Hypertension and nephrology

[More Strict Target Values Underway?]

VÁRALLYAY Zoltán

FEBRUARY 10, 2017

Hypertension and nephrology - 2017;21(01)

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Hypertension and nephrology

[Letter to our Readers]

KÉKES Ede, KISS István

Hypertension and nephrology

[The importance and techniques of fluid status assessment in patients with heart and kidney disease]

LEDÓ Nóra, HORVÁTH Viktor József, TISLÉR András

[Managing the fluid balance in patients with chronic heart and kidney disease is critical, it exceptionally affects the success of the therapy. Therefore, it is crucial to recognize and treat the fluid overload or depletion as soon as possible. Plenty of methods are available to assess fluid status, which can help us to find the right diagnosis, plan and follow the therapy of the patients. The aim of our review article is to present the current techniques of estimating fluid status. Beside the widely used methods (e.g. physical examination, laboratory testing) we describe other techniques which are less common in the Hungarian clinical practice but easy to use, such as chest sonography and bioimpedance spectroscopy. To choose the right approach for assessing fluid status, we have to examine the advantages and disadvantages of the methods in consideration of the patient’s individual needs.]

Hypertension and nephrology

[Our clinical practice with perindopril/indapamide/amlodipine triple fixed-dose combination]

BATTYÁNYI Bertalan

[Notwithstanding the abundance of pharmacotherapeutic options available, the rate of optimal blood pressure control may be estimated as low as 20 to 40 per cent throughout Europe. The underlying causes of this include, among others, the substantial impact of using free combinations of several antihypertensive - this practice results in rather poor patient adherence. Fixed-dose dual combinations have been introduced just about two decades ago, and their popularity has been increasing progressively since then. Nevertheless, in a considerable proportion (>30%) of patients, achieving optimal blood pressure control requires treatment with at least three antihypertensive acting on different targets. Accordingly, a rational demand has grown for triple-fixed combinations. In Hungary, the fixed combination of perindopril (an ACEI), indapamide (a thiazide-like diuretic), and amlodipine (a calcium channel-blocker) has been available since last year. Our experience with this product shows, as confirmed by ABPM studies, that its routine use in hypertensive patients with cardiological comorbidities improves patient compliance, thereby enhancing also long-term blood pressure control.]

Hypertension and nephrology

[Effects of ketodiet in fourth-stage chronic renal failure]

KÓSA Dezider, GELENCSÉR Éva, PALOTAI Ágota, GASZTONYI Beáta

[The well-known progressive nature of chronic renal failure can be slowed by low protein diet of various degrees. We applied standard 0.6g/kg body weight diet with supplement of essential amino acids and keto acids, 1 tablet/10 kg body weight Ketosteril was administered to 100 patient with IV. stage chronic renal failure for 31.5 months in average (10-63 month). During observational period 11% of the patients started hemodialysis program, 4 patients died. At the end of the observational period on basis of laboratory value of renal function 31% of patients had III, 50% IV, 19% V. stage chronic renal failure. We applied calculated glomerular filtration rate (ml/min/1.73 m2) for following the renal function. Average GFR value reduced from 24.9 to 23.63 ml/min/1.73 m2 (not significant). In case of female patients, we found a milder loss in renal function, average GFR was reduced from 24.8 to 24.6 ml/min/1.73 m2. We observed that women hold on the prescribed diet in greater ratio. On basis of the BMI value calculated at end of our examination no patient was undernourished. 25.8% of the patients had normal body weight, 54.3% had overweight, 17.5% was obese and 2.4% severely obese. We followed the changes in state of nourishment by serum albumin value, average serum albumin was 42.92 g/l at beginning and did not change significantly (42.81 g/l at the end of our examination). Applying keto diet is safe and efficient in slowing the progression of severe chronic renal failure and improves the state of nourishment. Good state of nourishment achieved in predialytic stage is associated with low mortality ratio and gives opportunity to lower the mortality of patients starting dialysis program.]

Hypertension and nephrology

[Stroke incidence and prevalence in the world]

KÉKES Ede

[The incidence and prevalence of ischaemic and haemorrhagic stroke declined continuously from 1970 to 2010. The rate of incidence was the lowest in North America, within Europe in the Mediterranean countries, France and in Asian developed countries. The incidence and prevalence the progress of age have in - creased respectively. The outcome of haemorrhagic stroke is worse everywhere, than that of ischaemic form, rate of mortality/incidence is greater.]

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[Association between cyclothymic affective temperament and hypertension]

NEMCSIK János, BATTA Dóra, KŐRÖSI Beáta, RIHMER Zoltán

[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.]

Clinical Neuroscience

[Cases of inborn errors of metabolism diagnosed in children with autism ]

ÇAKAR Emel Nafiye, YILMAZBAŞ Pınar

[Autism spectrum disorder is a neurodevelopmental disorder with a heterogeneous presentation, the etiology of which is not clearly elucidated. In recent years, comorbidity has become more evident with the increase in the frequency of autism and diagnostic possibilities of inborn errors of metabolism. One hundred and seventy-nine patients with diagnosis of autism spectrum disorder who presented to the Pediatric Metabolism outpatient clinic between 01/September/2018-29/February/2020 constituted the study population. The personal information, routine and specific metabolic tests of the patients were analyzed retrospectively. Out of the 3261 patients who presented to our outpatient clinic, 179 (5.48%) were diagnosed with autism spectrum disorder and were included in the study. As a result of specific metabolic examinations performed, 6 (3.3%) patients were diagnosed with inborn errors of metabolism. Two of our patients were diagnosed with classical phenylketonuria, two with classical homocystinuria, one with mucopolysaccharidosis type 3D (Sanfilippo syndrome) and one with 3-methylchrotonyl Co-A carboxylase deficiency. Inborn errors of metabolism may rarely present with autism spectrum disorder symptoms. Careful evaluation of the history, physical examination and additional findings in patients diagnosed with autism spectrum disorder will guide the clinician in the decision-making process and chose the appropriate specific metabolic investigation. An underlying inborn errors of metabolism may be a treatable cause of autism.]

Clinical Neuroscience

Neuroscience highlights: Main cell types underlying memory and spatial navigation

KRABOTH Zoltán, KÁLMÁN Bernadette

Interest in the hippocampal formation and its role in navigation and memory arose in the second part of the 20th century, at least in part due to the curious case of Henry G. Molaison, who underwent brain surgery for intractable epilepsy. The temporal association observed between the removal of his entorhinal cortex along with a significant part of hippocampus and the developing severe memory deficit inspired scientists to focus on these regions. The subsequent discovery of the so-called place cells in the hippocampus launched the description of many other functional cell types and neuronal networks throughout the Papez-circuit that has a key role in memory processes and spatial information coding (speed, head direction, border, grid, object-vector etc). Each of these cell types has its own unique characteristics, and together they form the so-called “Brain GPS”. The aim of this short survey is to highlight for practicing neurologists the types of cells and neuronal networks that represent the anatomical substrates and physiological correlates of pathological entities affecting the limbic system, especially in the temporal lobe. For that purpose, we survey early discoveries along with the most relevant neuroscience observations from the recent literature. By this brief survey, we highlight main cell types in the hippocampal formation, and describe their roles in spatial navigation and memory processes. In recent decades, an array of new and functionally unique neuron types has been recognized in the hippocampal formation, but likely more remain to be discovered. For a better understanding of the heterogeneous presentations of neurological disorders affecting this anatomical region, insights into the constantly evolving neuroscience behind may be helpful. The public health consequences of diseases that affect memory and spatial navigation are high, and grow as the population ages, prompting scientist to focus on further exploring this brain region.

Lege Artis Medicinae

[Second game, 37th move and Fourth game 78th move]

VOKÓ Zoltán

[What has Go to do with making clinical decisions? One of the greatest intellectual challenges of bedside medicine is making decisions under uncertainty. Besides the psychological traps of traditionally intuitive and heuristic medical decision making, lack of information, scarce resources and characteristics of doctor-patient relationship contribute equally to this uncertainty. Formal, mathematical model based analysis of decisions used widely in developing clinical guidelines and in health technology assessment provides a good tool in theoretical terms to avoid pitfalls of intuitive decision making. Nevertheless it can be hardly used in individual situations and most physicians dislike it as well. This method, however, has its own limitations, especially while tailoring individual decisions, under inclusion of potential lack of input data used for calculations, or its large imprecision, and the low capability of the current mathematical models to represent the full complexity and variability of processes in complex systems. Nevertheless, clinical decision support systems can be helpful in the individual decision making of physicians if they are well integrated in the health information systems, and do not break down the physicians’ autonomy of making decisions. Classical decision support systems are knowledge based and rely on system of rules and problem specific algorithms. They are utilized widely from health administration to image processing. The current information revolution created the so-called artificial intelligence by machine learning methods, i.e. machines can learn indeed. This new generation of artificial intelligence is not based on particular system of rules but on neuronal networks teaching themselves by huge databases and general learning algorithms. This type of artificial intelligence outperforms humans already in certain fields like chess, Go, or aerial combat. Its development is full of challenges and threats, while it presents a technological breakthrough, which cannot be stopped and will transform our world. Its development and application has already started also in the healthcare. Health professionals must participate in this development to steer it into the right direction. Lee Sedol, 18-times Go world champion retired three years after his historical defeat from AlphaGo artificial intelligence, be­cause “Even if I become the No. 1, there is an entity that cannot be defeated”. It is our great luck that we do not need to compete or defeat it, we must ensure instead that it would be safe and trustworthy, and in collaboration with humans this entity would make healthcare more effective and efficient. ]

Clinical Neuroscience

The etiology and age-related properties of patients with delirium in coronary intensive care unit and its effects on inhospital and follow up prognosis

ALTAY Servet, GÜRDOGAN Muhammet, KAYA Caglar, KARDAS Fatih, ZEYBEY Utku, CAKIR Burcu, EBIK Mustafa, DEMIR Melik

Delirium is a syndrome frequently encountered in intensive care and associated with a poor prognosis. Intensive care delirium is mostly based on general and palliative intensive care data in the literature. In this study, we aimed to investigate the incidence of delirium in coronary intensive care unit (CICU), related factors, its relationship with inhospital and follow up prognosis, incidence of age-related delirium and its effect on outcomes. This study was conducted with patients hospitalized in CICU of a tertiary university hospital between 01 August 2017 and 01 August 2018. Files of all patients were examined in details, and demographic, clinic and laboratory parameters were recorded. Patients confirmed with psychiatry consultation were included in the groups of patients who developed delirium. Patients were divided into groups with and without delirium developed, and baseline features, inhospital and follow up prognoses were investigated. In addition, patients were divided into four groups as <65 years old, 65-75 yo, 75-84 yo and> 85 yo, and the incidence of delirium, related factors and prognoses were compared among these groups. A total of 1108 patients (mean age: 64.4 ± 13.9 years; 66% men) who were followed in the intensive care unit with variable indications were included in the study. Of all patients 11.1% developed delirium in the CICU. Patients who developed delirium were older, comorbidities were more frequent, and these patients showed increased inflammation findings, and significant increase in inhospital mortality compared to those who did not develop delirium (p<0.05). At median 9-month follow up period, rehospitalization, reinfarction, cognitive dysfunction, initiation of psychiatric therapy and mortality were significantly higher in the delirium group (p<0.05). When patients who developed delirium were divided into four groups by age and analyzed, incidence of delirium and mortality rate in delirium group were significantly increased by age (p<0.05). Development of delirium in coronary intensive care unit is associated with increased inhospital and follow up morbidity and mortality. Delirium is more commonly seen in geriatric patients and those with comorbidity, and is associated with a poorer prognosis. High-risk patients should be more carefully monitored for the risk of delirium.