Hypertension and nephrology

[The Spring Congress of the Hungarian Society of Hypertension Budapest, 17 May 2014]

KÉKES Ede

SEPTEMBER 20, 2014

Hypertension and nephrology - 2014;18(03-04)

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Hypertension and nephrology

[Visualization of glomerular filtration in animals in vivo - significant filtration in afferent arteriola. Regulation of endothelial permeability]

ROSIVALL László

[Recently we have in vivo visualized glomerular filtration and fluid flow from the JGA portion of afferent arteriole into JGA using intravital multiphoton microscopy. Fluorescence of the extracellular fluid marker lucifer yellow appeared in the interstitium around the distal portion of afferent arteriole before the filtration into Bowman's capsule. In isolated microperfused JGA we demonstrated fluid movement from the glomerulus into the MD tubule. All these prove that there is a significant and dynamic fluid flow exists in the JGA. Angiotensin II similar to VEGF plays a role in regulation of permeability/fenestration formation. Angiotensin II acts through AT1 receptor and PV-1 protein synthesis.]

Hypertension and nephrology

[Changes in prescribing practice of diuretics in the treatment of hypertension between 2007 and 2013 in the mirror of insurance data]

BARNA István, GYURCSÁNYI András

[Amongst diuretics, thiazides are the most commonly used antihypertensive agents. Due to their long-term effect, they are ideal for treatment of hypertension. Indapamide is a long-acting (half-life 14-16 hours) thiazide-like diuretic, which is effective in very small doses (1.25 to 5 mg). Indapamide mainly provides a forceful blood pressure lowering effect, by decreasing arteriolar and peripheral resistance due to its vasodilatative effect. Even in hypertensive, diabetic patients, indapamide does not affect the lipid metabolism or the carbohydrate metabolism. As an antihypertensive medicine, thiazide-type diuretics (only in small doses - 6.25- 12.5 mg hypothiazide, 12.5 mg chlorthalidone, 5 mg clopamide) can be the first choice, when dealing with essential hypertension disease without complications. They may also be used in monotherapy. When dealing with hypertension associated with old age or with isolated systolic hypertension, these products are recommended with “A” type evidence. For the treatment of left ventricular hypertrophy and post-stroke conditions associated with the treatment of hypertension, it is recommended to use indapamide in case of diabetes, furosemide and thiazide in case of a left ventricular dysfunction and heart failure, or a combination of these. When reviewing the national sales of mono-component diuretics between 2007 and 2013 in the National Health Insurance (OEP) database, we could see that the sales of hydrochlorothiazide, clopamide, and chlorthalidone decreased. In 2013 however, the sales of the latter experienced a turnover, which might indicate the activity of the followers of the new guideline. The use of diuretics with indapamide as their active substance increased. The prescription of diuretics used in a combination increased continuously between 2007 and 2010 and reached a monthly one million prescribed boxes. During the time in question, the use of products combined with hydrochlorothiazide (most products contain this agent) was the most dominant, but its share fell from 88% to 66% due to the growth of combinations containing the active ingredient indapamide. This is interesting because this combination is “unique” (perindopril + indapamide). During the period in question, only the prescription of this combination increased steadily. The use of diuretics is very important in antihypertensive therapy. If we compare the diuretics and their combinations to the recommendations, we can state that the treatment is done along the guidelines, or in other words the use of the metabolic neutral combination therapy is increasing.]

Hypertension and nephrology

[Local importance of Hantavirus infections in mirror of the latest virological, epidemiological and clinical results]

NÉMETH Viktória, OLDAL Miklós, SEBÕK Judit, WITTMANN István, JAKAB Ferenc

[Hantaviruses are widespread infectious agents carried by different rodent species. The majority of them belongs to viral zoonotic pathogens, sometimes causing severe human infections. Hantaviruses inflict hemorrhagic fever with renal syndrome in Eurasia and supposedly in Africa, and hantavirus cardio-pulmonary syndrome in the Americas. The relationship between the virus and its host species is a result of a several million year co-evolution. Although virus replication is most intense in the infected rodents' lungs, these animals do not develop disease, instead they carry and spread the pathogens throughout their lifetime by body fluids. In the majority of infections, the virus gets into the human body by vaporization of rodent body fluids or by direct contact. In Europe, Puumala (PUUV) and Dobrava-Belgrade (DOBV) hantaviruses are the most abundant hantaviral infectious agents. There are numerous studies described the presence of different genotipes of hantaviruses circulating in Hungary. Although the number of clinical and epidemiolgical studies are limited, the medical importance - especially in a high risk population - of these viruses are unqustionable. There are a variety of methods to identify hantaviral infections. Molecular biological methods (RT-PCR) - also enabling genotyping - and virus neutralization tests proved to be the most reliable tools. The latter technique requires virus culturing, which can only be carried out in high-containment laboratories.]

Hypertension and nephrology

[Chronic Renal Disease and the Role of Uric Acid in Hypertension and Cardiovascular Diseases]

KÉKES Ede

Hypertension and nephrology

[Rudolf de Châtel MD has Passed Away]

MAGYAR Hypertonia Társaság

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Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

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Neuroscience highlights: Main cell types underlying memory and spatial navigation

KRABOTH Zoltán, KÁLMÁN Bernadette

Interest in the hippocampal formation and its role in navigation and memory arose in the second part of the 20th century, at least in part due to the curious case of Henry G. Molaison, who underwent brain surgery for intractable epilepsy. The temporal association observed between the removal of his entorhinal cortex along with a significant part of hippocampus and the developing severe memory deficit inspired scientists to focus on these regions. The subsequent discovery of the so-called place cells in the hippocampus launched the description of many other functional cell types and neuronal networks throughout the Papez-circuit that has a key role in memory processes and spatial information coding (speed, head direction, border, grid, object-vector etc). Each of these cell types has its own unique characteristics, and together they form the so-called “Brain GPS”. The aim of this short survey is to highlight for practicing neurologists the types of cells and neuronal networks that represent the anatomical substrates and physiological correlates of pathological entities affecting the limbic system, especially in the temporal lobe. For that purpose, we survey early discoveries along with the most relevant neuroscience observations from the recent literature. By this brief survey, we highlight main cell types in the hippocampal formation, and describe their roles in spatial navigation and memory processes. In recent decades, an array of new and functionally unique neuron types has been recognized in the hippocampal formation, but likely more remain to be discovered. For a better understanding of the heterogeneous presentations of neurological disorders affecting this anatomical region, insights into the constantly evolving neuroscience behind may be helpful. The public health consequences of diseases that affect memory and spatial navigation are high, and grow as the population ages, prompting scientist to focus on further exploring this brain region.

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

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

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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.