Hypertension and nephrology

[News of the Hungarian Society of Hypertension]

JUNE 20, 2010

Hypertension and nephrology - 2010;14(03)

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Hypertension and nephrology

[Sevelamer: an old-new phosphate binder in chronic kidney disease]

BERECZKI Csaba, TÚRI Sándor

[Sevelamer HCl is a non-metal and non-calcium based phosphate binder, ion exchange resin, which not selectively binds the phosphate ions in the gastrointestinal tract. In Hungary since 2005, on the basis of strict professional guidelines, sevelamer is available therapy for chronic kidney disease patients with severe hyperphosphatemia on dialysis. On the basis of 17 prospective and retrospective studies, sevelamer HCl is an at least as effective phosphate binder as other calcium based binders, in reducing the serum phosphate level. The advantage of sevelamer compared to the other widely used calcium based phosphate binders is the significantly lower serum calcium level and less hypercalcemic episodes. Sevelamer therapy in chronic kidney disease patients reduces the progression of cardiovascular calcification and it has also a positive effect on cholesterol and LDL-cholesterol levels. The side effects of sevelamer therapy may be acidosis, and gastrointestinal complaints. This year the improved form, sevelamer carbonate, becomes available in Hungary. Sevelamer carbonate has similar phosphate and cholesterol binding capacity as that of sevelamer HCl, but it has several advantages: it has a positive effect on acid-base parameters, and may be administered in powder form, which is beneficial for children and for patients with swallowing disorders. The primary analysis of the DCOR study has not revealed any significant difference in the survival and cardiovascular mortality between patient groups treated with calcium based binder or sevelamer. The RIND trial data showed improved survival of new dialysis patients, who were initially treated with sevelamer. Further clinical studies are needed to kaverify the benefits of sevelamer therapy (mortality, cardiovascular calcification) in chronic kidney disease patients. The management of hyperphosphatemia in chronic renal failure is a major challenge even in the first decade of the 21th century. This is the fact, despite that recently three different groups of phosphate binders are available in the clinical practice: the calcium based binders (calcium carbonate, calcium acetate), sevelamer and lanthanum. Which is the best binder? A calcium based or a non-calcium based one? Over the past decade, these issues are in the mainstream of clinical research of nephrology.]

Hypertension and nephrology

[The significance of depressive disorders in patients with chronic kidney diseases]

ZALAI Dóra Márta, SZEIFERT Lilla, NOVÁK Márta

[In this article a practice-oriented narrative review of the depressive disorders in chronic kidney disease is provided. Depressive disorders affect approximately one fourth of the chronic kidney disease population. These mental disorders interfere with physical, cognitive and social functioning and are associated with poor prognosis of patients with chronic kidney disease. Bio-psycho-social factors, including immuno-inflammatory processes, disturbance in glucose- insulin homeostasis, sleep disorders, chronic pain, sexual difficulties, changes in social roles, losses in multiple areas of life and low social support increase the risk for the development of depression. Routine, regular screening of depression in the chronic kidney disease population seems to be warranted. Only limited published evidence is available on the therapeutic possibilities of depression in chronic kidney disease. Preliminary evidence indicates that short, structured psychotherapy may be effective for acute treatment and prevention of psychological distress. Some antidepressants can be applied without the need for dose adjustments. On the other hand, some of the psychotropic medications require dose reduction or should be avoided.]

Hypertension and nephrology

[Changes in endothelial cells caused by cigarette smoke]

WAGNER László, LACZY Boglárka, CSEH Judit, TAMASKÓ Mónika, MAZÁK István, MARKÓ Lajos, MOLNÁR Gergő Attila, WAGNER Zoltán, MOHÁS Márton, FEKETE Andrea, WITTMANN István

[Endothelial nitric oxide synthase enzyme is regulated through the phosphorylation of the Ser(1177) and the Thr(495) sites, which influence the biological availabilaty of nitric oxide. We examined the acute effect of cigarette smoke, which decreases nitric oxide production. Endothelial cells were treated with different concentrations and for different times with cigarette smoke buffer, then with reduced glutathione or different protein kinase inhibitors. We determined the total and the phosphorylated nitric oxide synthase levels with Western blot. Cigarette smoke increased phosphorylation in a concentration- and time dependent manner at the Ser(1177) site and more pronounced at the Thr(495) site. Besides, it also led to the dissociation of the active dimer form of the enzyme. Reduced glutathione inhibited these phosphorylations and prevented the dissociation of endothelial nitric oxide synthase enzyme. The inhibition of protein kinase A or B did not influence the effect of cigarette smoke. However, protein kinase C inhibitors increased the phosphorylation caused by cigarette smoke at Ser(1177), but decreased it at Thr(495) sites. Summarized, cigarette smoke shifts the phosphorylation of the enzyme towards an inhibitory state, further on, it leads to the dissociation of the enzymatically active form. This results in the decreased biological availabilaty of nitric oxide, in which protein kinase C may play an important role.]

Hypertension and nephrology

[A Guidance to Authors]

Hypertension and nephrology

[Recommendation for the treatment of hyperlipidemia in chronic renal disease]

MÁTYUS János, PARAGH György

[The incidence of chronic kidney disease continuously increases worldwide. Studies suggest that kidney disease is an as powerful cardiovascular risk factor as diabetes mellitus. Because of the high prevalence of lipid disorders, it is likely that dyslipidaemia plays a major role in the high cardiovascular risk of these patients. Evidence supports treating dyslipidaemia in patients with mild or moderate kidney disease, but the results of statin trials in dialysed patients are inconclusive. A practical treatment algorithm is proposed considering the special aspects, the effectiveness and safety of the drugs in the whole spectrum of kidney disease.]

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Clinical Neuroscience

Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm

BÉRES-MOLNÁR Anna Katalin, FOLYOVICH András, SZLOBODA Péter, SZENDREY-KISS Zsolt, BERECZKI Dániel, BAKOS Mária, VÁRALLYAY György, SZABÓ Huba, NYÁRI István

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo­gical examination excluded mycotic etiology of the aneu­rysm and “normal aneurysm wall” was described. The brain stem haemorrhage – Duret bleeding – was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.

Clinical Neuroscience

[Advanced Parkinson’s disease characteristics in clinical practice: Results from the OBSERVE-PD study and sub-analysis of the Hungarian data]

TAKÁTS Annamária, ASCHERMANN Zsuzsanna, VÉCSEI László, KLIVÉNYI Péter, DÉZSI Lívia, ZÁDORI Dénes, VALIKOVICS Attila, VARANNAI Lajos, ONUK Koray, KINCZEL Beatrix, KOVÁCS Norbert

[The majority of patients with advanced Parkinson’s disease are treated at specialized movement disorder centers. Currently, there is no clear consensus on how to define the stages of Parkinson’s disease; the proportion of Parkinson’s patients with advanced Parkinson’s disease, the referral process, and the clinical features used to characterize advanced Parkinson’s disease are not well delineated. The primary objective of this observational study was to evaluate the proportion of Parkinson’s patients identified as advanced patients according to physician’s judgment in all participating movement disorder centers across the study. Here we evaluate the Hungarian subset of the participating patients. The study was conducted in a cross-sectional, non-interventional, multi-country, multi-center format in 18 countries. Data were collected during a single patient visit. Current Parkinson’s disease status was assessed with Unified Parkinson’s Disease Rating Scale (UPDRS) parts II, III, IV, and V (modified Hoehn and Yahr staging). Non-motor symptoms were assessed using the PD Non-motor Symptoms Scale (NMSS); quality of life was assessed with the PD 8-item Quality-of-Life Questionnaire (PDQ-8). Parkinson’s disease was classified as advanced versus non-advanced based on physician assessment and on questions developed by the Delphi method. Overall, 2627 patients with Parkinson’s disease from 126 sites were documented. In Hungary, 100 patients with Parkinson’s disease were documented in four movement disorder centers, and, according to the physician assessment, 50% of these patients had advanced Parkinson’s disease. Their mean scores showed significantly higher impairment in those with, versus without advanced Parkinson’s disease: UPDRS II (14.1 vs. 9.2), UPDRS IV Q32 (1.1 vs. 0.0) and Q39 (1.1 vs. 0.5), UPDRS V (2.8 vs. 2.0) and PDQ-8 (29.1 vs. 18.9). Physicians in Hungarian movement disorder centers assessed that half of the Parkinson’s patients had advanced disease, with worse motor and non-motor symptom severity and worse QoL than those without advanced Parkinson’s disease. Despite being classified as eligible for invasive/device-aided treatment, that treatment had not been initiated in 25% of these patients.]

Hypertension and nephrology

[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

Evaluation of anxiety, depression and marital relationships in patients with migraine

DEMIR Fıgen Ulku, BOZKURT Oya

Aim - The aim of this study was to evaluate the frequency and characteristics of attacks in patients with migraine, to determine the effects of anxiety or depressive symptoms, and to evaluate the marital relationships of patients with migraine. Method - Thirty patients who were admitted to the neurology outpatient clinic of our hospital between July 2018 and October 2018 and were diagnosed with migraine according to the 2013 International Headache Society (IHS) diagnostic criteria were included in this cross-sectional study. Age, sex, headache frequency and severity, depressive traits, marital satisfaction and anxiety status were examined. We used the Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Maudsley Marital Questionnaire (MMQ) and Visual Analogue Scale (VAS) for measuring relevant parameters. Results - The mean severity of migraine pain according to VAS scale was 6.93 ± 1.41 and the mean number of migraine attacks was 4.50 ± 4.24. The mean BDI score of the patients was 12.66 ± 8.98, the mean MMQ-M score was 19.80 ± 12.52, the mean MMQ-S score was 13.20 ± 9.53, the mean STAI-state score was 39.93 ± 10.87 and the mean STAI-trait score was 45.73 ± 8.96. No significant correlation was found between age, number of migraine attacks, migraine duration, migraine headache intensity, and BDI, STAI and MMQ scores (p>0.05). But there was a positive correlation between MMQ-S and scores obtained from the BDI and STAI-state scales (p<0.05). Conclusion - In this study more than half of the migraine patients had mild, moderate or severe depression. A positive correlation was found between sexual dissatisfaction and scale scores of depression and anxiety.

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.