Hypertension and nephrology

[News of the Hungarian Society of Hypertension]

DECEMBER 30, 2012

Hypertension and nephrology - 2012;16(06)

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Hypertension and nephrology

[Molecular mechanisms leading to renal fibrosis: the origin of myofibroblasts]

HIMER Leonóra, SZIKSZ Erna, KOVÁCS Krisztián, ÓNODY Anna, Reusz György, FEKETE Andrea, TULASSAY Tivadar, VANNAY Ádám

[There are about a quarter of million patients who need chronic renal replacement therapy in Europe, and the estimated number of patients with chronic kidney disease is about tenfold higher. Interestingly, regardless of the initiating cause the mechanism of fibrosis is similar to each other in the different chronic kidney diseases. In general, the damaged glomerular or tubular cells release danger signals and produce chemotactic stimuli, which trigger the rapid recruitment of leukocytes. The infiltrating immune cells and the damaged renal cells then produce high levels of proinflammatory cytokines, growth factors, chemokines and adhesion molecules which contribute to glomerular/tubular injury, accumulation of further leukocytes and myofibroblasts, which are the effector cells of renal fibrosis. However the origin of myofibroblasts is still controversial. Recent hypotheses suggest that they are originated from different renal cells, such as epithelial and endothelial cells, pericytes or bone marrow derived fibrocytes. The myofibroblasts thus generated serve as key cellular mediators of renal fibrosis. Myofibroblasts have migratory capacity, are resistant to apoptosis, produce several growth factors and cytokines and according to our present knowledge these cells are the main source of collagen-I and -III rich extracellular matrix in the fibrous tissue. Organ fibrosis is characterized with excessive deposition of extracellular matrix leading to glomerular sclerosis and renal tubulointerstitial fibrosis. The excessive deposition of fibrous tissue replaces healthy kidney tissue; nephrons disappear and kidney function declines gradually. In this article the knowledge is summarized on the molecular changes leading to the generation of renal myofibroblasts.]

Hypertension and nephrology

[Recommendation on the Screening and Testing of Albuminuria, Proteinuria and Hematuria in the Everyday Practice of GPs and Internists]

MÁTYUS János, OLÁH Anna, NAGY Judit, WITTMANN István

Hypertension and nephrology

[The improvement of the rate of reaching the target blood pressure and the quality of care of hypertensive patients with applying telemedicine facilities]

KISS István, KÉLES Ede

[The authors summarize the facilities of the telemedicine and telemonitoring system. The methods of telemedicine and their combination with home blood pressure measurement or the help of a nurse or pharmacist are reviewed. In the light of the latest results the authors are led to the conclusion that the intensive spread of using the facilities of telemedicine is necessary in the present-day Hungarian healthcare system. At the same time it is also determined that the methodical and technical potential is not enough to further enhance the efficiency in itself. The personal contact and the possibility of interactive monitoring from distance are definitely crucial for the continuous maintenance of the reached target blood pressure in patients suffering from hypertension and also for the augmentation of patient adherence regarding applying medicine.]

Hypertension and nephrology

[Acute heart failure and acute renal injury: pathophysiology and management of cardiorenal syndrome type 1]

LÁSZLÓ Ágnes, ÁCS Tamás, JÁRAI Zoltán

[The functional connection between heart and kidney is well known. Several types of this relationship have been recently characterized as cardiorenal syndromes. The relevance of this relationship in clinical practice is supported by the fact, that the consequences of the primary dysfunction are profoundly influenced by the magnitude and the treatment possibilities of the secondary dysfunction. Moreover, the administered therapy for heart failure can deteriorate renal hemodinamics, or side effects of the treatment can lead to the worsening of the clinical picture. Loop diuretics decrease venous congestion, but also induce neurohormonal activation and a decrease in glomerular filtration rate. The body of positive evidence with the use of mineralocorticoid receptor antagonists in acute settings is limited. Inotropic agents on the one hand improve hemodinamics, on the other hand increase the danger of arrhythmia and mortality (levosimendan seems to be an exception). Aquaretics decrease symptoms without influencing mortality. The natriuretic peptide neseritid improved clinical symptoms, but did not improve endpoints in clinical trials. Vasodilators improve hemodinamics, but their usefulness is limited because of their profound hypotensive effect. The effectiveness and benefits of ultrafiltration has to be tested in more clinical trials. Because of such treatment difficulties the management of these patients is a complex task that needs the involvement of intensive therapeutic specialists, nephrologists and cardiologists. This review focuses on the pathophysiology and possible management of the patients with acute heart failure with acute kidney injury, called type 1 cardiorenal syndrome from the cardiologist’s point of view.]

Hypertension and nephrology

[Professor István Vas MD, Who Changed the Outcome of Peritoneal Dialysis]

POLNER Kálmán

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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

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.

Hypertension and nephrology

[Thought about renovascular hypertension by a special case report]

GAJDÁN Nikolett, LÉGRÁDY Péter, BAJCSI Dóra, MORVAY Zita, NAGY Endre, LETOHA Annamária, KYPROS Constantinou, FEJES Imola, SONKODI Sándor, ÁBRAHÁM György

[Renovascular hypertension is a well-known form of secunder hypertension. Two thirds of cases are caused by atherosclerotic plaque and one third are caused by fibromuscular dysplasia. The prevalence of it is less than 1%. Digital subtraction angiography is considered the goldstandard diagnostic method. The 58-year old female patient was hospitalized with resistant hypertension. Duplex ultrasonography showed fibromuscular stenosis the in left renal artery. Percutaneous transluminal angioplasty and stenting were performed. Her blood pressure normalized. The patient did not attend the control examinations. Next time in 2001, she was referred to our emergency department with increased blood pressure of 210/140 mmHg. Following control ultrasonography angiography showed total occlusion of the left renal artery and significant stenosis of the right renal artery. Left nephrectomy was necessary due to shrunken kidney and dilatation and stenting of the right renal artery. The blood pressure normalized again. Since 2004 until 2014 despite of the regular visits, we detected in stent restenosis of the right renal artery almost in each year. Even so, renal function was preserved all the time. In autumn of 2014, the patient suffered severe stroke, and few months later at the age of 74 she died. There are many open questions to discus concerning the right treatment of renovascular hypertension yet. Even so by performing 12 intravascular interventions we could ensure her acceptable quality of life for 16 years.]

Lege Artis Medicinae

[Anti-atherosclerotic effects of Ca-antagonists in the light of new clinical data]

ALFÖLDI Sándor

[Based on in vitro and animal research, it has been found that calcium antagonist drugs are capable of inhibiting directly the atherosclerotic process. In spite of their advantegous antiatherosclerotic effect, the fast-release, first-generation dihydropyridines had an unfortunate effect on the number of newly developed myocardial infarctions and on cardiovascular mortality. New, controlled clinical studies have found long acting calcium antagonists to decrease significantly the progression of the atherosclerosis in the carotid artery - verified with B-mode ultrasound scans - and the appearance of cardiovascular clinical events, when either proven coronary sclerosis (PREVENT, CAPARES studies) or hypertension (INSIGHT, ELSA, VHAS) was present. If further clinical trials (CAMELOT, NORMALISE - now under way) justify these promising clinical data, then long-acting calcium channel blockers may become new and significant tools in the prevention of the progression and clinical complications of atherosclerotic disease.]