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Han S, Choi H, Park H, Kim JJ, Lee EJ, Ham YR, Na KR, Lee KW, Chang YK, Choi DE. Omega-3 Fatty Acids Attenuate Renal Fibrosis via AMPK-Mediated Autophagy Flux Activation. Biomedicines 2023; 11:2553. [PMID: 37760994 PMCID: PMC10525956 DOI: 10.3390/biomedicines11092553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
The unilateral ureteral obstruction (UUO) injury model is well-known to mimic human chronic kidney disease, promoting the rapid onset and development of kidney injury. ω3-poly unsaturated fatty acids (PUFAs) have been observed to protect against tissue injury in many disease models. In this study, we assessed the efficacy of ω3-PUFAs in attenuating UUO injury and investigated their mechanism of action. The immortalized human proximal tubular cells human kidney-2 (HK2) were incubated for 72 h with docosahexaenoic acid (DHA) or eicosapentaenoic acid (EPA) in various concentrations, in the presence or absence of transforming growth factor (TGF)-β. DHA/EPA reduced the epithelial-mesenchymal transition in the TGF-β-treated HK2 cells by enhancing autophagy flux and adenosine monophosphate-activated protein kinase (AMPK) phosphorylation. C57BL/6 mice were divided into four groups and treated as follows: sham (no treatment, n = 5), sham + ω3-PUFAs (n = 5), UUO (n = 10), and UUO + ω3-PUFAs (n = 10). Their kidneys and blood were harvested on the seventh day following UUO injury. The kidneys of the ω3-PUFAs-treated UUO mice showed less oxidative stress, inflammation, and fibrosis compared to those of the untreated UUO mice. Greater autophagic flux, higher amounts of microtubule-associated protein 1A/1B-light chain 3 (LC3)-II, Beclin-1, and Atg7, lower amounts of p62, and higher levels of cathepsin D and ATP6E were observed in the kidneys of the omega-3-treated UUO mice compared to those of the control UUO mice. In conclusion, ω3-PUFAs enhanced autophagic activation, leading to a renoprotective response against chronic kidney injury.
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Affiliation(s)
- Suyeon Han
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (E.-J.L.); (Y.-R.H.); (K.-R.N.); (K.-W.L.)
| | - Hyunsu Choi
- Clinical Research Institute, Daejeon Saint Mary’s Hospital, Daejeon 34943, Republic of Korea;
| | - Hyerim Park
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea; (H.P.); (J.-J.K.)
| | - Jwa-Jin Kim
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea; (H.P.); (J.-J.K.)
| | - Eu-Jin Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (E.-J.L.); (Y.-R.H.); (K.-R.N.); (K.-W.L.)
| | - Young-Rok Ham
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (E.-J.L.); (Y.-R.H.); (K.-R.N.); (K.-W.L.)
| | - Ki-Rayng Na
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (E.-J.L.); (Y.-R.H.); (K.-R.N.); (K.-W.L.)
| | - Kang-Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (E.-J.L.); (Y.-R.H.); (K.-R.N.); (K.-W.L.)
| | - Yoon-Kyung Chang
- Department of Nephrology, Daejeon Saint Mary’s Hospital, Catholic University of Korea, Daejeon 34943, Republic of Korea
| | - Dae-Eun Choi
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (E.-J.L.); (Y.-R.H.); (K.-R.N.); (K.-W.L.)
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea; (H.P.); (J.-J.K.)
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Kim MJ, Jeon JW, Kim HR, Park H, Han S, Hwang Y, Park H, Park K, Lee EJ, Ham YR, Na KR, Lee KW, Choi DE. Ratio of Extracellular to Intracellular Water Is Associated with Permanent Catheter Patency Survival in Patients Receiving Maintenance Hemodialysis. Diagnostics (Basel) 2023; 13:2545. [PMID: 37568908 PMCID: PMC10417513 DOI: 10.3390/diagnostics13152545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/25/2023] [Accepted: 07/30/2023] [Indexed: 08/13/2023] Open
Abstract
Patients undergoing dialysis through a permanent catheter often experience infection or malfunction. However, few studies have clarified the predictors of permanent catheter patency survival in patients undergoing hemodialysis. We assessed the relationship between the parameters of body composition monitoring (BCM), determined before the initiation of dialysis, and the patency survival of the permanent catheters inserted in 179 patients who commenced hemodialysis between 14 January 2020 and 31 August 2021. The relationships between permanent catheter patency at 6 weeks and BCM parameters, laboratory tests, age, sex, comorbidities, and medications at baseline were studied using Kaplan-Meier survival curves. Permanent catheter patency was observed to be superior at high extracellular-to-intracellular (ECW/ICW) ratio (p < 0.005). After adjustment for covariates, the ECW/ICW ratio remained an independent factor associated with permanent catheter patency survival. When patients with non-patent catheters were subdivided into infection and malfunction groups, and the associations of BCM parameters were evaluated in those groups, the ECW/ICW ratio was not significantly associated with permanent catheter patency survival in the infection group (p = 0.327); instead, a significant association was found for the lean tissue index (p < 0.001). In the malfunction group, the ECW/ICW ratio remained significantly associated with permanent catheter patency survival (p < 0.001).
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Affiliation(s)
- Moo-Jun Kim
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea; (M.-J.K.); (J.-W.J.); (H.-R.K.)
| | - Jae-Wan Jeon
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea; (M.-J.K.); (J.-W.J.); (H.-R.K.)
| | - Hae-Ri Kim
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea; (M.-J.K.); (J.-W.J.); (H.-R.K.)
| | - Hyerim Park
- Department of Medical Science, Chungnam National University, Daejeon 35015, Republic of Korea;
| | - Suyeon Han
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
| | - Yunkyeong Hwang
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
| | - Heewon Park
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
| | - Kyungho Park
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
| | - Eu-Jin Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
| | - Young-Rok Ham
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
| | - Ki-Ryang Na
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
| | - Kang-Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
| | - Dae-Eun Choi
- Department of Medical Science, Chungnam National University, Daejeon 35015, Republic of Korea;
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea; (S.H.); (Y.H.); (H.P.); (K.P.); (E.-J.L.); (Y.-R.H.); (K.-W.L.)
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Han S, Kim MJ, Ko HJ, Lee EJ, Kim HR, Jeon JW, Ham YR, Na KR, Lee KW, Lee SI, Choi DE, Park H. Diagnostic and Prognostic Roles of C-Reactive Protein, Procalcitonin, and Presepsin in Acute Kidney Injury Patients Initiating Continuous Renal Replacement Therapy. Diagnostics (Basel) 2023; 13:diagnostics13040777. [PMID: 36832265 PMCID: PMC9955569 DOI: 10.3390/diagnostics13040777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
For reducing the high mortality rate of severe acute kidney injury (AKI) patients initiating continuous renal replacement therapy (CRRT), diagnosing sepsis and predicting prognosis are essential. However, with reduced renal function, biomarkers for diagnosing sepsis and predicting prognosis are unclear. This study aimed to assess whether C-reactive protein (CRP), procalcitonin, and presepsin could be used to diagnose sepsis and predict mortality in patients with impaired renal function initiating CRRT. This was a single-center, retrospective study involving 127 patients who initiated CRRT. Patients were divided into sepsis and non-sepsis groups according to the SEPSIS-3 criteria. Of the 127 patients, 90 were in the sepsis group and 37 were in the non-sepsis group. Cox regression analysis was performed to determine the association between the biomarkers (CRP, procalcitonin, and presepsin) and survival. CRP and procalcitonin were superior to presepsin for diagnosing sepsis. Presepsin was closely related to the estimated glomerular filtration rate (eGFR) (r = -0.251, p = 0.004). These biomarkers were also evaluated as prognostic markers. Procalcitonin levels ≥3 ng/mL and CRP levels ≥31 mg/L were associated with higher all-cause mortality using Kaplan-Meier curve analysis. (log-rank test p = 0.017 and p = 0.014, respectively). In addition, procalcitonin levels ≥3 ng/mL and CRP levels ≥31 mg/L were associated with higher mortality in univariate Cox proportional hazards model analysis. In conclusion, a higher lactic acid, sequential organ failure assessment score, eGFR, and a lower albumin level have prognostic value to predict mortality in patients with sepsis initiating CRRT. Moreover, among these biomarkers, procalcitonin and CRP are significant factors for predicting the survival of AKI patients with sepsis-initiating CRRT.
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Affiliation(s)
- Suyeon Han
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Moo-Jun Kim
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Ho-Joon Ko
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Eu-Jin Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Hae-Ri Kim
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea
| | - Jae-Wan Jeon
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea
| | - Young-Rok Ham
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Ki-Ryang Na
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Kang-Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Song-I. Lee
- Department of Pulmonary and Critical Care Medicine, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
- Correspondence: (S.-I.L.); (D.-E.C.)
| | - Dae-Eun Choi
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea
- Correspondence: (S.-I.L.); (D.-E.C.)
| | - Heyrim Park
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Republic of Korea
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Lee EJ, Hwang HB, Han SH, Ham YR, Shin JA, Lee KW, Na KR, Choi DE. Serum Growth Differentiation Factor-15/Albumin Ratio as a 2-Year Survival Marker of End-Stage Renal Disease Patients Initiating Maintenance Hemodialysis. Diagnostics (Basel) 2022; 12:diagnostics12020257. [PMID: 35204349 PMCID: PMC8870838 DOI: 10.3390/diagnostics12020257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/07/2022] [Accepted: 01/19/2022] [Indexed: 02/01/2023] Open
Abstract
It is important to identify risk factors related to mortality in end-stage renal disease (ESRD) patients starting renal replacement therapy. Recently, several studies proposed that growth-differentiation factor-15 (GDF-15) is a possible biomarker for the prognosis of patients on maintenance hemodialysis. Here, we investigated the predictive value of serum GDF-15/Albumin ratio on two-year mortality in ESRD patients initiating maintenance hemodialysis. The study was a single center, retrospective study on ESRD patients starting maintenance hemodialysis with a follow-up of two years. All patients completed laboratory test and bioimpedance spectroscopy prior to the initiation of the first dialysis. The patients were stratified into quartiles according to the quartiles of serum GDF-15/Albumin ratio. Among the 159 patients, the mean age was 61.78 ± 12.52 years and median survival was 20.03 ± 7.73 months. The highest GDF-15/Albumin quartile was significantly more associated with the increased risk of all-cause mortality than other quartiles (unadjusted hazard ratio (HR): 8.468, 95% CI 2.981–24.054, p < 0.001). Older age and a higher overhydration state were associated with GDF-15/Albumin ratio. The ROC analysis confirmed that the ability of the GDF-15/Albumin ratio to predict mortality was superior to GDF-15 or albumin alone. In conclusion, the GDF-15/Albumin ratio measured at the initial maintenance hemodialysis is an independent prognostic marker of two-year mortality in ESRD patients.
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Affiliation(s)
- Eu-Jin Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea; (E.-J.L.); (H.-B.H.); (S.-H.H.); (Y.-R.H.); (K.-W.L.)
| | - Haet-Bit Hwang
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea; (E.-J.L.); (H.-B.H.); (S.-H.H.); (Y.-R.H.); (K.-W.L.)
| | - Soo-Hyun Han
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea; (E.-J.L.); (H.-B.H.); (S.-H.H.); (Y.-R.H.); (K.-W.L.)
| | - Young-Rok Ham
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea; (E.-J.L.); (H.-B.H.); (S.-H.H.); (Y.-R.H.); (K.-W.L.)
| | - Jin-Ah Shin
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Korea;
| | - Kang-Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea; (E.-J.L.); (H.-B.H.); (S.-H.H.); (Y.-R.H.); (K.-W.L.)
| | - Ki-Ryang Na
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea; (E.-J.L.); (H.-B.H.); (S.-H.H.); (Y.-R.H.); (K.-W.L.)
- Correspondence: (K.-R.N.); (D.-E.C.)
| | - Dae-Eun Choi
- Department of Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea; (E.-J.L.); (H.-B.H.); (S.-H.H.); (Y.-R.H.); (K.-W.L.)
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Korea;
- Correspondence: (K.-R.N.); (D.-E.C.)
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Kim HR, Jeon JW, Bae HJ, Shin JA, Ham YR, Na KR, Lee KW, Choi DE, Hyon YK. Body Fat Plays an Important Role in of Bioimpedance Spectroscopy-Based Dry Weight Measurement Error for Patients with Hemodialysis. Diagnostics (Basel) 2021; 11:diagnostics11101907. [PMID: 34679605 PMCID: PMC8535067 DOI: 10.3390/diagnostics11101907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/04/2021] [Accepted: 10/14/2021] [Indexed: 12/02/2022] Open
Abstract
Accurate dry weight (DW) estimation is important for hemodialysis patients. Although bioimpedance spectroscopy (BIS) is commonly used to measure DW, the BIS-based DW frequently differs from the clinical DW. We analyzed the characteristics of patients whose BIS-based DWs were over- and underestimated. In this retrospective cohort study, we evaluated 1555 patients undergoing maintenance hemodialysis in Chungnam National University Hospital. The gap (DWCP-BIS) was calculated by comparing the BIS and clinical DWs. We analyzed the clinical characteristics of patients with positive (n = 835) and negative (n = 720) gaps. Compared with other patients, the DWCP-BIS-positive group had higher extracellular water (ECW) level and extracellular/intracellular water index (E/I) and had lower weight, body mass index (BMI), lean tissue index (LTI), fat tissue index (FTI), fat mass (FAT), and adipose tissue mass (ATM). The DWCP-BIS-negative group exhibited elevated BMI, FTI, FAT, and ATM; however, it had lower height, ECW, and E/I. Linear regression analysis revealed that FAT significantly predicted DWCP accuracy. The clinical DW of patients with a low fat mass tended to be underestimated, while the clinical DW of patients with comparatively large fat reserves tended to be overestimated. These characteristics will aid in the reduction of BIS-based DW errors.
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Affiliation(s)
- Hae-Ri Kim
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Korea; (H.-R.K.); (J.-W.J.)
| | - Jae-Wan Jeon
- Department of Nephrology, Chungnam National University Sejong Hospital, Sejong 30099, Korea; (H.-R.K.); (J.-W.J.)
| | - Hong-Jin Bae
- Department of Nephrology, Cheongju St. Mary’s Hospital, Cheongju 28323, Korea;
| | - Jin-Ah Shin
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Korea;
| | - Young-Rok Ham
- Nephrology, Medical School, Chungnam National University, Daejeon 35015, Korea; (Y.-R.H.); (K.-R.N.); (K.-W.L.)
| | - Ki-Ryang Na
- Nephrology, Medical School, Chungnam National University, Daejeon 35015, Korea; (Y.-R.H.); (K.-R.N.); (K.-W.L.)
| | - Kang-Wook Lee
- Nephrology, Medical School, Chungnam National University, Daejeon 35015, Korea; (Y.-R.H.); (K.-R.N.); (K.-W.L.)
| | - Dae-Eun Choi
- Department of Medical Science, Medical School, Chungnam National University, Daejeon 35015, Korea;
- Nephrology, Medical School, Chungnam National University, Daejeon 35015, Korea; (Y.-R.H.); (K.-R.N.); (K.-W.L.)
- Correspondence: (D.-E.C.); (Y.-K.H.)
| | - Yun-Kyong Hyon
- Division of Industrial Mathematics, Data Analytics Team, National Institute for Mathematical Sciences, Daejeon 34047, Korea
- Correspondence: (D.-E.C.); (Y.-K.H.)
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Ryu S, Oh SK, Son SH, Jeong WJ, You YH, Ham YR. Reversible Acute Blindness in Suspected Metformin-Associated Lactic Acidosis. J Emerg Med 2019; 57:e153-e156. [PMID: 31591073 DOI: 10.1016/j.jemermed.2019.06.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/05/2019] [Accepted: 06/29/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Metformin is commonly used for the treatment of type 2 diabetes mellitus. Renal insufficiency is one of the contraindications for its use. Inadvertent prescription in patients with renal insufficiency may lead to metformin-associated lactic acidosis (MALA), which is associated with a high risk of mortality. Consequently, the early recognition and management of MALA is essential. CASE REPORT We present the case of a 68-year-old man who had reversible blindness resulting from severe lactic acidosis. On presentation, he was alert, oriented, and had no complaints except mild abdominal discomfort and blindness. He denied any history of trauma or drug abuse. The results of the laboratory studies showed severe metabolic acidosis with a high anion gap and increased levels of serum creatinine. There were no predisposing ocular or neurologic lesions that could have induced the blindness. Although the blood levels of methanol, ethanol, and metformin were not estimated, correction of acidosis and hemodialysis led to a complete recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rarely, transient blindness may occur in patients with fatal severe metabolic acidosis. Evaluation for the presence of metabolic acidosis and a detailed medical history are essential in the management of acute blindness in such patients.
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Affiliation(s)
- Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Se-Kwang Oh
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Seung-Ha Son
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Won-Joon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Yeon-Ho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Young-Rok Ham
- Department of Nephrology, Chungnam National University Hospital, Daejeon, Republic of Korea
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