Hypertension and nephrology

[Prominents in Hungarian nephrology Professor Gyula Petrányi (1912–2000). I. part]


SEPTEMBER 20, 2011

Hypertension and nephrology - 2011;15(04)

[A nation can only survive and keep its identity through its traditions. This is why the initiative to launch this series coming from professor János Radó is worthy of attention. Gyula Petrányi is an outstanding personality in 20th century internal medicine, to be more precise in nephrology and immunology, his activity being wide-ranging. The first part of the current summmary of his work deals with a tribute to his personality, and his role in immunomodularity treatment in glomerulonephritis. The second part shall cover his role in spreading renal biopsy, screening and caring kidney patients, dialysis, in developing kidney patients’ care, furthermore in clinicopharmacology and renal transplantation.]



Further articles in this publication

Hypertension and nephrology

[Advantages of fixed combinations in the treatment of hypertensive patients]


[In 60-70% of patients with hypertension, a significant decrease in blood pressure can only be achieved by a combination of antihypertensive drugs. International as well as national guidelines emphasise the numerous advantages and the importance of combination treatment. Fixed combinations are particularly advantageous, as their use improves patients’ compliance. This paper summarises the available information on the possible combinations of the nine major antihypertensive drug groups distributed in Hungary, and for details the results published on the recently approved and introduced fixed combination of telmisartan and amlodipine.]

Hypertension and nephrology

[Association of body composition and mortality in patients on maintenance dialysis]


[Overweight [body mass index (BMI) = 25-30 kg/m2] and obesity (BMI ≥30 kg/m2) have become mass phenomena with a pronounced upward trend in prevalence in most countries throughout the world and are associated with increased cardiovascular risk and poor survival. In patients with end stage renal disease (ESRD) undergoing maintenance hemodialysis an “obesity paradox” has been consistently reported, i.e., a higher BMI is incrementally associated with better survival. Whereas this “reverse epidemiology” of obesity is relatively consistent in maintenance hemodialysis patients, studies in peritoneal dialysis patients have yielded mixed results. However, BMI is unable to differentiate between adiposity and muscle mass and may not be an acceptable metric to assess the body composition of ESRD patients. Assessing lean body mass, in particular skeletal muscle, and fat mass separately are needed in ESRD patients using gold standard techniques such as imaging techniques. Alternatively, inexpensive and routinely measured surrogate markers such as serum creatinine, waist and hip circumference or mid-arm muscle circumference can be used. We have reviewed and summarized salient recent data pertaining to body composition and clinical outcomes about the association of survival and body composition in peritoneal and hemodialysis patients.]

Hypertension and nephrology

[Coexistence of diabetes mellitus and (nephrogenic) diabetes insipidus]

RADÓ János

[In this report we describe a patient with nephrogenic diabetes insipidus associated with diabetes mellitus. The 44-year-old patient was seen by us for the first time when she was 5 years old in 1972, as a member of a family with nephrogenic diabetes insipidus associated with other congenital renal diseases. Surveying five generations by family history we found in four genarations (supported with investigations in three genarations) five patients suffering from the combination of renal tubular acidosis, polycystic kidney disease and nephrogenic diabetes insipidus. Nephrogenic diabetes insipidus was confirmed with blood and urine osmolality measurements performed during water deprivation as well as during administration of synthetic vasopressins. Renal tubular acidosis was confirmed with blood and urine gas analysis and bicarbonate and acid loadings. Polycystic kidney disease was diagnosed with physical findings, imaging and in the case of a deceased patient by necropsy. The autosomal dominant trait was obvious in the family characteristic to the distal renal tubular acidosis and polycystic kidney disease. The clinical picture was dominated by the polydipsia and polyuria. Significant interindividual differences were found in vazopressin resistance responsible for the nephrogenic diabetes insipidus. In our patient metabolic syndrome (diabetes mellitus, hypertension, obesity, abnormal lipid and uric acid levels) and disturbances in calcium metabolism (nephrolithiasis and osteomalacia) were associated with renal disorders. The 39 year long observation period (with some discontinuations) the patient was treated almost without pauses with bicarbonate, desmopressin, thiazide, NSAIDs supplemented with the administration of vitamin D3, antidiabetics etc. Despite of the listed and other diseases the patient’s mood is quite good, her physical condition is relatively satisfactory while she is working regularly physically.]

Hypertension and nephrology

[Biosimilar erythropoesis stimulating agents - from registration to clinical practice]

KISS István

[The original patent drugs appear immediately on expiry of all rights in generic and biosimilar drugs in the pharmaceutical market, favorable supply option which helps in the rational management of medicines, mainly for generic drugs cheaper to allow more patient care. Of course, this is a well-organized legal and regulatory framework, thoughtful strategy can be successful in every respect. In another non-identical molecular structure biosimilar drugs in different immunogenicity of knowledge and risk is not defined in clinical practice and therefore the risk is still underestimated and not well regulated in the world, and increasing the number reported is the antibody formation case of a biosimilar erythropioetin also. The immunogenicity of original biological and of biosimilar drugs in identifying, defining a prominent role in the post-marketing surveillance, pharmacovigilance, and the special methods of control of immunogenicity. The original and the biosimilar medicines interchangeability, marketability of the assets relating to the regulations are not uniform in Europe or the European registration scheme is an important new biosimilar medicinal products, is that the medicinal product, the documentation is not expected to be accompanied by a risk management plan, as well as action to ensure the safety (pharmacovigilance) as part of the collection and reporting of adverse reactions to the official. It is important that the professional management of renal anemia guidelines - the practice of nephrology erythropoietin therapy - clearly define the biological medicines (originator and biosimilar erythropoietin) application requirements and suggestions. Consequently, this summary wants to draw attention to the therapeutic potential of biosimilar drugs, generic drugs to distinguish between explicit and the potential risks and the need to reduce the risks of professional and health policy decisions.]

Hypertension and nephrology

[Role of calcimimetics in the treatment of secondary hyperparathyroidism in dialysed patients ]

[The authors summarize the pathophysiology and main clinical features of the condition which was previously called secondary hyperparathyroidism (sHTP) and renal osteodystrophy (ROD) in chronic kidney disease patients. Recently this entity has been renamed as chronic kidney disease - mineral and bone disorders (CKD-MBD), which more accurately describes the complexity of the condition including changes in laboratory parameters, bone turnover and vascular calcification. The calcium sensing receptor (CaR) plays a central role in the pathophysiology of CKD-MBD. Calcimimetics, which increase the sensitivity of the CaR to calcium, represent a novel and potentially advantageous class of medications for the management of the condition. Currently cinacalcet is the only available calcimimetic for clinical practice. Robust preclinical and human clinical trials have demonstrated that calcimimetics increase the expression of calcium sensing and the vitamin D receptors, attenuate parathyroid hyperplasia, decrease all four laboratory parameters (iPTH, Ca, P and Ca × P), optimize bone turnover and may slow down vascular calcification. As a results, cinacalcet based therapy is preferable and beneficial strategy in the treatment of CKD-MBD in patients on maintenance dialysis.]

All articles in the issue

Related contents

Clinical Neuroscience

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


[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. ]

Hypertension and nephrology

[Tubulointerstitial nephritis and uveitis syndrome]


[Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare and underdiagnosed oculorenal disorder that is characterized by the development of acute tubulointerstitial nephritis and uveitis. The median age of onset is 15 years, but it may occur at any age. There is a female predominance. Uveitis might occur before, after, and also concomitantly with tubulointerstitial nephritis. The symptoms are typically non-specific, including fever, loss of appetite, weight loss, nausea and vomiting, weakness, abdominal pain, arthralgias and myalgias. Laboratory findings reveal an acute impairment of renal function, anaemia and elevated inflammatory parameters. Urinary findings are consistent with tubulointerstitial nephritis including subnephrotic proteinuria, sterile leucocyturia, microhaematuria, and tubular dysfunction (e.g. normoglycemic glycosuria). The prognosis appears to be good, especially in children. Persistent renal dysfunction only develops in a small proportion of cases. In this paper, we present the case of a 39-year-old female patient with TINU syndrome, and review the literature.]

Hypertension and nephrology

[Covid-19 and the kidney]

PATÓ Éva, DEÁK György

[Covid-19 pandemy has emerged from Wuhan, China in December 2019. The infection affects not only the lung but other organs such as the kidney, as well. The relation between Covid-19 infection and the kidney is bidirectional. On one hand, Covid-19 infection may cause kidney damage in 50-75% of the cases resulting in proteinuria, haematuria and acute kidney injury (AKI). The etiology of AKI is multifactorial. Main pathogenic mechanisms are direct proximal tubular cell damage, sepsis-related haemodinamic derangement, citokine storm and hypercoagulability. The virus enters proximal tubular cells and podocytes via the ACE2 receptor followed by multiplication in the lysomes and consequential cell lesion. Histopathology shows acute tubular necrosis and acute tubulointerstitial nephritis. AKI is a strong predictor of mortality in critically ill patients. On the other hand, the risk of Covid-19 infection and mortality is substantially increased in patients with chronic kidney disease – especially in those with a kidney transplant or on dialysis – due to their immunocompromised status. Among haemodialysis patients, infection may spread very easily due to the possibility of getting contacted in the ambulance car or at the dialysis unit. The mortality rate of patients on renal replacement therapy with Covid-19 infection is 20-35%. In order to avoid mass infection it is obligatory to employ preventive measures and implement restricions along with (cohors) isolation of infected patients. In Hungary, every dialysis or kidney transplant patient with Covid-19 infection should be admitted to dedicated Covid-19 wards.]

Hypertension and nephrology

[Experience with mycophenolate mofetil containing immunosuppressive regimen in de novo kidney transplant recipients (ORANGE study).]


[Mycophenolate mofetil (MMF) has been used as an immunosuppressive agent in renal transplant recipients for more than two decades. The aim of the ORANGE study was to collect data with respect to the efficacy and safety of MMF containing immunosuppressive regimens during standard nephrology care in Hungarian clinical centres. Efficacy of the therapy was primarily evaluated via moni - toring of renal function based on glomerular filtration rate (GFR) values calculated on the basis of the MDRD-175 formula. A total number of 128 patients were en rolled in two clinical centres within the frames of an open-label, non-interventional study. During the course of the study, mean GFR values showed stable renal function between the 1st month (53.5±33.4 ml/min/1,73 m2) and the 12th month (58±16.3 ml/min/1,73 m2). Acute graft rejection occurred in 21 patients during the first month, further, 1-1 rejection was documented in the remaining period between 2-6 and 6-12 months after renal transplantation, respectively. The graft survival was 100% 1 month after renal transplantation, while this ratio was calculated to be 98.4% after 12 months.]

Lege Artis Medicinae

[Polyneuropathy as a first sign of microscopic polyangiitis]

ZÖLD Éva, HORVÁTH Ildikó Fanny, TARJÁN Péter, BARTA Zsolt, ZEHER Margit

[INTRODUCTION - Microscopic polyangiitis (MPA) is a systemic autoimmun disease characterized by necrotizing small vasculitis. MPA belongs to the ANCA-associated vasculitides. The disease can affect many of the body’s organ systems. Major organs involved are kidneys, skin, peripheral nerves and lungs. In addition, generalized symptoms such as fever and weight loss are very common. CASE REPORT - In January 2013 a 56-year old woman presented with weight loss, lower leg numbness, walking difficulty and petechiae on the lower legs. One month later, laboratory examinations showed progressive kidney dysfunction, anemia, hypersedimentation and elevated C reactive protein level, but further tests and investigations for potential bacterial infection and tumors were all negative. In sum, clinical signs and symptoms suggested systemic vasculitis, which was proved by the kidney biopsy and ENG examination. From these findings, microscopic polyangiitis was diagnosed with polyneuropathy and glomerulonephritis. The patient was a Hepatitis B (HBV) virus carrier, which can be provoking factor for vasculitis. Corticosteroid and six treatment cycles of intravenous pulse cyclophosphamide were performed for induction of remission. After treatment her symptoms improved and kidney function was normalized. Antiviral treatment was started because of HBV reactivation in October 2013. As a new manifestation of MPA, pulmonary symptoms were appeared in November 2013 and the patient was treated with synchronization of plasmapheresis and pulse cyclophosphamide with good clinical effectivity. Now, she is treated with methotrexate as immunosuppressive treatment and control examinations indicate the remission of the disease with proper renal function. CONCLUSION - We draw attention to a rare case of vasculitis and underline the importance of both the early diagnosis and the early and effective immunosuppressive therapy. Peripheral neuropathy may occur as a result of having systemic vasculitis. Nevertheless, the exploration and elimination of provoking factors are also must be part of the management and the regular follow-up is essential to recognize the disease relapses, thus avoid permanent organ damage.]