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ȯÀÚ¾ÈÀü °­¿¬Â÷ »ï¼ºÃ¢¿øº´¿ø¿¡ ´Ù³à¿Ô½À´Ï´Ù.


1. Management of diabetic nephropathy (»ï¼ºÃ¢¿øº´¿ø ½ÅÀå³»°ú ÀÌÀ¯Áö)

Albuminuria ¾øÀÌ diabetic nephropathy°¡ ¿Ã ¼ö ÀÖ½À´Ï´Ù.

Reasons for decreased GFR in adults with type 2 DM who do not have albuminuria
- Age-associated renal senescece
- Intestinal fibrosis
- Ischemic vascular disease, such as atherosclerotic imvolvement of renal artery
- Cholesterol microemboli
- Previous use of RAS blokade

CKD ȯÀÚ´Â hypoglycemia À§ÇèÀÌ ³ô½À´Ï´Ù.

´ç´¢º´¼º ½Åº´Áõ ȯÀÚ¿¡¼­ metformin »ç¿ëÀº lactic acidosis À§ÇèÀÌ ³ô½À´Ï´Ù. Lactic acidosis´Â µå¹°Áö¸¸ ÀÏ´Ü ¹ß»ýÇÏ¸é »ç¸Á·üÀÌ 45-48%ÀÏ Á¤µµ·Î À§ÇèÇÕ´Ï´Ù. ¹Ì±¹ FDA¿¡¼­´Â creatinine 1.4-1.5 ÀÌ»óÀ̸é metformin Áß´ÜÀ» ±ÇÇÕ´Ï´Ù. ¿µ±¹¿¡¼­´Â Á¶±Ý ´À½¼ÇÑ ÀÔÀåÀ» °¡Áö°í Àִµ¥, GFR 30 ÀÌÇÏ¿¡¼­ metformin Áß´ÜÀ» ±ÇÇÏ°í ÀÖ½À´Ï´Ù.

The role of dietary protein restriction is uncertain in diabetes.

Ç÷´ç Á¶ÀýÀÌ Áß¿äÇÒ±î¿ä, Ç÷¾Ð Á¶ÀýÀÌ Áß¿äÇÒ±î¿ä?
- Normoalbuminuria to microalbuminuria: glucose control >> BP control
- Microalbuminuria and/or macroalbuminuria: BP control >> glucose control

Non-diabetic renal disease (NDRD) with or without diabetic nephropathy: typical diabetic nephropathy ȯÀÚÀÇ 35-78%¿¡¼­ microscopic hematuria°¡ µ¿¹ÝµË´Ï´Ù. ±× ¿øÀÎÀ¸·Î IgA nephropathy°¡ »ó´çÈ÷ ÈçÇÕ´Ï´Ù. ¾Æ·¡ÀÇ °æ¿ì¿¡ ÀǽÉÇغ¸¾Æ¾ß ÇÕ´Ï´Ù.

Major clinical clues suggesting the presence of NDRD
- Acute onset of renal disease; acue onset of proteinuria, progressive decline in renal function
- Actie urine sediment containing red cells and cellular casts
- Short duration of diabetes (<5 years)
- Absence of diabetic retinopathy in especially type 1 diabetes
- Presence of other systemic disease (e.g. HS purpura)
- Significant reduction in the GFR (>30%) within two to three months of the administration of ACEi or ARB


2. Á¶ÀýµÇÁö ¾Ê´Â Ç÷´ç - ´ÙÀ½ ½ºÅÜÀº ¹«¾ùÀΰ¡? (»ï¼ºÃ¢¿øº´¿ø ³»ºÐºñ³»°ú ¹èÁöö)

TargetÀ» Á¤ÇÏ°í, ÃʱâºÎÅÍ effectiveÇÏ°Ô Ä¡·áÇսôÙ. Glucose toxicity·Î ÀÎÇÏ¿© beta-cell functionÀÌ ¶³¾îÁö´Â °ÍÀ» ¸·¾Æ¾ß ÇÕ´Ï´Ù.

Barriers to effective glucose management
1) Conservative management
- Ineffective diet/exercise initiative
- Delayed efficacy due to a slow traditional stepwise approach
- Suboptimal helathcare systems impede achievement of glycemic goals
2) Lack of perceived efficacy
- Insufficient communication with patients
- Poor adherence to antidiabetic regimens
3) Lack of knowledge of underlying pathophysiology
- Inappropriate prescription of medication

2015-2016³â ±Þ¿© º¯È­
- Àν¶¸° Æ÷ÇÔ ÀÚÀ¯·Î¿î 3Á¦ º´ÇÕ¿ä¹ý º¸ÇèÀû¿ë (¾ÆÁ÷ SGLT2 inhibitor´Â Á¦ÇÑÀÌ ¾øÀ½)
- Dapagliflozin + metformin + SU (±Þ¿©ÀÎÁ¤: 2016³â 1¿ù 1ÀÏ)
- Dapagliflozin + metformin + insulin ±Þ¿©ÀÎÁ¤
- GLP-1 agonist¿¡ ´ëÇÑ BMI ±âÁØ ¿ÏÈ­ (BMI 30 → 25 kg/m2)
- ´çÈ­Ç÷»ö¼Ò ±Þ¿©±âÁØ È®´ë ¹× ½É»ç±âÁØ ¾ÈÈ­: 2015³â 8¿ù 1ÀϺÎÅÍ 2°³¿ù °£°Ý °Ë»ç °¡´É
- ´ç´¢º´ °ü¸® Çʼö ¼Ò¸ðÇ°ÀÇ º¸À强 È®´ë: Àν¶¸°À» Åõ¿©ÇÏ´Â ¸ðµç ȯÀÚ·Î È®´ë. Ç°¸ñµµ Ç÷´ç ÃøÁ¤ ½ÃÇèÁö, äÇ÷ħ, Àν¶¸° ÁÖ»ç±â, Àν¶¸° Ææ ´Ïµé±îÁö


3. °©»ó¼± ¾Ï ¼ö¼úÀû Ä¡·á (»ï¼ºÃ¢¿øº´¿ø ¿Ü°ú ÀÌÁØÈ£)

¿ì¸®³ª¶ó ¼Ò¾Æ ¹× û¼Ò³â °©»ó¼±¾Ï ¹ß»ý·üÀº Áõ°¡ÇÏ°í ÀÖ½À´Ï´Ù. »ï¼º¼­¿ïº´¿ø ¼Ò¾Æ ¹× û¼Ò³â °©»ó¼±¾Ï Áø´Ü °æ·Î´Â (1) Á¾¾çÀÌ ¸¸Á®Áü (69%), (2) ´Ù¸¥ ÁúȯÀÇ Ä¡·á µµÁß (19%), (3) ÃÊÀ½ÆÄ °Ë»ç (12%) ¼øÀ̾ú½À´Ï´Ù.

2015³â ´ëÇÑ °©»ó¼± ³»ºÐºñ ¿Ü°ú °¡À̵å¶óÀÎ graft
- ¸ðµç Áø´ÜµÈ °©»ó¼±¾ÏÀº ¼ö¼úÀÌ ÀÏÂ÷ Ä¡·áÀÌ´Ù.
- 0.5 cm ¹Ì¸¸ÀÇ °©»ó¼± ¹Ì¼¼ À¯µÎ¾Ï¿¡¼­´Â ȯÀÚ¿¡°Ô ÃæºÐÇÑ Á¤º¸¸¦ Á¦°øÇÑ ÈÄ ¼±ÅÃÀûÀ¸·Î Áø´Ü ÈÄ ¹Ù·Î ¼ö¼úÇÏÁö ¾Ê°í ÀÏÁ¤ ±â°£ °æ°ú°üÂû ÇÏ´Â °ÍÀÌ °¡´ÉÇÏ´Ù.
- 1 cm ÀÌ»óÀÇ ºÐÈ­ °©»ó¼±¾Ï ȯÀÚÀÇ Ãʱ⠼ö¼úÀº °©»ó¼±ÀüÀýÁ¦¼ú ȤÀº °©»ó¼±±ÙÀüÀýÁ¦¼úÀ» ½ÃÇàÇÏ´Â °ÍÀ» Àû±ØÀûÀ¸·Î ±Ç°íÇÑ´Ù.
- 1 cm ¹Ì¸¸ÀÇ ´ÜÀÏ º´¼Ò ºÐÈ­ °©»ó¼±¾ÏÀÌ µÎ°æºÎ¿¡ ¹æ»ç¼± Á¶»ç·Â°ú 1¼¼´ë ³»¿¡ ºÐÈ­ °©»ó¼±¾ÏÀÇ °¡Á··ÂÀÌ ¾ø°í °©»ó¼± ³»¿¡ ±¹ÇѵǾî ÀÖ°í, ÁÖº¯ °æºÎ ¸²ÇÁÀý ÀüÀÌ°¡ ¾ø´Â ȯÀÚÀÇ Ãʱ⠼ö¼úÀº °©»ó¼±¿±ÀýÁ¦¼úÀ» Àû±ØÀûÀ¸·Î ±Ç°íÇÑ´Ù.

Oncoplastic thyroid surgery: (1) trans-axillary approach, (2) bilateral axillo-breast approach (BABA surgery)


[ÀÌÁØÇà comment]

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4. Common GI cause of RLQ abdominal pain (»ï¼ºÃ¢¿øº´¿ø ¿µ»óÀÇÇаú ±èÀç¼ö)

RLQ pain
Appendicitis
Diverticulitis
Epiploic appendagitis
Omental infarction
Transient small bowel intussusception
Enterocolitis
Mesenteric lymphadenitis


[References]

1) ¼º±Õ°ü´ëÇб³ â¿øº´¿ø ³»°ú ¿¬¼ö°­Á 2016

2) ¼º±Õ°ü´ëÇб³ â¿øº´¿ø ³»°ú ¿¬¼ö°­Á 2017

© ÀÏ¿ø³»½Ã°æ±³½Ç ¹Ù¸¥³»½Ã°æ¿¬±¸¼Ò ÀÌÁØÇà. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.