[Microalbuminuria. From diabetes to cardiovascular risk]. / Mikroalbuminurie. Od diabetu ke kardiovaskulárnímu riziku.

An increased albuminuria level, known as microalbuminuria is associated with a range of diseases, most frequently with diabetes mellitus and hypertension. Microalbuminuria in type 1 diabetes is an early sign of diabetic nephropathy onset, while it tends to be an indicator of the level of cardiovascular risk in type 2 diabetes and essential hypertension. At present, an increased albumin excretion is considered to be a renal symptom of generalized endothelial dysfunction. A simple investigation, not bothersome to a patient, should be performed early and repeatedly in all patients with diabetes and hypertension, as low microalbuminaemia levels can be managed with appropriate treatment.

[Hypertension and cardiovascular complications of chronic renal failure]. / Hypertenze a kardiovaskulární komplikace thronického selhání ledvin.

Chronic renal failure is associated with a significant cardiovascular risk due to an increased incidence of cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidemia). Cardiovascular mortality is due to an increased incidence of left ventricular hypertrophy, ischemic heart disease and chronic heart failure. Management focuses on risk factors, mainly high blood pressure in patients with mild to moderate chronic kidney disease, but it often fails in patients with chronic kidney failure.

[Treatment of dyslipidemia in patients with metabolic syndrome and chronic kidney disease]. / Lécba dyslipidemie u pacientu s metabolickým syndromem a chronickým onemocnením ledvin.

Dyslipidemia, often present in patients with metabolic syndrome and chronic kidney disease, contributes to increased cardiovascular risk and progression of renal impairment. In these patients, the probability of death from cardiovascular complications is higher than death consequent to terminal renal failure. Positive neuroprotective effects ofstatins and fibrates are being attributed to hypolipidemic as well as other, lipid-unrelated, properties. Statins are able to slow down the decline in glomerular filtration rate and may decrease proteinuria. Nevertheless, conclusive evidence that statins decrease the incidence of cardiovascular complications in patients with advanced chronic kidney disease is still lacking. Through their effect on albuminuria, fibrates contribute to slowing down ofthe progression of diabetic nephropathy. Controlled trials and clinical practice have shown that monotherapy with statins as well as fibrates is safe. Management of combined dyslipidemia requires, apart from the selection of a suitable statin-fibrate combination, careful monitoring of potential adverse effects and treatment tolerability and compliance. The results of the Czecho-Slovakian pivot study KOLCHRI have demonstrated the efficacy and safety of fenofibrate combined with low dose statin in patients with metabolic syndrome and stage 2-4 chronic kidney disease.

[Diabetes mellitus, hypertension and kidney]. / Diabetes mellitus, hypertenze a ledviny.

The correlations co-exist among diabetes mellitus, hypertension and the kidney. Renal injury will develop in 35% type 1 and type 2 diabetes mellitus patients. Diabetic nephropathy is the key factor for the occurence of hypertension in type 1 diabetes mellitus. In case of type 2 diabetes mellitus with prevalent essencial hypertension the diabetic nephropathy is supporting factor for the development of hypertension. Untreated or inadequately treated hypertension accelerates the progression of diabetic renal impairment. The presence of diabetes mellitus as well as hypertension or proteinuria is significant cardiovascular risk factor. The goal of treatment with angiotensin converting enzyme inhibitors or AT1 receptor of angiotensin II blockers is both slowing-down of renal injury progression and reduction in risk of cardiovascular complications.

Diagnostic haemoperfusion.

Haemoperfusion and standard blood culture techniques were compared in the recovery of pathogenic Escherichia coli and Staphylococcus aureus strains circulating in the blood of rabbits with experimental bacteriaemia. On the average, diagnostic haemoperfusion gave positive isolations in 93.3%, blood cultures in 51.7%. This difference in favour of haemoperfusion tended to increase with the decreasing intensity of bacteriaemia. Clinically, haemoperfusion helped to establish correct diagnosis in a 46-year-old female patient with diabetic nephropathy and absceding staphylococcal pyelonephritis, whose blood and urine cultures were repeatedly negative. In this patient the authors succeeded in isolating the cause of septicaemia with the aid of the Czechoslovak haemoperfusion column Hemasorb 400 C. This study implies that diagnostic haemoperfusion used for the isolation of pathogens from blood is more reliable and less time-consuming than routine culture techniques.

[An imported case of hemorrhagic fever with renal syndrome]. / Importovaný prípad hemoragické horecky s renálním syndromem.

The authors present a case of haemorrhagic fever with renal syndrome imported from a region of endemic occurrence of hantaviruses in the Balkans. The patient contracted the infection in connection with service in the Czech UNPROFOR unit. The affection manifested itself as renal insufficiency and required a total of seven haemodialyses for complete recovery. The epidemiological context and clinical course of the disease are described in detail.

[Use of the low-molecular heparin, Fraxiparine, during hemodialysis]. / Pouzití nízkomolekulárního heparinu Fraxiparine pri hemodialýze.

BACKGROUND: The prerequisite of effective haemodialyzation treatment is prevention of blood coagulation in the extracorporeal circulation. The objective of the study was to evaluate the effectiveness, safety and dosage of low-molecular heparin nandroparinum calcium--Fraxiparine (Sanofi) in haemodialyzation treatment of adult patients. METHODS AND RESULTS: In 29 patients (22 men, 7 women, age 54 +/- 12 years) a total of 2125 haemodialyses were made on a capillary dialyzer with a cuprophane membrane extending over 3.6 +/- 0.5 hours, incl. 84 (9 subjects) with acute and 2041 (20 subjects) with chronic irreversible renal failure. In none of the procedures complete coagulation occurred, partial coagulation of the dialyzer or the presence of fibrin deposits in the return line was found only in 148 (7%) haemodialyses, statistically significantly more frequently in acute procedures (48; 57%; p < 0.01), as compared with chronic procedures (100; 5%). The authors did not observe any haemorrhage during or after haemodialysis. The total dose of Fraxiparine needed in acute dialyses was higher (6900 +/- 2400 U.I. aXa) as compared with chronic procedures (5400 +/- 1700 U.I. aXa) the difference is however not statistically significant. In 1910 haemodialyses (89.9%) only a single bolus dose was used 5100 +/- 1400 U.I. aXa Fraxiparine (70 U.I./kg). CONCLUSIONS: Low-molecular heparin Fraxiparine administered as a bolus makes safe and effective anticoagulation during haemodialysis possible and does not call for laboratory follow-up of the anti-Xa level. In acute haemodialyses larger doses are needed.

[Hemorrhagic fever with renal syndrome]. / Hemoragická horecka s renálním syndromem.

The authors describe the illness of a Czech soldier who while serving in the UNPROFOR forces in an area with the endemic occurrence of hantaviruses became infected with this agent and developed haemorrhagic fever with renal syndrome. The severe clinical course which called for seven haemodialyzation procedures led to the patient's recovery. The authors describe the course of the disease and epidemiological circumstances.

[The sorption effectiveness of Czech-manufactured hemoperfusion sorbents for amatoxins]. / Sorpcní úcinnost ceských hemoperfuzních sorbentu pro amatoxiny.

BACKGROUND: Haemoperfusion was introduced in the treatment of intoxications with Amanita phalloides in 1974. Haemoperfusion over active charcoal is used most frequently. The objective of the present study was to compare the sorption capacity of Czech haemoperfusion sorbents of the charcoal and resin type for amatoxins extracted from dried Amanita phalloides. METHODS AND RESULTS: Haemoperfusion sorbents on the basis of charcoal-Chemviron SC XII and on the basis of synthetic resin--Amberlite XAD 2 were used in experiments in vitro. Recirculation of an aqueous extract of Amanita phalloides over a haemoperfusion column with a volume of 400 ml located in a closed system took 4 hours. Amanitin levels (alpha and beta) were assessed by HPLC. Two-hour perfusion over Amberlite XAD led to removal of the entire amount of both amanitins from the aqueous solution. Four-hour perfusion over charcoal, however, reduced the original alpha amanitin level by 24% (p < 0.05) and of beta amanitin by 8% (change not significant). Extraction of alpha and beta amanitin by the resin sorbent varied between 0.95-1.00. The type of charcoal used, produced from the shells of coconuts, had a low extraction activity, cca 12%. CONCLUSIONS: The assembled results provide evidence that the synthetic resin Amberlite XAD 2 has a more than ten times greater sorption capacity, as compared with charcoal (Chemviron SC XII) and that in experiments in vitro it removes rapidly and effectively alpha and beta amanitin from an aqueous solution. Although during sorption of mycotoxins from plasma or blood the sorption rate and total capacity declines amberlite resins (Czech haemoperfusion column Hemabsorb A2) can be recommended for use in clinical toxicology.

[Renoprotective effects of antihypertensives]. / Renoprotektivní úcinky antihypertenziv.

A characteristic feature of a majority of chronic renal diseases is their progressive course. The speed of deterioration of renal function depends besides an aetiology of a primary disease on the level of systemic (and glomerular) blood pressure and a degree of proteinuria. Angiotensin II plays an important role in the use of hemodynamic and nonhemodynamic factors of progression. Inhibitors of angiotensin converting enzyme or angiotensin antagonists comparable with other hypertensives used in blood pressure control have more substantial renoprotective effects both in diabetic and nondiabetic kidney diseases. A prerequisite of an effective renal protection is reaching the target blood pressure corresponding with present European and American recommended values < or = 130/80 mm Hg. The least risk of chronic renal disease progression is when systolic blood pressure is 110-120 mm Hg and in proteinuria plain 1 g/24 hod. A practical implementation of renal protection is difficult in patients with renal insufficiency in spite of the used combination of angiotensin converting enzyme inhibitors or angiotensin antagonists and other antihypertensives.

[Hypertension and the kidneys]. / Hypertenze a ledviny.

The relationship between the kidneys and hypertension is multiple. Impaired renal function preventing adequate sodium excretion participates in the pathogenesis of primary hypertension. Renal diseases are the most frequent cause of secondary hypertension. Bilateral and unilateral parenchymatous affections predominate (5% of all hypertensions) over renovascular causes (2%). In the course of hypertension regardless of its etiology renal damage may develop--nephroangiosclerosis or atherosclerosis of the renal arteries with unilateral or bilateral affection (renal ischaemic disease). Hypertension is an important factor in progression of chronic renal diseases towards irreversible renal failure.

[Hypertension and chronic renal insufficiency--chronic kidney failure]. / Hypertenze a chronická renální insuficience--chronické selhání ledvin.

The prevalence of hypertension in patients with chronic renal insufficiency is high. In the stage of renal insufficiency it is 60% and in conservatively terminal renal failure it is as high as 90%. After the initiation of dialyzation treatment it declines temporarily, it is higher during chronic haemodialysis (50-80%) and lower in continuous ambulatory peritoneal dialysis (30%). After transplantation it is recorded in 70-80% recipients of a renal graft. Among the causes of renal hypertension in subjects with conservatively treated chronic renal insufficiency at present secondary renal impairment is increasing--in type 2 diabetes and also renal vascular affection due to atherosclerotic changes and essential arterial hypertension. Approximately 30% of patients where chronic dialyzation treatment is started, come "from the street". In the pathogenesis of renal hypertension sodium retention is involved with volume expansion and an impaired ratio of the formation of vasoactive (vasopressor and vasodepressor) substances. In chronic renal failure the volume component of hypertension predominates markedly. The causes of the development of hypertension after renal transplantation are multifactorial and are most closely associated with immunosuppressive treatment and graft rejection. Pharmacological treatment of renal hypertension prefers inhibitors of the angiotensin converting enzyme (possibly angiotensin II antagonists) because of their concurrent renoprotective action. In the stage of renal insufficiency they call for reduced doses and combination with other antihypertensive agents. The objective of treatment is to achieve a blood pressure < 130/80 mm Hg. In chronic dialyzation treatment the main therapeutic provision in hypertension is adjustment of the volume of extracellular fluid by regime provisions and effective haemoelimination treatment. Calcium blockers are useful in particular in the treatment of hypertension in haemodialyzed subjects and in hypertension after renal transplantation.

[Amanita poisoning and the importance of sorption hemoperfusion in its therapy]. / Otravy muchomurkami a význam sorpcní hemoperfuze pri jejich lécení.

Intoxications with poisonous mushrooms, in particular toadstools, are still a serious medical problem. The author presents contemporary views on the etiopathogenesis of intoxications with Amanita phalloides, the clinical picture of the phalloid syndrome and its prognosis. He emphasizes the importance of a comprehensive therapeutic approach, incl. the administration of antidotes (penicillin G and silibinin) and extracorporeal haemoelimination treatment. Early sorption haemoperfusion, either alone or combined with haemodialysis or plasmapheresis, prevent the development of hepatic and renal failure and significantly reduce the mortality from mushroom poisoning. The results of amanitine sorption in in vitro experiments and in the treatment of human intoxications justify the use of biocompatible synthetic resin sorbents (Amberlite XAD-2) in the treatment of mushroom poisoning rather than active charcoal.

[Is absorption hemoperfusion effective in the treatment of baclofen poisoning?]. / Je sorpcní hemoperfúze úcinná pri lécení otravy baclofenem?

By six-hour sorption haemoperfusion over active charcoal in a 33-year-old woman intoxicated with baclofen (Baclofen Polfa) the initial plasma concentration was reduced by 87%, while from the blood only 3% of the ingested dose were removed. Therefore the capacity of baclofen elimination was tested by perfusion and dialysis in vitro. Two-hour dialysis with the Czechoslovak haemodialyzer Chiraplat was equally effective for removal of baclofen from an aqueous solution (21.2 mg) as four-hour perfusion over active charcoal and resin--Czechoslovak haemoperfusion columns Hemasorb 800 C (19.4 mg) and Hemasorb 800 A-4 (18.9 mg). Because during the first 30 minutes of perfusion the resin sorbent has a double extraction, as compared with dialysis, it is better to use in serious intoxication haemodialysis and haemoperfusion concurrently.

[Incidence of arterial hypertension during and after acute glomerulonephritis]. / Výskyt arteriální hypertenze behem a v období po akutní glomerulonefritide.

The authors investigated the incidence of arterial hypertension during acute glomerulonephritis in adults and during the period after glomerulonephritis. Hypertension was recorded in 34% of 126 patients treated on account of acute glomerulonephritis (mean age 23 +/- 6 years). Only in six patients the diastolic pressure was higher than 15.3 kPa. At the end of hospitalization hypertension persisted in four subjects. After a three-year interval following glomerulonephritis hypertension was recorded in 15% of 119 examined subjects. In 7 subjects it was isolated, in another 11 associated with a pathological finding in urine. Four to twenty years after acute glomerulonephritis (mean 11.5 years) in a group of 81 subjects hypertension was recorded in 31%. In six patients it was an isolated finding, in 19 instances it was associated with a pathological finding in urine and possibly impaired renal function. In adult age transient hypertension is associated with about one third of all cases of acute glomerulonephritis. Subsequent presence of hypertension in these patients is frequent and increases with the follow up period. Without an invasive examination it is not possible differentiate secondary hypertension from essential hypertension, in particular in subjects with isolated hypertension or hypertension associated with mild proteinuria.

[Metoprolol and metipranolol in the treatment of hypertension-- comparison of the effects of a single dose and administration for 1 month]. / Metoprolol a metipranolol v lécbe hypertenze--srovnání úcinku jednorázové dávky a jednomesícního podávání.

In six subjects the hypotensive action of metoprolol (Betaloc, Egis) after a dose of 166.7 +/- 47.1 mg and metipranolol (Trimepranol, Spofa) 21.7 +/- 3.7 mg was investigated. Betaloc influences after one month's administration the systolic blood pressure more effectively in a recumbent position and upright position and the diastolic pressure in a sitting position and after walking. The authors investigated also indicators of the circulation, blood sugar values, values of immunoreactive insulin, aldosterone and plasma renin activity after a single dose of 10 mg Trimepranol or 100 mg Betaloc. Betaloc caused a significant drop of the systolic blood pressure already after 15 minutes, Trimepranol after 30 minutes, in both instances the maximum effect was recorded after 45 minutes and persisted throughout the six-hour investigation. The diastolic blood pressure and heart rate were influenced only little. The blood sugar levels after Betaloc rose significantly during the first hour, after both drugs during the third hour. No correlation was found between changes of the blood sugar level and immunoreactive insulin levels. No differences were revealed as regards the effect on plasma renin activity and aldosterone levels.

[Determination of quantitative proteinuria from a single urine sample based on the protein:creatinine ratio]. / Stanovení kvantitativní proteinurie z jednorázove odebraného vzorku moci na podklade pomeru bílkovina:kreatinin.

Assessment of quantitative proteinuria is associated with collection of urine over several hours. This is, however, not always possible, in particular in ambulatory patients. Therefore efforts are made to assess the urinary protein per 24 hours on the basis of the proteinuria index, i.e. the ratio protein:creatinine in a single urine specimen. In a group of forty patients the authors demonstrated the closest correlation (correlation coefficient = 0.910374) between quantitative proteinuria and the index of proteinuria in urine specimens which were collected during daily activity. The closeness of this correlation depends on renal function. Assessment of quantitative proteinuria from a single urine sample on the basis of the protein:creatinine ratio is therefore useful in subjects with a preserved or not very restricted renal function.

[Isolated hematuria in adolescents and adults. The value of renal biopsy]. / Izolovaná hematurie u dospívajících a dospelých. Výteznost ledvinové biopsie.

In 103 subjects with asymptomatic isolated haematuria (persisting for more than 6 months in the absence of proteinuria, bacteriuria, impaired haemocoagulation or urological disease) renal biopsy was performed. The mean age of the patients was 25.2 years, range 14-58 years. In 94% glomerular changes were detected--most frequently minimal glomerular lesions (67%) and proliferative mesangial glomerulonephritis (15%). Focal segmental proliferative glomerulonephritis was rare (4%). Immunofluorescent examination revealed IgA nephropathy in 40% (all cases of diffuse and focally segmental proliferative glomerulonephritis and one quarter of minimal glomerular lesions). Changes of tubules and interstitium were recorded in 26%, with the exception of one patient they were always associated with glomerular affection. From the investigation ensues that the predominating cause of isolated asymptomatic haematuria, not clarified by non-invasive examination, is usually not serious and is an affection frequently associated with tubulointerstitial changes. As many as 40% of isolated cases of haematuria may be the manifestation of IgA nephropathy. The deposition of IgA is more frequently associated with a more advanced grade of glomerular affection. Indication of diagnostic renal biopsy in isolated haematuria remains individual.

[Circulating heparin-like anticoagulant--2 cases of successful therapy]. / Cirkulující antikoagulans heparinové povahy--dva prípady úspesné lécby.

In the circulation of patients with severe haemorrhagic conditions in rare instances an anticoagulant of heparin nature can be detected, the exact origin of which has not been elucidated so far. These patients can be treated by protamine sulphate. The authors present their own observations in two women where the circulating anticoagulant of heparin nature was detected during a haemorrhagic condition after spontaneous rupture of an enlarged spleen and in scleroderma with organ affection. In both instances treatment was successful.