Hypertension and nephrology

[Terciary hyperparathyreosis or not? ? You cannot solve it alone: combined treatment in severe osteitis fibrosa cystica]

HERSZÉNYI Eszter, PATÓ Éva, SZALAY László, BÍRÓ Zsolt, György Andrea, DEÁK György

DECEMBER 08, 2012

Hypertension and nephrology - 2012;16(05)

[Phosphate retention, consequential rise of the phosphaturic fibroblast growth factor-23 that decreases the level of calcitriol resulting in hypocalcemia facilitates the development of secondary hyperparathyroidism (sHPT) in chronic kidney disease (CKD). Hyperphosphatemia, hypocalcemia and low calcitriol level result in increasing secretion of parathormone (PTH). While sHPT occures frequently in CKD, the development of therapy-resistant and hypercalcemic tertiary hyperparathyroidism is rare due to current therapeutic approaches. We present the case of a 41 year old, treated schizophrenic, hemodialized male patient with severe osteitis fibrosa cystica, severe hyperparathyroidism (PTH 2500 pg/ml) - considered to be tertiary - and with repeated pathologic fractures. While hospitalized, the patient was under supervised, combined therapy with the vitamin D receptor activator paricalcitol and the calcimimetic cinacalcet that resulted in marked decrease of PTH level to 1589 pg/ml. However, after discharge from the hospital due to the lack of compliance he failed to take his medications and PTH had risen to the initial level. This case demonstrates that severe hyperparathyroidism thought to be therapy resistant responds well to a combination of paricalcitol and cinacalcet however, patient compliance is essential to therapeutic success.]

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Hypertension and nephrology

[Treatment of hypertension in chronic kidney disease and in renal failure]

KISS István

[The number of patients with chronic renal disease is growing steadily over the past decade. The reason for this is the increasing number of patients developing diabetes mellitus and hypertension, diseases that have common complication of chronic kidney disease. There is evidence that in chronic kidney disease or end-stage renal disease high blood pressure is more common which has a very complex management. Renal patients were able to participate in a small number of clinical studies, so the evidence base of antihypertensive therapy from these studies is limited. Therefore professional guidelines made with thumbnail analysis are very important, which now appeared as the KDIGO recommendations in November 2012. The author of this quick presentation of the practice undertook to summarize the important messages of this paper.]

Hypertension and nephrology

[The interpretation of metabolic syndrome]

KÉKES Ede, KISS István

[The significant increase of the splanchnic ectopic fat, the disturbance of carbohidrate metabolism, atherogenic dyslipidemia and high blood pressure creates the syndrome so called deadly quartet. These components promote the early appearance of cardiovascular diseases (ischemic heart disease, stroke, peripheral artery disease, etc.) as well as the enormous growth of type 2 diabetes mellitus. It was thought, that the ectopic fat is the only background of the syndrome and the insulin resistance with hyperinsulinemia as well as the disruption of associated endocrine regulatory balance system and elevated sympathetic drive explain jointly the clinical events. We now know that cytokines released by ectopic fat issue (CRP, TNF-α, IL-6 etc.) launch processes in our organism, which contribute to the development of vascular remodelling, endothelial dysfunction and in the end to that of atherothrombotic processes. The diagnostic criteria of the syndrome were changed continuously parallel growing theoretical knowledge till 2009, when on the Harmony Conference the important components of the syndrome were accepted, but some laboratory and other parameters do not enter into everyday praxis.]

Hypertension and nephrology

[Role of ramipril/amlodipine fixed combination in treatment hypertension of patients with chronic kidney disease]

VÁRKONYI Magdolna, SIMONYI Gábor

[Hypertension is an important risk factor of chronic kidney disease (CKD) however CKD can cause hypertension. Untreated CKD may result in renal failure. Hypertension and CKD are important cardiovascular risk factors. Several mechanisms play role in the worsening of renal function. The main pathogenetic factor is the increased activity of the renin-angiotensin-aldosteron system (RAAS) that can result in glomerulosclerosis, destroy of nephrons and proteinuria. In the treatment of hypertension in CKD patients inhibiting RAAS is very important because ACE-inhibitors and angiotensin-receptor blockers provide efficient control not only of blood pressure, but also of proteinuria, an effect associated with improved long-term nephroprotection. Between ACE-inhibitors ramipril has proved nephro- and cardiovascular protection effect. Fix combination therapy of ramipril with amlodipine has a very pronounced blood pressure lowering effect and can improve patient compliance too.]

Hypertension and nephrology

[The importance of health-centered approach in the management of hypertensive patients]

VÁLYI Péter

[In the everyday clinical practice the main objectives are the accurate establishment of the diagnosis and evidence based treatment of diagnosed disease. Besides the accustomed, rigorously medical, simplifying aspect, the bio-psycho- social approach is gaining an increasing importance. The objective of the article is, taking modern definition of health into account, emphasizing the importance of a new approach in the complex management of patients, having primary hypertension, a disease, impairing not only target organs, as well as the whole person, seriously influencing the health status of the affected person. In the management of a hypertensive patient, besides decreasing blood pressure, preventing and treating target organ complications and coexisting diseases, we should assess the whole person impairment, the effects of environmental and personal factors, and their influence on activities of daily living and participation in the life of the society, consequently, the changes in health status. This complex approach permits alone the more complete restoration of health of an affected person.]

Hypertension and nephrology

[Association between the genetic polymorphism of heat-shock protein 72 and pediatric kidney diseases]

BÁNKI Nóra Fanni, RUSAI Krisztina, KÁROLY Éva, SZEBENI Bea, VANNAY Ádám, SALLAY Péter, REUSZ György, TULASSAY Tivadar, SZABÓ J. Attila, FEKETE Andrea

[Recurring urinary tract infections (UTI) in childhood may result in chronic- and end-stage-renal-disease (ESRD), which leads to the initiation of dialysis and renal transplantation (NTx). Heat shock protein (HSP) 72 protects the kidney, whereas it refolds destroyed proteins and cells, and helps regenerating the renal tissue. The HSPA1B (1267)G allele is associated with lower HSP72 expression. This study assesses the role of HSPA1B A(1267)G polymorphism using PCR-RFLP in 103 children treated because of recurrent UTI, 26 children after NTx and 235 healthy controls. Clinical data were also evaluated. HSPA1B (1267)GG genotype and HSPA1B (1267)G allele occurred more frequently in the UTI (p=0.0001; CI: 1.378-2.68) and in the NTx (p=0.014; CI: 2.29-187.7) patient group than in the controls group, and were associated with a higher risk for scarring (p=0.012; CI: 0.33-1.00) and renal malformation (p=0.0072; CI: 1.623- 140.6). Our data indicate a relationship between the carrier status of HSPA1B (1267)G allele and the development of recurrent UTI and ESRD, raising further questions about the clinical and therapeutic relevance of these polymorphism.]

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Risk factors for ischemic stroke and stroke subtypes in patients with chronic kidney disease

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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.

Lege Artis Medicinae

[Notes on the management of hypertension in chronic kidney disease ]

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

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[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.]

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.]