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Lege Artis Medicinae

SEPTEMBER 20, 2018

[Differential diagnosis and treatment of hyponatraemia]

NÉMETH Zsófia, DEÁK György

[Hyponatraemia (serum sodium concentration < 136 mmol/l) is the most frequent electrolyte abnormality that inceases the risk of both in-hospital, and outpatient mortality. Antidiuretic hormone action or low glomerular fitration rate or low excretable osmoles or their combination are involved in its pathogenesis. Differential diagnosis is based on medical and medication histories, serum- and urine osmolality and urine sodium concentration. Measurement of fractional excretions of urea and uric acid help identifying low effective circulting volume, renal hypoperfusion. Symptomatic hyponatraemia or an acute decrease of serum sodium concentration exceeding 10 mmol/l should be treated with 3% NaCl to avoid impending threat to life. The principles of the treatment of chronic hyponatraemia are restriction of water intake and elimination of etiologic factor(s) (eg. medications - most often thiazides). In case of contracted axtracellular volume, isotonic saline should be given. In case of euvolaemia, restriciton of water intake is fundamental. In case of expanded extracellular volume, (heart failure, liver cirrhosis, nephrosis), water and NaCl intake should be restricted along with aldosteron antagonist and loop diuretic therapy. In chronic hyponatraemia, the rise of serum sodium concentration should not exceed 10 mmol/l during the first 24 hours and 8 mmol/l/day thereafter. ]

Hypertension and nephrology

FEBRUARY 20, 2018

[How the recognition and treatment of primary aldosteronism could be improved?]

BAJNOK László

[Practically there were no randomized, controlled trials in the area of PA so far, but recently two such ones have appeared. In addition, both are paradigm- forming; yet not built into (yet?) the expert opinions. In the field of primary aldosteronism (PA), there is a sharp contrast between the world’s leading experts in many areas. There is consensus in respect that hypokalaemia, therapy resistance and vascular complications are more common in PA than in primary hypertension. According to prestigious studies, the ratio of surgically correctable cases can be around 5% of hypertension. However, only a tiny fraction of these cases are ever investigated even in the developed countries. Specific treatment might be reached more easily by a multi-speed approach applicable for domestic conditions in which one of the alternatives is the diagnostic process itself. In the latter, following aldosterone criteria are proposed: at screening greater than 15 ng/dl when associated with low renin, in the suppression test, for further testing (adrenal CT) a concentration above 5 ng/dl. This would provide a sufficient balance between sensitivity and specificity. Another solution could be the more widespread use of low dose spironolactone in resistant hypertension.]

Hypertension and nephrology

DECEMBER 08, 2012

[Role of ramipril/amlodipine fixed combination in treatment hypertension of patients with chronic kidney disease]

VÁRKONYI Magdolna, SIMONYI Gábor

[Hypertension is an important risk factor of chronic kidney disease (CKD) however CKD can cause hypertension. Untreated CKD may result in renal failure. Hypertension and CKD are important cardiovascular risk factors. Several mechanisms play role in the worsening of renal function. The main pathogenetic factor is the increased activity of the renin-angiotensin-aldosteron system (RAAS) that can result in glomerulosclerosis, destroy of nephrons and proteinuria. In the treatment of hypertension in CKD patients inhibiting RAAS is very important because ACE-inhibitors and angiotensin-receptor blockers provide efficient control not only of blood pressure, but also of proteinuria, an effect associated with improved long-term nephroprotection. Between ACE-inhibitors ramipril has proved nephro- and cardiovascular protection effect. Fix combination therapy of ramipril with amlodipine has a very pronounced blood pressure lowering effect and can improve patient compliance too.]

Hypertension and nephrology

SEPTEMBER 20, 2011

[Two cases of hyponatremic hypertensive syndrome due to unilateral stenosis of the renal artery]

LAKATOS Orsolya, GYÖRKE Zsuzsanna, VAJDA Péter, JUHÁSZ Zsolt, DEGRELL Péter, SULYOK Endre, MOLNÁR Dénes

[Eighty percent of secondary hypertension in childhood is of a renal cause, and ten percent of these cases are due to renovascular disease. Rarely, unilateral stenosis of the renal artery can lead to hyponatremic hypertensive syndrome as a consequence of critical renal ischemia, which is characterized by serious hypertension, electrolyte disturbances (hyponatremia, hypokalemia), polyuria and increased activity of the renin angiotensin aldosterone system. The authors review the cases of a 27-month-old and a 3-year-old boy, in whom HHS developed due to a severe stricture of the renal artery. With the removal of the nonfunctioning kidney, polyuria and electrolyte disturbances resolved, the level of renin normalised, and anti-hypertensive therapy could be gradually ceased. The authors emphasize that the measurement of blood pressure in children is crucial, especially in cases of polyuria, polydipsia, proteinuria and failure to thrive. Early recognition is very important, and a kidney with a function under ten percent must be removed before hypertension can be stabilized. In case of an electrolyte disturbance associated with hypertension, the possibility of hyponatremic hypertensive syndrome must be considered in childhood as well.]

Lege Artis Medicinae

MARCH 20, 2001

[Antiatherosclerotic effect of ACE inhibitor drugs]

CZURIGA István

[Based on animal and human research data, it is likely that renin-angiotensin-aldosteron system has an important role in the pathogenesis and progression of atherosclerosis. It has been demonstrated in several large clinical trials that ACE inhibitors reduce the risk of ischemic events in patients with left ventricular dysfunction. Whereas some benefits of ACE inhibitors may be related to the lowering of blood pressure, other specific effects on vasculature have also been proposed. ACE inhibitors appear to possess unique cardioprotective and vasculoprotective properties even for patients without hypertension or left ventricular dysfunction. Recent data suggest that most patient with atherosclerotic cardiovascular disease should be considered for ACE inhibitor therapy, unless they are intolerant or have contraindication for the drug. The goal of this article is to review the data from clinical trials that support the anti-atherosclerotic and antiischemic effects of ACE inhibitors.]

Lege Artis Medicinae

MARCH 20, 2010

[Secondary hyperaldosteronism resulting from a feeding disorder]

TÓTH Géza, RÁCZ Károly, FŰTŐ László

[INTRODUCTION - A number of diseases can cause hyperreninaemia and secondary hyperaldosteronism due to the stimulation of the renin-angiotensin system (RAS). The authors present a case of a patient suffering from a feeding disorder, whose secondary hyperaldosteronism verified by hormone examinations recovered after resolution of the feeding disorder. CASE REPORT - The authors found that the patient, who had been on an extreme vegetarian diet and avioded all forms of common salt as well as natural sodium intake for 8 years, had consistently normal electrolite levels, normal blood pressure, elevated plasma renin activity (PRA) and plasma aldosterone levels. Salt loading and postural tests verified secondary hyperaldosteronism. All known diseases that might lead to elevated RAS activity were excluded. After cessation of the salt-restricted diet, the patient’s PRA and plasma aldosteron levels returned to the normal range, which confirmed the possibility that the secondary hyperaldosteronism developed because of the feeding disorder. CONCLUSION - The authors have not found similar hormon alterations due to alimentary causes in humans in the literature. According to their hypothesis, the feeding disorder might lead to secondary hyperaldosteronism via affecting the system or systems that regulate RAS activity.]

Lege Artis Medicinae

DECEMBER 10, 2009

[Resistant hypertension - differential diagnosis and therapy]

TISLÉR András

[Hypertension is considered resistant to therapy if the target blood pressure is not achieved despite treatment with three different types of antihypertensive drugs, including a diuretic. Causes of therapy resistance may be grouped into three broad categories: Pseudoresistance can be the result of inadequate blood pressure measurement technique, the “white-coat” effect or the patients’ noncompliance with pharmacological and nonpharmacological medical advices. Evaluation of the measurement technique - including the size of the cuff used - and blood pressure monitoring at home can help identify the causes of pseudoresistance. Secondary resistance comprises drug interactions and concomitant medical conditions that elevate blood pressure or antagonize antihypertensive therapy. In addition, secondary resistance can result from disorders associated with secondary hypertension, among which appropriate screening for hyperaldosteronism as well as for renoparenchymal and renovascular hypertension need special emphasis. Suboptimal therapy is frequently related to subclinical volume overload and the use of inappropriate type or dosing of diuretics. Furthermore, when choosing the optimal drug combination, care should be taken to inhibit the various systems that regulate blood pressure as much as possible. In addition to combining the most frequently used antihypertensive drugs, the use of aldosterone antagonists, vasodilators, nitrates or drugs affecting the central nervous system might help to optimise treatment.]

LAM Extra for General Practicioners

JUNE 20, 2010

[Secondary hyperaldosteronism resulting from a feeding disorder]

TÓTH Géza, RÁCZ Károly, FŰTŐ László

[INTRODUCTION - A number of diseases can cause hyperreninaemia and secondary hyperaldosteronism due to the stimulation of the renin-angiotensin system (RAS). The authors present a case of a patient suffering from a feeding disorder, whose secondary hyperaldosteronism verified by hormone examinations recovered after resolution of the feeding disorder. CASE REPORT - The authors found that the patient, who had been on an extreme vegetarian diet and avioded all forms of common salt as well as natural sodium intake for 8 years, had consistently normal electrolite levels, normal blood pressure, elevated plasma renin activity (PRA) and plasma aldosterone levels. Salt loading and postural tests verified secondary hyperaldosteronism. All known diseases that might lead to elevated RAS activity were excluded. After cessation of the salt-restricted diet, the patient’s PRA and plasma aldosteron levels returned to the normal range, which confirmed the possibility that the secondary hyperaldosteronism developed because of the feeding disorder. CONCLUSION - The authors have not found similar hormon alterations due to alimentary causes in humans in the literature. According to their hypothesis, the feeding disorder might lead to secondary hyperaldosteronism via affecting the system or systems that regulate RAS activity.]

Lege Artis Medicinae

FEBRUARY 20, 2005

[ALDOSTERONE AT THE BEGINNING OF THE 21ST CENTURY]

GLÁZ Edit, SZŰCS Nikolett, VARGA Ibolya

[The discovery of aldosterone as the principal mineralocorticoid hormone led to a new era in the study of the regulation and the pathological/clinical relevance of the fluid-salt homeostasis and blood pressure. Here, we discuss briefly the history of the discovery of aldosterone, its biosynthesis, the mechanism of action, regulation and the diseases which are associated with its pathologically increased production and hypertension: primary and secondary hyperaldosteronisms. Considering their clinical significance, we focus on primary hyperaldosteronisms as they represent a considerable portion of secondary hypertensions that can be definitively cured. Differential diagnosis issues related to other forms of hypertension of different origins are discussed in detail. Recent findings of the past fifteen years indicate that besides its classical genomical actions aldosterone has much more diverse non-genomic actions as well including proinflammatory and profibrotic effects even in physiological concentrations. Based on these observations, aldosterone can be regarded as a risk hormone in the aetiology of cardiomyopathies, vasculopathies and neuropathies and therapeutical consequences are also discussed.]