Hypertension and nephrology

[Acute heart failure and acute renal injury: pathophysiology and management of cardiorenal syndrome type 1]

LÁSZLÓ Ágnes, ÁCS Tamás, JÁRAI Zoltán

DECEMBER 30, 2012

Hypertension and nephrology - 2012;16(06)

[The functional connection between heart and kidney is well known. Several types of this relationship have been recently characterized as cardiorenal syndromes. The relevance of this relationship in clinical practice is supported by the fact, that the consequences of the primary dysfunction are profoundly influenced by the magnitude and the treatment possibilities of the secondary dysfunction. Moreover, the administered therapy for heart failure can deteriorate renal hemodinamics, or side effects of the treatment can lead to the worsening of the clinical picture. Loop diuretics decrease venous congestion, but also induce neurohormonal activation and a decrease in glomerular filtration rate. The body of positive evidence with the use of mineralocorticoid receptor antagonists in acute settings is limited. Inotropic agents on the one hand improve hemodinamics, on the other hand increase the danger of arrhythmia and mortality (levosimendan seems to be an exception). Aquaretics decrease symptoms without influencing mortality. The natriuretic peptide neseritid improved clinical symptoms, but did not improve endpoints in clinical trials. Vasodilators improve hemodinamics, but their usefulness is limited because of their profound hypotensive effect. The effectiveness and benefits of ultrafiltration has to be tested in more clinical trials. Because of such treatment difficulties the management of these patients is a complex task that needs the involvement of intensive therapeutic specialists, nephrologists and cardiologists. This review focuses on the pathophysiology and possible management of the patients with acute heart failure with acute kidney injury, called type 1 cardiorenal syndrome from the cardiologist’s point of view.]



Further articles in this publication

Hypertension and nephrology

[The apparatus which controls our kidney too. Part 2 - Structure and function of the juxtaglomerular apparatus]


[The juxtaglomerular apparatus is comprised of the macula densa (a specialregion of the distal tubule), the renin producing granular or epithelioid-cells of the afferent arteriole, the extraglomerular mesengial cells, and the efferent arteriole’s section bordering this region. Somewhat more general definitions also exist. Recently, distinctive morphological and functional associations have been identified between the components of the JGA and some common mediators (e.g. adenosine, angiotensin, NO, prostaglandins, etc.). Current data suggest that each cell of the macula densa also contain few cilia that may have a role in sensing fluid flow. The distal section of the afferent arteriole (possessing the same structure as the glomerular capillaries) is covered by fenestrated endothelium. Trace dose of ferritin particles can pass through the afferent arteriole’s fenestrae into the interstitium of the JGA due to the considerable hydrostatic pressure gradient. The parietal lamina of Bowman’s capsule, which covers the renin granulated cells of the afferent arteriole behaves much like the visceral lamina in that the epithelial cells of the parietal lamina exhibit foot processes and filtration slits. The urinary space is regularly bulging into the extraglomerular mesangium. Therefore, the notion has been refuted that the JGA, which contains neither blood nor lymph capillaries, is a closed system engaging in only slow fluid exchange. Furthermore it is affirmed that the afferent arteriole consists of two morphologically and functionally disparate segments, the ratio of which is considerably modified by the activity of the renin-angiotensin system.]

Hypertension and nephrology

[The improvement of the rate of reaching the target blood pressure and the quality of care of hypertensive patients with applying telemedicine facilities]

KISS István, KÉLES Ede

[The authors summarize the facilities of the telemedicine and telemonitoring system. The methods of telemedicine and their combination with home blood pressure measurement or the help of a nurse or pharmacist are reviewed. In the light of the latest results the authors are led to the conclusion that the intensive spread of using the facilities of telemedicine is necessary in the present-day Hungarian healthcare system. At the same time it is also determined that the methodical and technical potential is not enough to further enhance the efficiency in itself. The personal contact and the possibility of interactive monitoring from distance are definitely crucial for the continuous maintenance of the reached target blood pressure in patients suffering from hypertension and also for the augmentation of patient adherence regarding applying medicine.]

Hypertension and nephrology

[Blood pressure self-measurement with telemonitoring technology]

KÉKES Ede, KISS István, SAMU Antal, SZEGEDI János, MEZEI Rudolf

[Authors present the guidelines, indications and utility value of home selfmeasurements of blood pressure. They report the results of the most important clinical studies. They analyze the methodology of the measurements within telemedicinal solutions and describe the consultative scopes associated with the measurement methods already applied in clinical practice. Their own telemonitoring system - called Medistance - is then presented. They have created three modules for the long term registration of blood pressure in hypertensive patients: 1. an individual module for the hypertensive patients, the elderly, the family, for patients with high cardiovascular risk and for the physicians. 2. a module for the pharmaceutical care, 3. a module for the communities (social homes, club for the elderly, etc.). The Medistance system is functioning for two years in our count]

Hypertension and nephrology

[Molecular mechanisms leading to renal fibrosis: the origin of myofibroblasts]

HIMER Leonóra, SZIKSZ Erna, KOVÁCS S. Krisztián, ÓNODY Anna, Reusz Anna, REUSZ György, FEKETE Andrea, TULASSAY Tivadar, VANNAY Ádám

[There are about a quarter of million patients who need chronic renal replacement therapy in Europe, and the estimated number of patients with chronic kidney disease is about tenfold higher. Interestingly, regardless of the initiating cause the mechanism of fibrosis is similar to each other in the different chronic kidney diseases. In general, the damaged glomerular or tubular cells release danger signals and produce chemotactic stimuli, which trigger the rapid recruitment of leukocytes. The infiltrating immune cells and the damaged renal cells then produce high levels of proinflammatory cytokines, growth factors, chemokines and adhesion molecules which contribute to glomerular/tubular injury, accumulation of further leukocytes and myofibroblasts, which are the effector cells of renal fibrosis. However the origin of myofibroblasts is still controversial. Recent hypotheses suggest that they are originated from different renal cells, such as epithelial and endothelial cells, pericytes or bone marrow derived fibrocytes. The myofibroblasts thus generated serve as key cellular mediators of renal fibrosis. Myofibroblasts have migratory capacity, are resistant to apoptosis, produce several growth factors and cytokines and according to our present knowledge these cells are the main source of collagen-I and -III rich extracellular matrix in the fibrous tissue. Organ fibrosis is characterized with excessive deposition of extracellular matrix leading to glomerular sclerosis and renal tubulointerstitial fibrosis. The excessive deposition of fibrous tissue replaces healthy kidney tissue; nephrons disappear and kidney function declines gradually. In this article the knowledge is summarized on the molecular changes leading to the generation of renal myofibroblasts.]

Hypertension and nephrology

[Professor István Vas MD, Who Changed the Outcome of Peritoneal Dialysis]


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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.]

Clinical Neuroscience

Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

Hypertension and nephrology

[About the care of patients with hyperuricaemia and gout]

[This consensus document is intended to provide guidance for the effective and efficient treatment of asymptomatic individuals with high uric acid levels and gout patients.]

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.]