Hypertension and nephrology

[Article Reports]

FEBRUARY 20, 2014

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



Further articles in this publication

Hypertension and nephrology

[Fenestration of endothelium of juxtaglomerular arteriole]


[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]


[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]


[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]


[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.]

All articles in the issue

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Lege Artis Medicinae

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

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

[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. ]

Clinical Neuroscience

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.

Clinical Neuroscience

[Ulcerative carpal tunnel syndrome]


[The carpal tunnel syndrome is the most frequent compression-induced neuropathy. A severe but rare clinical manifestation of this disorder associates with ulceration, acral osteo-lysis and mutilation of the terminal phalanges of the second and third fingers. Recognition of this disorder is difficult, because various dermatological and internal diseases might lead to acral ulcerative lesions, and these patients are seldom referred to neurological and/or electrodiagnostic examination. In this article, we present three cases of this rare clinical form of carpal tunnel syndrome and discuss the electrodiagnostic findings. The early diagnosis is important since decompression of the median nerve in due time might prevent mutilation and could significantly improve the patients’ quality of life.]