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Clinical Neuroscience

NOVEMBER 30, 2019

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

SEPTEMBER 12, 2018

[Treatment of hypertension in kidney transplant patients]

KOVÁCS Tibor, WAGNER László

[Most of the renal transplant recipients suffer from hypertension. Hypertension substantially contributes to the high cardiovascular mortality in this population. The recommendation of the Hungarian Society of Hypertension and the international guidelines suggest to achieve less than 130/80 mmHg as target blood pressure in these patients. Several factors may be in the background of hypertension after kidney transplantation, which can be summarized as factors from the recipient-side, the donorside and factors provoked by transplantation itself. In most of the cases early after transplantation high doses of immunosuppressive drugs (especially calcineurin inhibitors and steroids) are responsible for the increased blood pressure. There are some further special methods apart from the general recommendations which are needed during the examination of hypertension of kidney transplant patients: e.g. measurement of blood trough-level of immunosuppressive drugs, investigation of bone-mineral disorder, screening for the level and causes of anaemia, check-up of the renal graft circulation. Kidney transplant patients suffering from hypertension usually need more than two antihypertensive drugs beyond the use of non-pharmaceutical antihypertensive methods. In the early posttransplantation period calcium channel blockers are preferred antihypertensive medications, because they counterbalance the vasoconstrictive effect of calcineurin inhibitors. The administration of renin-angiotensin-aldosterone inhibitors are rather suggested after the stabilization of renal function (from the 1-3 months posttransplantation). When designing antihypertensive strategy, comorbidities and special factors should be regarded as well, especially volume overload, proteinuria, allograft function (GFR), diabetes, other cardiovascular risk factors, previous cardiovascular events. The setup of an individual therapeutical strategy is advised in view of all these factors, which is different according to the timing after transplantation: the perioperative, the early postoperative phases and from 1-3 months after transplantation have special focuses.]

Hypertension and nephrology

FEBRUARY 10, 2016

[Incorporation of ortho- and meta-tyrosine into cellular proteins leads to erythropoietin-resistance]

MIKOLÁS Esztella Zsóka, KUN Szilárd, LACZY Boglárka, MOLNÁR Gergő Attila, SÉLLEY Eszter, KŐSZEGI Tamás, WITTMANN István

[Introduction: Erythropoietin (EPO) is a glycoprotein hormone, which is responsible for the proliferation and differentiation of erythroid cell lines. Since it is widely used as the treatment of renal anaemia, EPO-resistance is a common concern. Aims: We aimed to perform in vitro experiments to investigate a possible mechanism of EPO-hyporesponsiveness. Methods: We used a factor dependent erythroblast cell line (TF-1). Two independent observers calculated cell counts simultaneously on day 1; 2 and 3 in Bürker cell counting chambers. Colorimetric method was used to measure protein concentrations. Measurement of protein-bound para-, ortho- and meta-tyrosine was performed with reverse phase high performance liquid chromatography with fluorescence detection. We determined ERK and STAT5 activation using Western blot method. Results: In case of ortho- and meta-tyrosine pretreated cells time-dependent, EPOinduced proliferative activity was decreased compared to the 1.7 fold elevation of cell counts seen in para-tyrosine cultured cells. Protein concentration of ortho- and metatyrosine treated samples was significantly lower than control cells on the third day. Addition of para-tyrosine reclaimed EPO-sensitivity. Erythroblasts treated with orthoor meta-tyrosine contained lower concentrations of protein-bound para-tyrosine with higher ortho- and meta-tyrosine content. EPO dependent activation of ERK and STAT5 could be inhibited by ortho- or meta-tyrosine treatment. Conclusions: Elevated level of protein-bound ortho- and meta-tyrosine in erythroblasts can result in the pathological modification of intracellular signaling, leading to EPOhyporesponsiveness.]

Hypertension and nephrology

APRIL 20, 2015

[Tubulointerstitial nephritis and uveitis syndrome]

BAJCSI Dóra, FEJES Imre, KEMÉNY Éva

[Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare and underdiagnosed oculorenal disorder that is characterized by the development of acute tubulointerstitial nephritis and uveitis. The median age of onset is 15 years, but it may occur at any age. There is a female predominance. Uveitis might occur before, after, and also concomitantly with tubulointerstitial nephritis. The symptoms are typically non-specific, including fever, loss of appetite, weight loss, nausea and vomiting, weakness, abdominal pain, arthralgias and myalgias. Laboratory findings reveal an acute impairment of renal function, anaemia and elevated inflammatory parameters. Urinary findings are consistent with tubulointerstitial nephritis including subnephrotic proteinuria, sterile leucocyturia, microhaematuria, and tubular dysfunction (e.g. normoglycemic glycosuria). The prognosis appears to be good, especially in children. Persistent renal dysfunction only develops in a small proportion of cases. In this paper, we present the case of a 39-year-old female patient with TINU syndrome, and review the literature.]

Hypertension and nephrology

JULY 20, 2013

[Practical aspects of therapy by erythropoiesis stimulating agents in renal anaemia]

DEÁK György, HERSZÉNYI Eszter, AMBRUS Csaba, KISS István

[Prevalence of renal anaemia due to insufficient production of erythropoietin increases progressively in the course of renal function deterioration. Renal anaemia is treated by erythropoesis stimulating agents (ESA). Outcomes of randomized clinical trials have taught us to avoid the strategy of normalization of hemoglobin (HGB) levels by ESA therapy as it may increase the risk of cardiovascular events and mortality. The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anaemia published in 2012 recommends to start ESA therapy in the 90-100 g/l HGB range and suggests to keep HGB concentrations below 115 g/l. It is an inappropriate strategy to aim at normalizing hemoglobin (HGB) levels by ESA therapy because it may lead to progressive escalation of ESA doses even in the presence of diminished ESA responsiveness. High ESA doses and diseases causing ESA hyporesponsiveness eg. infections, chronic inflammation, malnutrition, insufficient dose of dialysis, severe hyperparathyroidism, iron deficiency are related to increased risk of mortality. KDIGO Clinical Practice Guideline for Anaemia emphasizes the importance of assessing and treating causes of ESA hyporesponsiveness, limits ESA dose escalation and recommends gradually changing ESA doses to avoid high amplitude HGB oscillation.]

Lege Artis Medicinae

JUNE 21, 2006

[MUMMIFIED ANCYLOSTOMA DUODENALE IN THE DUODENUM CAUSING SEVERE ANAEMIA]

KOVÁCS Valéria, SZABÓ Andrea, GODA Mária, MAGYAR Éva, RÁCZ István

[INTRODUCTION - We report on a patient with the remains of a mummified hookworm (Ancylostoma duodenale) found in his duodenal bulb which was later successfully removed with a polypectomy snare. CASE PRESENTATION - An 81-year-old man who took 100 mg aspirin daily was admitted because of severe iron-deficiency anaemia. After transfusion with 5 units of packed red blood cells upper endoscopy was performed. On the anterior wall of the duodenal bulb an 8 to10 mm long thread-like foreign body was found embedded in a sessile polyp-like mucosal protuberation with ulcerated inner margin. The entire pathologic structure was removed by mucosectomy. Histologically the thread-like body was found to be a lifeless female Ancylostoma duodenale containing a large amount of eggs and the surrounding ulcerated mucosa was also deeply infiltrated by hookworm particles. Follow-up endoscopy after four months showed normal gastroduodenal mucosa. CONCLUSION - An interesting case of hookworm infection is reported where an old infection caused chronic mucosal injury with reactive inflammation and mucosal ulceration. Aspirin therapy provoked chronic occult bleeding causing severe anaemia. With the endoscopic removal of the unusual structure total mucosal and clinical healing was achieved.]

Lege Artis Medicinae

NOVEMBER 20, 2007

[HAEMOGLOBIN CYCLICITY IN RENAL ANAEMIA]

REUSZ György, SZABÓ J. Attila

[Erythropoiesis stimulating agents are glycoproteins in which the oligosaccharide chains that terminate in sialic acid bind to the peptide with glycosidic bond. The lower the sialic acid content of the erythropoietin, the higher its receptor affinity, while its half-life in the circulation decreases. The biological effect depends on the balance of these factors. In the third-generation erythropoiesis stimulating molecule CERA (continuous erythropoietin receptor activator) a large polyethylene glycol molecule is substituted for sialic acid to ensure slow elimination and better biological efficiency. During treatment with erythropoiesis stimulating agents, haemoglobin levels show cyclic fluctuation. This cyclicity is undesirable, so its frequency and amplitude should be reduced as much as possible. The most recent results suggest that CERA may reduce haemoglobin cyclicity.]

Lege Artis Medicinae

MARCH 20, 2005

[CELIAC DISEASE AND SPLENOPULPOMA IN THE BACKGROUND OF ANE]

MEKKEL Gabriella, BARTA Zsolt, KOVÁCS Judit, TÓTH László, BURIS László, RESS Zsuzsa, GERGELY Lajos, ZEHER Margit

[INTRODUCTION - Celiac disease causes inflammation with villus destruction in the duodenal and jejunal regions. The consequent secondary malabsorption affects many physiological processes adversely causing iron/folate deficiency type anaemia most frequently. This type of anaemia can disappear with the regeneration of the mucosa by gluten-free diet without any substitution. CASE REPORT - Authors report a case of a patient suffering from iron deficiency anaemia caused by celiac disease. The anaemia did not cease by dietary restrictions and iron supplementation and repeated examinations verified a rare benign tumor of the spleen which can cause anaemia as well. CONCLUSION - In connection with this case, the authors summarise the common knowledge of celiac disease and splenopulpoma calling the attention to the benefits of screening celiac disease and the necessity of splenectomy in similar cases.]

Lege Artis Medicinae

NOVEMBER 20, 2007

[TREATMENT OF ANAEMIA IN A PATIENT WITH SMALL CELL LUNG CANCER]

TAMÁSI Lilla, WOLLÁK András

[INTRODUCTION - Anaemia is a common complication among patients with malignant tumours, and is due to the disease itself or to the oncologic treatment. Anaemia worsens the patient’s quality of life and hampers anti-cancer treatment in the appropriate intervals and doses. Erythropoiesis stimulating protein therapy in the anaemia of oncologic patients raises the haemoglobin level, reduces the need for red blood cell transfusion and improves quality of life. This drug has recently become accessible in Hungary for the treatment of chemotherapy-induced anaemia in patients with small cell lung cancer. CASE REPORT - In this paper the case of a 64- year-old woman with small cell lung cancer who survived for more than 2 years is presented. Two-line chemotherapy was administered together with irradiation and darbepoetin alpha supportation. The successful treatment of anaemia with darbepoetin alpha permitted the administration of chemotherapy in the necessary intervals and doses. CONCLUSIONS - The adequate use of erythropoiesis stimulating protein facilitates the management of patients with small cell lung cancer, and improves their quality of life.]

Lege Artis Medicinae

FEBRUARY 21, 2004

[ACUTE DERMATOMYOSITIS ASSOCIATED TO THE CARCINOMA OF THE PROSTATE]

TÁLLAI Béla, MORSHED Ali Salah, FLASKÓ Tibor, PONYI Andrea, DANKÓ Katalin, TÓTH Csaba

[INTRODUCTION - In some cases of polymyositis/ dermatomyositis (PM/DM) of autoimmune origin, different malignant tumours can initiate the difficult cascade mechanisms at cell level leading to the rapid weakness of the skeletal muscles. Till now, in the international literature only four cases of PM/DM associated with cancer of prostate has been reported. CASE REPORT - Authors present a case of a 57 yearold male patient, where weakness in patient's movements developed leading to total immobility in 3 months. Purple discoloration developed on his hand and face. Significantly elevated creatin kinase (CK) levels and blood sediment rate with mild anaemia were observed during laboratory examinations. Dysphagia and lack of appetite resulted in the loss 10 kgs in body weight. Both clinical evaluation, elevated serum CK level, skin symptomes, positive electromyography and muscle biopsy confirmed acute definitive dermatomyositis. Urological examination revealed a palpable hard area at the right lobe of the prostate. Prostate biopsy confirmed the presence of carcinoma in the right lobe of the prostate. There was no sign or symptome referring to either local propagation or distant manifestation. Therefore, radical prostatectomy was performed, the tumorous prostate and both seminal vesicles were removed. Histological examination proved malignant focus in the right lobe of the prostate. After the operation patient gradually became stronger, corticosteroid medication were decreased then stopped. Patient's original muscle power and movement recovered and his previous body weight was regained. During the regular control examinations all results of laboratory tests are in normal range. CONCLUSION - In the background of some autoimmune diseases malignant tumours can be revealed. It is rare when urological neoplasms initiative the process. In men with PM/DM commencing beyond 50 years of age it is necessary to think of the presence of prostate cancer, which can be cured by performing radical operation in appropriate time.]