Hypertension and nephrology

[Importance, prevalence and therapy of vitamin D deficiency]

SZABÓ András

FEBRUARY 28, 2011

Hypertension and nephrology - 2011;15(01)

[Annual citations in the PubMed database on vitamin D were approximately 5000, this represents a doubling in the last decade and a 20% increase in the last year. There is renewed interest in vitamin D synthesis, metabolism and action. The two principal reasons for increased interest can be: 1. new knowledge regarding the nonhormonal, autocrine, and paracrine actions of 1,25-dihydroxylated vitamin D metabolites in man, 2. the worsening, worldwide trend to vitamin D insufficiency. Clinical vitamin D research in last years has confirmed the presence of a worldwide problem of vitamin D depletion, a problem that appears to be worsening. Largescale population based studies bear out long-held concerns that low serum 25(OH)D levels are associated with a number of adverse outcomes in the human musculoskeletal, innate immune, and cardiovascular systems. In fact, low vitamin D levels are significantly associated with all-cause mortality in the U.S. population and Hungary respectively. It is hypothesized that the global rise in incidence of obesity contributes to the worsening of the problem of vitamin D deficiency, amplifying adverse impacts on the host skeleton, immunoreactivity to microbes, and metabolic status. Finally, it should be remembered that treatment of vitamin D deficiency has two phases: restoration of 25(OH)D levels up to more than 30 ng/ml; and maintenance of the serum 25(OH)D level in that range. The present upper level (UL) of vitamin D intake that is deemed to be safe (2000 IU/day) must be re-evaluated considering data acquired over the past 15 years.]



Further articles in this publication

Hypertension and nephrology

[Scylla and Charybdis - the treatment of hypertension]

RADÓ János

Hypertension and nephrology

[The effect of antihypertensive drugs on central blood pressure]


[It is well known, that there is a difference between peripheral and central systolic and pulse pressure. As the pressure wave travels distally from the heart, there is a significant increase, which is called pressure amplification. Central blood pressure can be measured easily and non-invasively, and the result shows a positive correlation with cardiovascular end-points. Several antihypertensive drugs can differently decrease central and peripheral blood pressure. The effect of diuretics on central systolic and pulse pressure is neutral or negative. While traditional β-blockers (e.g. atenolol) have a definitive negative effect, nebivolol shows a positive one. The calcium antagonists tend to have a favorable effect, while the clear beneficial effect of the angiotensin converting enzime inhibitors is well documented. There are only few data on angiotensin receptor blockers, however, the results seem to be promising.]

Hypertension and nephrology

[The clinical significance of peripheral and central blood pressure form the neurologist’s point of view]


[Hypertension - affecting both the large and the small cerebral vessels - is the most frequent risk factor for cerebrovascular disorders manifesting in stroke, hypertensive encephalopathy or vascular dementia. The central pressure measured at the proximal part of the aorta has more important role in the development of vascular hypertrophy and carotid atherosclerosis than the pressure measured in the brachial artery. Central aortic pressure more accurately reflects the filling conditions of the left ventricle and thus the pressure conditions affecting the cerebral vascular system, than brachial pressure values, therefore possibly predicts more reliably the risk of cardiovascular events than brachial pressure values. Features of the stiffness of large arteries (like pulse wave velocity) more directly reflect the chronic effect of ageing, hypertension and diabetes than brachial or even central aortic pressure. Therefore in upcoming clinical trials arterial stiffness and central aortic pressure should be considered as possible surrogate endpoints. Antihypertensive treatment is an important part of primary and secondary stroke prevention. Decreasing blood pressure in hypertensive subjects significantly decreases the risk of stroke and other vascular events, and the extent of risk reduction primarily depends on the extent of the decrease in blood pressure. Several factors should be considered when choosing from treatment options. The use of traditional β blockers - partly due to their smaller effects on central blood pressure - decreased recently. Further observations will decide on the role of third generation β blockers in the prevention of cardiovascular mortality and morbidity.]

Hypertension and nephrology

[Direct renin inhibitors]


[The mechanisms of action of direct renin inhibitors and the important clinical findings gained by the first, clinically approved drug, aliskiren are discussed. The relative lack of side effects and the very long-lasting antihypertensive action of aliskiren is emphasized. Investigations showing efficacy and protective effects of aliskiren and its combinations with other antihypertensive drugs (diuretics, calcium antagonists, angiotensin converting enzyme inhibitors, angiotensin receptor blockers) against hypertension-induced subclinical organ damage as well as still ongoing clinical trials are also described.]

Hypertension and nephrology

[The importance of epithelial-mesenchymal transition in kidney fibrosis]


[Epithelial-mesenchymal transition (EMT) plays a central role in physiological and pathological processes of embryogenesis, carcinogenesis and tissue fibrosis. During EMT epithelial cells may transform to myofibroblasts, which are the effector cells of fibrosis. In our summary the process of EMT and its medical importance will be reviewed in relation to renal fibrosis. Regardless of the initiating cause the final common mechanism of organ fibrosis is similar in the different chronic renal diseases. It always involves major inflammatory responses, however the molecular mechanisms involved are still elusive. The EMT now takes centre stage as the point of convergence between inflammation and the progression of degenerative fibrotic diseases. Understanding the pathomechanism of EMT and the significance of signalling pathways involved in this process may lead to a new therapeutic approach in the treatment of chronic renal diseases.]

All articles in the issue

Related contents

Lege Artis Medicinae

[Benefits of SGLT-2 inhibitors: beyond glycemic control]

BALOGH Zoltán, SIRA Lívia

[In the recent years, according to international and Hungarian guidelines, in addition to lifestyle modification, metformin is the preferred initial glucose-lowering drug for most people with type 2 diabetes, if not contraindicated. Sodium glucose co­transporter-2 inhibitors have been shown to reduce progression of chronic kidney disease, or kidney failure, as well as the risk of hospitalizations for congestive heart failure and (mainly in secondary prevention) cardiovascular death in patients with type 2 diabetes. For major adverse cardiovascular events and for the renoprotection, there seems to be no class effect. On the other hand, a class effect of sodium glucose co­transporter-2 inhibitors is evident for hospitalization for heart failure. In this review the authors summarize novel data about sodium glucose cotransporter-2 inhibitors, and about their new perspectives in the near future.]

Clinical Neuroscience

Risk factors for ischemic stroke and stroke subtypes in patients with chronic kidney disease

GÜLER Siber, NAKUS Engin, UTKU Ufuk

Background - The aim of this study was to compare ischemic stroke subtypes with the effects of risk factors, the relationship between grades of kidney disease and the severity of stroke subtypes. Methods - The current study was designed retrospectively and performed with data of patients who were hospitalised due to ischemic stroke. We included 198 subjects who were diagnosed with ischemic stroke of Grade 3 and above with chronic kidney disease. Results - In our study were reported advanced age, coronary artery disease, moderate kidney disease as the most frequent risk factors for cardioembolic etiology. Hypertension, hyperlipidemia, smoking and alcohol consumption were the most frequent risk factors for large-artery disease. Female sex and anaemia were the most frequent risk factors for small-vessel disease. Dialysis and severe kidney disease were the most frequent risk factors in unknown etiologies, while male sex, diabetes mellitus, prior stroke and mild kidney disease were the most frequent risk factors for other etiologies. National Institute of Health Stroke Scale (NIHSS) scores were lower for small-vessel disease compared with other etiologies. This relation was statistically significant (p=0.002). Conclusion - In order to improve the prognosis in ischemic stroke with chronic kidney disease, the risk factors have to be recognised and the treatment options must be modified according to those risk factors.

Hypertension and nephrology

[Case report of supine hypertension and extreme reverse dipping phenomenon decades after kidney transplantation]

BATTA Dóra, KŐRÖSI Zita Beáta, NEMCSIK János

[Supine hypertension, a consequence of autonomic neuropathy, is a rarely recognized pathological condition. Reported diseases in the background are pure autonomic failure, multiple system atrophy, Parkinson’s disease, diabetes and different autoimmune disorders. In our case report we present a case of supine hypertension which developed in a patient decades after kidney transplantation. The patient was followed for 25 months and we demonstrate the effect of the modification of antihypertensive medications. At the time of the diagnosis supine hypertension appeared immediately after laying down (office sitting blood pressure (BP): 143/101 mmHg; office supine BP: 171/113 mmHg) and on ambulatory blood pressure monitoring (ABPM) extreme reverse dipping was registered (daytime BP: 130/86 mmHg, nighttime BP: 175/114 mmHg). After the modification of the antihypertensive medications in multiple times, both office supine BP (office sitting BP: 127/92 mmHg; office supine BP: 138/100 mmHg) and on ABPM nighttime BP improved markedly (daytime BP: 135/92 mmHg, nighttime BP: 134/90 mmHg). In conclusions, our case report points out that autonomic neuropathy-caused supine hypertension and extreme reverse dipping can develop in chronic kidney disease, after kidney transplantation. The modification of the antihypertensive medications can slowly restore this pathological condition.]

Hypertension and nephrology

[Monitoring of effectiveness of ramipril-amlodipine fixed combination, a non-interventional trial (Ramona study). Subgroup analysis of patients with chronic kidney disease]


[Hypertension and chronic kidney disease are independent cardiovascular risk factors. The 5th Cardiovascular Consensus Conference has recommended chronic kidney disease in high-risk category. In chronic kidney disease hypertension is observed in most cases. In patients with chronic kidney disease blood pressure targets are as 140/90 mmHg blood pressure below must be achieved without overt proteinuria. In chronic kidney disease combined antihypertensive therapy treatment should be initiated according the Hungarian Society of Hypertension recommendations. Aims: Monitoring the effectiveness and safety of the fix combination of ramipril/amlodipine Egiramlon® therapy in chronic kidney disease suffering from mild or moderate hypertension despite antihypertensive treatment. Patients and methods: Open, prospective, phase IV clinical observational study, which involved known chronic kidney disease (age over 18 years) with mild or moderate hypertension. Ramipril/amlodipine fixed combination (5/5, 5/10, 10/5 or, 10/10 mg) were administered or titrated in three visits, during the 4 months of trial period. The doses of the fixed combination drugs were determined individually during the visits by the 923 physicians involved in the study. The target blood pressure value was <140/90 mmHg according the new guidelines of ESH/ESC. Results: 70.1% of total patient (9169) was fulfilled the protocol during the four month of trial (6423 patients). In this population 194 patients suffered from chronic kidney disease. The age of patients was 68.52±1.84 (mean±SD) years, 85 (43.8) women and 109 (56.2%) men. 74.74% of total patients with chronic kidney disease has reached target blood pressure at the end of 4th month (primary endpoint). The blood pressure has decreased significantly (all p<0.0001) from 158.04/90.46±9.97/8.30 mmHg (1. visit) to 138.77/82.12±10.68/7.21 mmHg 2. visit and to 130.40/78.59±7.56/5.75 at the and of trial (3. visit), it means -27.64/- 11.87 mmHg decrease from the beginning of the 4th Month (3. visit). eGFR level increased significantly from 46.3±16.49 ml/min/1,73m2 to 49.0±19.58 ml/min/1,73m2. Patients suffered from chronic kidney disease have tolerated well the various doses of fixed combination of ramipril/amlodipine, and adverse events have no occurred correlation of treatment.]

Hypertension and nephrology

[Risk estimates of advanced chronic kidney disease and predicting mortality in dialyzed patients]


[In mostly the second part of the last decade lots of epidemiological study have been released about the progression of the chronic kidney disease (CKD) and theirs connection with the risk of death. The fact that lots of nephrologist from all over the world (from Canada to New-Zealand) are pretty much interested in this topic is absolutely proved by national (REIN Study – French Registry) and international (KDIGO Controversies Conference, DOPPS 1-5, or the European AROII Study) researchers with these epidemiological questions in their focus. The risk estimation facts that are able to show the life expectancy of patients with CKD 3-5 (expected time to dialysis or mortality risk before renal replacement therapy – RRT) and the early or hopefully longer survival odds of the dialyzed ones could be very useful not only for the medical stuff but also for the patients. In case of the predialyzed patients the focus has to be on the Bansal score and also on the Kidney Failure Risk Equation (KFRE) scores (with 4 and 8 variable); on the other hand in dialyzed patients the REIN score that prognose a short-term survival and the Cohen model (both are easy calculated with webcalculators) are in the highlight of importance. There is not a big difference (2- 7%) in validated researches between the prognosed and the real survival dates. Despite of this prediction has to always be evaluated individually in favour of the best decision we can make for the patients and in order to choose the right treatment: conservative therapy, dialysis or transplantation.]