정상인 및 급성취장염환자에 있어서의 amylase-creatinine clearance ratio에 관한 연구
Study on the amylase-creatinine clearance ratio in normal adults and patients with acute pancreatitis
급성취장염에 있어서 amylase-creatinine clearance의 비(Cam/Car) 진단적가치를 규명하기 위하여 정상인 42예와 급성취장염환자 26예, 만성취장염환자 5예 및 기타질환환자 51예에 대해서 Cam/Ccr을 측정하여 다음과 같은 결론을 얻었다.
급성취장염환자에서 발병후 48시간 이내에는 전예에서 혈청 amylase 치의 증가를 보였으나 발병후 48시간-7일사이에는 혈청 amylase 치는 26예중 12예서, 뇨 amylase 배설량은 11예에서 정상치를 보였다.
이에 비하여 Cam/Ccr 치는 발병후 48시간-7일사이에 평균치가 4.55±1.30%로서 정상인의 평균치보다 2.8배 증가되었으며, 정상치를 보인 경우가 3예에 불과하여 혈청 amylase치와 뇨 amylase 배설량의 측정보다도 진단적가치가 높았다.
또한 만성취장염이나 기타질환에 있어서 혈청 amylase 치 및 뇨 amylase 배설량은 정상치 보다 증가된 경우가 있었으나 Cam/Car은 모두 정상범위였다.
따라서 급성취장염의 감별진단에 있어서 혈청 amylase 치와 뇨 amylase 배설량을 측정함과 동시에 Cam/Car을 산정함으로써 진단의 정확성을 높일 수 있으리라고 생각된다.
Since it has become well established that an elevated serum amylase level is the "since qua non" of a valid diagnosis of acute pancreatitis, this laboratory precedure has been accepted as an essential part of the routine workup of the acute abdominal case. As data has accumulated and been analyzed, a considerable number of published reports have stressed that not only is the serum amylase elevated in many non-pancreatic conditions, but the elevation is noted only for a limited time after the attack of acute pancreatitis.
Though much has been written about urinary amylase, the data and conclusions are conflicting, and in consequence urinary amylase excretion is infrequently used in practice. Urinary excretion of amylase has been shown to be increased and to remain
elevated for several days after the return of serum amylase levels to normal in patients with acute pancreatitis. It has also been found that the renal clearance of amylase tends to be greatly increased and is relatively greater than that of creatinine in patients with acute pancreatitis.
In 1969, Levitt, Rapoport, and Cooperband suggested an ingenious device whereby renal clearance of amylase expressed as a percentage of simultaneous creatinine clearance(Cam/Ccr) not only rose in acute pancreatitis to levels several times higher than normal, but also included, within the index ratio, information concerning the serum amylase, the urinary amylase and the state of renal function to minimize irrelevant changes due to variations in renal function. Whether the increased amylase clearance is specific for pancreatitis or whether it also occurs
in other conditions that can be associated with elevated serum amylase levels is not known. But from their study of normal subjects and patients with acute pancreatitis, they concluded that determination of the Cam/Ccr ratio would enhance the diagnostic value of amylase determinations.
The present investigation reports an analysis of serum amylase, urinary amylase and derived Cam/Ccr ratio in 42 normal controls and 26 patients with acute pancreatitis, 5 with chronic pancreatitis and 51 with non-pancreatic disease, including 15 with acute cholecystitis, 17 with liver disease and 19 with peptic ulcer at the Yonsei University College of Medicine and Severance Hospital from March, 1975 through September, 1975.
1. In 42 normal subjects, the mean Cam/Ccr ratio was 1.75±0.76%(mean±S.D.), the serum amylase 126±26 units and the urinary amylase 269±171 units per 2 hours/ Reasonable upper ranges of normalcy can be established for these parameters, i.e.:
Serum Amylase 178 units
Urinary amylase 611 units per 2 hours
2. In 26 patients with acute pancreatitis, the serum amylase was elevated in all subjects who could be studied before 48 hours after the attack, and from 48 hours to the seventh day, the serum amylase was decreased to 195 units, but still higher than normal(p<0.01).
The urinary amylase and Cam/Ccr ratio which were studied from 48 hours to the seventh day along with the serum amylase were also elevated to 930 units per 2 hours and 4.55% respectively(p<0.01).
The serum amylase and urinary amylase returned to normal in 12 and 11 patients respectively after 48 hours of acute pancreatitis. In contrast, only three of 26 patients with acute pancreatitis had a Cam/Ccr ratio below 3.27%.
3. In chronic pancreatitis, even the serum amylase rose significantly (mean; 293 units, p<0.01) during an acute recurrent attack, the urinary amylase and Cam/Ccr ratio remained within normal range in all 5 patients.
4. In patients who may have symptoms similar to acute pancreatitis without pancreatic disease, the mean serum amylase, urinary amylase and Cam/Ccr ratio were all within normal range. Though the serum amylase and/or urinary amylase may rose occasionally, the Cam/Ccr ratio disclosed normal levels in all patients.
This observation suggests that the renal permeability to amylase is altered in only acute pancreatitis among the conditions which may reveal similar symptoms of acute pancreatitis, and provides a basis for using the Cam/Cor ratio in the differential diagnosis of hyperamylasemia.