07. 원저 KJM hwp

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1 대한내과학회지 : 제 92 권제 1 호 단일기관에서장기치료한복막투석과혈액투석환자의치료경과비교 1 을지대학교의과대학을지병원신장내과, 2 여수전남병원내과 김정민 1 이세진 1 서동균 1 이기영 1 류상열 2 이소영 1 Comparison of Peritoneal Dialysis and Hemodialysis Patients Following Extended Treatment Periods in a Single Center Jeong-Min Kim 1, Se-Jin Lee 1, Dong-Kyun Seo 1, Ki-Young Lee 1, Sang Ryol Ryu 2, and So-Young Lee 1 1 Division of Nephrology, Department of Internal Medicine, Eulji General Hospital, Eulji University College of Medicine, Seoul; 2 Department of Internal Medicine, Yeosu Jeonnam Hospital, Yeosu, Korea Background/Aims: Improvements in dialysis therapies and patient care are leading to more patients receiving dialysis for longer periods of time. Survival rates with peritoneal dialysis (PD) are superior to those with hemodialysis (HD) during the initial 2-3 years; however, data comparing the outcomes of these two methods are lacking. Thus, we performed a retrospective study of patients treated with dialysis for longer than 3 years to investigate patient condition according to mode of dialysis. Methods: A total of 80 patients currently being treated by dialysis for at least 36 months at the Eulji Medical Center were included in this study. Patients laboratory data and admissions histories over the prior 3 years were reviewed. Dialysis adequacy, body composition, and cytokine levels were quantified. Results: A total of 39 PD and 41 HD patients, with no difference in mean age or gender, were compared. Regarding dialysis adequacy, 97.5% of HD patients met the criterion of 1.2 Kt/V or higher, whereas only 58% of PD patients satisfied the required weekly Kt/V of 1.7. Inflammatory cytokines were significantly elevated in PD patients; however, PD patients with adequate dialysis expressed the same inflammatory cytokines as HD patients. Conclusions: The delivery of adequate dialysis to PD patients over extended periods of time is difficult. Thus, more rigorous management of PD patients is required to avoid insufficient dialysis and inflammation. (Korean J Med 2017;92:45-52) Keywords: Renal dialysis; Peritoneal dialysis; Cytokines Received: Revised: Accepted: Correspondence to So-Young Lee, M.D. Division of Nephrology, Department of Internal Medicine, Eulji General Hospital, Eulji University College of Medicine, 68 Hangeulbiseok-ro, Nowon-gu, Seoul 01830, Korea Tel: , Fax: , leesy1146@eulji.ac.kr Copyright c 2017 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 - The Korean Journal of Medicine: Vol. 92, No. 1, 서론말기신부전으로투석치료를받는환자의수는점차증가하고있다. 대한신장학회말기신부전환자등록사업에따르면 2011년도말에총투석환자는 50,289명으로증가하였고, 이중혈액투석환자가 42,596명, 복막투석환자가 7,694명으로보고되었다. 즉혈액투석환자가 84.7% 이며복막투석환자가 15.3% 로이식환자와혈액투석환자는점차증가하고있으며복막투석환자는감소하는것이우리나라뿐아니라세계적인추세로생각된다 [1]. 또한당뇨환자의증가, 노령인구의증가로투석환자의수가증가하고있을뿐아니라유지투석을받고있는기간도점차길어지고있다. 본연구는장기간투석치료를받고있는투석환자들에서혈액투석치료와복막투석치료의치료경과를비교하기위하여진행되었다. 복막투석과혈액투석의치료성적및생존율비교에대한연구가계속보고되고있으나아직결론은확실하지않다. 다만비교적투석기간이짧은투석을시작한지 2년이내의환자들에서는복막투석치료군의생존율이더높음이최근보고되고있으며이는복막투석환자에서잔여신기능보존이더유리함때문으로설명되고있다 [2,3]. 그러나비교적장기간투석치료를받은환자들에서는혈액투석군이복막투석군보다생존율이높을것으로생각되는데초기 2년이내의성적을제외한장기간의치료경과를비교한논문은비교적많지않다 [4]. 복막투석환자의경우, 투석기간이길어지면서복막성상의변화등으로인해적절한투석효율을유지하기어려울수있으며이에따른여러가지요독성합병증발생빈도가혈액투석환자에비해증가할수있다. 반면중분자물질제거에는우수성이있어장기복막투석환자에서혈액투석환자에비해치료의우월성이있을수있다. 그런데이러한치료의장기장단점을비교한관찰연구는많지않다. 본연구는단일기관에서투석치료를시작한지 3년이경과한환자들을대상으로복막투석환자와혈액투석환자에서의영양상태, 칼슘-인수치, 수분저류상태등다방면에서의요독인자와만성신부전환자의특징적인염증상태와관련하여염증성사이토카인그리고이러한상태에영향을미칠수있는인자로서투석적절도를비교하였다. 또한각치료군에서의입원횟수와원인, 사망률등을관찰하였다. 이러한비교를통해 3년이상경과한장기투석환자들에서의치료경과를복막투석환자와혈액투석환자에서비교해봄으로 써장기복막투석치료의적절성과발전방향을모색해보고자한다. 대상및방법환자군및자료수집을지병원에서 36개월이상투석치료를받는투석환자를대상으로하였다. 이중치료기간이 36개월미만이거나치료기간중다른방법의투석 ( 혈액투석환자의경우복막투석치료 ) 을 3개월이상받은적이있는환자는연구대상에서제외하였고, 최근 2주이내급, 만성염증질환을앓았거나, 현재활성도를보이는면역학적질환, 면역억제제를복용하고있는환자를제외하고혈액투석환자 41명과복막투석환자 39명을대상으로하였다. 대상환자들의의무기록을조사하여원인질환, 투석기간, 3년이후부터현재까지의입원력을비교하였고, 3년이후부터측정한검사실소견들, complete blood cell count, 생화학적검사소견, 칼슘, 인수치등과치료를위해병원을방문하였을때의투석전혈압을대략 10회정도의값을평균하여평균값을기록하였다. 또한이들을대상으로연구를계획한시점으로부터 1년간의전향적관찰기간을가지며관찰기간 1년동안염증인자, 투석적절도등을측정하여비교하였고체수분측정기 (body composition monitor, BCM; Fresenius Medical Care AG&Co. KGaA, Germany) 를이용, 수분조절상태를측정하였으며, 관찰기간 1년동안의치료방법의변화, 사망률등을조사하였다. 투석적절도의비교는 2006년 NFK DOQI guideline 에따라혈액투석환자에서 Kt/V 1.2를기준으로하였고, 복막투석환자의경우 weekly Kt/V 1.7 이상을기준으로하였다 [5]. 염증인자측정복막투석환자의경우, 관찰기간이시작되는마지막 1년이시작되는시점에서매달실시하는정기검사때체취한혈액을이용, 혈장을분리하여냉동보관하였고, 혈액투석환자에서는주중간의투석전채취한혈장을이용, 상용화된 quantitative sandwich enzyme immunoassay (Quantilkine, R&D system, Minneapolis, MN, USA) 를사용하여총 interleukin (IL)-1β, IL-6, IL-8, IL-10 등을정량하였다. 정량가능범위는 IL-10의경우, pg/ml 였으며이범위를벗어날경우 10배희석하여측정하였다

3 - Jeong-Min Kim, et al. Comparison of dialysis patients - 수분조절상태측정 결 과 양군의부종조절상태를평가하기위해체수분측정기 (BCM) 를이용하였다. 복막투석환자의경우투석액을저류한상태에서, 혈액투석환자의경우투석이끝나고 30분후, 안정상태에서생체전기저항을이용, 세포외액양을총수분량으로나누어 1.5 이상인경우를과수분상태로정의하였고 [6] 부종상태를측정하였다. 관찰기간 1년간 2회를측정하여평균한후, 혈액투석환자와복막투석환자간의차이를비교하였다. 통계분석통계적분석을위해 SPSS 소프트웨어 version 14.0 (SPSS Inc,, Chicago, IL, USA) 를사용하였으며각변수들은 t-test 및 chi-square test 를통해비교하였고, p값이 0.05 미만인경우통계적으로유의한값으로판단하였다. 환자군의특성총 80명의환자중복막투석환자 39명, 혈액투석환자 41 명이었고두군간에평균연령, 남녀비에는차이가없었다. 평균투석기간은복막투석환자가 71.58개월, 혈액투석환자가 78.95개월이었으며두군간의유의한차이는없었다. 혈액투석환자중당뇨환자의비율이더높았고, 복막투석환자의경우혈액투석환자의경우보다잔여신기능이많이남아있을때투석을시작하는경향을보였다 (Table 1). 혈액투석환자와복막투석환자에서의요독인자의다각적비교수분조절상태, 영양상태, 칼슘, 인등의무기질대사, 염증반응등이투석환자의생존율과관계되므로 [6,7] 이들을각군에서비교하였는데, 복막투석환자가더 body mass in- Table 1. Characteristics of PD and HD patients PD patients (n = 39) HD patients (n = 41) p-value Age, years ± ± Gender (F/M) 21/18 17/ Length of Tx, months ± ± DM 24/39 (61.5) 34/41 (82.9) Initial GFR Values are presented as mean ± SD or n (%). PD, peritoneal dialysis; HD, hemodialysis; F, female; M, male; Tx, treatment; DM, diabetic mellitus, GFR, glomerular filtration rate. Table 2. Comparison of biochemical markers between PD and HD patients PD patients (n = 39) HD patients (n = 41) p-value Weight, kg ± ± BMI, kg/m ± ± TG ± ± LDL-cholesterol 89.1 ± ± HbA1c 7.62 ± ± Albumin, mg/dl 3.51 ± ± 0.04 < 0.05 Hemoglobin, g/dl 10.2 ± ± Uric acid, mg/dl 6.81 ± ± Calcium, mg/dl 8.65 ± ± Phosphorus, mg/dl 5.59 ± ± Ca P 48.5 ± ± PTH, pg/ml ± ± Values are presented as mean ± SD. PD, peritoneal dialysis; HD, hemodialysis; BMI, body mass index; TG, triglyceride; LDL, low-density lipoprotein; Ca, calcium; P, Phosphorus; PTH, parathyroid hormone

4 - 대한내과학회지 : 제 92 권제 1 호통권제 674 호 dex (BMI) 가높았고중성지방수치가높았으며저밀도콜레스테롤이높은경향을보였다. 반면에헤모글로빈과알부민, 요산수치는복막투석군에서더낮게측정되었다. 부갑상선호르몬수치에는두군간에차이가없었으나인수치는복막투석환자군에서더높았다 (Table 2). 체수분측정기를이용하여각군의환자의수분조절상태를평가하였다. 복막투석환자의 56% 가과수분상태였고혈액투석환자의 48.3% 가과수분상태로두군간의수분조절상태에큰차이는없었다. 또한두군간의수축기혈압에는차이가없었으나확장기혈압은복막투석군이높게측정되었다 (Table 3). 투석이적절하게잘이루어지는지가이러한여러요독인자에영향을줄수있으므로투석적절도를양군에서비교하였다. 투석적절도의지표로여러가지인자를함께고려해야하나, 현재가장많이이용하고있는 Kt/V를기준으로환자의 투석적절도를평가하였다. 혈액투석환자의경우 97.5% 의환자가 Kt/V 1.2 이상을만족하였으나복막투석환자의경우 58% 만이 Kt/V 1.7 기준을만족하였다 (Table 4). 염증반응의수치로 C-reactive protein (CRP), IL-6, IL-8, IL-10, IL-1β 등을측정하였는데 [8], 사이토카인중 IL-10이복막투석환자에서의미있게높았고 CRP, IL-6, IL-8, IL-1β 등은두군간에유의한차이는없었다. 이러한염증인자의값이투석의영향을받을가능성이있으므로복막투석환자에서 Kt/V 값이 1.7 이상인군과 1.7 미만인군으로나누어다시염증수치를평균해보면 Kt/V가 1.7 미만인복막투석환자군에서는혈액투석환자군보다 IL-10, IL-1β 값이의미있게높았고 IL-6, IL-8 값도높은경향을보였다 (Table 5). 염증수치의비교를복막평형도결과에도적용해보았는데, 복막평형도검사결과저투과도 (low peri- Table 3. Volume and blood pressure control between PD and HD patients PD patients (n = 39) HD patients (n = 41) p-value Overhydration, L 1.78 ± ± Overhydration (> 1.5 L) 14/25 (56) 15/31 (48.3) Systolic BP, mmhg ± ± Diastolic BP, mmhg 78.2 ± ± Values are presented as mean ± SD or n (%). PD, peritoneal dialysis; HD, hemodialysis; BP, blood pressure. Table 4. Comparison of uremia between PD and HD patients PD patients (n = 39) HD patients (n = 41) p-value BUN, mg/dl 51.6 ± ± Cr, mg/dl ± ± Kt/V urea 1.83 ± ± 0.06 ND Kt/V > target Weekly Kt/V > /31 (58) Kt/V > /40 (97.5) <0.05 Values are presented as mean ± SD or n (%). PD, peritoneal dialysis; HD, hemodialysis; BUN, blood urea nitrogen; Cr, creatinine; ND, not determined. Table 5. Comparison of inflammatory cytokines between PD and HD patients based on dialysis adequacy PD patients HD patient p-value Group 1 a (n = 14) Group 2 b (n = 7) Group 3 C (n = 41) (Group 1 vs. 3/Group 2 vs. 3) IL ± ± ± 1.59 (0.31/0.48) IL ± ± ± 2.54 (0.52/0.24) IL ± ± ± 0.07 (< 0.05/< 0.05) IL-1β 0.90 ± ± ± 0.15 (0.55/0.021) Values are presented as mean ± SD. PD, peritoneal dialysis; HD, hemodialysis; IL, interleukin. a PD patients with Kt/V > 1.7. b PD patients with Kt/V < 1.7 c HD patients

5 - 김정민외 5 인. 복막및혈액투석환자의치료비교 - Table 6. Comparison of inflammatory cytokines between PD and HD patients based on the peritoneal equilibrium test PD patients HD patient p-value Group 1 a (n = 10) Group 2 b (n = 10) Group 3 c (n = 36) (Group 1 vs. 3/Group 2 vs. 3) IL ± ± ± 1.62 (0.71/0.95) IL ± ± ± 2.57 (0.27/0.97) IL ± ± ± 0.07 (0.58/0.03) IL-1β 4.08 ± ± ± 0.16 (0.37/0.05) Values are presented as mean ± SD. PD, peritoneal dialysis; HD, hemodialysis; IL, interleukin. a PD patients with low peritoneal equilibrium test (PET). b PD patients with low average, high average, and high PET. c HD patients. Table 7. Comparison of admission histories between PD and HD patients Admission Hx (mean no.) PD patients (n = 39) HD patients (n = 41) p-value Total 3.35 ± ± Technical failure 0.35 ± ± Infection 1.05 ± ± Cardiovascular event 0.15 ± ± Metabolic 0.48 ± ± Volume control 0.20 ± ± Mortality 4 (10.2) 3 (7.3) ND Change of modality 6 (15.3) 0 ND Values are presented as mean ± SD or n (%). Hx, history; PD, peritoneal dialysis; HD, hemodialysis; ND, not determined. toneal equilibration test) 를보인환자에서다른평형도를가진환자들보다 IL-6, IL-8, IL-10, IL-1β가높은경향을보였고, IL-10, IL-1β 값은저투과도를보이는복막투석환자군에서혈액투석환자군에비교하였을때의미있게높게측정되었다 (Table 6). 복막투석환자와혈액투석환자의입원력및사망률비교본원에서 3년이상투석치료를받는투석환자에서투석치료를받기시작하고 3년이경과한후의입원력을의무기록을조사하여비교하였다. 복막투석군이 3.35 ± 0.45회, 혈액투석군이 3.04 ± 0.5회로두군간의입원횟수에는차이가없었다. 복막투석환자의경우복막염으로인해감염으로입원치료한경우가혈액투석환자보다많았고, 혈액투석환자의경우동정맥루와관련된혈관치료를위해또는심부전, 허혈성심장질환, 부정맥, 뇌경색, 뇌출혈그리고말초혈관질환등심혈관계합병증발생으로입원한횟수가복막투석환자보다많았으며, 그외칼륨조절등대사성이상, 수분조절문제등으로입원한횟수는두군간에차이가없었다 (Table 7). 의무기록조사를시작한시점부터 1년간의관찰기간을가지며환자의사망률과치료방법의변화를관찰하였는데복막투석환자의경우 39명중 4명이사망하였고, 6 명이혈액투석으로전환하였으며, 혈액투석환자의경우는 3명이사망하였고, 복막투석으로전환한환자는없었다. 고찰복막투석과혈액투석치료의우월성및치료효과에대해서는아직의견이분분하며, 다양한임상연구가필요하다 [9]. 2014년 Choi 등 [10] 이한국의유지투석환자를대상으로일반인과비교하여사망의위험도를계산하였는데, 혈액투석환자의경우일반인에비해사망의위험도가약 배정도높으며복막투석환자의경우는 배정도로높다고보고한바있다. 또한최근의경향은이러한투석환자의사망률은투석기간에비례하지않고기저질환, 나이등이관여하지만일반적으로복막투석환자의경우치료시작초기 2년간은혈

6 - The Korean Journal of Medicine: Vol. 92, No. 1, 액투석환자보다사망의위험도가낮으며이는잔여신기능보전이원인인것으로설명되고있다 [2,4]. 잔여신기능이남아있는경우, 신장의내분비기능이유지되며, 정상수분상태가유지되고환자의생존율과관계있다고생각되는저분자요독물질제거에복막투석보다신장을통한제거가훨씬효율적으로일어나기때문이라고생각할수있다 [11,12]. 따라서잔여신기능이거의남아있지않다고생각되는 3년이상투석을받은환자에서는요독증, 수분조절, 영양문제, 염증상태등이혈액투석을받는환자들에비해문제가될수있을것이라고생각되나이를객관적으로비교한연구는많지않다 [13,14]. 본연구는잔여신기능이없어졌다고생각되는, 투석을시작한지 3년이지난환자들의전반적인치료의경과를혈액투석과복막투석환자를나누어비교하였고, 이를통해단일기관에서장기간투석을받아오고있는투석환자들을대상으로각각의치료방법의경과를비교하고자하였다. 환자들의투석기간은평균 70개월정도였고반이상의환자가기저질환으로당뇨가원인이었다. 다른연구결과와마찬가지로본원의환자들도복막투석환자의경우비만한환자가많았고중성지방및저밀도콜레스테롤은높은경향이었으며환자의사망률과가장연관성이있다고알려진알부민수치는의미있게낮았다 [15]. 이는복막투석액을통한혈당흡수증가와단백질손실에기인하는것으로생각된다. 또한혈색소, 인조절에있어서는혈액투석환자보다더관리가안되는등, 열등한결과를보여주었다. 과수분상태자체가요독성인자중하나로투석환자의사망률과관련이있다는인식이증가하고있다 [16]. 본연구에서는수분측정기를이용, 객관적인과수분상태를측정하였는데수분조절에관련하여서는두군간에차이가없었다. 또한혈액투석환자와복막투석환자의혈장에서염증성사이토카인을측정하였다. 투석환자들은산화성스트레스의영향, 투석막과의접촉, 염증성사이토카인의지속적생성및제거감소로인해만성염증상태에놓이게된다 [17]. 이러한염증반응이동맥경화, 심혈관계합병증발생, 환자의사망률과관련이있는것으로알려져있다 [18]. 두군간에 CRP 및염증성사이토카인인 IL-6, IL-8, IL-1β 값에는차이가없었으나 IL-10 값은복막투석군에서의미있게높았다. 이러한염증성사이토카인의값이투석의효과에영향을받는지알아보기위해복막투석군에서 Kt/V 값이 1.7 이상인 군과 1.7 미만인군으로나누어혈액투석군과다시비교해보면복막투석치료를받는환자중 Kt/V 값이 1.7 미만인군은혈액투석군보다염증성사이토카인이높은경향을보여주었다. Kt/V 값이 1.7 미만인환자수가적어서통계적인의미는없지만이러한염증성사이토카인도중분자물질로복막투석이제대로이루어진다면, 혈액투석보다는복막투석에의해제거가잘될것으로생각해볼수있겠다. 다만투석적절도가낮은투석환자에서의혈중사이토카인의증가가염증반응의활성도자체가증가한것인지, 염증성사이토카인의제거가안되서발생하는이차적현상인지는아직연구가필요할것으로생각된다. 그러나이러한사이토카인측정결과는우리가아직알고있지못하는다른요독물질의제거에있어서도위와같은결과를보일수있을것을예측하게한다. 이연구의제한점으로는두군간의치료기간이의미있게차이나지는않았지만, 투석치료를시작한지 3년이지난환자들을대상으로하였고검사결과를비교한시점이정확히 3년이되는시작시점이아니므로두군간의치료기간을일치시켜비교하지못하였다는점이되겠고, 후향적연구이므로 3년이시작되는시점에서의두군에서환자의사망과관련된위험인자를일치시키지는못하였다는점을들수있다. 그러나최대한오차를줄이기위해 3년이후의검사결과를여러번측정한값을평균하여평균값을비교하여오차를줄이고자하였다. Jaar 등 [3] 은투석치료를시작한지 2년이상이된환자에서혈액투석환자에비해생존율이감소하는이유로잔여신기능의감소로인한수분, 전해질조절의어려움, 시간경과에다른복막성질의변화로인해복막투석효율성의감소, 혈액투석보다의료진과의접촉이적으므로관리가잘안되는점등을이유로설명하였다. 본연구결과에서각군환자의생존율을직접비교하지는않았지만투석환자의생존율에영향을미치는가장중요한인자중하나로의료진의철저한관리가중요함을보여주었다. 잔여신기능이감소됨에따라수분조절상태에는두군간의차이가없었으나투석적절도의감소가복막투석군에서뚜렷이관찰되었고적절한투석이이루어지지않은환자에서염증성사이토카인이높게측정되는일관된결과를보여주었다. 혈중사이토카인의수치가세포내에서생성되는양에비해아주적은양이므로이결과로환자의염증상태를비교하기는어려우나, 이러한결과는다른요독물질의제거에미치는적절한투석의영향

7 - Jeong-Min Kim, et al. Comparison of dialysis patients - 을간접적으로보여주는결과라고생각된다. 장기복막투석환자의경우, 투석적절도의감소가진행하며, 의료진과의접촉이혈액투석환자에비해적어관리가소홀해질수있음을염두에두고투석효율을높이고관리가철저히이루어질수있도록환자교육과의료진의관심이더욱필요한치료군이라고생각된다. 요 목적 : 투석을시작한지 3년이지났으며잔여신기능이없어졌다고생각되는환자들의혈액투석치료와복막투석치료간의치료경과를비교하였다. 대상및방법 : 을지병원에서 36개월이상투석치료를받는투석환자를대상으로하였다. 대상환자들의의무기록을조사하였고, 검사실소견을평균하여기록하였다. 투석적절도와체수분량을측정하였고염증성사이토카인을측정하여치료방법에따른차이를비교하였다. 결과 : 총 80명의환자중복막투석환자 39명, 혈액투석환자 41명이었고두군간에평균연령, 남녀비에는차이가없었다. 혈액투석환자의경우 97.5% 의환자가 Kt/V 1.2 이상을만족하였으나복막투석환자의경우 58% 만이이기준을만족하였다. 복막투석환자가더 BMI가높았고중성지방수치가높았으며저밀도콜레스테롤이높은경향을보였고두군간의수분조절상태에큰차이는없었다. 염증수치는 Kt/V가 1.7 미만, 저투과도를보이는복막투석환자군에서더의미있게높게측정되었다. 결론 : 장기복막투석환자의경우, 혈액투석에비해효율적인투석적절도유지가어렵다. 이러한투석효율의감소가복막투석환자를상대적인과염증상태에이르게하는원인이될수있다고생각된다. 따라서장기복막투석환자의경우, 투석효율을높이고관리가철저히이루어질수있도록환자교육과의료진의관심이더욱필요한치료군이라고생각된다. 약 중심단어 : 혈액투석 ; 복막투석 ; 사이토카인 REFERENCES 1. Jin DC. Current status of dialysis therapy for ESRD patients in Korea. J Korean Med Assoc 2013;56: Han SH, Lee JE, Kim DK, et al. Long-term clinical outcomes of peritoneal dialysis patients: single center experience from Korea. Perit Dial Int 2008;28 Suppl 3:S21-S Jaar BG, Coresh J, Plantinga LC, et al. Comparing the risk for death with peritoneal dialysis and hemodialysis in a national cohort of patients with chronic kidney disease. Ann Intern Med 2005;143: Mircescu G, Stefan G, Gârneaţă L, Mititiuc I, Siriopol D, Covic A. Outcomes of dialytic modalities in a large incident registry cohort from Eastern Europe: the Romanian Renal Registry. Int Urol Nephrol 2014;46: Kim SH, Kim YK, Yang CW. The efficacy of dialysis adequacy. J Korean Med Assoc 2013;56: Aguiar PV, Santos O, Teixeira L, et al. Overhydration prevalence in peritoneal dialysis - a 2 year longitudinal analysis. Nefrologia 2015;35: Lai S, Molfino A, Russo GE, et al. Cardiac, inflammatory and metabolic parameters: hemodialysis versus peritoneal dialysis. Cardiorenal Med 2015;5: Jacobs P, Glorieux G, Vanholder R. Interleukin/cytokine profiles in haemodialysis and in continuous peritoneal dialysis. Nephrol Dial Transplant 2004;19 Suppl 5:V41-V Stanley M; CARI. The CARI guidelines. Peritoneal dialysis versus haemodialysis (adult). Nephrology (Carlton) 2010;15 Suppl 1:S24-S Choi H, Kim M, Kim H, et al. Excess mortality among patients on dialysis: comparison with the general population in Korea. Kidney Res Clin Pract 2014;33: Unal A, Kavuncuoglu F, Duran M, et al. Inflammation is associated to volume status in peritoneal dialysis patients. Ren Fail 2015;37: Bargman JM, Thorpe KE, Churchill DN; CANUSA Peritoneal Dialysis Study Group. Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 2001;12: Rocco M, Soucie JM, Pastan S, McClellan WM. Peritoneal dialysis adequacy and risk of death. Kidney Int 2000;58: Heaf JG, Løkkegaard H, Madsen M. Initial survival advantage of peritoneal dialysis relative to haemodialysis. Nephrol Dial Transplant 2002;17: Tang Y, Zhong H, Diao Y, Qin M, Zhou X. Peritoneal transport rate, systemic inflammation, and residual renal function determine peritoneal protein clearance in continuous ambulatory peritoneal dialysis patients. Int Urol Nephrol 2014;46: Yılmaz Z, Yıldirim Y, Aydin FY, et al. Evaluation of fluid status related parameters in hemodialysis and peritoneal dialysis patients: clinical usefulness of bioimpedance analysis. Medicina (Kaunas) 2014;50:

8 - 대한내과학회지 : 제 92 권제 1 호통권제 674 호 Musial K, Zwolińska D. The impact of dialysis modality on novel markers of stress reaction, matrix remodeling and endothelial damage in children on chronic dialysis. Blood Purif 2014;38: Wang AY, Woo J, Lam CW, et al. Is a single time point C-reactive protein predictive of outcome in peritoneal dialysis patients? J Am Soc Nephrol 2003;14:

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar