11-14이찬희

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1 대한응급의학회지제 24 권제 4 호 Volume 24, Number 4, August, 2013 원 저 요관결석환자에서자연배출의기대치료실패예측인자 CHA 의과학대학교분당차병원응급의학과, CHA 의과학대학교구미차병원응급의학과 1 이찬희 김영갑 박상현 이주택 이창재 1 김옥준 최성욱 김의중 정태녕 배진건 Predictors for the Failure of Expectant Management for the Spontaneous Passage of Ureteral Calculi Chan Hee Lee, M.D., Yung Kap Kim, M.D., Sang Hyun Park, M.D., Ju Taek Lee, M.D., Chang Jae Lee, M.D. 1, Ok Jun Kim, M.D., Sung Wook Choi, M.D., Eui Chung Kim, M.D., Tae Nyoung Chung, M.D., Jin Kun Bae, M.D. Purpose: Ureteral calculi are commonly encountered in the emergency department. Ureteral calculi influence the quality of life of patients, causing pain and economic burden. The optimal management of ureteral calculi remains a challenge for practicing physicians; therefore, this study was designed to determine which factors are related to the failure of their spontaneous passage. Methods: This study was a retrospective review of the medical records of one hundred ninety-five patients who visited the emergency department complaining of renal colic from February 2012 to December Bivariate analyses were conducted relating physical, laboratory, and radiological methods to predict the failure of spontaneous passage. A multivariate logistic regression model was then derived, with all variables in the final model significant at p<0.05. Results: One hundred twenty-eight stones were spontaneously expelled and sixty-seven were not. The mean stone size was significantly larger in the non-passage group than the passage group (p<0.001). When the stones were located in the upper ureter, or on the right side, the spontaneous passage rate was lower (p<0.001, p=0.035). 책임저자 : 이창재경상북도구미시형곡동 855 CHA의과학대학교구미차병원응급의학과 Tel: 054) , Fax: 054) cyber030@hanmail.net 접수일 : 2013년 5월 31일, 1차교정일 : 2013년 6월 5일게재승인일 : 2013년 6월 30일 403 Increased neutrophils and positive tests for urinary protein and bilirubin were also associated with the decreased likelihood of spontaneous passage (p=0.046, p=0.029, and p=0.048, respectively). In addition, the longer duration of symptoms and a previous history of ureteral calculi were related to a lower chance of spontaneous passage (p=0.005, p=0.019). Conclusion: Prognostic factors of failure, after the initial expectant management of ureteral calculi, included: calculi size, location (e.g., side), the duration of symptoms, the previous history, neutrophil levels, urinary bilirubin levels, and urinary protein levels. Therefore, emergency physicians need to cautiously decide between watchful waiting and interventions in these patients. Key Words: Ureteral calculi, Renal colic, Watchful waiting, Pain Department of Emergency Medicine, College of Medicine, The CHA University, Bundang CHA Hospital, Bundang Korea, Gumi CHA Hospital, Gumi 1 서 요관결석은갑자기발생한측복부통증을특징으로하며응급실에서흔하게볼수있는질환가운데하나이다. 전세계적으로요관결석의유병률은 2~20% 이며 5~12% 의인구가일생에한번이상요관결석으로인한통증을느낀다 1,2). 또한요관결석의기왕력을가진환자중 1/3은 1년내에재발되며 5년내에거의 50% 의재발률을보인다 3). 요관결석은극심한통증및불편감으로인해환자들의삶의질을악화시킬뿐만아니라반복적인입원및치료로인해환자들에게경제적인부담을준다 4,5). 더욱이국내및전세계적으로요관결석의유병률및치료비용또한증가하고있어서그중요성이날로커지고있다 6). 이러한요관결석의임상적 경제적특징으로인해요관결석환자의적절한치료계획수립은매우중요하다. 요관결석의치료는크게대기요법, 충격파쇄석술 (extra- 론

2 404 / 대한응급의학회지 : 제 24 권제 4 호 2013 corporeal shockwave lithotripsy, ESWL), 요관경하제석술 (ureteroscopic removal of stone, URS), 경피적신장결석제거술 (percutaneous nephroithotomy, PCNL), 복강경또는개복수술등의방법이있다. 하지만요관결석으로인한초기통증치료는비교적잘확립되어있는데비해통증조절이후의치료에대해서는명확히정해진것이없다 7). 조절되지않는급성통증, 신장기능저하, 비뇨기계패혈증, 신장주위조영제혈관외유출등과같은즉각적인중재적치료의적응증이아닌경우에는, 10 mm 이하결석의 90% 에서자연배출이가능하고경제적인효율성을고려하여초기치료로서경과관찰및주기적인검사를실시하게된다 8). 그러나대기요법을진행하는도중환자들은급성통증악화, 비뇨기계감염등과같은의도하지않은부작용을경험하기도한다. 최근한연구에따르면대기요법을계획한환자중 50% 의환자가자연배출에실패하거나자연배출을기다리는동안요로감염, 수신증및지속적인통증등의합병증을경험했다고한다 9). 이에저자들은급성측복통을주소로응급센터에내원하여요관결석을진단받은후대기요법을계획한환자들을대상으로하여자연배출여부및관련된임상적인요인들과검사요인들을분석하여대기요법의급성기치료실패의예측인자를살펴보고자하였다. 대상과방법 1. 대상 2012년 2월부터 12월까지 11개월간급성측복부통증을주소로 850병상규모의일개도시지역종합병원응급의료센터에내원한환자들중전산화단층촬영을통해요관결석을진단받은사람들을대상으로하였으며후향적으로의무기록을검토하였다. 선천성요로계기형이있는경우, 만성신부전 사구체신염과같은기저신질환이있는경우, 요관내카테터를삽입하고있는경우, 통증의지속시간이 24시간이상경과하여내원한경우, 게실염, 담낭내결석등타과적인질환이동반된경우, 고막체온이 38도이상이며신우신염과같은감염을동반한경우, 최근에감염성질환을진단받은경우, 2주이내에항생제를처방받은경우, 최근 2달이내에수술을받은경우는연구대상에서제외하였다. 동기간동안전산화단층촬영을통해총 441명의요관결석환자가진단되었으며급성통증조절이후당일혹은익일비뇨기과외래진료를보게하였다. 이중응급실내원이후또는비뇨기과외래방문이후추적관찰이되지않은환자 125명, 외래에서비뇨기과의사가바로충격파쇄석술또는요관경하제석술을시행한환자 103명, 의무기록이미비한환자 15 명, 동측에 2개이상의결석이진단된환자 3명, 총 246명을 제외한 195명의환자를대상으로연구를진행하였다. 대기요법을시행하기로한환자들은소염진통제와알파차단제를처방받았고 1주또는 2주간격으로외래를통해추적관찰을시행하였으며증상이심해지면외래또는응급실을재방문하도록교육을받았다. 총관찰기간은 Tchey 등 10) 의연구결과를참조하여 2주로하였으며, 결석의자연배출 (spontaneous passage, SP) 성공은비뇨기과전문의에의해환자의증상이소실되고 Kidney, ureter, bladder view (KUB) 나 computed tomography (CT) 등의추적영상검사에서결석이보이지않아결석이배출됐다고판단된것으로정의하였다. 2주이상증상이지속되거나소변검사및영상검사에서결석의증거가남아있다고판단되는경우, 대기요법진행중극심한통증이나부작용으로외래또는응급실을재방문하여중재적시술을받은경우는자연배출실패군으로정의하였다. 2. 방법의무기록을후향적으로분석하여환자의성별, 나이, 증상발현시간 ( 분 ), 내원시통증강도, 총진통제투여수, 마약성진통제투여유무, 요관결석의과거력유무, 요관결석의위치, 측면 ( 좌우 ) 및크기, 수신증동반여부에대한정보를얻었다. 내원시통증의강도는점수식평정척도 (numerical rating scale) 을사용하여 0부터 10까지기록하였으며. 요관결석에대한정보는시행한전산화단층촬영의영상의학과전문의판독결과를기준으로하였다. 판독결과상크기가표기되지않은경우는가로영상 (axial image) 에서의가장긴직경으로표기하였으며결석의위치는신우 (renal pelvis) 부터천골의상부경계 (upper border of the sacrum) 까지를상부요관 (proximal ureter), 천골의상부와하부경계사이 (between the upper and lower border of the sacrum) 를중부요관 (mid ureter), 천골의하부경계 (lower border of the sacrum) 부터요관방광이음부 (ureterovesical junction) 까지를하부요관 (distal ureter) 으로구분하였다. 실험실검사인자로는혈액검사 12개항목 [ 백혈구수 (white blood cell count), 분절과립구백분율 (segmented granulocyte percent), 혈색소 (hemoglobin), 적혈구용적률 (hematocrit), 혈청아스파르테이트아미노전달효소 (serum aspartate aminotransferase), 혈청알라닌아미노전달효소 (serum alanine aminotransferase), 총빌리루빈 (total bilirubin), 혈청나트륨 (sodium), 혈청칼륨 (potassium), 혈청염화물 (chloride), 혈액요소질소 (blood urea nitrogen), 크레아티닌 (creatinine)] 과소변검사 11개항목 [ 요잠혈 (urine blood), 요빌리루빈 (urine bilirubin), 요케톤 (urine ketone), 요단백 (urine protein), 요아질산염 (urine nitrite), 요당 (urine glucose), 요산도

3 이찬희외 : 요관결석환자에서자연배출의기대치료실패예측인자 / 405 (urine PH), 요비중 (urine specific gravity), 옥살산칼슘 (calcium oxalate), 인산염 (amorphous phosphate), 요백혈구 (urine leukocyte)] 을사용하였다. 혈액검사 12개항목과요산도및요비중은연속형자료값을이용하였으며. 나머지소변검사 9개항목은양성과음성으로구분하였다. 통계학적분석은 PASW statistics 18 (SPSS Inc., Chicago, IL, USA) 을사용하였다. 연속형자료값은측정값의정규성여부를확인하기위해 Kolmogorov- Smirnov one sample test와 Shapiro-Wilk test를시행하였으며, 정규성만족시 Student s t-test로, 정규성을만족하지않을시 Mann-Whitney U 검정을시행하여비교하였다. 이산형자료값은교차분석 (chi-square test) 을사용하였으나각셀의기대도수 5미만인셀이전체셀의 20% 이상시에는 Fisher s exact test로재분석하였다. 이중통계적으로유의한인자들을예측가능인자로선별하여자연배출실패군에대하여로지스틱회귀분석을시행하여주요변수를찾기위한최종모델을도출하였으며그요인을오즈비 (Odds ratio, OR) 를통해산출하였다. 통계학적유의수준은 p값이 0.05 미만인경우로정의하였다. 결과 1. 일반적인특성전체환자 195명중자연배출성공군이 128명, 자연배출 Table 1. Comparison of baseline characteristics and clinical findings. Spontaneous passage + Spontaneous passage - (n=128) (n=67) p-value Age (yrs) <0.588* Mean±std (IQR) ±14.12 (21).45.39±13.71(19) Sex, n (%) <0.839 Male 063 (49.2%) 34 (50.7%) Female 065 (50.8%) 33 (49.3%) Stone PHx, n (%) <0.019 Yes 017 (13.3%) 18 (26.9%) No 111 (86.7%) 49 (73.1%) Side, n (%) <0.035 Left 058 (45.3%) 41 (61.2%) Right 070 (54.7%) 26 (38.8%) Onset (min) <0.005 Mean± std (IQR) ± (126) ± (189) Pain scale <0.249 Mean±std (IQR) 7.16±2.29 (4) 6.72±2.39 (3) No. of Analgesics <0.668 Mean±std (IQR) 1.55±0.78 (1) 1.46±0.61 (1) Opioid, n (%) <0.453 Yes 079 (61.7%) 45 (67.2%) No 049 (38.3%) 22 (32.8%) Stone size (mm) <0.001 Mean±std (IQR) ±1.43 (1.9) ±2.74 (3.0) Hydronephrosis, n (%) <0.739 Yes 122 (95.3%) 63 (94.0%) No 006 (04.7%) 04 (06.0%) Location, n (%) <0.001 Upper 024 (18.8%) 32 (47.8%) Mid 006 (04.7%) 01 (03.6%) Lower 098 (76.6%) 34 (50.7%) * Student t-test Mann-Whitney U-test Chi-square test Fisher s exact test std: standard deviation, IQR: interquartile range, PHx: past history

4 406 / 대한응급의학회지 : 제 24 권제 4 호 2013 실패군이 67명이었다. 전체환자의평균연령은 46.14± 13.96세였으며, 자연배출성공군은 46.53±14.12세, 자연배출실패군은 45.39±13.71세로두군간유의한차이는없었다 (p=0.588). 성별은전체환자중남자가 97명 (49.7%) 이었고여자는 98명 (50.3%) 으로남녀비율은큰차이가없었다. 자연배출성공군에서는남자가 63명 (49.2%), 여자가 65명 (50.8%) 이었고자연배출실패군에서는남자가 34명 (50.7%), 여자는 33명 (49.7%) 으로두군간유의한차이는없었다 (p=0.839). 요관결석의과거력유무 (p=0.019), 좌우측면 (p=0.035), 요관결석의크기 및위치 (all p<0.001) 와증상발현시간 (p=0.005) 은두군간통계적으로유의한차이를보였다. 그외마약성진통제투여유무, 수신증동반여부, 내원시통증의강도와총진통제투여수는두군간유의한차이가없었다 (Table 1). 2. 혈액검사결과및소변검사결과분절과립구백분율은두군간차이가있었다 (p=0.046). 그외백혈구수를포함한 11개의혈액검사인자들은두군간차이가없었다. 소변검사에서는요빌리루빈 Table 2. Comparison of laboratory findings (Blood and Urine). Mean±std (IQR) Spontaneous passage + Spontaneous passage - (n=128) (n=67) p-value White blood cell (k/ul) ±2.48 (3.15) ±3.10 (3.36) Neutrophil (%) ±14.79 (22.3) ±15.25 (26.9) Hemoglobulin (g/dl) 14.02±1.43 (2.0) 14.06±1.44 (2.0) 0.881* Hematocrit (%) 41.33±3.91 (5.8) 41.33±3.80 (5.6) 0.993* AST (IU/L) 24.55±13.19 (7) ±26.14 (8) ALT (IU/L).27.69±24.91 (17).27.28±20.00 (18) Total bilirubin (mg/dl) 00.61±0.23 (0.3) 00.60±0.37 (0.3) Na (meq/l) ±2.11 (3) ±2.27 (3) K (meq/l) 04.11±0.37 (0.6) 04.04±0.39 (0.5) Cl (meq/l) ±2.55 (3) ±2.87 (3) BUN (mg/dl) 15.50±4.74 (6.3) 15.60±4.50 (5.6) Creatinine (mg/dl) 01.01±0.19 (0.2) 01.02±0.17 (0.2) U.pH 06.27±0.85 (1.5) 06.22±0.80 (1.0) U.SG ±0.01 (0.01) ±0.01 (0.01) U.Blood Positive 115 (89.8%) 64 (95.5%) Negative 013 (10.2%) 03 (04.5%) U.Bilirubin Positive 002 (01.6%) 05 (07.5%) Negative 126 (98.4%) 62 (92.5%) U.Ketone Positive 011 (08.6%) 08 (11.9%) Negative 117 (91.4%) 59 (88.1%) U.Protein Positive 021 (16.4%) 20 (29.9%) Negative 107 (83.6%) 47 (70.1%) U.Nitrite Positive 0 (0%) 02 (03%) Negative 128 (100%) 65 (97%) U.Glucose Positive 008 (06.2%) 04 (06.0%) Negative 120 (93.8%) 63 (94%) U.Leukocyte Positive 013 (10.2%) 08 (11.9%) Negative 115 (89.8%) 59 (88.1%) U.Ca oxalate Positive 003 (02.3%) 05 (07.5%) Negative 125 (97.7%) 62 (92.5%) U.Phosphate Positive 006 (04.7%) 02 (03%) Negative 122 (95.3%) 65 (97.0%) * Student t-test Mann-Whitney U-test Chi-square test Fisher s exact test std: standard deviation, IQR: interquartile range, AST: serum aspartate aminotransferase, ALT: serum alanine aminotransferase, BUN: Blood urea nitrogen, ph: potential of hydrogen, SG: specific gravity, U: urine

5 이찬희외 : 요관결석환자에서자연배출의기대치료실패예측인자 / 407 (p=0.048) 과요단백 (p=0.029) 은자연배출군에서높았으며, 그외 9개인자는두군간통계적으로유의한차이가없었다 (Table 2). 3. 다중로지스틱회귀분석이연구에서조사된변수들중 p값이 0.05 미만인예측가능인자는요관결석의크기, 증상발현시간, 요관결석의과거력, 요관결석위치및측면, 분절과립구백분율, 요빌리루빈, 요단백총 8개였다. 주요변수를찾기위해 8개의유효변수를포함하여다중로지스틱회귀분석 ( 후진 : Wald법 ) 을시행하였다. 1단계에서요관결석과거력, 2단계에서요단백, 3단계에서증상발현시간, 4단계에서분절과립구백분율, 마지막 5단계에서요빌리루빈변수가제거되었으며최종적으로요관결석크기 (p<0.001), 측면 ( 좌우 )(p=0.073) 과요관결석의위치 (p=0.019) 3개변수로이루어진회귀식이도출되었다. 로지스틱회귀분석모형식은아래와같다. logit( 자연배출실패 )= [ 요로결석크기 (mm)] [ 요관결석의측면 ] [ 중부요관결석 ] [ 하부요관결석 ] 요관결석의크기가 1 mm 증가할수록자연배출에실패할가능성은 1.867배높아졌으며하부요관결석은상부요관결석에비해자연배출에실패할가능성이 0.342배더낮았다. 비록통계적으로유의하진않았지만요관결석이우측에있을경우좌측에있을경우보다자연배출에실패할확률이 2.344배더높았다 (Table 3). 고찰요관결석의명확한치료방침이정해진것은없지만 10 mm 이하의결석은 90% 가자연배출이가능하므로주로 대기요법을실시하게된다 8). 하지만 Song 등 11) 의연구에서 2주간의대기요법을시행받는환자들중 47.4% 가자연배출이되지않아충격파쇄석술또는요관경하제석술을실시받는다고한다. 그러므로응급실에흔하게내원하는요관결석환자들의자연배출가능성을예측하여대기요법및중재적시술대상자를적절히선정하는것은매우중요하다. 하지만요관결석자연배출과관련된기존의논문은대부분자연배출기간을 1달내지 2달이상으로보고있지만, 2주이상의대기요법은환자의치료순응도가떨어질수있고현재국내의임상에서도크기가 5 mm 이하의결석의경우 2주의대기요법후치료할것을권장하고있다 11). 또한기존의연구들은주로결석의크기및위치, 전산화단층촬영소견등의유의성만을비교했으나본연구에서는자연배출에영향을미치는요인을임상적, 영상의학적검사뿐만아니라응급실에서흔히진행하는실험실적검사인자들로확장하여이들의다변량분석을통해상호연관성을배제하고유의인자의독립성을확인하였다. 즉, 본연구는우리나라진료실정에맞게 2주간의자연배출기간을가지고여러응급센터내에서기본적으로널리시행하는여러인자들을통해자연배출실패를예측하려는첫연구로서그의의가있다. 요관결석의크기 (p<0.001) 및위치 (p<0.001) 는자연배출실패가능성을확인할수있는유의한인자이다. 본연구에서는결석의크기가크고, 상부에위치할수록자연배출이실패할가능성이높은결과를확인할수있었다. Coll 등 12) 의연구에따르면요관결석의크기및위치가자연배출가능성과는유의한상관관계가있는데요관결석의크기가 1, 4, 7, 10 mm로커질수록자연배출률이 87, 72, 47, 27% 로낮아지며, 또한크기가 14 mm인결석의경우위치에따라근위부요관 47%, 중위부요관 80%, 원위부요관 77%, 방광요관이행부 92% 로하부에위치할수록자연배출가능성이높아진다고보고하고있다. 비록다변량회귀분석에서는통계적유의성을보이진않 Table 3. Final logistic regression model (Wald, backward). β SE Odds ratio Lower 95% CI Upper p-value Size <0.001 Side Left Right <0.073 Location <0.019 Upper Mid <0.153 Lower <0.007 Intercept <0.001 SE: standard error, CI: confidence interval

6 408 / 대한응급의학회지 : 제 24 권제 4 호 2013 았지만요관결석이우측에있을때좌측보다자연배출에실패할가능성이 2배이상높았다. Miller와 Kane 13) 의연구에서는결석의크기가작고, 하부에위치하고, 우측에위치할수록자연배출이잘되고중재적시술을필요로하는가능성이낮다고상반된결과를보고하였으나, Sfoungaristos 등 14) 은좌측에위치한요관결석이자연배출이잘된다고보고하고있고이를뒷받침할만한가설로서좌측요관은복막에단단하게붙어있지않은반면우측요관은복막에단단하게붙어있어서요관의연동운동이저하되어자연배출을지연시킨다고제시하였다. 결석의좌우위치에따른자연배출가능성에대해서는본연구및기존의연구들에서서로상충되는결과가나오므로보다더대규모의연구가필요할것으로사료된다. Arumuham 등 15) 은요관결석과거력이있는환자들이과거력이없는환자들에비해급성통증악화로인해재입원하는가능성이더높고자연배출에실패할가능성이높다고보고하였다. 본연구에서도과거요관결석기왕력이있는환자가자연배출가능성이더낮은결과를단변량비교를통해확인할수있었다. 요관결석의자연배출을예측하기위해통증조절정도와결석의크기와의상관관계에대한연구가있었다. Prina 등 16) 의연구에서는결석이 6 mm 이상으로큰경우더많은진통제및마약성진통제를필요로하게되는데이는요관의더욱심한확장을의미하므로자연배출의실패를예측하는인자일것이라고가설을세우고연구를시작했지만두요인간의유의한상관관계는얻지못하였다. 그들은통증은개인의교육및문화에따라다르게표현될수있으므로유의한관계를얻지못했다고기술하였다. 하지만그들의연구에서도통증의강도및조절정도와자연배출의상관관계를알아보려고했을뿐통증의지속시간과자연배출실패여부의상관관계를알아보려는시도는이루어지지않았다. 본연구에서도기존의연구와유사하게통증의강도, 사용된진통제의수, 마약성진통제투여여부와결석의자연배출과유의한상관관계가없음이확인되었다. 하지만통증의지속시간이긴군이짧은군에비해자연배출실패가능성이유의하게높음을확인할수있었다. 단백질과요관결석과의관계에대해서는기존의여러연구들이진행되어왔다. Robertson 등 17) 은서구사회에서동물성단백질섭취가요관결석의유병률을증가시킨다고보고하였으며, Brockis 등 18) 의연구또한단백질섭취가체내에서의대사성산증을유발하여골조직에서의칼슘재흡수및소변으로의칼슘배출을증가시켜요관결석을유발한다고보고하였다. Schwille 등 19) 은특발성재발성요관결석환자들을대상으로시행한연구에서요관결석그자체가아니라산화적대사의저하로인해네프론의기능에영향을주어서신장에서의알부민이아닌단백질의배출을증가시켜서단백뇨를유발시킨다고보고하였다. 빌리루빈은헤모글로빈이분해되어만들어지는물질로서간에서글루크론산과결합하여신장에서소변을통해배설된다. 정상성인에서소변 1 dl당 0.02 mg의빌리루빈이검출된다고하며담도폐쇄나간세포파괴와같은상황에서증가한다고알려져있다 20). 하지만기존의연구들에서요빌리루빈과요관결석자연배출과의관계를확인하려는시도는이루어지지않았다. 본연구에서는요빌리루빈이요관결석자연배출실패와유의한연관성을가진인자임을확인한첫연구로서의미가있다. 요단백및요빌루리빈이요관결석의자연배출실패에영향을미치는기전은현재까지자세히확인된바는없으므로보다정확한기전확인을위해서는대단위의추가적인연구가필요할것으로보인다. 분절과립구백분율또한요관결석자연배출과유의한상관관계가있는인자임이확인되었다. 본연구에서는자연배출실패군에서분절과립구백분율이유의하게높았는데이는기존의 Nuss 등 21) 의연구에서요관결석으로인한지속적인염증반응이요관의탄성과요관내경을감소시켜결석의자연배출을힘들게한다고밝힌것과유사한결과이다. 반면에 Sfoungaristos 등 7,14) 은자연배출성공군이실패군에비해백혈구및분절과립구백분율이높다고보고하고있다. 백혈구및분절과립구백분율은결석이요관을따라내려가면서요관점막에일으키는염증반응의지표인데, 요관을따라쉽게내려가지못하는결석은염증반응또한적게유발하므로백혈구및분절과립구백분율도낮을것이라는가설을제시하고있다. 분절과립구백분율또한요관결석자연배출과의관련성및그기전에대해서도역시추가적인연구가필요해보인다. 본연구에는몇가지제한점이있다. 첫째, 본연구는일개대학병원의응급의료센터에서 11개월간시행된결과로연구결과가대외적타당성을가진다고할수없고, 본원의특수성등을고려하여연구의일반화에있어주의가필요하다. 추후비슷한규모의대학병원과의협업을통한대규모연구가필요할것으로보인다. 둘째, 본연구는의무기록과전산화단층촬영판독검토를통해후향적으로이루어져기록미비와연구자료누락으로인한편이가능성이있다. 결론요관결석대기요법의급성기치료실패의예측인자로는요관결석의크기및측면, 증상발현시간, 요관결석과거력, 요관결석의위치, 분절과립구백분율, 요빌리루빈과요단백이통계적으로유의하였다. 특히다변량분석에서는요로결석의크기가크고, 상부요관에위치할수록, 좌측보다는우측에위치할수록자연배출에실패할가능성이더높았으므로이런환자들에게는대기요법여부와중재적시술여부를선정하는데더신중할필요가있다.

7 이찬희외 : 요관결석환자에서자연배출의기대치료실패예측인자 / 409 참고문헌 01. Picozzi SC, Marenghi C, Casellato S, Ricci C, Gaeta M, Carmignani L. Management of ureteral calculi and medical expulsive therapy in emergency departments. J Emerg Trauma Shock. 2011;4: Johri N, Cooper B, Robertson W, Choong S, Rickards D, Unwin R. An update and practical guide to renal stone management. Nephron Clin Pract. 2010;116: The Korean Society of Emergency Medicine. Emergency medicine. 1st ed. Seoul: Koonja; p Mahmood A, Silbergleit A, Olson R, Cotant M. Urolithiasis: the influence of stone size on management. Nat Clin Pract Urol. 2007;4: Bensalah K, Pearle M, Lotan Y. Cost-effectiveness of medical expulsive therapy using alpha-blockers for the treatment ofdistal ureteral stones. Eur Urol. 2008;53: Jang WK, Hong YK. The efficacy of furosemide-based medical expulsive therapy with tamsulosin and deflazacort for symptomatic distal ureter stones. Korean J Urol. 2008;49: Sfoungaristos S, Kavouras A, Katafigiotis I, Perimenis P. Role of white blood cell and neutrophil counts in predicting spontaneous stone passage in patients with renal colic. BJU Int. 2012;110: Preminger GM, Tiselius HG, Assimos DG, Alken P, Buck C, Gallucci M et al guideline for the management of ureteral calculi. J Urol. 2007;78: Han MC, Park YY, Shim BS. Effect of tamsolusin on the expectant treatment of lower ueteral sones. Korean J Urol. 2006;4: Tchey DU, Ha YS, Kim WT, Yun SJ, Lee SC, Kim WJ. Expectant mnagement of ureter stones: Outcome and clinical factors of spontaneous passage in a single institution's experience. Korean J Urol. 2011;52: Song DW, Jeong TY, Lee SI, Kim DJ. Predicting factors for spontaneous passage of ureteral calculi based on unenhanced helical CT findings. Korean J Urol. 2008;49: Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am J Roentgenol. 2002;178: Miller OF, Kane CJ. Time to stone passage for observed ureteral calculi: a guide for patient education. J Urol. 1999;162: Sfoungaristos S, Kavouras A, Perimenis P. Predictors for spontaneous stone passage in patients with renal colic secondary to ureteral calculi. Int Urol Nephrol 2012;44: Arumuham V, Mehta S, Almpanis S, Nicol D, Ajayi L. Is follow-up required for uncomplicated distal ureteric stones <6 mm? Int J Surg. 2011;7: Prina LD, Rancatore E, Secic M, Weber RE. Comparison of stone size and response to analgesic treatment in predicting outcome of patients with renal colic. Eur J Emerg Med. 2002;9: Robertson WG, Heyburn PJ, Peacock M, Hanes FA, Swaminathan R. The effect of high animal protein intake on the risk of calcium stone-formation in the urinary tract. Clini Sci (Lond). 1979;57: Brockis JG, Levitt J, Cruthers SM. The effects of vegetable and animal protein diets on calcium, urate and oxalate excretion. Br J Urol. 1982;54: Schwille PO, Schmiedl A, Wipplinger J. Idiopathic recurrent calcium urolithiasis (IRCU): variation of fasting urinary protein is a window to pathophysiology or simple consequence of renal stones in situ? A tripartite study in male patients providing insight into oxidative metabolism as possible driving force towards alteration of urine composition, calcium salt crystallization and stone formation. Eur J Med Res. 2009;14: McPherson, RA, Pincus MR. Henry s clinical diagnosis and management by laboratory methods. 22th ed. Philadelphia: Elsevier; p Nuss GR, Rackley JD, Assimos DG. Adjunctive therapy to promote stone passage. Rev Urol. 2005;7:67-74.

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