Hypertension and nephrology

[First experiences with percutaneous renal denervation in management of resistant hypertension]

SCHULCZ Domonkos1, NAGY Ferenc Tamás2, THURY Attila2, BAJCSI Dóra1, FEJES Imola1, LETOHA Annamária1, CONSTANTINOU Kypros1, UNGI Imre2, ÁBRAHÁM György1, LÉGRÁDY Péter1

APRIL 08, 2017

Hypertension and nephrology - 2017;21(02)

[Percutaneous transluminal radiofrequency renal denervation is a promising new therapeutic method for the treatment of primary resistant hypertension. The intervention decreases the systemic sympathetic over activation and thus arterial blood pressure. In the 1st Department of Medicine of the University of Szeged, 9 resistant hypertensive patients (2 male, 7 female; mean age: 55.0±4.0 years) had all the conditions were required for renal denervation at the time of interventions were performed. We measured the blood pressure together with the heart rate of the patients on the day preceding the intervention, right after the intervention, at discharge from hospital, then at months 6, 9 and 15. The mean blood pressure was 178/107±7/5 mmHg before the intervention. After denervation mean blood pressure decreased right after the intervention, at discharge from hospital, as well as at months 6, 9 and 15, respectively -15/-17 mmHg; -36/-16 mmHg; -19/-9 mmHg; -27/-21 mmHg and -15/- 16 mmHg. Besides decreasing of blood pressure, the antihypertensive drug therapy also decreased, however, it was not the primary aim of the intervention. No denervation- related intra- or perivascular complications were detected. The findings of our study proved the efficacy and safety of renal denervation in the treatment of primary resistant hypertension, of course with an appropriate patient selection. Our study was not relevant to determine whether this method is accompanied with a significant decrease of cardiovascular morbidity and mortality. Answers may come only based on randomized sham controlled studies with great case numbers.]

AFFILIATIONS

  1. Szegedi Tudományegyetem, Általános Orvostudományi Kar, I. Sz. Belgyógyászati Klinika, Nephrologia-Hypertonia Centrum, Szeged
  2. Szegedi Tudományegyetem, Általános Orvostudományi Kar, II. Sz. Belgyógyászati Klinika és Kardiológiai Központ, Invazív Kardiológiai Részleg, Szeged

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[The number of elderly people and the kidney disease’s importance connected to it has increased worldwide, therefore the chronic kidney disease became an endemic. Parallel to the dwindling of population the people in it age. Because of the men’s higher mortality rate the proportion of women in the elderly is greater. Prognosis indicates that by 2060 every third citizen will be aged 65 or more. Between 1990 and 2015 the life expectancy at birth increased by 6.95 years in the case of men (in 1990 it was 61.13, and in 2015 it was 72.08) and by 4.9 years in the case of women (in 1990 it was 73.7, and in 2015 it was 78.6) in Hungary. Chronic kidney disease concerns 10 to 14 % of the population and 1% of all of them suffers from end stage kidney failure. In the end of 2015 3.52 million patients received kidney replacement therapy around the globe (2.42 million received hemodialysis, 329000 received peritoneal dialysis and 704 000 lived with transplanted kidneys). Of all the risk factors of chronic kidney disease age, hypertension, diabetes mellitus and obesity stand out as the most important ones. The kidneys’ anatomy and function change in elderly age, making it possible for the kidney disease to manifest in greater numbers. The elderly dialysis patients’ number increases worldwide which is connected to their higher life expectancy and better life prospects which on the other hand ultimately means that more and more patient lives to suffer from kidney disease. It cannot be disregarded either that the increasing number of elderly patients suffering from hypertension or diabetes means that because these are causes of kidney disease, the latter’s numbers are also increasing. International data indicates that in the case of incident ESRD patients their number was between 68-2784 and the older than 75 years was 142-1660 per million population. In Hungary there was 778/pmp and 677/pmp, respectively. In 2015 the ratio of incident dialysis patients the ones aged above 65 was 58,9% in the case of incident patients and 50,3% in the case of prevalent patients. The ratio of the ones aged above 75 was 28,2% in the case of incident patients and 22,6% in the case of prevalent patients. The number of elderly dialysis patients differs by region too. Dialysis treatment started in elderly age requires special knowledge and teamwork, similarly to the question of refusing the treatment. The latter team work, adequate experts (doctors and nurses) and the related professions’ representatives build the foundations of a proper clinical practice.]

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[Efficacy of a fixed-dose association of amlodipine and lisinopril in grade II and III hypertensive patients]

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[We conducted an observational study, with ambulatory blood pressure monitoring (ABPM), to evaluate the efficacy of a fixed-dose combination of Amlodipine (5 mg) and Lisinopril (20 mg) in grade II and III hypertensive patients, over an 8 week intervention period. Thirty non-medicated hypertensive patients were enrolled, 36% female, with a mean age of 52.44±11.54 years, a body mass index of 28.73±4.54 kg/m2, and brachial office systolic (SBP) and diastolic (DBP) blood pressure of 174.43±15.06 mmHg and 102.83±10.67 mmHg, respectively. All patients performed a 24 hours ABPM at baseline and after a treatment period of 8 weeks with the fixed-dose association. Brachial office blood pressure and routine blood and urine samples were also obtained in both moments. A significant reduction in blood pressure was observed after the treatment with the fixed-dose association. The proportion of patients with controlled ambulatory blood pressure after the treatment was 69%, considering the normalization of the systolic and diastolic ambulatory pressures over the daytime, nighttime and 24 hours. Considering the brachial office blood pressures, the proportion of controlled hypertensive patients reached 79%. A significant improvement was also seen in microalbuminuria (reduction of 37.40 mg/24h; IC: 2.82-71.97; p=0.035) and fasting glycaemia (reduction of 11.53 mg/dl; IC: 3.46-19.61; p=0.007). No side effects were reported during the 8 week treatment period. The treatment of grade II and III hypertensive patients with a fixed-dose association of Amlodipine (5 mg) and Lisinopril (20 mg) during 8 weeks is effective controlling blood pressure. Furthermore, evidences indicate that the efficacy of the association is achieved quickly, safely and with good tolerability.]

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[The author summarizes on the base of forty year’s experience in the field of Hungarian nephrological care, that which are the main developmental problems and possibilities in the clinical nephrology and in dialysis therapy in Hungary recently. There is a clear claim to change in the training of nephrological nurses and nephrologists, and it is very important the organized education of predialysis patients, improving capacity of outpatient nephrological care in his opinion. He recommends organizing the total nephrological care in every county (except nephropathology and renal transplantation) and changing the relevant health law. He emphasizes the importance of conservative care in chronic kidney diseases and home renal replacement therapies. Highly educated nurses must play much more important role in care of dialyzed patients (with more competencies). It is very important planned start in dialysis, and instead of uniform regimes, the therapy provided individually. He suggests measuring of the health-related quality of life regularly and the survival of patients on renal replacement therapy, also. It would be important to determine the residual renal function in dialysis program, monthly. He is considering the phenomenon of “recovery of renal function” and the problem of withdrawal of dialysis.]

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