Hypertension and nephrology

[Initiation of antihipertensive therapy with fix combinations, focusing on perindopril, amlodipine and indapamide]

FARSANG Csaba

APRIL 10, 2016

Hypertension and nephrology - 2016;20(02)

[Early clinical studies proved that most hypertensive patients (>70%) need drug combinations to reach the target blood pressure. We should combine two or three - sometimes more - drugs from different antihypertensive classes for quicker normalisation of blood pressure and to reduce incidence and severity of hypertensive complications. Several international and Hungarian (MHT 2015) guidelines emphasize the advantages of fix combinations against free combinations. Most frequently used combinations contain ACEi + calcium antagonist, or ACEi + diuretic. From them I will focus on the perindopril + amlodipine or perindopril + indapamide combinations. If we do not reach target blood pressure, triple fix combinations (e.g. perindopril + amlodipine + indapamide) can also be used. Now there are fix combinations of different strengths, therefore we may start the therapy with these fix combinations according to patients’ characteristics (e.g. age, complications, concomitant diseases).]

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Hypertension and nephrology

[Blood pressures of adolescents at screening program in Budapest]

KORMOS-TASI Judit, GÁCSI Erika, SCHEURING Noémi, TÓTH Fanni, CZINNER Antal, SZABÓ László

[The Aim of the screening program was to investigate the blood pressure and the association with obesity, hypercholesterinaemia and increased body fluid in adolescents. Methods: A screening program was conducted during the period from April 2010 to May 2011.The screenings consisted of: blood pressure, heart rate, body composition determination, cholesterol, blood glucose, weight, height and BMI. Results: 2226 children fullfied all of the outlined criteria. Their range of age was between 14–18 years. The average systolic blood pressure was 126.34±12.55 Hgmm volt. At boys were higher 131.87±13.59 then at girls 117.49±5.69 Hgmm. The average diastolic blood pressure was 71.86±8.74 Hgmm. There were also higher at boys 72.61±9.17 then at girls 66.69±5.04 Hgmm. High systolic blood pressure (95%<) were 307/1326 cases at girls, and 403/876 cases at boys. High diastolic blood pressure were together with high systolic blood pressure, but less frequency. High diastolic blood pressure occurred at 85 girls and at 90 boys. Overweight and obes were 18.994% of girls and 15.26% of boys. The percentage of pathological high blood pressure was most frequent among boys and girls who are in the overweight group. The pathologically high level of body fat percentage appeared to be 12.98% among girls and 5.9% among boys. In elevated BMI groups the frequency of high body fat was 66% among girls and 81% among boys. The mean cholesterol was significantly higher in the overweight and obese group. Conclusions: Rates of hypertension and overweight and obesity are high in school children in Budapest, and increased bodyweight is a significant risk factor for hypertension. The results of the study will help to design preventive programmers.]

Hypertension and nephrology

[Plasma ortho-tyrosine/para-tyrosine ratio predicts hyporesponsiveness to erythropoiesis-stimulating agents in dialyzed patients]

KUN Szilárd, MIKOLÁS Esztella, MOLNÁR Gergő Attila, SÉLLEY Eszter, LACZY Boglárka, CSIKY Botond, KOVÁCS Tibor, WITTMANN István

[Objectives: Patients suffering from end-stage renal failure (ESRF) are mostly treated with erythropoiesis-stimulating agents (ESAs). They often show hyporesponsiveness to ESA, which condition is associated with elevated production of free radicals. Phenylalnine (Phe) is converted into para- and ortho-tyrosine (p- and o- Tyr) by hydroxyl free radical. o-Tyr is produced exclusively in this way. However, physiological isomer p-Tyr is formed in significantly higher amounts by phenylalaninehydroxylase, mainly in the kidney. It has been shown that p-Tyr production is decreased in ESRF. As a result, p-Tyr can be replaced by o-Tyr in proteins, e.g. in proteins playing part in signal transduction of erythropoietin. We aimed to study the association of different Tyr isoforms with ESA-responsiveness. Methods: Four groups of volunteers were involved in our cross-sectional study: healthy volunteers (CONTR; n=16), patients on hemodialysis without ESA-treatment (non-ESA-HD; n=8), hemodialyzed patients with ESA-treatment (ESA-HD; n=40) and patients on continuous peritoneal dialysis (CAPD; n=21). Plasma p-, o-Tyr and Phe levels were detected using a high performance liquid chromatography (HPLC)-method, with fluorescence detection. ESA-demand was expressed as ESA-dose, ESAdose/ body weight and erythropoietin resistance index1 (ERI1, weekly ESA-dose/body weight/hemoglobin). Multivariate regression models were used to examine predictors of ESA-demand. In these models, most of the known predictors of ESA-hyporesponsiveness were included. Results: Lower p-Tyr levels were found in dialyzed patients compared with control subjects. In contrast, o-Tyr levels and o-Tyr/p-Tyr ratios were higher in dialyzed patients. Regarding dialyzed patients, o-Tyr level and o-Tyr/p-Tyr ratio were higher in ESA-HD than in non-ESA-HD and CAPD groups. Weekly ESA-dose/body weight and ERI1 correlated with o-Tyr/p-Tyr ratio (r=0.441, p=0.001; r=0.434, p=0.001, respectively). Finally, o-Tyr/p-Tyr ratio proved to be an independent predictor of ERI1 (β=0.330, p=0.016). Discussion: Our results suggest that elevation of o-Tyr/p-Tyr ratio could be responsible for ESA-hyporesponsiveness in dialyzed patients.]

Hypertension and nephrology

[Rilmenidin - a versatile combination partner in the treatment of high blood pressure]

KÉKES Ede

[The rilmenidin as an imidazoline agonist drug strongly decreases the central sympathetic activity, release of renine and the RAS activity. Because of these advantageous properties the peripheral vascular resistance falls and the blood pressure is decreased. Today it is excellent tool for combination therapy. Useful especially in stress induced hypertension. The antihypertensive effects of ACE inhibitors sor calcium antagonists are increased by rilmenidine. This drug decreases the insuline resistance, it has a positive effect on the carbohydrate and fat metabolism, because it is useful as a complementary therapy in metabolic syndrome and diabetes mellitus of type II. It is useful in stress induced hypertension, and in menopause as well.]

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[Association between cyclothymic affective temperament and hypertension]

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[Affective temperaments (cyclothymic, hypertymic, depressive, anxious, irritable) are stable parts of personality and after adolescent only their minor changes are detectable. Their connections with psychopathology is well-described; depressive temperament plays role in major depression, cyclothymic temperament in bipolar II disorder, while hyperthymic temperament in bipolar I disorder. Moreover, scientific data of the last decade suggest, that affective temperaments are also associated with somatic diseases. Cyclothymic temperament is supposed to have the closest connection with hypertension. The prevalence of hypertension is higher parallel with the presence of dominant cyclothymic affective temperament and in this condition the frequency of cardiovascular complications in hypertensive patients was also described to be higher. In chronic hypertensive patients cyclothymic temperament score is positively associated with systolic blood pressure and in women with the earlier development of hypertension. The background of these associations is probably based on the more prevalent presence of common risk factors (smoking, obesity, alcoholism) with more pronounced cyclothymic temperament. The scientific importance of the research of the associations of personality traits including affective temperaments with somatic disorders can help in the identification of higher risk patient subgroups.]

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[Thiazide- or thiazide-like diuretics should be used in the treatment of patients with hypertension? Particularities of the situation in Hungary]

VÁLYI Péter

[Diuretics have remained the cornerstone of the antihypertensive treatment since their widespreading in the 1960s. According to the 2018 ESC/ESH Guidelines for the management of arterial hypertension, in the absence of evidence from direct comparator trials and recognizing that many of the approved single-pill combinations are based on hydrochlorothiazide, this drug and thiazide-like indapamide can be considered suitable antihypertensive agents. In the 2018 Hungarian guidelines indapamide is named as the most efficacious diuretic in the treatment of patients with hypertension. The aim of the publication is redefining thiazide- and thiazide-like diuretic use in the treatment of hypertensive patients, with particular attention to presently available hydrochlorothia­zide and indapamide, and their combination drugs in Hungary.]

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[Notes on the management of hypertension in chronic kidney disease ]

AMBRUS Csaba

[The prevalence of hypertension among pa­tients with chronic kidney disease is high, reaching more than 80%. Hypertension is both one of the main causes and also the most common consequence of chronic kidney disease. It is also a main factor responsible for the high cardiovascular morbidity and mortality in this patient population. Blood pressure control can improve patient outcomes, lower cardiovascular risk and slow down the progression of kidney dis­ease, irrespective of the underlying cause. The optimal therapy should therefore focus not only on blood pressure reduction but also on renoprotection. Basic understanding of the renal pathophysiology in hypertension and renal effects of various medications is of paramount importance. In this review, we summarized cornerstones of the antihypertensive therapy in patients with chronic kidney disease. The management of patients receiving kidney replacement therapies, such as hemodialysis, peritoneal dialysis or transplanta­tion requires special knowledge and expe­rience, therefore it is not discussed here. The aim of this review was to allow non-nephrologist physicians to take care of their kidney patients with more confidence and effectiveness.]

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[The importance of assessing subclinical organ damage in risk prediction of hypertensive patients]

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[As the cardiovascular risk influences the quality and intensity of blood pressure lowering therapy, the goal blood pressure values and the frequency of medical control of hypertensive patients, as well as global risk assessment has an important role in the management of hypertension. In the last couple of years many data have been accumulated showing the poor prognostic value of traditional cardiovascular risk factors. This is the reason why recent Hungarian and international guidelines on the management of hypertension advise the screening for subclinical organ damage. Our goal was to summarize the importance of subclinical organ damage by discussing recently published literature on this topic. An overview has been made on the markers of vascular subclinical damage, like carotid atherosclerosis proved with carotid ultrasonography, peripheral arterial disease assessed with ankle-brachial pressure index measurements and vascular rigidity defined with pulse wave velocity measurements. The prognostic values of myocardial hypertrophy assessed with ECG and/or echocardiography and renal damage proved with decreased estimated glomerular filtration rate and proteinuria are also discussed. Summing up what has been said so far, the assessment of subclinical organ damage has a role in cardiovascular risk prediction, however more randomized and prospective studies have to be performed to define the most suitable (i.e. the most reliable and the most cost-effective) markers for this purpose.]

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[The effects of angiotensin receptor blockers on the nervous system in hypertension and dementia]

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[The renin-angiotensin system (RAS) is one of the most important mechanisms regarding the pathomechanism and treatment of hyprtension. The most of the elements of the RAS are found in the nervous system too. The effect of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ARBs) is based on the inhibition of the RAS. ARBs might have a special role in the central nervous system because they do not decrease the production of angiotensin but inhibit its harmful effects mediated through the AT1 receptor while allowing the stimulation of AT2 receptors with resulting pleiotrophic actions. Hypertension is the most important risk factor for stroke and has a negative effect on cognitive functions. Antihypertensive treatment has an effect on the nervous system; in addition to the consequences of the reduced blood pressure, ARBs might provide additional advantages in stroke and dementia prevention.]