Hypertension and nephrology

[News of the Hungarian Society of Nephrology]

FEBRUARY 20, 2012

Hypertension and nephrology - 2012;16(01)

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Hypertension and nephrology

[Chronotherapy of hypertension - individualized treatment according to the circadian blood pressure profile]

SZAUDER Ipoly, UJHELYI Gabriella

[The circadian (24 h) rhythm shows great importance in the pharmacotherapy of hypertension. There is growing interest in how to best tailor the treatment of hypertensive patients according to the circadian blood pressure pattern of each individual. Significant administration-time differences are in the chronokinetics of antihypertensive medication. The therapeutic coverage and efficacy of different antihypertensive drugs are all markedly dependent on the circadian time of drug administration. Administration of ACE inhibitors, ARBs, doxazosin and aspirin at bedtime, as opposed to upon wakening, results in an improved diurnal/nocturnal blood pressure ratio (recommended for nondipper type of hypertension). Other antihypertensive medications: calcium channel blockers and β receptor blockers are non effective at the circadian blood pressure pattern. Chronotherapy provides a means of individualizing the treatment of hypertension according to the circadian blood pressure profile of patients and constitutes a new option to optimize blood pressure control and reduce the risk of cardiovascular disease and the risk of end organ injury.]

Hypertension and nephrology

[Guidelines and clinical practice: clinical audit of CKD-MBD in Hungarian dialyzed patients]

KISS István, KISS Zoltán, SZABÓ András, SZEGEDI János, BALLA József, LADÁNYI Erzsébet, CSIKY Botond, ÁRKOSSY Ottó, TÖRÖK Marietta, TÚRI Sándor, KULCSÁR Imre

[Patients suffering from chronic kidney disease reach the end-stage renal disease in ever growing numbers and this necessitates the start of their dialysis treatment. The alteration of bone and mineral metabolism together with the development of the consequent organ damages starts in early stages of the chronic kidney disease. The goal of our present trial was to survey the alterations or characteristics (laboratory results, concomitant diseases and treatment practice in Hungary) of the calcium (Ca) and phosphate (PO4) metabolisms [mineral-bone disorder occurring in chronic kidney disease (CKD-MBD) or formerly known as secunder hyperparathyreosis or renal ostedistrophy] in patients chronically treated with dialysis. We collected and analyzed data/results from 5334 chronically dialyzed patients. We categorized the patients into different groups according to the guidelines of CKD-MBD so basically by the level of serum calcium and parathormone (PTH) (se-Ca level is below or above 2.4 mmol/l; PHT level is below 65 pg/ml, between 65-150, 150-300, 300-500, 500-800 pg/ml or above 800 pg/ml) and then the characteristic variances were compared. The two most frequent primary causes of end-stage renal disease are hypertension (23%) and diabetes mellitus (22%). Serum calcium level was below the upper limit of the normal range (Ca <2.4 mmol/l) in the greatest proportion of our patients (n=4386), while the parathormone level was elevated (PTH >500 pg/ml) in large portion of patients (n=833). Likewise in a significant part of our patients (44.9%) the parathormone level was low (PTH <150 pg/ml). The concurrent pathological elevation of both the serum calcium and the parathormone levels was found in only a minority of the patients (n=150; 2.8%). All of the drugs influencing calcium-phosphate and parathormone levels were already accessible during the time of origin of the trial in Hungary, although the financial limitations significantly affected their prescription. This is one of the reasons why local treatment practice was not fully aligned with guidelines. On the other hand the application of native vitamin D had an especially low prevalence. To sum up, our results match the European practice on the whole, although we definitely need improvement in reaching the treatment targets and also the clinical treatment practice leading to it. We will prepare a proposal for further analysis and longterm extension of this trial.]

Hypertension and nephrology

[Infections associated to vesicoureteral reflux disease in children below 1 year of age: the infulence of continuous antibiotic prophylactic therapy on the prevalence of resistant pathogenic bacteria]

MÁTTYUS István, KENESEI Éva, VÁSÁRHELYI Barna

[Background: The primary goal when children with vesicoureteral reflux disease (VUR) are treated is the prevention of pyelonephritis and persisting renal damage. Continuous antibiotic prophylaxis (CAP) is usually applied to reach this aim. The selection of resisting pathogens is the major risk of CAP. The aim of our survey was to describe the patterns of pathogenic strains leading to pyelonephritis in patients treated with and without CAP. Patients and method: The pathogenic strains implicated in pyelonephritis were identified in 48 and 56 children below 1 year of age who were treated with or without CAP, respectively, between years 2006 and 2011. Results: Breakthrough urinary tract infections developing in the presence of CAP are more frequently (with about a double risk) caused by polyresistant bacteria compared to infections that emerged without CAP. Nevertheless, it should be noted that the prevalence of resistant pathogens was about 40% even in infants without CAP. Discussion: The pattern of pathogenic strains leading to pyelonephritis alters significantly even in the cohort of children below 1 year of age treated with CAP to prevent infections associated to VUR. The risk may be decreased through the rational use of antibiotics. To reach this goal national guidelines on VUR should be updated and the role of additional non-antibiotic treatment should be established.]

Hypertension and nephrology

[Multi-photon fluorescence microscopy in the revealance of kidney physiology]

PRÓKAI Ágnes, BERTA Nóra, VANNAY Ádám, SZIKSZ Erna, KIS-PETIK Katalin, FEKETE Andrea, TOMA Ildikó, TULASSAY Tivadar, KELLERMAYER Miklós, PETI-PETERDI János, SZABÓ J. Attila

[In this review we discuss the importance of the multi-photon fluorescence microscopy in the relevance of kidney physiology. Most functions of the kidney, including the clearance of metabolic waste products, maintenance of body fluid, electrolyte homeostasis and blood pressure are achieved by complex interactions between multiple renal cell types and previously inaccessible structures that have been difficult to study. Multi-photon fluorescence microscopy offers an advanced imaging technique for deep optical sectioning of living tissues and organs with minimal deleterious effects. Dynamic regulatory processes and multiple functions in the intact kidney can be quantitatively visualized in real time with submicron resolution. This article reviews the application of multi-photon imaging technology that provided the most complex, spatial and temporal portrayal of renal function, depicting as well as analyzing the components and mechanisms involved in renal (patho)physiology such as glomerular structure and function, tubular transport, tubular-vesicular interaction and the intrarenal renin-angiotensin system.]

Hypertension and nephrology

[Statin therapy and hyperuricemia in hyperlipidemia - the clinical importance of atorvastatin]

CSIKY Botond

[Population based studies have proven that serum level of uric acid is a cardiovascular risk factor. Uric acid is produced in the human body as a result of the degradation of endogenous and exogenous purin nucleotids. It is eliminated mainly by the kidneys and in a small amount through the gastrointestinal tract. Serum uric acid can be decreased by some medical therapies. It has been demonstrated that atorvastatin treatment can decrease significantly uric acid level in patients with hyperlipidemia. Other statins do not seem to have such an effect. The uric acid lowering effect of atorvastatin is dose-dependent, and it most likely acts by increasing the renal elimination. The cholesterol, trgiglycerid and uric acid lowering effect of atorvastatin may have an important role in decreasing cardiovascular risk.]

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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.]

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

[Decisional collisions between evidence and experience based medicine in care of people with epilepsy]

RAJNA Péter

[Background – Based on the literature and his long-term clinical practice the author stresses the main collisions of evidence and experience based medicine in the care of people with epilepsy. Purpose – To see, what are the professional decisions of high responsibility in the epilepsy-care, in whose the relevant clinical research is still lacking or does not give a satisfactory basis. Methods – Following the structure of the Hungarian Guideline the author points the critical situations and decisions. He explains also the causes of the dilemmas: the lack or uncertainty of evidences or the difficulty of scientific investigation of the situation. Results – There are some priorities of experience based medicine in the following areas: definition of epilepsy, classification of seizures, etiology – including genetic background –, role of precipitating and provoking factors. These are able to influence the complex diagnosis. In the pharmacotherapy the choice of the first drug and the optimal algorithm as well as the tasks during the care are also depends on personal experiences sometimes contradictory to the official recommendations. Same can occur in the choice of the non-pharmacological treatments and rehabilitation. Discussion and conclusion – Personal professional experiences (and interests of patients) must be obligatory accessories of evidence based attitude, but for achieving the optimal results, in some situations they replace the official recommendations. Therefore it is very important that the problematic patients do meet experts having necessary experiences and also professional responsibility to help in these decisions. ]

Clinical Oncology

[Complications of infusion treatment with emphasis on extravasation of cytostatics]

HARISI Revekka

[The extravasation of cytostatics is the most signifi cant complication of infusion therapy in cancer treatment. Extravasation refers to the inadvertent infi ltration of cytostatic drugs into subcutaneous or subdermal tissues surrounding the intravenous or intraarterial administration site. According to literature data incidence estimates between 0,01-7%. Extravasated drugs are classifi ed according to their potential for causing damage as vesicant, irritant and nonvesicant. Knowledge of risk factors, the patientrelated and treatment-related ones is important to minimize the occurrence of extravasation. In order to reduce the risk of extravasation, the staff involved in the tumor infusion therapy must be specially trained to implement several preventive and therapeutical protocols. In 2012, ESMO-EONS has put together a new comprehensive treatment protocol on the topic of cytostatics extravasation. Protocol recommended that every oncological department, who administers chemotherapy have to have extravasation trained team and a standby extravasation kit. According to the new ESMO-EONS guideline subcutaneous corticoids are not recommended, anymore. In case of mechloretamine extravasation the recommendation is immediate subcutaneous injection of sodium thiosulfate. After extravasation of anthracyclines, mitomycin C and platin salts the best treatment opportunity is subcutan dimethyl sulfoxide administration. In case of anthracyclines’ extravasation intravenous dexrazoxane treatment is also effective. Hyaluronidase, injected into or under the skin, facilitates absorption of extravasated drugs because of increases connective tissue permeability, promotes the spreading and reduces the local concentration of the extravasated citostatic agents. Hyaluronidase might be effi cacious in preventing skin necrosis by extravasation due to vinca alkaloids. The treatment of unresolved tissue necrosis or pain lasting more than 10 days is surgical debridement. Because of the medical and juristic importance of the extravasation event, it is necessary to establish uniform guidelines for treatment of extravasation, in all Hungarian Oncological Centers.]

Hungarian Radiology

[The Spring Event of the Society of Hungarian Radiologists Ultrasonography Section Budapest, 28 March 2003]

HARKÁNYI Zoltán, MORVAY Zita