Hypertension and nephrology

[Voiding sonocystography with ultrasound contrast material for the diagnosis of vesicoureteral reflux]

KIS Éva1

APRIL 20, 2011

Hypertension and nephrology - 2011;15(02)

[Voiding sonocystography with intravesical administration of ultrasound contrast agent is a sensitive method to detect vesicoureteral reflux without irradiation. Depicting microbubbles in the ureters and collecting system is feasible even with very small amounts of a second-generation ultrasound contrast agent, Sonovue. The reflux is graded (I-V) in a similar manner to the system used in voiding cystourethrography. In this article a detailed description is presented.]

AFFILIATIONS

  1. Semmelweis Egyetem, I. Sz. Gyermekgyógyászati Klinika, Budapest

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[Change in the approach of the treatment of hypertension in Hungary. Five years results of the „Live below 140/90!” Program]

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[One of the potentials of the effective fight against endemic diseases is their exposition and the recognition of their dangers and risk factors. The other possibility is to increase the professional knowledge of the medical and healthcare employees along with the patients’ co-operation. For the prevention of complications and the adequate treatment of hypertension an extensive compliance program, called „Live below 140/90!” was initiated by the Hungarian Society of Hypertension in 2005. The mission was to give knowledge to the non-professional public about the symptoms of the disease and how to get information about it while helping patients’ relatives. The first message was the “Hit the target blood pressure value!”. With careful planning, treatment and taking of medicines the next phase could begin. The ratio of the patients who reached the target blood pressure increased by 5% during the two years of the Program between 2005 and 2007 therefore the message changed to “Hold the blood pressure there!”. The next step in the Program was to prevent the forming of complications and to treat the co-morbidities effectively among patients with pre-diabetes or diabetes and hypertension in 2008. The slogan was “Prevent the complications!”. As part of the Program we organized a roadshow named the “Day of caring!” and we announced the “Conscious Care” substudy focused on the public summoning about the stroke which is the most dangerous complication of hypertension. The year of 2011 is an absolutely new beginning in the communication of the Program since we started to use some very modern tools of the 21st century including YouTube, Facebook and others for the better education of the people. Based on the results of the initial Program we got to know the risks, co-morbidities, complications and the characteristics of the Hungarian hypertensive patients. We have recognized that most of the patients belong to the high and very high risk hypertensive category. Also more than 30 percent of them have a pre-diabetes condition. We have found that increased caring helps to build up the patients’ co-operation which in return improves the decrease of their blood pressure significantly. The Program therefore continues in 2011! Our intention is to enlarge the Hungarian Hypertension Register database and to get to know more and more epidemiologic and therapeutic features of the hypertension disease.]

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[The aging of the population, the high prevalence of chronic diseases and the consequent rapid increase of healthcare expenditures present a difficult challenge for the medical care system and for the society in the developed countries. Sleep disorders are increasingly recognized as very frequent chronic diseases with significant pathophysiological and psychosocial consequences. In the last 20 years an increasing number of studies reported high prevalence of sleep disorders, such as restless legs syndrome in patients with kidney disease. Chronic renal failure is the most common condition presenting with secondary restless legs syndrome. It is associated with insomnia, depressive symptoms and anxiety, impaired quality of life, as well as elevated cardiovascular risk. Compliance of the patients with restless legs syndrome is decreased, and it is more likely that they discontinue dialysis treatment. This may be related to higher mortality in kidney disease patients with restless legs syndrome.]

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[INTRODUCTION - International and Hungarian (JNC-7, ESH/ESC2007 és 2009, MHT 2009) Guidelines suggest a target blood pressure <140/90 mmHg for hypertensive patients, and <130/80 mmHg for those with high/very high cardiovascular risk (e.g. patients with diabetes mellitus, chronic renal disease). It was proved that for achieving the most efficient antihypertensive effect and reducing side effects, thd use of drug combinations is needed in most patients. In Hungary, ACE-inhibitor plus diuretic combination is one of the most frequently used one in Hungary. The vérnyomáscsökaim of the PICASSO study was to evaluate the efficacy and metabolic effects of the fixed combination of high-dose perindopril plus indapamide (Coverex-AS Komb Forte®) in clinical practice of hypertonologists, cardiologists and general practicioners. PATIENTS AND METHODS - Patients with uncontrolled, grade 1 or 2 primary hypertension, age, >18 years were involved in the open, 3-month, multicentre, prospective, observational, non-interventional clinical study if the treating physician indicated a combination treatment with higher dose antihypertensive drugs. Blood pressure (also with ABPM), heart rate, metabolic parameters (plasma lipids, blood sugar, Na, K, creatinine, uric acid, GGT) were measured by routine methods, medical history and quality of life parameters were registered on a validated questionnaire. Changes in the above parameters were also separately evaluated in patients with different risk factors or with concomitant diseases. RESULTS - Data of 9683 patients were evaluated (54% women, 46% men, average age 61.8 years). By the end of the therapy used in the study, blood pressure average decreased from 159/93 to 131/80, by ABPM from 145/83 to 126/74 mmHg (24hr averages, systolic/diastolic blood pressure, respectively), the heart rate from 79 to 73 beats/min (p<0,001). Target blood pressure was achieved in 75,4% of patients with no major concomitant disease, but only in 14% of those with a concomitant disease characterised by lower target blood pressure. The diurnal index by ABPM did not change substantially. Clinically significant decreases were found in the plasma levels of total cholesterol, LDL-cholesterol, triglycerides, fasting glucose and uric acid levels, but there were no major changes in serum levels of HDLcholesterol, Na, K, and GGT. Quality of life parameters significantly improved by the end of the study. CONCLUSIONS - Combinations of perindopril and indapamide can be successfully and safely used in everyday practice.]

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[Water metabolism in the organism is regulated very exactly under normal circumstances. Sometimes, however, when the level of the antidiuretic hormone is inappropriately high and fluid consuming is not limited, water intoxication can develop. This is especially paradoxical during treatment with diuretics. Authors observed in a cachectic, potassium wasting, 87-year-old female patient, hyponatremia associated with clinical water intoxication developing in a hot period of summer, during long-term thiazide diuretic (chlorthalidone) treatment administered because of high blood pressure. Diagnosis was based besides the clinical picture on the severe hyponatremia and was supported by the relatively high urine osmolality in the presence of a very low plasma osmolality. Despite treatment of hyponatremia in accordance to the recommandations “overcorrection” occurred and turned into fatal hypernatremia. In the period of low plasma osmolality the patient was treated with intravenous infusions containing isotonic saline supplemented with potassium. When hypertonicity developed hypotonic intravenous infusions were given. Authors discuss the literature of hyponatremia with special reference to the dilemmas of therapy such as “slow” versus “rapid” correction as well as procedures to be done in case of “overcorrection”.]

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[Voiding sonocystography with ultrasound contrast material for the diagnosis of vesicoureteral reflux]

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[Voiding sonocystography with intravesical administration of ultrasound contrast agent is a sensitive method to detect vesicoureteral reflux without irradiation. Depicting microbubbles in the ureters and collecting system is feasible even with very small amounts of a second-generation ultrasound contrast agent, Sonovue. The reflux is graded (I-V) in a similar manner to the system used in voiding cystourethrography. In this article a detailed description is presented.]

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[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.]

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