outcomes by Different Renal Replacement Therapy in Patients with End-Stage Renal Disease Secondary to Lupus Nephritis

Background/Aims Many studies have compared patients with systemic lupus erythematosus (SLE) on renal replacement therapy (RRT) with non-lupus patients. However, few data are available on the long-term outcome of patients with end-stage renal disease (ESRD) secondary to SLE who are managed by different types of RRTs. Methods We conducted a retrospective multicenter study on 59 patients with ESRD who underwent maintenance RRT between 1990 and 2007 for SLE. Of these patients, 28 underwent hemodialysis (HD), 14 underwent peritoneal dialysis (PD), and 17 patients received kidney transplantation (KT). We analyzed the clinical outcomes in these patients to determine the best treatment modality. Results The mean follow-up period was 5 ± 3 years in the HD group, 5 ± 3 years in the PD group, and 10 ± 5 years in the KT group (p = 0.005). Disease flare-up was more common in the HD group than in the KT group (p = 0.012). Infection was more common in the PD and HD groups than in the KT group (HD vs. KT, p = 0.027; PD vs. KT, p = 0.033). Cardiovascular complications were more common in the HD group than in the other groups (p = 0.049). Orthopedic complications were more common in the PD group than in the other groups (p = 0.028). Bleeding was more common in the HD group than in the other groups (p = 0.026). Patient survival was greater in the KT group than in the HD group (p = 0.029). Technique survival was lower in the PD group than in the HD group (p = 0.019). Conclusions Among patients with ESRD secondary to SLE, KT had better patient survival and lower complication rates than HD and lower complication rates than PD. The prognosis between the HD and PD groups was similar. We conclude that if KT is not a viable treatment option, any alternative treatment should take into account the patients general condition and preference.

Prevalence of diabetic nephropathy in primary care type 2 diabetic patients with hypertension: data from the Korean Epidemiology Study on Hypertension III (KEY III study)

BACKGROUNDnThe prevalence of albuminuria is known to be higher in hypertensive compared to normotensive nondiabetic patients. In addition, systolic blood pressure (BP) is found to be an independent risk factor for albuminuria in type 2 diabetes mellitus (T2DM). Based on these findings, the prevalence of albuminuria is expected to be higher in T2DM with hypertension relative to T2DM without hypertension, but it has been largely unexplored.nnnMETHODSnPrevalence rates of microalbuminuria, macroalbuminuria and renal insufficiency (RI) were investigated among 3738 hypertensive T2DM patients from 350 nationwide primary care clinics. Independent factors associated with albuminuria and RI were also characterized.nnnRESULTSnClinical and laboratory data of 3712 patients were included in the analysis. BP was controlled in only 1164 patients (31.4%). There were 2595 normoalbuminuric patients (70.6%), and microalbuminuria and macroalbuminuria were present in 850 (23.1%) and 230 (6.3%), respectively. The prevalence of RI was 32.1% based on estimated glomerular filtration rate (eGFR) by Modification of Diet in Renal Disease formula. Systolic BP correlated significantly with the natural logarithmic values of urinary albumin-to-creatinine ratio (ACR) (R = 0.16, P < 0.0001). Multivariate logistic regression analysis revealed that male sex, the duration of diabetes, systolic BP, glycated hemoglobin and eGFR were significant independent factors associated with the presence of albuminuria, while advanced age, female sex, the duration of diabetes and urinary ACR were significant independent risk factors for RI.nnnCONCLUSIONSnA significant proportion of T2DM patients with hypertension had albuminuria and RI, and the duration of diabetes mellitus rather than the duration of hypertension was a significant independent factor associated with albuminuria and RI.

Experience of Anti-Viral Therapy in Hepatitis B-Associated Membranous Nephropathy, Including Lamivudine-Resistant Strains

Background/Aims Chronic hepatitis B infection is a common cause of secondary membranous nephropathy (MN) in endemic areas. Lamivudine treatment improves renal outcome in patients with hepatitis B virus-associated MN (HBV-MN), but prolonged use leads to the emergence of lamivudine-resistant variants. We describe our experience treating lamivudine-resistant and other strains of HBV-MN with new antiviral drugs. Methods Of the 89 patients biopsied and diagnosed with MN from 1996 to 2011, 10 positive for hepatitis B surface antigen were recruited for this study. We investigated the clinical courses, therapeutic responses, and prognoses of patients with HBV-MN. Results The incidence of HBV-MN among the original 89 patients was 11.2%. Of these patients, four were treated with supportive care and six with antiviral drugs. One of the four patients treated with supportive care had a spontaneous remission. Four of the six patients treated with antiviral drugs were given lamivudine, and the other two were given entecavir. Two of the four patients treated with lamivudine achieved complete remission with seroconversion (i.e., development of anti-hepatitis B e antigen antibodies), whereas the other two had lamivudine-resistant strains, which were detected at 22 and 23 months after lamivudine treatment, respectively. We added adefovir to the treatment regimen for one of these patients, and for the other patient we substituted clevudine for lamivudine. Both of these patients experienced complete remission, as did the two patients initially treated with entecavir, neither of whom showed resistance to the drug. Conclusions New nucleoside analogues, such as entecavir, adefovir, and clevudine, can be effective for treatment of HBV-MN, including lamivudine-resistant strains.

Serum Ferritin Predicts Mortality Regardless of Inflammatory and Nutritional Status in Patients Starting Dialysis: A Prospective Cohort Study

Background: The impact of serum ferritin on prognosis in patients starting hemodialysis (HD) is not fully elucidated. Methods: A prospective cohort of 946 incident HD patients from 26 dialysis centers in Korea was selected for this study. Patients were divided into tertiles according to natural logarithm (Ln) ferritin concentrations. Results: During a median follow-up of 39 months, 88 (9.3%) patients died. Multivariate Cox proportional hazard analysis demonstrated that Ln ferritin was independently associated with an increase in cardiovascular mortality risk (hazard ratio (HR) 1.604, 95% CI 1.040-2.474, p = 0.033), infection-related mortality risk (HR 1.916, 95% CI 1.056-3.476, p = 0.032), and all-cause mortality risk (HR 1.547, 95% CI 1.156-2.069, p = 0.003). Conclusion: Serum ferritin levels at the time of HD commencement were a significant independent risk factor for mortality regardless of systemic inflammation and nutritional status. Therefore, elevated serum ferritin levels could be an effective indicator for prognosis.

Nephrocalcinosis Associated with Primary Aldosteronism

Chul Woo Yang. MD, Department of internal Medieine, Kang Nam St. Mary’s Hospital, Catholic University Medical College, No. 505 Banpo-Dong Seoeho-Ku, 137-040 (South Korea) Dear Sir, It has been known that prolonged hypo-kalemia is associated with renal interstitial fibrosis, renal cyst formation and impairment of renal function [Tj; however, nephrocalcinosis associated with primary aldosteronism is rarely reported [2]. A 45-year-old woman was admitted to our hospital because of intermittent muscle cramps, polyuria and polydip-sia which developed 7 years earlier. At admission, blood pressure was 200/110 mm Hg. Biochemical findings indicated sodium 146 mEq/1, potassium 2.2 mEq/1, chloride 109 mEq/1, BUN 8.6 mg/dl, creatinine 0.8 mg/dl, total protein 7.8 g/dl, albumin 4.4 g/dl, AST 19 IU/1, ALT 13 IU/1, alkaline phosphatase 113 IU/1, calcium 8.9 mg/dl, phosphorus 2.5 mg/dl, magnesium 2.2 mg/dl. Twenty-four hour urine collections indicated sodium 135 mEq, potassium 50 mEq, calcium 102 mg, phosphorus 168 mg, magnesium 4.2 mg. Arterial blood gas analysis showed pH 7.42. pO: 89.5 mm Hg. HCO, 29.5 mm Hg, PCCK 44.7 mm Hg, and urine gas analysis showed pH 6.87, P02 119.4 mm Hg. PC02 36.6 mm Hg. HCO, 9.2 mm Hg. The hormone study revealed PTH 0.24 ng/ml (normal: -0.88 g/ml). 25-(OH) vitamin D 11.6 ng/ml (normal: 9-42 ng/ml), ACTH 3.0 pg/ml (normal: -37 pg/ml), 24-hour urine cortisol 57.8 μg/day (normal: 10-80 μg/day), metane-phrine 1.0 mg/day (normalup to 1.2 mg/ day), VMA 4.1 mg/day (normal: below 5 mg/ day). Plasma renin activity and aldosterone concentration before and after adrenalec-tomy are shown on table 1. Intravenous pyelography findings were unremarkable. The computed tomography of the abdomen showed bilateral medullary calcification and adrenal mass (2× 1 cm) consistent with adrenal tumor (fig. 1. 2). Adrenalec-tomy was performed on the 9th hospital day, and clinical symptoms, blood pressure and hypokalemia improved shortly after operation. This case shows that prolonged hypokalemia in primary aldosteronism can be one of the causes of nephrocalcinosis. The causes of nephrocalcinosis are primary hyperparathy-

Early Graft Dysfunction Due to Renal Vein Compression

We here report on an unusual case of early renal transplant dysfunction due to renal vein compression. Graft function was initially good but oliguria and massive hematuria developed on the 3rd day after transplantation. Duplex sonography showed turbulent blood flow of the renal vein, and renal venography confirmed renal vein compression. Exploratory laparotomy was performed and diuresis was initiated just after nephropexy. In conclusion, renal vein compression is a rare complication but should be included in the possible causes of early renal transplant dysfunction since this can be simply diagnosed by duplex sonography and is easily remedied by nephropexy.