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.]

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

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[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.]

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Clinical Neuroscience

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[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.]