Lege Artis Medicinae



MAY 20, 2005

Lege Artis Medicinae - 2005;15(05)

[The authors assess the two main outcomes of the immunosuppressive therapy after renal transplantation: graft and patient survival. According to their view, evidence from randomised clinical trials results can be well complemented by the several unique transplant registries and outcome research based upon these databases. The comparison of evidence from these two sources addresses the question of achievable outcome under ideal (controlled) versus real life conditions. Based on a systematic review of the relevant clinical trials and registries it can be stated, that in the case of some immunosuppressants (mycophenolate mofetil vs azathioprine, microemulsified cyclosporin vs cyclosporin and tacrolimus vs cyclosporin) the improvement in the intermediate outcome can lead to improved graft and patient survival, while in the case of other drugs no significant difference in hard endpoints were detected (tacrolimus vs microemulsified cyclosporin). Evidence on graft and patient survival differences could not be derived from traditional randomised clinical trials, only from transplant registries. For the sake of improved evidence based therapeutic guidelines in renal transplantation, authors call for further development of the Hungarian transplant registry.]



Further articles in this publication

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[Methods of nuclear cardiology have been applied for several decades and there is continuous development in this area. The most commonly used modality is the myocardial perfusion scintigraphy (MPS). During stress MPS, the presence and the severity of ischaemic heart disease (IHD) can be detected. Resting MPS can show a freshly developing acut myocardial infarction (AMI) immediately, but new and old infarcted myocardial areas can not be distinguished by this method. Using SPECT (single photon emission tomography) examination and quantitative analysis can improve the accuracy of MPS. With gated SPECT we can analyse both the perfusion and the function of left ventricle. To examine the function of left and right ventricle the “gold standard” non-invasive method is MUGA (multiple gated acquisition) of blood pool scintigraphy. After only a few hours of the onset of AMI we can detect it with the socalled infarct avid scintigraphy using radiopharmaceuticals which accumulate in affected area. Following an AMI it is essential to differentiate among high and low risk patients for revascularisation treatment, therefore distinguishing the viable (hibernating) and non-viable (necrotic) myocardium with imaging techniques is an important task. Preserved metabolism as the sign of viable myocardium can be detected both by SPECT (most accurately by thallium rest-redistribution scintigraphy) and PET (detecting glucose metabolism by F-18-FDG). Adrenerg receptor scintigraphy can show the sympathetic innervation: in the case of a transplanted heart it can detect the reinnervation and in the case of malignant ventricular tachyarrhythmias the risks and the severity of the illness.]

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[In the focus: Dermatology]


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[Neutropenia is an immunocompromised state commonly occurring in hematological practice. The underlying disorder responsible for a critical drop in absolute granulocyte count can either be of congenital or acquired nature. Neutropenic patients frequently develop serious, at times even fatal infections. Severity of illness, outcome, type of infecting organisms are markedly influenced by additional risk factors such as impaired T- or B-lymphocyte function as well as the injury of biological barriers. Neutropenic infections should generally be treated according to evidence-based guidelines. However, in certain groups of patients, where randomized trials are lacking, all identified components of immunodeficiency should be taken into account and antimicrobial treatment or prophylaxis should individually be tailored.]

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[Who should provide the definitive care of the patient with osteoporotic fracture?]


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[Cardiopulmonary resuscitation is the progressive management of sudden cardiac arrest with the goal of restoring spontaneous circulation and preserve vital organ functions. Sudden cardiac death occuring out of hospital is still one of the major causes of death among otherwise healthy and young population however, approppriate management - certainly including resuscitation as the first step - might provide a reasonably good quality of life. Long term outcome of resuscitation is mainly determined by the links of the Chain of Survival, eg. early access, early CPR, early defibrillation and early advanced care. The aim of this review is to present the upto- date concepts for the best management of these survival links.]

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Hypertension and nephrology

[Dialysis in Hungary: 2003-2009]

KULCSÁR Imre, SZEGEDI János, LADÁNYI Erzsébet, TÖRÖK Marietta, TÚRI Sándor, KISS István

[The authors show the data of Hungarian dialysis statistics from 2003 to 2009. The questionnaire-based data collection was made by the Dialysis Committee of the Hungarian Society of Nephrology. The number of all patients entered in the dialysis program increased by 45.2% over six years (an average of 7.5% per year) and the number of new ones increased by 51.2% (8.5% per year). The increase in number of patients treated with haemodialysis was 39% (6.5% per year) in this period. The increase in the number of patients in the peritoneal dialysis program was extremely high: 80.6% (an average of 13.4% per year). The population incidence of new dialysed patients was 332/1 million in 2003 and 483/1 million in 2009. The population point prevalence at the end of the year was 437/1 million in 2003, but 607/1 million in 2009. The penetrance of peritoneal dialysis was 12.8% in 2009. Differences exist among the regions of Hungary in the number of patients, the penetrance of peritoneal dialysis and the prevalence of renal replacement therapies. Among patients suffering in conditions which lead to end stage renal disease the proportion of patients with diabetic or hypertensive nephropathies is increasing and the proprtion of patients with glomerular or tubulointerstitial damage is decreasing. The number (and rate) of the elderly people is growing continuously year by year. The rate of patients on waiting list for renal transplantation is decreasing (the rate was 20% in 2003, but only 10.7% in 2009). There is also a slow decrease in the number of the annual renal transplantations. The mortality rate of chronically dialysed patients shows a little increase. Five dialysis centres for paediatric patients and 58 for adults have been functioning in Hungary by the end of 2009. In average 106 patients have been treated by each Hungarian dialysis centre in contrast to the optimal of 60 persons. The number of nephrologists increased between 2003 and 2007, but slightly decreased since then. The case is similar regarding nephrological nurses.]

Hypertension and nephrology

[Functional and morphologic changes in patients with new-onset dyslipidemia after transplantation]


[The principal risk factors for cardiovascular mortality after transplantation are hyperglycemia, hypertriglyceridemia, immunosuppressive therapy, obesity, and smoking. Among 115 patients, we assessed the risk factors for new-onset dyslipidemia, and their effects on the function and histopathology changes in the allografts one year after transplantation. Evaluating the risk factors and the initial recipient data, we observed a significant difference in age when comparing normal versus new-onset dyslipidemia patients (p=0.002). The difference in body mass index was significant one year after kidney transplantation when comparing normal with new-onset dyslipidemia patients (p=0.02). The trigliceride levels were significantly higher among those on cyclosporine- A than those on tacrolimus (3.02±1.51 mmol/l vs 2.15±1.57 mmol/l, p=0.004). The difference also proved to be significant for the total cholesterol level: 5.43±1.23 mmol/l versus 4.42±1.31 mmol/l respectively (p=0.001). In regard to allograft function there was no significant difference one year after transplantation between the normal and new-onset dyslipidemia patients. When assessing morphologic changes in the kidney, we observed significantly more frequent interstitial fibrosis/tubular atrophy among new-onset dyslipidemia than normal function patients. Disruption of lipid homeostasis is known to severely damage the allograft. Without timely recognition and treatment, these conditions may not only lead to irreversible damage in the allograft, but also increase cardiovascular risk.]

Lege Artis Medicinae

[Effect of mycophenolate sodium therapy on quality of life of renal transplant patients]


[Enteric-coated mycophenolate sodium (EC-MPS; Myfortic®, Novartis Pharma AG, Basel, Switzerland) is an enteric-coated formulation delivering MPA. Enteric-coated MPS has been developed with the aim of improving the upper GI tolerability of MPA while providing a therapeutical equivalence. The primary objective of the study was to measure the quality of life of kidney transplant patients, with special attention to gastrointestinal symptoms during mycophenolate sodium therapy. The secondary objective was to measure the mean daily mycophenolate sodium dose during routine therapy. These two parameters can significantly influence long-term graft survival of the patients. The study was a multicentric, non-interventional, 12 weeks, single arm, cohort, observational study, in which 251 adult, kidney transplant patients were enrolled in 4 study centers. As part of the study, the patient completed a questionnaire to assess the gastrointestinal status: the Gastrointestinal Symp­tom Rating Scale (GSRS). The patient’s average age was 51.03 years by the time of the inclusion. 61% of the patients were male and 39% female. Kidney transplant was performed averagely 6.3 years (SD: 4.3 years) prior to the screening visit. At the first visit the average intensity of gastrointestinal side effects was 0.87, at the final visit was 0.28. The change of the average number of gastrointestinal side effects between the first and last visit was examined by Wilcoxon test, and it was significant (p<0.0001). Patients had to complete the GSRS questionnaire aiming at five gastrointestinal symptom groups. In all five symp­tom-groups significant (p<0.0001) improvement was observed between the visits. Our results support that, in renal transplant patients with gastrointestinal undesirable effects due to MMF, using enteric-coated mycophenolate sodium may increase the maximum tolerated dose of MPA and reduce GI disorders.]

Hypertension and nephrology

[Prominents in Hungarian nephrology Professor Gyula Petrányi (1912-2000). Part II]


[A nation can only survive and keep its identity through its traditions. This is why the initiative to launch this series coming from professor János Radó is worthy of attention. Gyula Petrányi is an outstanding personality in 20th century internal medicine, to be more precise in nephrology and immunology, his activity being wide-ranging. The first part of the current summary of his work deals with a tribute to his personality, and his role in immunomodularity treatment in glomerulonephritis. The second part shall cover his role in spreading renal biopsy, screening and caring kidney patients, dialysis, in developing kidney patients’ care, furthermore in clinicopharmacology and renal transplantation.]

Hypertension and nephrology

[Covid-19 and the kidney]

PATÓ Éva, DEÁK György

[Covid-19 pandemy has emerged from Wuhan, China in December 2019. The infection affects not only the lung but other organs such as the kidney, as well. The relation between Covid-19 infection and the kidney is bidirectional. On one hand, Covid-19 infection may cause kidney damage in 50-75% of the cases resulting in proteinuria, haematuria and acute kidney injury (AKI). The etiology of AKI is multifactorial. Main pathogenic mechanisms are direct proximal tubular cell damage, sepsis-related haemodinamic derangement, citokine storm and hypercoagulability. The virus enters proximal tubular cells and podocytes via the ACE2 receptor followed by multiplication in the lysomes and consequential cell lesion. Histopathology shows acute tubular necrosis and acute tubulointerstitial nephritis. AKI is a strong predictor of mortality in critically ill patients. On the other hand, the risk of Covid-19 infection and mortality is substantially increased in patients with chronic kidney disease – especially in those with a kidney transplant or on dialysis – due to their immunocompromised status. Among haemodialysis patients, infection may spread very easily due to the possibility of getting contacted in the ambulance car or at the dialysis unit. The mortality rate of patients on renal replacement therapy with Covid-19 infection is 20-35%. In order to avoid mass infection it is obligatory to employ preventive measures and implement restricions along with (cohors) isolation of infected patients. In Hungary, every dialysis or kidney transplant patient with Covid-19 infection should be admitted to dedicated Covid-19 wards.]