Hypertension and nephrology

[Therapeutic apheresis in pediatry]

TÚRI Sándor, BERECKI Csaba, HASZON Ibolya, PAPP Ferenc

OCTOBER 20, 2013

Hypertension and nephrology - 2013;17(03-04)

[The possible mechanisms of therapeutic plasma mexchange: 1. the removal of circulatory plasma factor (anti Gbm disease, myasthenia gravis, Guillain Barré syndrome), 2. monoclonal antibody (Waldenström macroglobulinemia, myeloma protein), 3. circulatory immuncomplexes cryoglobulinaemia, myeloma protein, SLE), 4. alloantibody, 5. toxic factor, 6. replacement of a specific plasma factor, 7. a repear of the function of reticulo-endothelial system, 8. the removal of the inflammatory mediators, 9. the changes of the ratio of antigen-antibody which makes immuncomplexes more soluble, 10 stimulation of lymphocyte clones for supporting the cytotoxic therapy. Indications of emergency plasmapheresis: 1. Goodpasture syndrome with rapidly progressive glomerulonephritis and hemoptoe, 2. hyperviscosity syndrome, 3. TTP/HUS, 4. High level of factor VIII inhibitor, 5. respiratory insufficiency Guillain-Barré syndrome, 6. myasthenia gravis, 7. acute mushroom intoxication, or protein bound toxins. Further indications for plasmapheresis: 8. cryoglobulinemia, 9. other cases of rapidly progressive glomerulonephritis (when steroid+ cyclophosphamide are ineffective), 10. Wegener granulomatosis, 11. polyarteritis nodosa, 12. systemic lupus erythematosus (when steroid and cyclophosphamid therapy is not effective or associated with cerebral vasculitis, antiphospholipid syndrome combined with bleeding and thrombosis), 13. focal segmental glomerulosclerosis (resistant for therapy), 14. acute tubulointerstitial nephritis, 15. acute vascular rejection, 16. rheumatoid arthritis systemic type, 17. hypertrigliceridemia (≥25 mM), 18. thyreotoxic crisis, 19. acute necrotizing pancreatitis, 20. acute fulminant hepatitis, 21. paraquat intoxication, 22. snake bite (when antiserum is unavailable), 23. drug intoxication.]



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Hypertension and nephrology

[The role of juxtaglomerular apparatus in regulation of renal hemodinamics]


[The tubuloglomerular feedback mechanism (TGF) is one of the basic processes in the regulation of renal microcirculation. During the activation of TGF the macula densa senses the tubular fluid and ions loads and initiates a rather complex mechanism in juxtaglomerular apparatus resulting in a change of GFR and tubular load. During the activation of TGF there is humoral signaling in the interstitial extraglomerular area. The concentration of the mediator depends on the extraglomerular interstitial fluid movement through the fenestrated endothelium, which is determined by the actual pressures. A new and fast GFR regulation mechanism is described as a consequence.]

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[Nutritional status of hemodialysis patients, and the role of dietician in the complex care of renal patients]

POLNER Kálmán, KOVÁCS Lívia, HARIS Ágnes

[In chronic renal failure severe cardiovascular complications develop, which are the cause of death in 50% of the patients. According to recent results, behind the accelerated atherosclerosis, malnutrition and inflammation, developing in patients with chronic renal failure, play significant role. Malnutrition and inflammation show close relationship to the serum albumin level, which is an independent predictor of mortality. Authors studied the nutritional parameters of 94 chronically hemodialysis patients. Patients had been dialysed for more than three months, for 3×4-4.5 hours weekly. Among them 36% had diabetes. According to BMI (body mass index) 42.5% of the patients was normally nourished (20-24 kg/m2), 11.7% of them had malnutrition, 28.7% was overweight, and 17.1% was mildly or moderately obese. Subjective Global Assessment (SGA), calculated by dietician, revealed, that 47.9% of the patients has normal nutritional condition, all the others had some degree of malnutrition. Serum albumin level showed close correlation with the nutritional status, also with an inflammatory marker, the CRP. Only 63.8% of the patients had higher than 40g/l serum albumin. Those, who had higher than 10 mg/l CRP value, had significantly lower serum albumin (38.7±3.4 g/l), comparing to the albumin of the patients, whose CRP was below 10 mg/l (40.5±3.9 g/l, p=0.04). Comparing anthropometrical data, there was no significant difference between diabetic and non-diabetic patients. Grouping patients by their ages, the malnutrition, defined by SGA scores and by serum albumin level, was significantly worse in patients older than 80 years, than in the younger than 50 years old subjects, which signals increased risk of mortality of the elderly patients. A case presentation demonstrates, that malnutrition can be diagnosed at early stage by appropriate nutritional assessment, and it can be corrected by timely and satisfactory energy- and nutrient-substitution, in severe cases by specially prepared nutritional supplements, and thereby the patient’s severe cardiovascular risk can be ameliorated. The successful treatment of hemodialysis patients requires change in medical practice, and close cooperation between physicians and dieticians.]

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[The prognostic role of placental growth factor in pregnancies complicated by hypertensive disorders]


[Placental growth factor (PlGF) is a member of the proangiogenic VEGF-family; it is mainly produced by throphoblast cells. During the last years numerous studies have shown that circulating PlGF-level in maternal plasma is decreased and its suluble receptor sFlt-1 shows increased expression. In the present study we examined the prognostic accuracy of Alere Triage® PlGF-Assay in hypertensive disorders of pregnancy and its relation with the length of pregnancy. 130 pregnant women were involved in this case-control study (PE: 23, HELLP-syndrome: 20, superimposed praeeclampsia: 17, chronic hypertension: 25, gestational hypertension: 18 and normal control: 27). Blood draw occured between the 22nd and 34th gestational week. PlGF levels were measured by the Alere Triage® PlGF Assay using samples from the maternal plasma. The plasma PlGF-levels of women whose pregnancies were complicated by hypertensive disorders were significantnormotoly lower compared to those who had uncomplicated pregnancies and the decrease were greater in those patients who delivered before the 35th gestational week. The PlGF-test was positive in 93,7% of those women who delivered before the 35th gestational week and in 90,5% of those who delivered before the 37. gestational week. The vast majority of preeclamptic (PE: 95,7%, SIPE: 82,4%) and HELLP-syndrome (95%) patients had positive PlGF tests, the 60% of the chronic hypertension and the 44,4% of the gestational hypertension patients have also shown positive results. The main conclusion of this study is that the PlGF levels using maternal plasma are lower in those pregnancies which are complicated by hypertension and show strong correlation with the severity of the hypertensive disorder. We perceived high sensitivity values in detecting preeclampsia, HELLP-syndrome and superimposed preeclampsia. In the future we may use this method to separate high risk women for hypertensive disorders and it may improve the perinatal outcome]

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