Hypertension and nephrology

[Article Reports]

FEBRUARY 20, 2014

Hypertension and nephrology - 2014;18(01-02)

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Hypertension and nephrology

[Fenestration of endothelium of juxtaglomerular arteriole]

ROSIVALL László

[For the first time, we demonstrated the fenestration in the endothelium of the distal portion of renal afferent arteriole (AA), which is unusual among high pressure vessels. The fenestrae are co-localized with renin producing granular epithelioid cells; this arrangement makes it likely that the relatively large renin molecules may use this path to enter into the plasma. We also demonstrated that the length and area of this fenestrated segment 1) correlates with the activity of the renin-angiotensin system (RAS), 2) may change by age, in response to some stimuli such as thirst and in some diseases, 3) allows filtration of fluid prior to the glomerular filtration, which can be as high as about 30% of GFR. This morphology and the high filtration volume in AA is one of the most striking observations of renal microcirculation, and question several basic renal physiological issues.]

Hypertension and nephrology

[Effect of age on the function of renin-angiotensin system]

VÁMOS Zoltán, CSÉPLÕ Péter, KOLLER Ákos

[Angiotensin II (Ang II) by activating angiotensin type 1 receptors (AT1R) is one of the most potent vasoconstrictors in the regulation of vasomotor tone and thus systemic blood pressure. In this study, we hypothesized that aging alters Ang II - induced vasomotor responses and expression of vascular mRNA and protein angiotensin type 1 receptor (AT1R). Thus, carotid arteries were isolated from newborn, young, middle age, old and senescent rats and their vasomotor responses were measured in a myograph (DMT-600) to repeated administrations of Ang II. Vascular relative AT1R mRNA level was determined by qRT-PCR and the AT1R protein density was measured by Western blot. Contractions of vessels to the first administration of Ang II increased from newborn to young and middle age rats then they decreased to senescent rats. In general, second administration of Ang II elicited reduced contractions, but they also first increased and then they decreased to old age. Similarly, the AT1R mRNA level and the AT1R protein density increased from newborn to young and middle age rats then they decreased to senescent rats. The pattern of these changes correlated with functional vasomotor data. We conclude that aging (newborn to senescence) has substantial effects on Ang II-induced vasomotor responses and AT1R signaling suggesting that it is - and thus regulation of systemic blood pressure is - determined primarily by genetic programs.]

Hypertension and nephrology

[Physical activity, physical function and exercise in chronic kidney disease]

NAGY Judit, APOR Péter, KISS István

[This review summarize the decreased physical activity and physical function of chronic kidney disease patients from the early stage of their renal disease; the favourable effects of exercise training on physical activity and function as well as on progression of chronic renal diseases. At the end, there is a recommendation for implementation of exercise in this renal patient population. The conclusion is that, on the basis of the evidences patients with chronic renal disease should be advised to increase their physical activity in all stages of their renal disea]

Hypertension and nephrology

[Risk categories, goals and treatment of hypercholesterolemia in Europe and in the recommendations of the AHA/ACC]

PADOS Gyula, KARÁDI István, AUDIKOVSZKY Mária, REIBER István, PARAGH György

[Hypercholesterolemia is one of the most important major risk factors that can be most influenced. Its treatment is based on guidelines. In 2013 in Hungary the common guideline of 17 societies (MKKK) as well as the recommendations of EAS/ESC and those of IAS are at disposal. These recommendations have established similar risk categories and strict LDL-cholesterol goals (<1.8 mmol/l). On 12 November, 2013, in the USA after a long drawn debate the AHA/ACC - without any lipid association - issued a new cholesterol (Ch) guideline, which drasticly differs from the existing national and European recommendations. According to AHA/ACC each patient with cardiovascular disease or diabetes should be treated with statin, irrespective of the Ch value, All patients with a LDL-Ch level over 4.9 mmol/l should also be treated with statin. In primary prevention those with values between 1.8-4.9 (LDL-Ch), or 3.5-8.0 mmol/l (Ch) would also be given statin, if their risk is more than 7.5%, with the new calculator system (“Statin Benefit Groups”). These recommendations would eliminate the classic risk categories (very-high, high, moderate risk), would abolish the system of treatment goals, as well as the regular Ch test. The non-statin therapy is not supported even in combinations. A big part of the population with low Ch level would also receive statin based on the results with the calculator, meaning that in the USA the number of those treated might double. Not only the European (e.g. EAS/,ESC) but even American societies (National Lipid Association 2013-2014) (e.g. NLA) oppose to the new guideline of AHA/ACC.]

Hypertension and nephrology

[Blood presssure paradoxon in very elderly patients]

SZÉKÁCS Béla, BÉKÉSI Gábor, KISS István

[The paper is warning for the necessity of very complex consideration before taking antihypertensive therapeutic decisions (indication, point or points of actiou, blood pressure target levels, dynamics of BP reduction, etc) for elderly hypertensive patients. Blood pressure reduction can mean efficient protection against cardiovascular events also among the elderly hypertensives. However in those old and very old hypertensive patients who have not only severe stiffness of their large vessels but suffer in advanced co-morbidities and integrated pathologic geriatric syndromes, the blood pressure reduction can result in sometimes even life threatening general deterioration. Antihypertensive therapeutic dilemmas of elderly caregivers appear mainly in relation to old hypertensive patients of age over 80 years. For this „very old” age period the HYVET study gave us evidence based conclusions about the cardiovascular protective usefulness of combined antihypertensive treatment resulting in BP reduction to 150 Hgmm systolic BP target levels. However a non-negligable rate of selection of the included patients in HYVET study can weaken the generalizability of the HYVET findings in this age period and the extensibility of its antihypertensive therapeutic conclusions for the entire „very old” population because this population has also a high proportion of patients with chronic progressive illnesses and general decline. Thus the elderly hypertensives’ caregiver must always carefully and critically balance between the messages of the HYVET and the nonselective observational follow up studies among elderlies showing frequently the so-called epidemiologic blood pressure/ mortality paradoxon. The paper is also trying to find potencial pathomechanical interpretations and point of actions for the epidemiologic blood pressure/mortality paradoxon found in the very old population.]

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Clinical Neuroscience

Comparison of direct costs of percutaneous full-endoscopic interlaminar lumbar discectomy and microdiscectomy: Results from Turkey

ÜNSAL Ünlü Ülkün, ŞENTÜRK Salim

Microdiscectomy (MD) is a stan­dard technique for the surgical treatment of lumbar disc herniation (LDH). Uniportal percutaneous full-endoscopic in­terlaminar lumbar discectomy (PELD) is another surgical op­tion that has become popular owing to reports of shorter hos­pitalization and earlier functional recovery. There are very few articles analyzing the total costs of these two techniques. The purpose of this study was to compare total hospital costs among microdiscectomy (MD) and uniportal percutaneous full-endoscopic interlaminar lumbar discectomy (PELD). Forty patients aged between 22-70 years who underwent PELD or MD with different anesthesia techniques were divided into four groups: (i) PELD-local anesthesia (PELD-Local) (n=10), (ii) PELD-general anesthesia (PELD-General) (n=10), (iii) MD-spinal anesthesia (MD-Spinal) (n=10), (iv) MD-general anesthesia (MD-General) (n=10). Health care costs were defined as the sum of direct costs. Data were then analyzed based on anesthetic modality to produce a direct cost evaluation. Direct costs were compared statistically between MD and PELD groups. The sum of total costs was $1,249.50 in the PELD-Local group, $1,741.50 in the PELD-General group, $2,015.60 in the MD-Spinal group, and $2,348.70 in the MD-General group. The sum of total costs was higher in the MD-Spinal and MD-General groups than in the PELD-Local and PELD-General groups. The costs of surgical operation, surgical equipment, anesthesia (anesthetist’s costs), hospital stay, anesthetic drugs and materials, laboratory wor­kup, nur­sing care, and postoperative me­dication diffe­red significantly among the two main groups (PELD-MD) (p<0.01). This study demonstrated that PELD is less costly than MD.

Lege Artis Medicinae

[Comment to the article titled “Exploratory study of outcomes of blood sample mass examinations by rank correlations”]

Clinical Neuroscience

A variant of Guillain-Barre syndrome after SARS-CoV-2 vaccination: AMSAN

TUTAR Kaya Nurhan, EYIGÜRBÜZ Tuğba, YILDIRIM Zerrin, KALE Nilufer

Introduction - Coronavirus disease 2019 (COVID-19) is a respiratory infection that has rapidly become a global pandemic and vaccines against SARS-CoV-2 have been developed with great success. In this article, we would like to present a patient who developed Guillain-Barré syndrome (GBS), which is a serious complication after receiving the inactive SARS-CoV-2 vaccine (CoronaVac). Case report – A 76-year-old male patient presented to the emergency department with nine days of progressive limb weakness. Two weeks prior to admission, he received the second dose of CoronaVac vaccine. Motor examination revealed decreased extremity strength with 3/5 in the lower extremities versus 4/5 in the upper extremities. Deep tendon reflexes were absent in all four extremities. Nerve conduction studies showed predominantly reduced amplitude in both motor and sensory nerves, consistent with AMSAN (acute motor and sensory axonal neuropathy). Conclusion - Clinicians should be aware of the neuro­logical complications or other side effects associated with COVID-19 vaccination so that early treatment can be an option.

Clinical Neuroscience

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.

Clinical Neuroscience

[Consensus statement of the Hungarian Clinical Neurogenic Society about the therapy of adult SMA patients]

BOCZÁN Judit, KLIVÉNYI Péter, KÁLMÁN Bernadette, SZÉLL Márta, KARCAGI Veronika, ZÁDORI Dénes, MOLNÁR Mária Judit

[Background – Spinal muscular atrophy (SMA) is an autosomal recessive, progressive neuromuscular disorder resulting in a loss of lower motoneurons. Recently, new disease-modifying treatments (two drugs for splicing modification of SMN2 and one for SMN1 gene replacement) have become available. Purpose – The new drugs change the progression of SMA with neonatal and childhood onset. Increasing amount of data are available about the effects of these drugs in adult patients with SMA. In this article, we summarize the available data of new SMA therapies in adult patients. Methods – Members of the Executive Committee of the Hungarian Clinical Neurogenetic Society surveyed the literature for palliative treatments, randomized controlled trials, and retrospective and prospective studies using disease modifying therapies in adult patients with SMA. Patients – We evaluated the outcomes of studies focused on treatments of adult patients mainly with SMA II and III. In this paper, we present our consensus statement in nine points covering palliative care, technical, medical and safety considerations, patient selection, and long-term monitoring of adult patients with SMA. This consensus statement aims to support the most efficient management of adult patients with SMA, and provides information about treatment efficacy and safety to be considered during personalized therapy. It also highlights open questions needed to be answered in future. Using this recommendation in clinical practice can result in optimization of therapy.]