대한응급의학회지제 20 권제 5 호 Volume 20, Number 5, October, 2009 원 저 응급의료센터에내원한급성신우신염환자에서초기 C-reactive Protein 과신장전산화단층촬영의유용성 가톨릭대학교의과대학응급의학교실 김미경 우선희 이운정 정시경 최세민 최승필 박규남 Predictive Value of C-reactive Protein and Kidney Computed Tomography in Patients with Acute Pyelonephritis Mi Kyung Kim, M.D., Seon Hee Woo, M.D., Woon Jeong Lee, M.D., Si Kyoung Jeong, M.D., Se Min Choi, M.D., Seung Pill Choi, M.D., Kyu Nam Park, M.D. Purpose: This study was conducted to determine the predictive value of the C-reactive protein (CRP) and kidney computed tomography (CT) in the emergency department (ED) for predicting the severity of acute pyelonephritis. Methods: One hundred thirty-nine patients who were diagnosed with acute pyelonephritis between January 2007 and June 2008 were enrolled in this study. The patient underwent a kidney CT in the ED and the CT findings were classified as normal, a focal wedge-shaped lesion, a multi-focal wedge-shaped lesion, a mass-effect lesion, and abscess formation. The symptoms, vital signs, past history, initial laboratory findings, serum CRP in the ED, and the length of the hospital stay based on the kidney CT grade in the ED were compared. Results: Among the 139 patients, 138 were females and the mean age was 48.5±17.7 years. We classified the CT grades as follows: grade 1, normal (n=20); grade 2, focal wedge-shaped lesion (n=25); grade 3, multi-focal wedgeshaped lesion (n=45); grade 4, mass-effect lesion (n=42); and grade 5, abscess formation (n=7). Statistically significant differences in leukocyte count, neutrophil ratio, ESR, CRP, and length of hospital stay existed between the CT grades. Patients were classified into two groups based on 책임저자 : 이운정인천광역시부평구부평6동 665번지인천성모병원응급의학과 Tel: 032) 510-5895, Fax: 032) 510-5065 E-mail: limleeem@catholic.ac.kr 접수일 : 2009년 4월 28일, 1차교정일 : 2009년 6월 2일게재승인일 : 2009년 8월 28일 555 the CT grade (the mild group [grades 1 and 2], and the severe group [grades 3~5]). The leukocyte count, neutrophil ratio, ESR, CRP, maximal body temperature, duration of fever, duration of pyuria >3 days, and length of hospital stay were greater in the severe group. Based on the results of multivariate logistic regression analysis, the CRP level was shown to be an independent predictor that affected the severe group. The area under the ROC curve for CRP was 0.775 (95% CI, 0.695~0.854). Conclusion: The CRP level in the ED was an independent predictor that affected the severe group. Thus, the initial CRP level with the kidney CT grade may be used as a prognostic indicator of acute pyelonephritis in the ED. Key Words: Pyelonephritis, Spiral computed tomography, C-reactive protein Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea. 서 급성신우신염은유병률이높은질환으로특히여성의경우해부학적요인으로인해약 20~35% 가일생동안한번이상경험하는것으로알려져있으며, 유병률은지역과성별에따라차이를보이나 1997년미국의통계자료에의하면입원치료를받은환자의숫자가여자는 10,000명당 11.7명, 남자는 10,000명당 2.4명에이른다고하였다. 국내보고로는 1년에인구 10,000명당 35.7명의높은발병률을보이고그중 5.5명이입원치료를받는질환으로응급의료센터에서빈번히접하는환자군이다 1,2). 환자들대부분이응급의료센터와외래를통하여입원여부를결정하게되며, 입원결정에있어임상양상및과거력, 기저질환, 방사선학적검사등을토대로결정하게되나응급의료센터에서입원여부를결정하는명확한프로토콜이없는실정이다. 급성신우신염은발열, 오한, 측복부통증, 전신근육통, 오심, 구토등의증상이보이고, 특히노인환자에서는섬 론
556 / 대한응급의학회지 : 제 20 권제 5 호 2009 망, 쇼크등의증상을보일수있으며, 검사소견상백혈구증가증, 농뇨, 세균뇨등을보이는임상증후군으로다양한임상증상이관찰되며, 이러한임상소견및검사결과만으로는응급의료센터내에서중증도를명확히감별하고예후평가를내리기는어렵다. 또한, 급성신우신염으로진단되더라도합병증이없는단순신우신염으로부터간질성염증단계를거쳐신농양형성에이르기까지질병의진행정도가다양하고, 침범부위도국소적이거나미만성인경우등의여러염증소견을보일수있어외래를통한경구항생제치료와입원치료사이에서치료방향을결정하기어렵다 3). 최근급성기반응단백 (acute reactive protein) 은응급의료센터내에서의검사율이높아지고있으며, 그중에서 C-reactive protein (CRP) 농도는대부분의세균성감염에대해감염시작후 4~8시간내에상승하기시작하여, 24~48시간내에최고치에도달하며효과적인치료시급격하게정상수치로떨어져감염성질환의중증도및치료반응평가에이용되고있다 4-6). 과거급성신우신염환자의입원기간중검사한최고 CRP 농도혹은퇴원시검사한 CRP 농도와임상경과간의여러연구들이이루어졌으나응급의료센터에서시행한초기 CRP 농도와임상경과의상관성에대한연구는부족한실정이다. 또한여러방사선학적방법중전산화단층촬영이보편화되면서급성신우신염의전산화단층촬영소견과임상소견의연관성에관한보고는많으나응급의료센터에서시행한초기검사결과및 CRP 농도, 임상적중증도와전산화단층촬영소견과의관계를보고한연구는드물다 7,8). 이에저자들은급성신우신염환자가응급의료센터에내원하여단시간내에확인이가능한초기 CRP 농도와응급의료센터내에서시행한신장전산화단층촬영소견및임상소견의상관관계를분석하여 CRP 농도와전산화단층촬영소견을이용하여환자의중증도를평가함으로향후급성 신우신염환자의예후판단및치료방침결정에기초가되고자본연구를계획하였다. 대상과방법본연구는 2007년 1월부터 2008년 6월까지인천성모병원응급의료센터에내원한 18세이상의환자중급성신우신염으로진단받고입원치료를받은환자 205명중응급의료센터에서 24시간이내에신장전산화단층촬영을시행한 139명의환자를후향적방법으로의무기록을조사하였다. 단, CRP의상승을가져올수있는요로결석등에의한 2차감염, 다른부위의감염이동반된경우, 요로계의이상및종양이동반된경우, 관절염의기왕력, 도뇨관을유치하고있는경우는제외하였다. 본연구는소속병원의의학윤리연구심의위원회의심의를통과하였다. 대상환자들은응급의료센터내원당시의나이, 생체활력징후및발열, 오한, 측복부통증, 오심, 구토, 배뇨통등의임상증상을조사하여 4가지이상의증상을호소하는경우를중한증상으로정의하여조사하였고, 발열기간, 급성신우신염의과거력, 당뇨병의과거력, 내원전항생제복용유무등을조사하여분석하였다. 또한응급의료센터에서초기에시행한검사결과중백혈구수및호중구의비율, erythrocyte sedimentation rate (ESR), CRP와임상경과로는입원기간내최고체온, 항생제치료시작후에도지속된발열기간및입원치료 3일후농뇨회복여부와환자들의입원기간등을확인하였다. 농뇨회복은입원 3일째요검사를통한고배율시야당백혈구의세포수가 5개미만인것으로정의하였다. 대상환자는모두내원한지 2시간이내에응급의료센터에서 CRP를포함한혈액검사를시행하였으며내원한지 Fig. 1. Flow sheet in acute pyelonephritis patients.
김미경외 : 응급의료센터에내원한급성신우신염환자에서초기 C-reactive Protein 과신장전산화단층촬영의유용성 / 557 24시간이내에응급의료센터에서신장전산화단층촬영을시행하여, 1명의방사선과전문의가판독후신실질내의관류결손부위의유무및모양에따라관류결손이없는군을제 1형, 국소쐐기형및선상음영을제 2형, 다발성쐐기형을제 3형, 종괴형을제 4형, 신농양형성을제 5형으로분류하여분석하였다 7). CRP를포함한혈액검사결과와임상양상을신장전산화단층촬영의분류에따라분석하였으며, 대상환자의중증도비교는 5형을다시제 1,2 형을경증군과제 3, 4, 5형을중증군으로분류하여두군의내원당시생체활력징후, 임상양상등을분석하였다. 또한신장전산화단층촬영소견이환자의임상경과의중증도를예측할수있는지분석하기위하여입원기간중최고체온, 두군에따른항생제치료시작후에도지속된발열기간및입원치료 3일후농뇨회복여부와환자들의입원기간을비교분석하였다. 통계적분석은 SPSS 12.0 프로그램을이용하여신장전산화단층활영소견에따른임상적지표들의비교시에는 ANOVA를이용하였으며, 연속변수는평균과표준편차를표기하고, student s t-test를사용하였고, 정규분포를따르지않는경우중앙값과범위를측정하여 Mann-Whitney U test로검정하였고, 질적변수의비교는 Chi-square test를이용하였다. 단변량분석에서의미있었던변수들을다중로지스틱회귀분석을통하여전산화단층촬영결과상중증군을예측할수있는독립적인위험인자를분석하였고, receiver operating characteristic (ROC) 곡선을통하여검사수치에따른민감도및특이도를구하였으며, 통계적유의수준은 p값이 0.05미만으로하였다. 결과 1. 급성신우신염환자의일반적인특성전체대상환자 139명중성별은 138명이여자였고 1명이남자였으며, 평균나이는 48.5±17.7세였고, 응급의료 센터내원시초기생체활력징후상수축기혈압이90 mmhg 이하로저혈압을보인경우가 7명 (5%), 맥박수가분당 100회이상의빈맥을보인경우가 71명 (51.1%), 과거력상당뇨병이동반된경우가 28명 (20.1%), 급성신우신염이있는경우가 36명 (25.9%) 이었다. 내원전이미항생제를복용하였던경우는 61명 (43.9%) 이었으며, 4가지이상의급성신우신염증상을호소하는경우인중한증상을보이는환자는 104명 (74.8%) 이었다. 2. 신장전산화단층촬영소견에따른급성신우신염환자의분류 대상환자들을신장전산화단층촬영소견에따라분류하면관류결손부위가없는제 1형이 20명 (14.4%), 국소쐐기형및선상음영인제 2형이 25명 (18.0%), 다발성쐐기형인제 3형이 45명 (32.4%), 종괴형인제 4형은 42명 (30.2%), 신농양형성인제 5형은 7명 (5.0%) 으로제 3,4 형의환자군이높은비율을차지하였다 (Fig.1). 각각의신장전산화단층촬영유형에따른입원후발열기간및내원초기에시행한혈액검사결과를비교하였을때, 내원전발열기간은각그룹간의차이가없었으나백혈구수및호중구의비율, ESR, CRP 및입원기간은각그룹간에서통계적으로유의한차이를보였다 (p<0.05)(table 1). 3. 신장전산화단층촬영소견에따른경증군과중증군의임상양상비교 신장전산화단층촬영의유형에따라 1~2형과 3~5형을각각경증군과중증군으로분류하여두군을분석한결과환자들의나이, 내원당시의저혈압및빈맥의유무, 당뇨병의유무, 급성신우신염의과거력, 내원전항생제사용유무, 내원전발열기간, 중한증상을보이는경우는통계학적으로유의한차이를보이지않은반면, 초기백혈구수및호중구의비율은 13.5±5.2 *10 3 /ul, 86.4±7.0% 로중증군에서더높았다 (p=0.013, p=0.012). 또한내원당시 Table 1. Clinical characteristics according to pattern of kidney CT findings Group I Group II Group III Group IV Group V (n=20) (n=25) (n=45) (n=42) (n=7) p-value* Duration of preadmission fever (days) 2.9±0.7 6.0±1.2 02.5±0.4 02.0±0.3 01.7±0.6 <0.832 Leukocyte counts (10 3 /ul) 10.4±6.20 11.6±4.90 12.9±4.6 13.4±4.9 17.2±9.6 <0.031 Neutrophil ratio (%) 0 78.2±18.1 8 2.9±8.0 85.8±7.6 86.9±6.4 86.9±7.4 <0.013 ESR (mm/hr) 29.0±12.3 30.3±11.7 037.3±10.9 34.7±9.2 39.0±5.3 <0.011 CRP (mg/dl) 65.3±55.1 90.6±65.0 171.6±90.5 143.7±87.0 192.7±91.1 <0.001 Hospital day (days) 5.2±2.3 5.7±1.5 06.3±1.6 06.8±2.4 09.1±1.7 <0.001 * calculated by one-way ANOVA test
558 / 대한응급의학회지 : 제 20 권제 5 호 2009 검사한 ESR, CRP는중증군에서 36.3±9.9 mm/hr, 160.7±89.5 mg/dl로의미있게높았다 (p=0.002, p<0.001)(table 2). 두군의임상경과를비교분석하면입원후지속된발열기간은중증군에서 1.7±1.0일로더길었으며, 입원후측정한최고체온또한 38.8±0.9 C로중증군에서유의하게높았다. 입원 3일째항생제치료후에도농뇨가지속되는경우는중증군에서 32명 (34.0%) 으로많아신장전산화단층촬영에따른중증군분류가환자의임상경과의중증도를예측하는데통계적으로의의가있었다 (Table 3). 단변량분석에서의미있었던인자들을다변량분석한결과초기혈청 CRP 농도 [odds ratio(95% CI): 1.010 (1.002~1.018)] 가전산단층화촬영상중증군을예측하는독립적인인자였다 (Table 4). ROC 곡선상 CRP 농도의경계값 (cut-off value) 은 122 mg/dl였으며이때민감도와특이도는 64.9%, 80.0% 를보였고 positive LR (likelihood ratio) 는 3.24, negative LR는 0.44였다. CRP 농도의곡선하면적 (AUC) 은 0.775(95% CI, 0.695~0.854) 였다 (Fig. 2). 고찰급성신우신염은신결핵과급성포도상구균감염을제외하고혈행성으로생기는경우는드물며대부분방광에서시작하여방광-요관역류, 신장내역류에의해균이신우신배, 신유두및신세관에이르러염증반응을일으키는박테리아의상행성요로감염에의해발생하고늑척추각압통, 발열, 농뇨등의특징적인임상양상을보이는증후군이다. 대부분임상소견및요검사에의해진단되고적절한항생제투여로치료되는질환이나항생제투여후에도 3일이상발열이지속되거나임상증상이악화되는경우에는요로폐색및신농양등의합병증의동반유무를확인하기위하여방사선학적검사가필요하다 9). 또한소아, 노인및전신상태가좋지못한경우에환자들은비전형적인임상소견을보여진단이모호하므로방사선학적검사가진단에도움을주는경우가많다. 따라서응급의료센터에내원한급성신우신염이의심되는환자에서초기에환자의중증도를예측할수있는인자가있다면조기에방사선학 Table 2. Comparison of demographic and clinical data between mild and severe group Mild group (n=45) Severe group (n=94) p-value Age (years) 48.7±19.2 48.5±17.0 <0.948 Hypotension* 02 (04.4%) 05 (05.3%) <0.825 Tachycardia 20 (44.4%) 51 (54.2%) <0.279 DM history 07 (02.2%) 21 (22.3%) <0.351 APN history 12 (26.7%) 24 (25.5%) <0.886 Prior antibiotics therapy 18 (40.0%) 43 (45.7%) <0.523 Duration of preadmission fever (days) 3.0 (1.0~30.0) 3.0 (1.0~15.0) <0.349 Severe symptom 31 (68.9%) 73 (77.7%) <0.263 Leukocyte counts (10 3 /ul) 11.0±5.5 13.5±5.2 <0.013 Neutrophil ratio (%) 80.8±13.5 86.4±7.0 <0.012 ESR (mm/hr) 29.7±11.9 36.3±9.9 <0.002 CRP (mg/dl) 79.4±61.5 160.7±89.5 <0.001 Systolic blood pressure <90 mmhg Heart rate >100 rates/min DM : diabetes mellitus APN : acute pyelonephritis calculated by student s t-test for continuous variables and chi-squared test for categorical variables Table 3. Comparison of clinical courses of patients between mild and severe group Mild group (n=45) Severe group (n=94) p-value* Maximal body temperature ( C) 38.2±0.9 38.8±0.9 <0.001 Duration of admission fever (days) 00.9±0.8 01.7±1.0 <0.001 Duration of pyuria >3 days 8(17.8%) 32(34.0%) <0.047 Hospital day (days) 05.5±1.9 06.7±2.1 <0.001 * calculated by student's t-test
김미경외 : 응급의료센터에내원한급성신우신염환자에서초기 C-reactive Protein 과신장전산화단층촬영의유용성 / 559 적검사를통해환자의치료방법을결정하는데도움이되리라생각되어본연구를계획하게되었다. 혈청 ESR과 CRP는급성기반응단백으로흔하게사용되고있으며, ESR은혈청에서적혈구의하강의정도를보는방법으로비교적검사법이간단하며대부분의병원에서시행되고있으나, 간접적으로급성기반응단백을측정하여혈청의농도나 fibrinogen에영향을많이받으며적혈구의크기, 모양, 수에따라오차가생길가능성이높다 10). 혈청 CRP는세균성감염이나외상, 조직괴사가있을경우 leukocyte endogenous mediator (LEM) 와 prostaglandin E1의자극으로간세포에서합성되는급성기반응단백으로보체를활성화시켜염증반응을일으키며, 다른급성기반응단백에비해쉽게측정이가능하고, 정량적인혈청 CRP의연속적측정은감염등의염증성상태의진단과감시장치로서유용하다 5). Biggi 등 11) 은소아에서혈청 CRP 가 DMSA 신스캔상신손상의유무를예측하는데유용한인자이고, CRP 농도의상승이신손상의정도를예측할수 Fig. 2. Receiver operating characteristic curves for prediction of severity in patients with acute pyelonephritis. 있는인자라고주장하였으며, Pulliam 등 12) 은혈청 CRP의농도가혈액백혈구의수치와중성구의비율보다감염의정도를판단하는데더욱의미있는검사라고주장하였다. 또한국내에서 Chung 등 5) 은급성신우신염으로내원한 59명의환자중혈청 CRP의농도가 15 mg/dl 이상인환자군의주사용항생제사용기간이평균 7.5일로, 15 mg/dl 이하인군의 6.3일보다더길었으며, Yang 등 6) 은급성신우신염환자중혈청최고 CRP 농도가 15 mg/dl 이상인환자군이입원기간과항생제사용기간이길었으며퇴원후재발율도높았다고보고하여 CRP 농도가환자의임상양상의중증도를반영하는데유용함을보였다. 저자들의연구에서도응급의료센터에내원한지 2시간이내에검사한 CRP 농도가환자의중증군즉전산화단층촬영상제 3~5 형의군을예측하는독립적인인자로통계학적으로유의하였으며, CRP 농도가 122 mg/dl 이상인경우민감도와특이도는 64.9%, 80.0% 를보였다. 이는 Bang 등 10) 이외래및응급실을통하여내원한급성신우신염환자를대상으로내원당시의혈청 CRP 수치가입원 3일째농뇨의회복을예측하는독립적인인자로입원여부를결정하는중요한검사로강조한바와일치한다. 과거급성신우신염의방사선학적검사로자주이용되던배설성요로조영술은약 75% 에서정상소견을보이고신장비대나조영제의배설이지연되는비특이적소견을보이는경우가많았으나, 최근에는신장전산화단층촬영이보편적으로시행되면서급성신우신염의초기병변을확인하고, 염증의범위와중증도를판단하며신반흔및위축등의합병증발병을예측할수있다는점에서효과적인검사로보고되고있다 13,14). 급성신우신염의가장흔한전산화단층촬영소견은하나또는여러개의쐐기모양의저음영병변으로이는염증부위의분절동맥 (segmental arteries), 엽간동맥 (interlobular arteries) 과수입세동맥 (afferent arterioles) 의불규칙한수축혹은간질부종에의한혈관압박으로인한허혈과백혈구및손상된세포로인한세뇨관의폐쇄로발생되며본연구에서도 70례 (50.4%) 를보였다. 쐐기모양 Table 4. Association of the clinical courses, laboratory findings and C-reactive protein in severe group with acute pyelonephritis on multivariate analysis Variables Univariate analysis Odds ratio (95% CI)* Multivariate analysis Odds ratio (95% CI)* Leukocyte counts (*10 3 /ul) 1.000 (1.000-1.000) NS Neutrophil ratio (%) 1.062 (1.018-1.108) NS ESR (mm/hr) 1.062 (1.024-1.102) NS CRP (mg/dl) 1.014 (1.008-1.021) 1.010 (1.003-1.018) Maximal body temperature ( C) 2.205 (1.419-3.426) NS Duration of admission fever (days) 2.996 (1.734-5.175) NS * calculated by logistic regression analysis
560 / 대한응급의학회지 : 제 20 권제 5 호 2009 의병변보다더욱심한부종과염증에의해형성되는종괴모양의병변은 42례 (30.2%) 에서보였고, 세뇨관및간질의염증치료가늦어지거나부적절하게되면종괴모양의병변은미세농양으로진행되며악화될경우거대농양 (macroabscess) 을형성하게되며이는본연구의 7례 (5.0%) 에서관찰되었다 15-17). 또한신장전산화단층촬영소견에따라분류한중증군즉다발성쐐기형, 종괴형및신농양을보이는군에서입원기간내의최고체온, 입원후발열기간, 입원기간, 입원 3일째농뇨회복유무등의임상양상간에통계적으로유의한차이가있어전산화단층촬영이환자들의중증도를판단하는데유용함을보였다. 이와같이급성신우신염의다양한염증의정도를내원당시초기의임상양상으로판단하는것은현실적으로어려워임상에서는환자의중증도를판단하는데방사선학적검사를자주이용하고있으나고가의비용으로모든환자에게적용하는것은제한이있다. 따라서저자들의연구에서초기 CRP 농도가환자의전산화단층촬영상중증군을예측하는독립적인인자로유의하여향후응급의료센터내원시초기 CRP 농도를통해급성신우신염환자의중증도를예측하여전산화단층촬영을시행한다면, 고가의방사선학적검사를줄이고급성신우신염환자의치료방침을조기에결정하는데도움이되리라생각된다. 본연구의제한점으로는연구대상이후향적으로일개병원에서이루어져환자수가적어일반화하기어려우며, CRP 농도의연속적인추적관찰을통한환자들을분석하지는못했다는점을들수있다. 그러나응급의료센터내원당시초기진찰소견과더불어빠르게결과를확인할수있는급성기반응단백들을포함한초기검사소견들을초기신장전산화단층촬영소견및임상경과와비교, 분석하여초기에급성신우신염환자의중증도를예측하는데전산화단층촬영소견과함께 CRP 농도를활용할수있음을보여그의의가있겠다. 결론응급의료센터내에서초기에측정한혈청 CRP 농도가전산화단층촬영의중증군을예측할수있는독립적인인자였으며, 내원 24시간이내에시행한전산화단층촬영소견에따라분류한경증군과중증군에서입원후발열기간, 입원 3일째농뇨회복유무, 입원기간등여러임상지표간에통계적으로유의한차이를보여전산화단층촬영이환자의예후를판단하는데유의함을보였다. 따라서향후응급의료센터에서초기 CRP 농도를통해급성신우신염환자의중증도를평가하여신장전산화단층촬영을시행한다면, 급성신우신염환자의치료방침을결정하고예후평가에도움이되리라생각된다. 참고문헌 01. Foxman B, Klemstine KL, Brown PD. Acute pyelonephritis in US hospitals in 1997: hospitalization and in-hospital mortality. Ann Epidemiol 2003;13:144-50. 02. Ki M, Park T, Choi B, Foxman B. The epidemiology of acute pyelonephritis in South Korea, 1997-1999. Am J Epidemiol 2004;160:985-93. 03. Rosenfield AT, Glickman MG, Taylor KJ, Crade M, Hodson J. Acute focal bacterial nephritis (acute lobar nephronia). Radiology 1979;132:553-61. 04. Yilmaz E, Batislam E, Tuglu D, Kilic D, Basar M, Ozluk O, et al. C-reactive protein in early detection of bacteriemia and bacteriuria after extracorporeal shock wave lithotripsy. Eur Urol 2003;43:270-4. 05. Chung H, Kim TW, Lee CH, Kim HS. The clinical significance of serum C-reactive protein in patients with acute uncomplicated pyelonephritis. Korean J Urol 2005;46:476-80. 06. Yang WJ, Cho IR, Seong do H, Song YS, Lee DH, Song KH, et al. Clinical implication of serum C-reactive protein in patients with uncomplicated acute pyelonephritis as marker of prolonged hospitalization and recurrence. Urology 2009;73:19-22. 07. Jo BJ, Kim KW, Yu JS, Kim JK, Yoon SW, Ha SK, et al. Acute pyelonephritis: role of enhanced CT scan in the prediction of clinical outcome. J Korean Radiol Soc 1997; 36:671-6. 08. Cho JT, Yun SC. Usefulness of renal computerized tomography in acute pyelonephritis. Korean J Nephrol 1999;18:96-104. 09. Roberts JA. Pyelonephritis, cortical abscess, and perinephric abscess. Urol Clin North Am 1986;13:637-45. 10. Bang SH, Chang IH, Han JH, Ahn SH. C-reactive protein is a useful marker to predict the severity and early response of acute pyelonephritis in women. Korean J Urol 2007;48:1143-8. 11. Biggi A, Dardanelli L, Cussino P, Pomero G, Noello C, Sernia O, et al. Prognostic value of the acute DMSA scan in children with first urinary tract infection. Pediatr Nephrol 2001;16:800-4. 12. Pulliam PN, Attia MW, Cronan KM. C-reactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection. Pediatrics 2001; 108:1275-9. 13. Rauschkolb EN, Sandler CM, Patel S, Childs TL. Computed tomography of renal inflammatory disease. J Comput Assist Tomogr 1982;6:502-6. 14. Hoffman EP, Mindelzun RE, Anderson RU. Computed tomography in acute pyelonephritis associated with dia-
김미경외 : 응급의료센터에내원한급성신우신염환자에서초기 C-reactive Protein 과신장전산화단층촬영의유용성 / 561 betes. Radiology 1980;135:691-5. 15. Dalla-Palma L, Pozzi-Mucelli F, Pozzi-Mucelli RS. Delayed CT findings in acute renal infection. Clin Radiol 1995;50:364-70. 16. Gold RP, McClennan BL, Rottenberg RR. CT appearance of acute inflammatory disease of renal interstitium. AJR Am J Roentgenol 1983;141:343-9. 17. Lee JK, McClennan BL, Melson GL, Stanley RJ. Acute focal bacterial nephritis: emphasis on gray scale sonography and computed tomography. AJR Am J Roentgenol 1980;135:87-92.