Hypertension and nephrology

[Article Reports]

VÁLYI Péter

OCTOBER 20, 2013

Hypertension and nephrology - 2013;17(03-04)

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Hypertension and nephrology

[Nutritional status of hemodialysis patients, and the role of dietician in the complex care of renal patients]

POLNER Kálmán, KOVÁCS Lívia, HARIS Ágnes

[In chronic renal failure severe cardiovascular complications develop, which are the cause of death in 50% of the patients. According to recent results, behind the accelerated atherosclerosis, malnutrition and inflammation, developing in patients with chronic renal failure, play significant role. Malnutrition and inflammation show close relationship to the serum albumin level, which is an independent predictor of mortality. Authors studied the nutritional parameters of 94 chronically hemodialysis patients. Patients had been dialysed for more than three months, for 3×4-4.5 hours weekly. Among them 36% had diabetes. According to BMI (body mass index) 42.5% of the patients was normally nourished (20-24 kg/m2), 11.7% of them had malnutrition, 28.7% was overweight, and 17.1% was mildly or moderately obese. Subjective Global Assessment (SGA), calculated by dietician, revealed, that 47.9% of the patients has normal nutritional condition, all the others had some degree of malnutrition. Serum albumin level showed close correlation with the nutritional status, also with an inflammatory marker, the CRP. Only 63.8% of the patients had higher than 40g/l serum albumin. Those, who had higher than 10 mg/l CRP value, had significantly lower serum albumin (38.7±3.4 g/l), comparing to the albumin of the patients, whose CRP was below 10 mg/l (40.5±3.9 g/l, p=0.04). Comparing anthropometrical data, there was no significant difference between diabetic and non-diabetic patients. Grouping patients by their ages, the malnutrition, defined by SGA scores and by serum albumin level, was significantly worse in patients older than 80 years, than in the younger than 50 years old subjects, which signals increased risk of mortality of the elderly patients. A case presentation demonstrates, that malnutrition can be diagnosed at early stage by appropriate nutritional assessment, and it can be corrected by timely and satisfactory energy- and nutrient-substitution, in severe cases by specially prepared nutritional supplements, and thereby the patient’s severe cardiovascular risk can be ameliorated. The successful treatment of hemodialysis patients requires change in medical practice, and close cooperation between physicians and dieticians.]

Hypertension and nephrology

[Recommendation on the Medical Investigation and Treatment of Kidney Stone Disease]

TISLÉR András, MÁTYUS János

Hypertension and nephrology

[Comparative Efficacy of Angiotensin Receptor Blockers in the Prevention of Macrovascular Disease in Diabetic Patients: a Population-Based Cohort Study]

LIPTÁK Judit

Hypertension and nephrology

[Report on the 7th National Psychonephrology and Rehabilitation Conference and the 4th National Psychosocial Resort Nurse Training in Gánt]

MUCSI István, POLNER Kálmán

Hypertension and nephrology

[Therapeutic apheresis in pediatry]

TÚRI Sándor, BERECKI Csaba, HASZON Ibolya, PAPP Ferenc

[The possible mechanisms of therapeutic plasma mexchange: 1. the removal of circulatory plasma factor (anti Gbm disease, myasthenia gravis, Guillain Barré syndrome), 2. monoclonal antibody (Waldenström macroglobulinemia, myeloma protein), 3. circulatory immuncomplexes cryoglobulinaemia, myeloma protein, SLE), 4. alloantibody, 5. toxic factor, 6. replacement of a specific plasma factor, 7. a repear of the function of reticulo-endothelial system, 8. the removal of the inflammatory mediators, 9. the changes of the ratio of antigen-antibody which makes immuncomplexes more soluble, 10 stimulation of lymphocyte clones for supporting the cytotoxic therapy. Indications of emergency plasmapheresis: 1. Goodpasture syndrome with rapidly progressive glomerulonephritis and hemoptoe, 2. hyperviscosity syndrome, 3. TTP/HUS, 4. High level of factor VIII inhibitor, 5. respiratory insufficiency Guillain-Barré syndrome, 6. myasthenia gravis, 7. acute mushroom intoxication, or protein bound toxins. Further indications for plasmapheresis: 8. cryoglobulinemia, 9. other cases of rapidly progressive glomerulonephritis (when steroid+ cyclophosphamide are ineffective), 10. Wegener granulomatosis, 11. polyarteritis nodosa, 12. systemic lupus erythematosus (when steroid and cyclophosphamid therapy is not effective or associated with cerebral vasculitis, antiphospholipid syndrome combined with bleeding and thrombosis), 13. focal segmental glomerulosclerosis (resistant for therapy), 14. acute tubulointerstitial nephritis, 15. acute vascular rejection, 16. rheumatoid arthritis systemic type, 17. hypertrigliceridemia (≥25 mM), 18. thyreotoxic crisis, 19. acute necrotizing pancreatitis, 20. acute fulminant hepatitis, 21. paraquat intoxication, 22. snake bite (when antiserum is unavailable), 23. drug intoxication.]

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Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

TOLVAJ Balázs, HAHN Katalin, NAGY Zsuzsanna, VADVÁRI Árpád, CSOMOR Judit, GELPI Ellen, ILLÉS Zsolt, GARZULY Ferenc

Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

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The yield of electroencephalography in syncope

NALBANTOGLU Mecbure, TAN Ozturk Ozlem

Introduction - Syncope is defined as a brief transient loss of consciousness due to cerebral hypoperfusion. Although the diagnosis of syncope is based on a thorough history and examination, electroencaphalography (EEG) is also an important investigational tool in the differential diagnosis in this group of patients. In this study we aimed to identify the diagnostic value of EEG in patients with syncope. Methods - We retrospectively examined EEG recordings of 288 patients with the diagnosis of syncope referred to the Cankiri State Hospital EEG laboratory, from January 2014 to January 2016. The EEG findings were classified into 6 groups as normal, epileptiform discharges (spike and sharp waves), generalized background slowing, focal slowing, hemispherical asymmetries, and low amplitude EEG tracing. The EEGs were separated according to gender and age. Results - Total of 288 patients were included in this study, 148 were females (51.4%) and 140 (48.6%) were males. Among all the EEG reports, 203 (70.5%) were normal, 8 of them (2.8%) showed generalized background slowing and 7 (2.4%) demonstrated focal slow waves. Epileptiform discharges occured among 13 patients (4.5%). Hemispherical asymmetries were detected in 10 patients (3.5%) and low amplitude EEG tracing in 47 patients (16.3%). There was no significant difference between age groups in EEG findings (p=0.3). Also no significant difference was detected in EEG results by gender (p=0.2). Discussion - Although the diagnosis of syncope, epilepsy and non-epileptic seizures is clinical diagnosis, EEG still remains additional method

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[Family planning in multiple sclerosis: conception, pregnancy, breastfeeding]

RÓZSA Csilla

[Family planning is an exceptionally important question in multiple sclerosis, as women of childbearing age are the ones most often affected. Although it is proven that pregnancy does not worsen the long-term prognosis of relapsing-remitting multiple sclerosis, many patients are still doubtful about having children. This question is further complicated by the fact that patients – and often even doctors – are not sufficiently informed about how the ever-increasing number of available disease-modifying treatments affect pregnancies. Breastfeeding is an even less clear topic. Patients usually look to their neurologists first for answers concerning these matters. It falls to the neurologist to rationally evaluate the risks and benefits of contraception, pregnancy, assisted reproduction, childbirth, breastfeeding and disease modifying treatments, to inform patients about these, and then together come to a decision about the best possible therapeutic approach, taking the patients’ individual family plans into consideration. Here we present a review of relevant literature adhering to international guidelines on the topics of conception, pregnancy and breastfeeding, with a special focus on the applicability of approved disease modifying treatments during pregnancy and breastfeeding. The goal of this article is to provide clinicians involved in the care of MS patients with up-to-date information that they can utilize in their day-to-day clinical practice. ]

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CANOMAD syndrome with respiratory failure

SALAMON András, DÉZSI Lívia, RADICS Bence, VARGA Tímea Edina, HORTOBÁGYI Tibor, TÖMÖSVÁRI Adrienn, VÉCSEI László, KLIVÉNYI Péter, RAJDA Cecília

CANOMAD (chronic ataxic neuropathy, ophthalmoplegia, M-protein agglutination, disialosyl antibodies) syndrome is a rare polyneuropathy. IgM paraproteins react with ganglioside-containing disialylated epitopes resulting in dorsal root ganglionopathy and B-lymphocyte infiltration of cranial and peripheral nerves. Clinical features include ataxia, slight muscle weakness, areflexia, sensory- and cranial nerve symptoms. Case studies have reported the efficacy of rituximab and intravenous immunoglobulin (IVIg) treatments. We present the case of a 57-year-old man, who had difficulty walking, with numbness and clumsiness in all limbs. He had areflexia, vibratory sensation loss and ataxia. Laboratory tests showed IgM monoclonal components and disialosyl antibodies in the serum. Nerve conduction studies indicated severe sensorimotor demyelinating polyneuroradiculopathy. Despite IVIg and rituximab treatments, the patient’s disease course gradually worsened and he died of respiratory failure. Neuropathological examination revealed dorsal column- and dorsal root atrophy with mixed mononuclear cell infiltration. This article aims to draw attention to this syndrome, and the use of early potent immunosuppressive treatment to improve patients’ quality of life.