Hypertension and nephrology

[Accredited continuing medical education]

JUNE 24, 2020

Hypertension and nephrology - 2020;24(03)

COMMENTS

0 comments

Further articles in this publication

Hypertension and nephrology

[Dear Reader]

KÉKES Ede, ALFÖLDI Sándor

Hypertension and nephrology

[Treatment of hypertension in patients with chronic renal failure]

SZLOVÁK Edina, SZILVESZTER Dolgos

[The prevalence of chronic renal failure and hypertension is steadily increasing worldwide. The risk of possible cardiovascular death in patient with advanced renal failure is greater than the risk of progression to end-stage renal failure. Therefore treating and achieving target blood pressure is important in order to slow renal function decline in parallel with cardiovascular risk reduction. However, guidelines do not specify a single blood pressure target to be achieved in patients with renal failure, but suggest evidence based, reno- and cardioprotective therapy. This paper summarizes the clinical practice of treating hypertension (drug and nondrug treatment, therapeutic algorithm, target value, effectiveness of therapy) in patients with chronic renal failure.]

Hypertension and nephrology

[Covid-19 and the kidney]

PATÓ Éva, DEÁK György

[Covid-19 pandemy has emerged from Wuhan, China in December 2019. The infection affects not only the lung but other organs such as the kidney, as well. The relation between Covid-19 infection and the kidney is bidirectional. On one hand, Covid-19 infection may cause kidney damage in 50-75% of the cases resulting in proteinuria, haematuria and acute kidney injury (AKI). The etiology of AKI is multifactorial. Main pathogenic mechanisms are direct proximal tubular cell damage, sepsis-related haemodinamic derangement, citokine storm and hypercoagulability. The virus enters proximal tubular cells and podocytes via the ACE2 receptor followed by multiplication in the lysomes and consequential cell lesion. Histopathology shows acute tubular necrosis and acute tubulointerstitial nephritis. AKI is a strong predictor of mortality in critically ill patients. On the other hand, the risk of Covid-19 infection and mortality is substantially increased in patients with chronic kidney disease – especially in those with a kidney transplant or on dialysis – due to their immunocompromised status. Among haemodialysis patients, infection may spread very easily due to the possibility of getting contacted in the ambulance car or at the dialysis unit. The mortality rate of patients on renal replacement therapy with Covid-19 infection is 20-35%. In order to avoid mass infection it is obligatory to employ preventive measures and implement restricions along with (cohors) isolation of infected patients. In Hungary, every dialysis or kidney transplant patient with Covid-19 infection should be admitted to dedicated Covid-19 wards.]

Hypertension and nephrology

[Hypertension and Covid-19 – Part I. Significance of age, underlying diseases, and ACEI/ARB therapy in hypertension and co-morbidities during SARS-Cov2 infection]

KÉKES Ede, SZÉKÁCS Béla, NAGY Judit, KOVÁCS Tibor

[The appearance of the Covid-19 epidemic in different continents shows specific clinical features. Confirmed infected patients are detectable from approximately 30 years, with a maximum between 40 and 70 years of age. At the same time, however, a significant proportion of those who die from the infection come from patients over 65 years. The prevalence and mortality rates of the hypertensive population show a very similar formation. Based on the data collected, it is not surprising that hypertension as the underlying disease in the Covid- 19 epidemic is the first in all analysis. A more precise analysis clarified that it is not hypertension per se, but co-morbidities and complications of hypertension that play a primary role behind large-scale mortality in old age, such as diabetes, coronary heart disease, stroke, heart failure, and chronic kidney disease. Data from China, North America, and Italy suggest that hypertension and diabetes – and in North America, pathological obesity – in infected patients actually only reflect the prevalence of these diseases in a given population. The presence of comorbidities (coronary artery disease, stroke, heart failure, arrhythmia, chronic kidney disease) – based on multivariate logistic regression analysis – presents a more risk for severe clinical course and mortality. Some recent analyses have provided strong evidence that ACEI/ARB treatment does not pose a higher risk for the course or outcome of infection. Their administration is constantly needed in hypertension and comorbidities due to their organ protective and slowing the progression of diseases.]

Hypertension and nephrology

[Systolic and diastolic blood pressure by height, BMI, gender and age between 14 and 18 years of age]

SZABÓ László, SCHEURING Noémi, GÁCSI Erika, KORMOS-TASI Judit

[The aim of the screening program was to investigate blood pressure levels in different ages according to obesity. Blood pressure, heart rate, body composition, bodyweight, height and BMI were assessed. 2202 adolescent (1326 girls, 876 boys) participated in the screening program. The mean systolic blood pressure of all screened adolescents was 126.34 ± 12.55 mmHg. Boy/girl values were 131.87 ± 13.59/117.49 ± 5.69 mmHg, p < 0.001. The mean diastolic blood pressure of all screened adolescents was 71.86 ± 8.74 mmHg. Boy/girl values were 72.61 ± 9.17/66.69 ± 5.04 mmHg, p < 0.001. The 50%, 90%, 95%, and 99% thresholds and cases for systolic, diastolic blood pressure, and the BMI and BodyFluid thresholds, detailed for 14–18 year olds, girls and boys, are tabulated. Systolic blood pressure (SBP) was over 99% in 12 girls (14- year-olds), 39 (15), 42 (16), 33 (17), 5 (18) to height. SBP was over 99% in 17 boys (14-year-olds), 73 (15), 100 (16), 33 (17), 5 (18) to height. It is emphasized that systolic blood pressure (SBP) is > 99% in 12 girls (14 years), 39 (15), 42 (16), 33 (17), 5 (18) to body height. SBP > 99% for 17 boys (14 years), 73 (15), 100 (16), 33 (17), 5 (18) to body height. Elevated diastolic values were associated with elevated systolic values, but less occurred. The percentage of high blood pressure was more frequent among boys and girls who were in the overweight group (58.6% and 18.6%). Normal blood pressure is higher in overweight and obese adolescents and is a significant risk factor for developing high blood pressure in young adulthood.]

All articles in the issue

Related contents

Clinical Neuroscience

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical Neuroscience

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations

EVRAN Sevket, KATAR Salim

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Lege Artis Medicinae

[A short chronicle of three decades ]

KAPRONCZAY Katalin

[Hungarian professional periodicals started quite late in European context. Their publish­ing, editing and editorial philosophy were equally influenced by specific historical and political situations. Certain breaking points of history resulted in termina­tion of professional journals (War of In­de­pendence 1848-1849, First and Se­cond World Wars), however there were pe­riods, which instigated the progress of sciences and founding of new scientific journals. Both trends were apparent in years after the fall of former Hungarian regime in 1990. The structure of book and journal publishing has changed substantially, some publishers fell “victim” others started successfully as well. The latters include the then-established publishing house Literatura Medica and its own scientific journal, Lege Artis Me­di­cinae (according to its subtitle: New Hun­garian Medical Herald) issued first in 1990. Its appearance enhanced significantly the medical press market. Its scientific publications compete with articles of the well-established domestic medical journals however its philosophy set brand-new trends on the market. Concerning the medical community, it takes on its problems and provides a forum for them. These problems are emerging questions in health care, economy and prevention, in close interrelation with system of public health institutions, infrastructure and situation of those providing individual health services. In all of them, Lege Artis Medicinae follows consequently the ideas of traditional social medicine.]

Lege Artis Medicinae

[Diagnosis and treatment of microvascular coronary heart disease. Specialities of conditions in Hungary]

SZAUDER Ipoly

[Invasive investigations show that in two-thirds of patients the myocardial ischaemia persists without obstructive coronary disease and any other heart conditions (INOCA). The underlying cause may be microvascular dysfunction (CMD) with consecutive microvascular coronary disease (MVD) and microvascular or epicardial vasospastic angina (MVA). The modern practice of clinical cardiology while using the developed non-invasive cardiac imaging permits exact measuring of the coronary flow with its characteristic indices. All of these improve the diagnosing of CMD-induced myocardial ischemia and provide opportunity to determine primary MVD cases. Since the recognition and treatment of MVD is significantly underrep­resented in the Hungarian medical care, the primary stable microvascular angina (MVA) is described in detail below with its modern invasive and non-invasive differential diagnosis and treatment, concerning especially its frequency provoked by high blood pressure and female coronary heart diseases. There are highlighted all recommended diagnostic procedures available under domestic conditions.]