Lege Artis Medicinae

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


MAY 20, 2019

Lege Artis Medicinae - 2019;29(04-05)

DOI: https://doi.org/10.33616/lam.29.023

[The prevalence of hypertension among pa­tients with chronic kidney disease is high, reaching more than 80%. Hypertension is both one of the main causes and also the most common consequence of chronic kidney disease. It is also a main factor responsible for the high cardiovascular morbidity and mortality in this patient population. Blood pressure control can improve patient outcomes, lower cardiovascular risk and slow down the progression of kidney dis­ease, irrespective of the underlying cause. The optimal therapy should therefore focus not only on blood pressure reduction but also on renoprotection. Basic understanding of the renal pathophysiology in hypertension and renal effects of various medications is of paramount importance. In this review, we summarized cornerstones of the antihypertensive therapy in patients with chronic kidney disease. The management of patients receiving kidney replacement therapies, such as hemodialysis, peritoneal dialysis or transplanta­tion requires special knowledge and expe­rience, therefore it is not discussed here. The aim of this review was to allow non-nephrologist physicians to take care of their kidney patients with more confidence and effectiveness.]



Further articles in this publication

Lege Artis Medicinae

[Physical inactivity and activity. Damage and benefit]


[Authors address the issue of inadequate physical activity worldwide and analyze their relationship with cardiovascular diseases and total mortality. In the inactivity "world map" it can be seen that in economically developed countries it is very common but other ethnic and regional factors also play a role and it is significantly more frequent at women. In our country this phenomenon due to combination of advanced civilization and computerization is also frequent. From 2000 to 2015, the trend of the presence of physical inactivity (FI) in the high income populations is steadily rising. Convincing evidence suggests that FI increases the risk of many common, serious diseases, including ischaemic heart disease, type 2 diabetes, breast cancer and colon carcinoma, and reduces the life expectancy. For these four diaseses, the incidence of FI occurs in about 1/3 of cases and 35% of total mortality. Its health value (PAF) ranges from 10 to 18%. Low (non-regular) exercise increases the risk of hypertension with or without family history. In subjects with moderate and intensive levels of physical activity (FA), there is a significantly lower mortality rate and the rate of occurrence of major cardiovasculars (CV) diseases compared to those with lower grade FA. Behind the positive effect of physical activity there is a multiple and complicated mechanism that manifests itself in the vascular system, in the physiological adaptation of the heart and in other metabolic and cellular effects. ]

Lege Artis Medicinae

[Perinatal faulty hormonal imprinting: early impact, late consequences]

CSABA György

[The description and basic study of hormonal imprinting were the first in the series of research, which led to the recognition of the role of perinatal chemical effects in the late (adult age) manifestation of some diseases and inclination to diseases. Today it is clear, that certain pathological states, as obesity or diabetes, hypo- or hyperactivity (autoimmunity and allergy) of immune system can be deduced to perinatal (hormonal or metabolic) imprinting. The perinatal hormonal (chemical) imprinting takes place at the first encounter between the developing hormone receptor and the target hormone which sets the binding capacity of the receptor for life. In the critical periods of ontogeny (in addition to the perinatal imprinting) it can be developed at weaning, in adolescence and in continuously dividing and differentiating cells during the whole life. It is provoked by considerable quantitative differences of the physiological hormone or the presence of strange target-hormone-like molecules. The faulty hormonal imprinting leads to the adult-age diseases at any time of life and is inherited epigenetically to the progeny generations. Faulty hormonal imprinting always could be present in earlier times however, at present, because of the erroneous multiplication of endocrine disruptors in the environment, nutrition and medicine, its importance is continuously growing. The effects of faulty hormonal imprinting seem to be dangerous however, it can be imagined in the far future also a positive effect by the transformation of the human endocrine system at an evolutionary route. In the metabolic or immunological imprinting as well, as in the DOHaD (Developmental Origins of Health and Disease) the foremost recognized hormonal (chemical) imprinting is materialized.]

Lege Artis Medicinae

[Treating methods of obstructive sleep apnea syndrome and related difficulties in daily practice ]


[Obstructive sleep apnea syndrome (OSAS) is the most common breathing disorder during sleep. Its incidence is between 2-4%, but in many cases, the disease is not recognized. It has many symptoms, but the most typical symptoms are loud snoring and daytime sleepiness. Treatment always consists of several elements depending on the patients’ specific needs. When deciding on which treatment to use efficiency and the patients’ compliance are the key factors. The necessity of the therapy can be determined by three criteria: clinical complaints (daytime discomfort), the severity of the breathing disorder and the accompanying cardiovascular diseases. Treating possibilities for the mild to moderate OSAS are lifestyle changes (losing weight, avoiding alcohol and sedative drugs), positional therapy, oral appliances, and varied surgical corrections. For patients with moderate to severe OSAS and mild OSAS with severe symptoms the first line therapy is continuous positive airway pressure. In addition to presenting new therapeutic options, the authors describe the role of the family physician in the care of apnea patients.]

Lege Artis Medicinae

[Rifaximin-α: More than antibiotic ]


[Antibiotic therapy might alter gut microbiome. The consequence of that is dysbiosis with or without immediate overt clinical manifestation. The beneficial effect of rifaximin, a non-absorbable broad spectrum antibiotic, in gastrointestinal and hepatic disorders is known for a long time. According to recent data rifaximin has not only antibiotic but also anti-inflammatory and, within antibiotics, a unique special eubiotic effect as well. It modulates the gut microbiome, restores eubiosis through increasing beneficial species’ count while not disturbing diversity.]

Lege Artis Medicinae

[Sweet Portraits, Bloody Wars, Destructive Epidemics ]


All articles in the issue

Related contents

Hypertension and nephrology

[Association between cyclothymic affective temperament and hypertension]


[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.]

Lege Artis Medicinae

[Thiazide- or thiazide-like diuretics should be used in the treatment of patients with hypertension? Particularities of the situation in Hungary]


[Diuretics have remained the cornerstone of the antihypertensive treatment since their widespreading in the 1960s. According to the 2018 ESC/ESH Guidelines for the management of arterial hypertension, in the absence of evidence from direct comparator trials and recognizing that many of the approved single-pill combinations are based on hydrochlorothiazide, this drug and thiazide-like indapamide can be considered suitable antihypertensive agents. In the 2018 Hungarian guidelines indapamide is named as the most efficacious diuretic in the treatment of patients with hypertension. The aim of the publication is redefining thiazide- and thiazide-like diuretic use in the treatment of hypertensive patients, with particular attention to presently available hydrochlorothia­zide and indapamide, and their combination drugs in Hungary.]

Clinical Neuroscience

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

GÜLER Siber, NAKUS Engin, UTKU Ufuk

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.

Hypertension and nephrology

[The importance of assessing subclinical organ damage in risk prediction of hypertensive patients]

GODINA Gabriella, JÁRAI Zoltán

[As the cardiovascular risk influences the quality and intensity of blood pressure lowering therapy, the goal blood pressure values and the frequency of medical control of hypertensive patients, as well as global risk assessment has an important role in the management of hypertension. In the last couple of years many data have been accumulated showing the poor prognostic value of traditional cardiovascular risk factors. This is the reason why recent Hungarian and international guidelines on the management of hypertension advise the screening for subclinical organ damage. Our goal was to summarize the importance of subclinical organ damage by discussing recently published literature on this topic. An overview has been made on the markers of vascular subclinical damage, like carotid atherosclerosis proved with carotid ultrasonography, peripheral arterial disease assessed with ankle-brachial pressure index measurements and vascular rigidity defined with pulse wave velocity measurements. The prognostic values of myocardial hypertrophy assessed with ECG and/or echocardiography and renal damage proved with decreased estimated glomerular filtration rate and proteinuria are also discussed. Summing up what has been said so far, the assessment of subclinical organ damage has a role in cardiovascular risk prediction, however more randomized and prospective studies have to be performed to define the most suitable (i.e. the most reliable and the most cost-effective) markers for this purpose.]

Lege Artis Medicinae

[The effects of angiotensin receptor blockers on the nervous system in hypertension and dementia]


[The renin-angiotensin system (RAS) is one of the most important mechanisms regarding the pathomechanism and treatment of hyprtension. The most of the elements of the RAS are found in the nervous system too. The effect of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ARBs) is based on the inhibition of the RAS. ARBs might have a special role in the central nervous system because they do not decrease the production of angiotensin but inhibit its harmful effects mediated through the AT1 receptor while allowing the stimulation of AT2 receptors with resulting pleiotrophic actions. Hypertension is the most important risk factor for stroke and has a negative effect on cognitive functions. Antihypertensive treatment has an effect on the nervous system; in addition to the consequences of the reduced blood pressure, ARBs might provide additional advantages in stroke and dementia prevention.]