The epidemiology of hypertension and its associated risk factors in the city of Debrecen, Hungary

The purpose of this work was to estimate the prevalence of hypertension and cardiovascular risk factors and its association with sociodemographic, behavioural and lifestyle characteristics among the adult population of the city of Debrecen, Hungary.A cross-sectional study was conducted in 1996. Amongst 21 800 inhabitants aged 30-65 y risk screening for cardiovascular disease (CVD) was estimated by a questionnaire that included sociodemographic, lifestyle characteristics, family history of CVD and results of self-reported data of body weight, height and blood pressure. Of the total of 19 961 surveyed sample, 37.02% were considered to be hypertensive, 53.73% were overweight, 32.18% were current smokers and 58.85% were physically inactive. Hypertensives were older than normotensives (50.81+/-9.01 vs 44.78+/-8.97 y, P<0.001). The prevalence of various risk factors amongst hypertensives as compared to normotensives were overweight (68.49 vs 45.06%, P<0.0001), current smoking (28.38 vs 34.41%, P<0.0001), physical inactivity (64.78 vs 55.36%, P<0.001), and high alcohol consumption (1.91 vs 1.06%, P<0.01). Of the hypertensives 37.11% were on drug therapy. Of those on therapy, only 17.03% had normal blood pressure. Being overweight and having low physical activity was positively associated with hypertension (OR=2.25, CI=2.11-2.40) and (OR=1.26, CI=1.15-1.38). Manual work, a family history of CVD, low education, and the male gender were also associated with hypertension and more CVD risk factors. These findings illustrate a very high prevalence of hypertension and CVD risk factors in Debrecen, indicating the importance of the need for more effective prevention programmes and control of hypertension in Hungary.

[Results and complications of parathyroidectomy in secondary hyperparathyroidism]

Retrospective study was performed to measure the results of parathyroidectomy in patients with secondary hyperparathyroidism. From 1987 to 2000, 48 patients underwent surgery for secondary hyperparathyroidism. There were 30 of 48 patients on haemodialysis treatment, and 11 patients were in pre-dialysis stage. Parathyroidectomy was performed after successful kidney transplantation in 4 cases. Indication of the surgery was extremely elevated serum level of parathyroid hormone (at least 10 fold elevation), which was resistant for the conservative medical therapy. Subtotal parathyroidectomy (3 1/2) was performed in 30 patients. Five patients underwent total parathyroidectomy and autotransplantation. Only 2 or 3 parathyroid glands have been removed in 13 patients. Haematoma occurred in 3 cases after parathyroidectomy. Recurrent nerve injury or septic complication did not occur. Two patients died in the early postoperative period due to cardiac failure. Tetania was noted in 2 patients after surgery. Permanent postoperative hypocalcaemia (over 6 months) occurred in 3 cases. Persistent hyperparathyroidism was diagnosed in 5 patients. In these patients 2 parathyroid glands were removed during the primary operation. Recurrent hyperparathyroidism was detected in 2 patients. Subtotal parathyroidectomy was carried out in these cases previously. At the reoperation for persistent and recurrent hyperparathyroidism, total parathyroidectomy and autotransplantation was performed. Serum alkaline phosphatase level and serum parathyroid hormone value decreased after surgery, except those patients with persistent hyperparathyroidism. Bone pain decreased in 96% of the cases and pruritus decreased in 92% of the patients after parathyroidectomy. Soft tissue calcification showed improvement in 45% of cases. In conclusion, the subtotal parathyroidectomy or total parathyroidectomy with autotransplantation cause a rapid decrease of PTH level and the improvement of the clinical symptoms in patients with medical treatment resistant secondary hyperparathyroidism. Persistent hyperparathyroidism occurs in those cases when inadequate parathyroidectomy was performed.

Inhibition of the superoxide anion release and hydrogen peroxide formation in PMNLs by flavonolignans

The mixture of flavonolignans [Legalon: silybin (2a), isosilybin (3), silydianin (4) and silychristin (5)] and derivatives of silybin (2b-d) were assessed for their inhibitory activity on the oxidative burst of PMA-stimulated human PMNLs. The inhibitory effect of flavonolignans on O(2)(-) release were compared with that of vitamin E (1). The flavonolignans tested exhibited the following order in inhibition of O(2)(-) release by PMA-stimulated PMNLs: 5,7,4"- trimethylsilybin (2c) approximately vitamin E (1) > Legalon >or= peracetylsilybin (2b) > silybin (2a) > peracetyl-5,7,4"-trimethylsilybin (2d). The flavonolignans inhibited not only the O(2)(-) release, but also the H(2)O(2) formation in PMA-stimulated PMNLs. The inhibitory capacity of flavonolignans on H(2)O(2) formation was similar to their inhibitory capacity on O(2)(-) release. These data suggest that the flavonolignans have antioxidant properties on the PMNL oxidative burst. The fact that the trimethyl derivative of silybin (2c) has a greater inhibitory effect than silybin itself suggests that the efficacy of the antioxidant properties is dependent on the lipophilicity of the molecules. This is underlined by the fact that peracetylation of all of the hydroxyl groups in silybin resulted in a total loss of the antioxidant activity of the molecule. In summary, flavonolignans inhibit the oxidative burst of PMNLs, and this inhibitory effect depends on the chemical structure of the flavonolignans.

Gemfibrozil increases paraoxonase activity in type 2 diabetic patients. A new hypothesis of the beneficial action of fibrates?

OBJECTIVE

The constellation of elevated triglycerides and decreased high-density lipoprotein is recognised as a risk factor for CAD and constitutes the major dyslipidemia in type 2 diabetes. The high-density lipoprotein associated paraoxonase activity can inhibit low-density lipoprotein oxidation and has an antiatherogenic effect. To determine the effect of gemfibrozil on the dyslipidemia and serum paraoxonase activity in patients with type 2 diabetes.

MATERIAL AND METHODS

Fifty-six type 2 diabetic patients with associated hypertriglyceridemia were involved. They were investigated for the effect of twice daily 600 mg of gemfibrozil on serum cholesterol, triglycerides, apolipoproteins, fibrinogen level, body mass index and glycated hemoglobin. Serum paraoxonase activity was measured spectrophotometrically.

RESULTS

After three months, it was observed that under the effect of gemfibrozil, serum triglyceride level was significantly decreased (from median: 3.46 mmol/l quartiles: q1=2.92 q3=5.28 to median 2.20 mmol/l quartiles: q1=1.79 q3=3.65; p<0.001) while protective high-density lipoprotein (from 1.02 +/- 0.22 mmol/l to 1.13 +/- 0.28 mmol/l; p=0.05) and apolipoprotein A(1) (from 1.56 +/- 0.33 g/l to 1.72 +/- 0.29; p<0.01) levels were significantly increased. Serum paraoxonase activity was found to be significantly increased (from median: 100.2 U/l quartiles: q1=60.1 q3=152.7 to median 118.7 U/l quartiles: q1=80.1 q3=171.0; p<0.001) after gemfibrozil treatment. The total cholesterol, low-density lipoprotein, apolipoprotein B, lipoprotein (a), glycated hemoglobin and fibrinogen levels were not significantly changed during the three-month treatment period. The standardized paraoxonase activity for HDL and apo A(1) were not significantly changed. Paraoxonase activity did not correlate with the concentration of glycohemoglobin and the duration of diabetes.

CONCLUSION

Twice daily administration of 600 mg of gemfibrozil is effective in type 2 diabetic patients with associated hypertriglyceridemia. It favorably lowers lipid levels, and improves antioxidant status by increasing serum paraoxonase activity.

[Epidemiology of hypertension in adolescence and factors influencing blood pressure]

The authors summarize the determining and influencing factors of adolescent hypertension. An overview of the definition and prevalence of hypertension in adolescence is given and the predictive role of the adolescent hypertension on the incidence of adult cardiovascular diseases is pointed out. According to the previous literature data, adult hypertension is more frequent in those people who have had hypertension in their adolescence. There are no widely used, population-based nomograms of adolescent hypertensives available. According to the opinion of the authors, a population-based hypertension screening program would help in delineating the factors influencing adolescent blood pressure, and the most frequent risk factors for hypertension in Hungary. With the follow-up and appropriate treatment of the hypertensives the reduction of target-organ damages may be possible.

Which parameters affect cytosolic free calcium in polymorphonuclear leukocytes of haemodialysis patients?

BACKGROUND

Cytosolic free calcium ([Ca(2+)](i)) is an important second messenger during stimulation in a wide variety of cells, including polymorphonuclear leukocytes (PMNs). Its mobilization in PMNs is altered in various diseases such as atherosclerosis and ageing. In chronic haemodialysis (HD) patients, both atherosclerosis and accelerated ageing are well known. Therefore [Ca(2+)](i) in resting PMNs of HD patients was determined along with certain parameters which might affect it, such as recombinant human erythropoietin (rHuEpo) treatment, calcium-phosphate balance, and biocompatibility of dialysis membranes.

METHODS

PMNs were separated by density centrifugation and [Ca(2+)](i) was determined by spectrofluorimetry using Quin 2/AM fluorescent dye. Laboratory parameters were determined by standard methods in clinical chemistry.

RESULTS

It was found that [Ca(2+)](i) in resting PMNs of HD patients not undergoing rHuEpo therapy was higher than that of controls. After 12-weeks of rHuEpo therapy, [Ca(2+)](i) decreased to near normal level. The role of erythropoiesis in normalization of [Ca(2+)](i) in resting PMNs was supported by PMN [Ca(2+)](i) which was elevated in patients who had low haemoglobin (<100 g/l) or haematocrit (<0.30) values. In some patients, including those receiving rHuEpo treatment, [Ca(2+)](i) remained high, suggesting a role for other parameters in increasing [Ca(2+)](i). One possible parameter might be the disturbed calcium-phosphate metabolism of chronic renal failure, because we found a strong correlation between [Ca(2+)](i) and plasma iPTH levels in HD patients (r=0.743, P<0.001). [Ca(2+)](i) was also elevated in PMNs of those patients who had either low plasma calcium or high plasma phosphate levels. PMN [Ca(2+)](i) of HD patients correlated positively with the duration of HD (r=0.671, P<0.001). However, there was no correlation between [Ca(2+)](i) and patient age. The dialysis procedure itself also transiently increased PMN [Ca(2+)](i) HD patients, independently of the type of dialysis membrane.

CONCLUSION

PMN [Ca(2+)](i) is modulated by various parameters in HD patients, including the degree of anaemia, disturbances of calcium metabolism, and duration of dialysis treatment. The elevated [Ca(2+)](i) of resting PMNs might contribute to altered functions in these cells.

Vitamin E, lipid profile, and peroxidation in hemodialysis patients

BACKGROUND

Hypertriglyceridemia, lipid peroxidation, and abnormalities of the plasma fatty acid (PUFA) profile may be important risk factors for the atherosclerotic cardiovascular disease in hemodialysis (HD) patients.

METHODS

We investigated how these factors are affected by vitamin E supplementation carried out by oral administration (clinical study 1) and dialysis with vitamin E-modified dialyzers (clinical study 2).

RESULTS

In the HD patients, conditions of relative vitamin E deficiency were observed [lowered vitamin E/triglyceride (TG) ratio] in the presence of high levels of thiobarbituric acid reactants (TBARs) and decreased levels of the polyunsaturated fraction of PUFAs paired with an increased amount of monounsaturated ones (MUFA). In both studies, vitamin E supplementation significantly increased the levels of vitamin E in the plasma without affecting TG levels and provided a partial correction of TBAR levels. Of note was the relative increase in the PUFA fraction, which gave solid proof of an anti(per)oxidant effect of vitamin E supplementation in HD patients. Vitamin E supplementation was also observed to increase plasma levels of reduced glutathione and NOx (NO2 + NO3).

CONCLUSION

The results suggest that vitamin E supplementation may be an effective accessory therapy to combat oxidative stress-lowering lipid peroxidation in HD patients.

[Hypophosphatemic oncogenic osteomalacia]

The first case of oncogen osteomalacia in Hungary is reported, to draw the attention of the medical profession to it and to present the new data about its pathomechanism. Pathological hip fracture caused by hypophosphataemic osteomalacia due to isolated renal phosphate wasting was found in a previously healthy 19 years old sportsman. In spite of daily 1.5 micrograms calcitriol treatment and phosphate supplementation, hypophosphataemia persisted for 13 years and he needed regular indometacin medication for his bone pain. During that time an 1.5 cm gingival tumour was found and radically removed. The serum phosphate level returned to normal in a few hours after the operation (preoperative 0.51, after 2, 4 and 8 hours 0.61, 0.68 and 0.79 mmol/l respectively), and remained normal without calcitriol. The histological examination showed epulis with fibroblast and vascular cell proliferation, which has never been previously reported in connection with oncogenic osteomalacia. The pain resolved after 3 months and the bone density became normal in one year. Oncogenic osteomalacia must be considered in every case presenting with atypical hypophosphataemic osteomalacia. Careful dental examination is needed also in the course of search for the underlying tumour. Every tumour-like growth, even the common epulis, has to be operated radically and serum phosphate monitored in the postoperative period in all such cases.

[Nil nocere! Phytotherapy causing nephropathy]

The summary draws attention to the nephropathy caused by "Chinese tea", with all its attendant risks that lead to organ damage. Available data from the literature describe more than 100 women who, at various times, underwent long-term slimming courses by taking two types of Chinese tea containing tablets, namely, Stefania tetranda and Magnolia officinalis. The nephropathy is characterized by severe anemia, tubular proteinuria, histologically chronic ischaemic, interstitial nephritis, accelerated decline in kidney function, and epithelial cell dysplasia of the urinary tract, with consequent inclination towards malignant transformation. The clinical and histological picture resembles that of the Balkan nephropathy. Apart from all these a proportion of the patients may develop aorta insufficiency. The author emphasises the hazards in one of the branches of alternative medicine, fitotherapy, and their prevention.

Prevalence of iodine deficiency and goitre during pregnancy in east Hungary

OBJECTIVE

To assess the iodine nutritional status and the prevalence of goitre during pregnancy in a region of Hungary that appeared to be iodine sufficient in previous studies.

DESIGN

A cross-sectional voluntary screening study was organized in which 313 pregnant women participated.

METHODS

Urine iodine concentration and the volume of the thyroid gland were measured in every woman. In the presence of low urinary iodine concentrations, goitre, or both, thyroid function tests were performed.

RESULTS

Iodine deficiency was found in 57.1% of the pregnant women, and was severe in 15.6%. The volume of the thyroid gland was enlarged in 19.2% of individuals. Nodular goitre was found in 17 women (5.4%). The frequency of goitre and the mean thyroid volume were increased in the group of iodine-deficient women. In the 89 cases of iodine deficiency or goitre, thyrotrophin concentrations were in the normal range; however, the free triiodothyronine:free throxine ratio was increased in 97% of them, indicating that the thyroid gland was in a stimulated state in these individuals.

CONCLUSIONS

Iodine deficiency with high prevalence of goitre was recognized among pregnant women in an area that previously appeared to be iodine sufficient. An unexpected mild iodine deficiency was also noted in the non-pregnant control group. Reassessment and continuous monitoring of iodine nutritional status is warranted even in populations that are apparently considered to be 'at no risk' of iodine deficiency, especially in pregnant women. Regular administration of iodine, starting at preconception or in early pregnancy and continuing during the period of nursing, is recommended in these regions.

Prevalence of cardiovascular risk factors of the smokers and non-smokers in the city of Debrecen, Hungary

The aim of our study was to compare the major cardiovascular disease (CVD) risk factors of smokers and non-smokers. Risk screening of CVD was estimated by a questionnaire, via interview. Random samples of 20 000 inhabitants of Debrecen, Hungary, aged 30-65 y, took part in the study. 19 922 questionnaires were considered appropriate for further evaluation. 32.2% of the participants (n=6410) were smokers, whose data were compared to those of the 68.8% of non-smokers (n=13 512). There were more male smokers than female (39.3% vs 27.7%), (P<0.001). 36.5% of males and 58.9% of females had not previously smoked regularly (P<0.001). 24.2% of males and only 13.3% of females were able to stop smoking (P<0.001). 8.7% of the participants smoked more than 20 cigarettes per day (14.8% of males, 5.0% of females), (P<0.001). Smokers were younger, with a mean age of 43.4 y vs 47.1 y for non-smokers (P<0.01). The ex-smokers and non-smokers had a higher body mass index than light, moderate and heavy smokers (26. 75+/-4.1 kg/m2 and 26.09+/-4.3 kg/m2 vs 24.87+/-3.9 kg/m2 and 24. 89+/-4.2 kg/m2 and 25.32+/-4.3 kg/m2, respectively), (P<0.001). The results of the last measured blood pressures did not differ between the two groups. 94.8% of smokers and 93.6% of non-smokers did not perform any regular leisure time exercises (P<0.01). 39.8% of smokers regularly ate fatty food, in comparison to 28.0% of non-smokers (P<0.001). 30.6% of smokers vs 28.6% of non-smokers were factory workers while 69.4% of smokers vs 71.4% of non-smokers did sedentary jobs (P<0.001). 2.3% of smokers vs 0.9% of non-smokers admitted regular consumption of alcohol (P<0.001). Amongst the parents and brothers/sisters of smokers the prevalence of heart attack was higher 19.7% vs 18.7%, than for those of non-smokers (P<0. 05). We observed an accumulation of cardiovascular risk factors in the case of smokers, which indicates the higher susceptibility of smokers to CVD.

Ferriporphyrins and endothelium: a 2-edged sword-promotion of oxidation and induction of cytoprotectants

Heme arginate infusions blunt the symptoms of patients with acute intermittent porphyria without evidence of the vascular or thrombotic side effects reported for hematin. To provide a rationale for heme arginate's safety, the present study examined the effects of various ferriporphyrins to sensitize human endothelial cells to free radical injury and to induce heme oxygenase and ferritin expression. Heme arginate, unlike hematin, did not amplify oxidant-induced cytotoxicity mediated by hydrogen peroxide (5.3 +/- 2.4 versus 62.3 +/- 5.3% (51)Cr release, P <.0001) or by activated neutrophils (14.4 +/- 2.9 versus 41.1 +/- 6.0%, P <.0001). Nevertheless, heme arginate efficiently entered endothelial cells similarly to hematin, since both markedly induced heme oxygenase mRNA (more than 20-fold increase) and enzyme activity. Even with efficient permeation, endothelial cell ferritin content was only minimally increased by heme arginate compared with a 10-fold induction by hematin; presumably less free iron was derived from heme arginate despite up-regulation of heme oxygenase. Hematin is potentially vasculopathic by its marked catalysis of oxidation of low-density lipoprotein (LDL) to endothelial-toxic moieties. Heme arginate was significantly less catalytic. Heme arginate-conditioned LDL was less than half as cytotoxic to endothelial cells as hematin-conditioned LDL (P <.004). It is concluded that heme arginate may be less vasculotoxic than hematin since it is an effective heme oxygenase gene regulator but a less efficient free-radical catalyst.

Disturbed LDL and scavenger receptor functions in monocytes from chronic haemodialysed patients

BACKGROUND

The most frequent complication in patients with end-stage renal failure on chronic haemodialysis (HD) treatment is atherosclerosis, i.e. the different forms of heart and vascular diseases. The complete disorder of serum lipid and lipoprotein patterns is well demonstrated, whereas our knowledge about the low-density lipoprotein (LDL) and scavenger receptor expression and function are poorly understood.

METHODS

In our current work, LDL and scavenger receptor expression and functions were simultaneously studied in monocytes obtained from 15 healthy male control subjects and from 11 chronic HD male patients applied with (125)I-labelled LDL, isolated from healthy volunteers. To study the scavenger LDL receptors, labelled acetylated LDL (acLDL) was used.

RESULTS

LDL binding to the monocytes of the HD-group was found to be decreased in comparison to that of the controls. As a result, the 50 microg LDL protein-induced inhibition of endogenous cholesterol synthesis was also diminished. In contrast, acLDL binding was greatly increased, though it could trigger only a low apoE synthesis. Consequently the number of cholesterol inclusions in monocytes was increased.

CONCLUSIONS

The disturbed expression and function of LDL and scavenger receptors both may play significant roles in pathogenesis of cardiovascular complications in chronic HD patients. Based on our present results, it can be assumed that dysfunction of scavenger receptors is at the centre of cardiovascular complications of HD patients with renal failure.

Serum paraoxonase activity changes in uremic and kidney-transplanted patients

Serum paraoxonase (PON) is a high-density lipoprotein (HDL)-associated hydrolase, which inhibits low-density lipoprotein oxidation. Uremic and kidney-transplanted patients have an increased risk of atherosclerosis, to which an increased lipoprotein oxidation may contribute. The aim of our study was to determine whether the PON activity or phenotype is altered in uremic and kidney-transplanted patients, and to compare the values with those of healthy controls. 117 uremic patients on long-term hemodialysis treatment, 115 renal-transplanted patients, and 110 healthy controls were involved in the study. The PON activity was significantly reduced in the uremic patients compared to controls (PON 101.36+/-30. 12 vs. control 188.05+/-58.96 U/ml; p < 0.001), while in kidney-transplanted patients the values were almost identical to those of controls (PON 161.5+/-35.39 U/ml). The different immunosuppressive drug combinations did not influence PON activity. To assess whether the altered PON activity was due to a decrease HDL level, we standardized the enzyme activity for the HDL concentration (PON/HDL ratio). We found that the standardized enzyme activity was lower in the uremic (102.7+/-54.8) and kidney-transplanted patients (144.5+/-32.7) when compared to controls (194.5+/-94.5; p < 0.001). The phenotypic distribution of PON in uremic, renal transplant and control patients are as follows: AA 66.67, 56.48 and 66.67%; AB 31. 62, 33.3 and 26.67%; BB 1.71, 10.19 and 6.67%. We conclude that the decreased PON/HDL and PON/apoA-1 ratios may lead to a reduction in the antioxidant capacity of HDL, which might contribute to the accelerated development of atherosclerosis in uremic and kidney-transplanted patients.

The role of technetium-99m methoxyisobutylisonitrile scintigraphy in the differential diagnosis of cold thyroid nodules

Various diagnostic techniques have been successfully used in the clinical management of cold nodules; however, the decision on whether to employ surgery or a conservative treatment is not always easy. This study was designed to appraise the diagnostic value of technetium-99m methoxyisobutylisonitrile (MIBI) scintigraphy in the assessment of cold nodules detected using (99m)Tc-pertechnetate. Fifty-two patients were included in the study. All had already been selected for surgery, based on their clinical and laboratory findings, including fine-needle aspiration biopsy. The total number of cold nodules on (99m)Tc-pertechnetate scans was 59. The thyroid scan was performed 20-40 min after i.v. injection of 400 MBq of (99m)Tc-MIBI. Uptake of MIBI in thyroid nodules was compared with that in the surrounding normal thyroid tissue, and a score of between 0 and 3 was assigned to each nodule as follows: 0, cold; 1, decreased; 2, equal; 3, hot. Definitive histology revealed nodular goitre in 24 cases, adenoma in 19, thyroiditis in 1, differentiated cancer in 12, medullary cancer in 2, and anaplastic cancer in 1. None of the degenerative nodules were hot on MIBI scan, while the adenomas showed a variety of MIBI imaging patterns, most frequently the score 3 pattern. In the diagnosis of differentiated thyroid cancer the sensitivities of score 3 and score 2+3 MIBI uptake patterns were 83% (10/12) and 100%, respectively. The score 3 MIBI uptake pattern had a specificity of 100% and a positive predictive value of 100% with respect to thyroid (benign and malignant) neoplastic diseases, whereas a specificity of 72% and a positive predictive value of 43% were observed in the detection of differentiated cancer. After a cold nodule had been detected using (99m)Tc-pertechnetate, a second scan with high MIBI uptake increased by 7.8 times the probability that this nodule would be a differentiated cancer. In conclusion, (99m)Tc-MIBI scintigraphy is a useful method in the differential diagnosis of cold thyroid nodules if the primary aim is to differentiate degenerative from neoplastic diseases rather than to differentiate benign from malignant nodules. High MIBI uptake considerably increases the probability of a differentiated thyroid cancer and facilitates immediate surgical removal, while decreased uptake actually excludes it. We suggest a combination of fine-needle aspiration biopsy and MIBI scan as a routine diagnostic approach to cold thyroid nodules.

QT dispersion in patients with end-stage renal failure and during hemodialysis

Interlead variability of the QT interval in surface electrocardiogram (ECG), i.e., QT dispersion, reflects regional differences in ventricular recovery time, and it has been linked to the occurrence of malignant arrhythmias in different cardiac diseases. The purpose of the study was to assess the effect of hemodialysis on QT and corrected QT (QTc) interval and dispersion in chronic hemodialyzed patients. Data of 34 nondiabetic patients (male/female = 21/13; mean age, 54 +/- 15 yr) on chronic hemodialysis were studied. Polysulfone capillaries and bicarbonate dialysate containing (in mEq/L) 135 Na+, 2.0 K+, 1.5 Ca2+, and 1.0 Mg2+ were used. Simultaneous 12-lead ECG were recorded before and after hemodialysis in a standard setting. The QT intervals for each lead were measured manually on enlarged (x3) ECG by one observer using calipers. Each QT interval was corrected for patient heart rate: QTc = QT/square root of RR (in milliseconds [ms]). The average cycle intervals were 853 +/- 152 ms predialysis and 830 +/- 173 ms postdialysis; the difference was not significant. The maximal QT interval changed significantly from 449 +/- 43 to 469 +/- 41 ms (P < 0.01). The corrected maximal QT interval increased significantly from 482 +/- 42 to 519 +/- 33 ms (P < 0.01). The QT dispersion changed from 56 +/- 15 to 85 +/- 12 ms (P < 0.001) and the corrected QT interval dispersion from 62 +/- 18 to 95 +/- 17 ms (P < 0.001). During hemodialysis, the serum potassium and phosphate levels decreased from 5.5 +/- 0.8 to 3.9 +/- 0.5 (mM) and from 2.3 +/- 0.5 to 1.6 +/- 0.4 (mM), respectively, whereas calcium increased from 2.2 +/- 0.23 to 2.5 +/- 0.22 (mM). It is concluded that hemodialysis increases the QT and QTc interval and QT and QTc dispersion in patients with end-stage renal failure. Thus, it may be stated that the nonhomogeneity of regional ventricular repolarization increases during hemodialysis. Measurement of QT and QTc dispersion is a simple bedside method that can be used for analyzing ventricular repolarization during hemodialysis.

[Effect of hemodialysis on QT dispersion in chronic uremia]

Interlead variability of the QT interval in surface 12-lead ECG (i.e. QT dispersion) reflects regional differences in ventricular recovery time and it has been linked to the occurrence of malignant arrhythmias in different cardiac diseases. The purpose of the study was to assess the effect of hemodialysis on QT dispersion in chronic hemodialyzed patients. The data of 34 patients (Male/Female = 21/13, mean age 54 +/- 15 years) on chronic hemodialysis were studied. Simultaneous 12 lead ECGs were recorded pre- and post-hemodialysis in a standard setting. The QT intervals for each lead were measured manually by one observer. Each QT interval was corrected for patient's heart rate: QTc = QT/square route of RR (sec). The maximal QT interval changed from 449 +/- 43 to 469 +/- 41 ms (p < 0.01). The maximal QTc interval increased from 482 +/- 42 to 519 +/- 33 ms (p < 0.01). The QT dispersion changed rom 56 +/- 15 to 85 +/- 12 ms (p < 0.001), and the QTc interval from 62 +/- 18 to 95 +/- 17 ms (p < 0.001). During hemodialysis the serum potassium and phosphate decreased from 5.5 +/- 0.8 to 3.9 +/- 0.5 (p < 0.001), and from 2.3 +/- 0.5 to 1.6 +/- 0.4, respectively, whereas calcium level increased from 2.2 +/- 0.23 to 2.5 +/- 0.22 (p < 0.001). It can be concluded that the hemodialysis increased the inhomogeneity of regional ventricular repolarization. Measurement of QT and QTc dispersion by a cheap and simple bedside method could predict the increased myocardial inhomogeneity in dialyzed patients.

The serum paraoxonase activity in patients with chronic renal failure and hyperlipidemia

Human serum paraoxonase is physically associated with an apolipoprotein (Apo-A1) and clusterin-containing high-density lipoprotein (HDL) and prevents low-density lipoprotein from lipid peroxidation. The aim of our study was to determine whether paraoxonase activity or phenotype is altered in patients with chronic renal failure and in hyperlipidemic subjects without renal insufficiency and to compare the values with those of healthy controls. We investigated the serum paraoxonase activity and polymorphism in 119 hemodialyzed uremic patients, 107 patients with primary hyperlipoproteinemia, and in 110 healthy control subjects. The serum paraoxonase activity was significantly decreased both in hyperlipidemic (p < 0.01) and uremic patients (p < 0.001) as compared with controls. On comparison, the serum paraoxonase activity was significantly lower (p < 0.001) in uremic than in hyperlipoproteinemic patients. The HDL and Apo-A1 levels were as follows: uremic < hyperlipidemic < control. To assess whether the observed reduction in paraoxonase activity was due to HDL and Apo-A1 level decreases, we standardized the enzyme activity for HDL and Apo-A1 concentrations. We found that the standardized paraoxonase activity (paraoxonase/HDL ratio) was also lower in the uremic patients (103.3 +/- 69.5) as compared with hyperlipidemic patients (137.64 +/- 81.0) and controls (194.45 +/- 94.45). The standardized values for Apo-A1 showed a similar tendency: paraoxonase/Apo-A1 ratio in uremic patients 89.64 +/- 47.8, in hyperlipidemic patients 128.12 +/- 69.83, and in controls 161.40 +/- 47.35. The phenotypic distribution of paraoxonase (AA, AB, BB) did not change significantly in the patient groups. These results suggest that HDL concentration and phenotypic distribution of paraoxonase may not be the only determining factors, but that other as yet undetermined factors could be involved in the enzyme activity changes.

Relative abundance of some free fatty acids in plasma of uremic patients: relationship between fatty acids, lipid parameters, and diseases

The unesterified fatty acid patterns in plasma of predialytic (PHD) and hemodialysis (HD) patients were determined. The HD patients were divided into three groups: (1) HD without cardiovascular disease (HD-norm); (2) HD with cardiomyopathy (HD-CAD), and (3) HD with hyperlipidemia (HD-hyp). The relative abundance of saturated fatty acids (SFAs) was greater in the plasma of HD-norm and HD-CAD patients (73.3 and 70.0%, respectively) than that in controls (62.6%), and the relative abundance of monounsaturated fatty acids (MUFAs) was significantly greater in the plasma of HD-hyp patients than that in controls (38.9 vs. 21.6%, p < 0.01). In all HD patients the relative concentration of polyunsaturated fatty acids (PUFAs) was lower than in controls. There were no significant differences in the fatty acid patterns of PHD patients. In conclusion, the relative abundance of SFAs and MUFAs in plasma of HD patients is associated with their concomitant lipid disorders and cardiomyopathy, while the low relative abundance of PUFAs was common in all HD patients.

[Granulocyte function and lipid peroxidation in untreated patients with hyperlipoproteinemia]

The fatty acid composition in free fatty acid and phospholipid fraction of plasma in untreated mildly hyperlipidemic patients were determined. The general trend was an increase in saturation in both free and phospholipid fractions of plasma in patients compared with that of healthy controls. Furthermore, arachidonic acid, precursor of formation of prostaglandins and leukotrienes was detected in significantly lower amount in plasma of mildly and untreated hyperlipidemic patients. These fatty acid abnormalities were connected with the increased lipidperoxidation in plasma lipids and in both resting and stimulated granulocytes.

[Lipid lowering treatment in secondary prevention following myocardial infarct]

1081 patients treated with myocardial infarction between 1990-1995 were investigated retrospectively, 652 (60.3%) of the patients were male and 429 (39.7%) were female. 154 (14.2%) patients had an early, while 927 (85.5%) patients had late myocardial infarction. Of the patients with early myocardial infarction 52.3% were smokers, 45.2% had positive family history for ischaemic heart disease or acute myocardial infarction. The lipid parameters were analysed in detail, because 83.3% of the patients were hyperlipoproteinaemic. The mean cholesterol level was 6.91 +/- 1.2 mmol/l, the HDL-C level was 1.19 +/- 0.38 mmol/l, the triglyceride level was 2.66 +/- 1.8 mmol/l, the LDL-C level was 4.71 +/- 1.2 mmol/l. The serum LDL-C and the HDL-C levels of the patients with early myocardial infarction were compared to the desirable levels suggested for secondary prevention. Only 7.2% of the male patients had a cholesterol level below 5.2 mmol/l, while all female patients cholesterol levels were above 5.2 mmol/l. Of the male patients 53.6%, while 78.6% of females had lower triglyceride levels than 2.3 mmol/l 78,6% of the male patients had higher protective HDL-C level in the optimal range (> 1.1 mmol/l). 12.5 percent of the male patients had an LDL-C level lower than the value targeted by secondary prevention (3.0 mmol/l), while all of the female patients LDL-C levels were higher. The authors emphasize the importance of secondary prevention and a more widespread use of lipid lowering treatment for patients after acute myocardial infarction.

[Use of erythropoietin in pregnancy: review of the literature in connection with 2 cases]

Recently a growing number of case reports has been published about successful pregnancy outcome of dialysed women on recombinant human erythropoietin therapy. During pregnancy the maternal demand for erythropoietin may undergo changes, with consideration of recombinant human erythropoietin therapy in the early stage of renal insufficiency, as is shown by our two reported cases. The use of recombinant human erythropoietin seems to be safe for the foetus: it does not cross the placental barrier, and therefore lacks any direct foetal effect. The treatment of anaemia with recombinant human erythropoietin carries benefits for both the mother and foetus. One of the most important preconditions for successful recombinant human erythropoietin therapy is adequate iron supplementation. Due to the increased risk of pregnancy induced hypertension or preeclampsia, there is a need for slow and gradual correction of anaemia, and an individually tailored target hematocrit. A close follow up of he patient by the obstetrical-nephrological team is essential, with the intensive monitoring of the fetuses. In some cases with normal renal function the stimulation of erythropoiesis with recombinant human erythropoietin may also be needed during the pregnancy.

[Interferon therapy in cryoglobulinemic membranoproliferative glomerulonephritis associated with hepatitis C virus infection]

The authors report the case of a 38 year old man with horseshoe kidney who developed a severe nephroso-nephritis syndrome, caused by cryoglobulinemic membranoproliferative glomerulo-nephritis. A combination of steroid and cyclophosphamide treatment resulted in partial improvement, but was discontinued after 12 weeks due to adverse reactions, with a consequent early relapse. The 4 week course of cyclosporine monotherapy proved ineffective and signs of cryoglobulinemia appeared. The elevation of transaminase, manifested during the immunosuppressive therapy demonstrated the presence of underlying chronic C hepatitis. In the light of the liver biopsy result, interferon treatment was commenced at a dose of 3 million unit thrice weekly. After 4 months of interferon treatment the persistent nephrotic range proteinuria decreased to below 0.5 g/day. Four months later clinical signs of cryoglobulinemia disappeared, and after the 10th month of interferon treatment no cryoglobulin could be detected in the patient's sera. After one year, the interferon treatment was discontinued following a negative PCR result for HCV. However, one month later the proteinuria increased and the quantitative hepatitis C virus nucleic acid test in sera became positive again. Our case demonstrates that interferon therapy may be effective in the treatment of cryoglobulinemic glomerulonephritis responding poorly to the immunosuppressive therapy, though larger doses or longer periods of treatment may be required to prevent relapses.

[Amyloidosis associated with dialysis]

Recently dialysis related amyloidosis has become a major complication in patients treated with long-term dialysis therapy. The serum level of the amyloid precursor beta 2-microglobulin is significantly elevated in uraemia, mostly due to the retention. The bioincompatibility of dialysis membranes and the endotoxin content of the dialysate may contribute to the synthesis and tissue deposition of beta 2-microglobulin, but the details of pathogenesis are not yet cleared. At first periarticular and perineural structures are involved in the deposition of amyloid. The carpal tunnel syndrome is of great differential diagnostic value, it appears frequently together with the beginning of the joint pain. The main target of arthropathy are the large and medium-sized joints symmetrically. Deposition of the amyloid to the subchondral bone cysts might lead to pathological fractures, mainly in the hips and destructive spondylarthrophathy might involve severe neurologic complications. Visceral organs (gastrointestinal and urogeniteal tract, heart etc.) are involved rarely and later. Ultrasonography and isotope methods in addition to the conventional radiologic examinations are also used to differentiate the joint complaints nowadays. The definitive diagnosis is based on immunohistology. The alteration of dialysis strategy first of all the usage of high permeable, biocompatibile membranes and pure dialysis water has a role in the prevention of disease and decreasing its progression. In the case of developed lesions timely surgical-orthopedic interventions are required in addition to drug therapy. Todays' renal transplantation is a successful treatment, but the consequences of amyloid depositions already formed can't be left out of considerations even after transplantation.

Lipid abnormalities in uraemic patients on chronic haemodialysis

Patients kept on haemodialysis because of chronic renal insufficiency were investigated for lipid profiles. The cholesterol level did not differ as compared to the age-matched control, while the triglyceride level was elevated. The correlation was found between the lipid parameters, period spent in dialysis programme and level of serum creatinine and urea. In renal failures of different origin the lipid levels are in relationship with the underlying disorders.

[Recombinant human erythropoietin in the therapy of anemia in hemodialyzed patients]

The authors reported on a three month long EPREX (human recombinant erythropoietin) therapy of 5 hemodialysis patients for the treatment of their anemia. The drug was administered in bolus form 2 or 3 times a week after dialysis in a dose of 50 to 150 IU/bodyweight increased gradually in every (or every second) week. Hgb ad Htk values were determined once a week while erythrocyte, leukocyte, thrombocyte and reticulocyte count once a month. Serum iron, TIBC, serum ferritin, BUN, serum creatinine, urea, serum ions, liver function assays, serum lipids and amylase were also established. Hgb, Htk levels and reticulocyte count have significantly increased in the 4th week of treatment already, severe anemia ceased with improved appetite, general condition and physical strength. Serum urea and LDH levels significantly increased while SGOT decreased. No significant change in leukocyte and thrombocyte count, serum Na, K, Ca, P, Cl, BUN, creatinine, total protein level, serum albumin, bilirubin, alkaline phosphatase, GGT, GPT, amylase and blood sugar as well as serum lipid level were observed. No adverse reactions occurred during the treatment. After the three gradually decreased and within 6 weeks they had to be transfused again. In three patients the need for transfusion has significantly grown after the treatment. The authors consider EPREX a highly efficient drug in the treatment of anemia in dialysis patients.

[Prevention of acute renal failure in rhabdomyolysis caused by alcohol and drug intoxication]

Authors report a case of rhabdomyolysis occurring in a chronic alcoholic patient where they suspect in the development of rhabdomyolysis beside the effect of alcohol also a role of drug intoxication and muscle compression. They found sustained myoglobinaemia and myoglobinuria, while in this case beside the hypocalcemia during the initial phase of rhabdomyolysis normal parathyroid hormone level was found. Therefore in alcoholic intoxicated patients the measurement of creatine kinase is indicated. Beside total lactate dehydrogenase the determination of isoenzymes is in some cases helpful. In the presented case despite extensive rhabdomyolysis, acute renal failure was prevented by early volumen replacement therapy and use mannitol-sodium bicarbonate infusions. Authors discuss the possibility of the role of calcium blocking agent nifedipine in the prevention of rhabdomyolysis and acute renal failure.

[Bone scintigraphy in uremic osteodystrophy]

99mTc-HEDP bone scan was carried out on 12 long-time haemodialysed patients, suffering from bone pains. X-ray examinations of the bone and laboratory tests (serum calcium, -phosphor, -alkaline phosphatase, -parathormone, -aluminium, -ferritin) were also performed. The scintigrams were evaluated by two semiquantitative scores. Based on diffuse, increased radiopharmacon uptake of the bones and more than five points in the Fogelman score 5 patients most likely had serious and 3 had moderate hyperparathyroidism. In two patients osteomalacy was presumed based on decreased radiopharmacon uptake of the bones, increased uptake of the soft tissues and zero Fogelman score. Mixed or other bone disease was suggested in two other patients. Good correlation was found between the results of bone scans, the parathormone values and the results of histology obtained after parathyreoidectomy of 4 patients and autopsy of two others. This non-invasive examination (ie. bone scan) is helpful in differential diagnosis of uraemic osteodystrophy and its wide use is proposed in domestic nephrological practice.

Experience with brulamycin therapy in dialysed patients

Forty-two patients with chronic renal insufficiency were subjected to Brulamycin therapy to combat complications such as sepsis, infection of the lower respiratory tract (bronchopneumonia) or of the urinary tract, Cimino fistula inflammation or peritonitis when the pathogenic agent was sensitive to nothing but aminoglycosides. The proper Brulamycin dose was selected under close clinical and laboratory control so as to fit the dialysed patient and his state of impaired renal function. The various forms of dialysis have been studied to determine their Brulamycin blood level diminishing effects. Familiarity with these effects is as important as with the patient's age, sex, body weight and actual state of renal function. The results confirm the experience gained by other authors that Brulamycin treatment--in curative non-toxic doses as indicated by the blood level index--is useful against severe infectious complications in anuric patients.

[The action spectrum of cytostatics in the management of glomerulonephritis]

It was reported on the results of the cytostatic immunosuppressive treatment during a 6 years' observation time in 100 patients with glomerulonephritis in immunopathogenesis. The diagnosing was made according to the homogeneous opinion: clinical, immunological and histological. Of the 100 patients 33 suffered from SLE and 67 from other nephropathies with immunopathogenesis. In the therapy were used prednisolone, 6-mercaptopurine, azathioprine, cyclophosphamide and their combination, respectively. On the one hand, the therapeutic results were estimated as short-term results, on the other hand as long-term results with regard to the clinical syndromes as well as to the individual histological forms according to the categories of the full remission, the partial remission and also as "unchanged". It was established, whether an optimum result may be achieved in the different clinical and histological types. The best results may be achieved with the combination of 6-mercaptopurine and cyclophosphamide. The cytostatic therapy of the glomerulopathies should be used more aimedly in different clinical syndromes and histological forms.

[Nephropathy associated with systemic lupus erythematosus]

The investigation of needle- kidney biopsy from patients with SLE- nephrotic syndrome was carried out by the aid of light- immunofluorescent- and electron microscopy. Membranous-, focal-proliferative-, and diffuse-proliferative forms of the SLE- nephrotic syndrome were distinguished. Clinical characteristics of the different forms are described. Authors believe, that the underlying process of nephrological symptoms of various degree as well as readily distinguishable clinico-pathological pictures is the formation of circulating immunocomplexes of different size, developing due to basic disease itself. Comparison of the clinical symptoms and the morphological picture indicate that the elapse of time between the onset of the underlying disease and the nephrotic syndrome has an important part in the formation of the SLE-nephropathy of focal- and diffuse-proliferative type.